南京DRG点数法付费在中医医院的实施效果及其完善策略探析——以某省三甲中医院为例

目的：分析医院实施DRG后对经济运营、医疗服务供给等方面的影响，为推进符合中医药特点的医保支付方式改革提供策略建议。方法：以南京市DRG点数法付费为例，从医院DRG病组、中医DRG病组和科室病组3个层面与全市进行横向比较，从医疗服务能力、医疗质量和医疗成本等维度与医院去年同期水平进行对比分析。结果：医院实施点数法付费后，存在中医病种组数覆盖面相对不足，中医特色明显科室DRG亏损相对明显，中医药特色优势发挥不显著等问题。结论：医院能够快速适应DRG点数法付费改革，在总体运行情况较好的情况下，仍然要加强对中医医保政策和中医病种入组等方面的研究，通过推行中西医结合多学科诊疗模式、统筹协调“绩效考核与医保支付”等措施，实现在DRG点数法付费下中医药特色优势得到充分发挥。     

基于DRG成本核算的公立医院中心供应室成本分摊方式测算△

随着我国 DRG付费方式改革进程的推进,有条件的公立医院陆续开展 DRG成本核算,不断加强医院的成本管理。但在实践中,医院成本核算结果,往往会因为选择了不同的分摊方式而不够准确。本文以医院中心供应室成本分摊为例,探索更加合理的分摊方式,产出更加可信可运用的成本核算结果,提供医院在DRG成本核算实施过程中一些新的思路和方法。     

DRG付费下的公立医院成本核算实践探究

DRG支付方式改革对公立医院运营产生了重要影响,XH医院在科室全成本核算的基础上,采用作业成本法核算全院全年的医疗服务项目成本,运用项目叠加法核算全年开展的805个DRG病组成本,对RU14等部分病种的病组成本与例均费用进行对比分析,挖掘DRG成本管理的重点,为医院优化绩效考核和病组结构,助力专科发展提供参考.     

DRG患者成本模型的构建及应用研究

精确测算医院DRG成本对于三级公立医院进行内部管理、成本控制及提升资源效率至关重要。本研究将加拿大患者成本核算法进行本土化应用，在分析单个住院患者就医流程和资源消耗的基础上构建住院患者成本模型，进而形成DRG病组成本，并将其用于住院成本管控和精细化管理，有效缩短了平均住院日和运维成本，为DRG定价回归成本提供参考。     

DRG支付方式下医院全面预算绩效管理路径重塑研究*

基于DRG精细化医保支付方式的内涵及要求，剖析DRG医保付费对医院全面预算绩效管理的影响，通过构建以 DRG应用为核心的全面预算绩效管理顶层设计，形成“1+2+3”预算绩效管理支撑框架；细化预算编制颗粒度，确立“项目+ 病组”双轨预算通道；建立事前定标、过程控制、事后分析的闭环管理路径，确定预算横到边、纵到底的合理管控方案；重构“核算+考核”双轮绩效体系，实现质量和效益的双向提升。     

胃肠外科DRG病组比价关系研究

[目的]核算样本医院胃肠外科DRG病组成本,开展胃肠外科DRG病组成本比价关系研究,为在DRG病组成本基础上理顺病组比价关系提供参考。[方法]采用费用成本转换法测算胃肠外科DRG病组成本,通过描述性统计分析胃肠外科DRG病组收益情况、病组价格与成本扭曲情况以及DRG病组之间的比价关系。[结果]胃肠外科79.59%的DRG病组亏损,合计亏损1475.3万元;科室内有28个病组PDPi的值位于0.8～1.3之外,其中24个病组为价格过低型扭曲;部分病组之间成本比和分值比差距较大,2个病组存在价格倒挂。[结论]胃肠外科DRG病组定价依据为病种历史费用,使得病组定价偏低,造成了多数病组的价格过低型扭曲,以及病组间比价关系不合理的现象。建议政府推广费用成本转换法的运用,能够准确且高效地算出全院DRG病组成本,并以DRG成本数据支撑病种组定价,动态分步调整病组价格,逐步理顺病种比价关系。     

医院科室全成本核算改进实例:以Z医院为例

科室成本核算是医院成本核算体系的基础,医院在开展医疗服务项目、病种和DRG成本的同时应回顾其科室成本核算的科学性。在三级分摊体系下,科室成本核算的关键点在于:确定成本额、划分成本责任中心和确定成本分摊系数。本文结合Z医院的实践经验,提出实现科室成本核算规范化、精准化的思路:夯实数据基础;明确成本中心;严格按照成本动因分摊。     

DRG病种成本动因识别及控制策略

目的 识别疾病诊断相关分组（DRG）病种成本动因，建立DRG病种成本动因模型和指标体系。方法 以成本动因理论为基础，结合DRG特征构建DRG病种成本动因模型，运用德尔菲法选取30位专家筛选DRG病种成本动因指标，采用问卷调查法和层次分析法建立DRG病种成本动因指标体系。结果 3轮专家咨询问卷的回收率和有效率均为100%，筛选确定一级指标3项、二级指标9项、三级指标33项。为确定指标权重，共发放问卷230份，有效率95.43%(209/219)，最终形成了DRG病种成本动因指标体系。其中，一级指标包括DRG结构性成本动因、DRG执行性成本动因和DRG内在性成本动因，权重分别为0.197 6、0.311 9、0.490 5。结论 依托DRG病种成本动因模型建立的DRG病种成本动因指标体系具有较高的科学性。DRG病种成本可以从医院资源配置、内部管理、个体行为3个方面进行控制。     

医院DRG成本分析与核算方法研究

目的 在医保支付方式改革背景下,按照国家推进公立医院高质量发展要求探索DRG成本核算方法,研究DRG成本管理路径。方法 建立分层核算方法,将现有的核算基础与管理要求的核算精度结合,核算DRG成本;同时基于核算结果,构建整体与局部相结合的DRG成本分析方法,并结合疾病诊断进行分析。结果 完善了DRG成本核算方法与分析路径。结论 科学核算与管理医院DRG成本对医院高质量发展具有指导意义,也为医疗保险完善DRG分组规则和制定付费标准提供依据。     

某医院耳鼻喉科DRG病组成本核算的实践探索

目的 成本核算是医院精细化运营的重要环节,文章梳理了医院DRG成本核算流程,以耳鼻喉科为案例进行实践探讨,为医院DRG成本核算工作的顺利实施提供参考。方法 以耳鼻喉科10个DRG病组为核算案例,包括选取DD29鼻腔、鼻窦组病例,对其病种临床路径前后的费用及成本进行单因素分析。结果 经研究发现,是否进入临床路径对患者的费用及成本有显著影响。结论 临床路径有助于建立规范化的DRG病种成本核算体系,通过成本数据优化DRG分组结果,构建全流程、整合式的医院成本核算信息系统。     

某大型三级公立医院在DRGs付费形势下医院管理探索

DRGs付费是当前国际上公认的比较先进和科学的付费方式,其强化了医保对医疗行为的引导、制约和监管作用,对医院管理提出了更高要求.自2018年沈阳市医保实施DRGs付费以来,某大型三级公立医院各相关部门协同配合,结合医院自身特点,积极探索管理办法,采取多种措施,逐步适应了医保支付方式改革,在控制医疗费用增长、提高医疗质量...     

价值医疗视角下医院按DRG付费制度实施效果分析

目的分析按疾病诊断相关分组(DRG)付费制度下医院行为方式改变和对医院运营管理影响。方法基于价值医疗视角从医疗成本和医疗质量构建指标体系,选择2021年1—4月(实施后)和2019年1—4月(实施前)上海市某妇产科医院病案首页共44 238例数据进行对比分析。结果医疗质量方面,DRG入组率达到了99.87%,全院病例组合指数增长了4.00%,达到了1.04,平均住院日由3.92天下降到3.65天,费用消耗指数由1.51下降到1.16,时间消耗指数由1.02下降到0.99,患者医疗纠纷投诉率由0.19%下降到0.07%。成本方面,DRG总权重增长了8.01%,DRG组数从140组增长到154组,药占比和耗占比保持相对稳定,次均费用由9 780元增长到12 037元。结论按DRG付费制度下试点医院的医疗质量、服务能力和效率同步提升,但是需要进一步加强医疗成本控制,提高精细化运营水平。     

儿科DRG病种组成本比价关系研究

目的:测算样本医院儿科109个DRG病种组成本,根据核算结果开展病种组比价研究,以期理顺病种组比价关系。方法:收集儿科2020年病种费用与成本相关数据,利用费用成本转换法测算儿科病种成本,采用统计描述方法分析儿科病种组费用、成本及比价关系。结果:58.71%的儿科DRG病种组呈现不同程度亏损;儿科DRG病种组费用与成本之间存在偏离;儿科DRG病种组比价关系尚未理顺。结论:建议有针对性地调整儿科医疗服务价格,突显儿童医疗服务价值,同时秉持比价合理的原则,推行以成本为基础的DRG病种组定价制度。     

基于DRG的某医院患者费用分析及医用耗材成本管控策略探讨

目的了解医院中重点DRG的费用结构及可能的影响因素,为政府部门、医疗机构提供合理控制医疗成本的建议。方法利用研究医院的病案首页数据和患者的DRG分组信息,统计分析重点DRG的有关费用信息。结果重点DRG患者总费用中医用耗材费用占比超过70%,且副高级、正高级职称医生以及各医生之间的费用差异有统计学意义。结论对于医用耗材的监管,医疗机构应在保障医疗质量和患者安全的前提下,做到促降价、严准入、防滥用、控成本。     

Management of Community-Acquired Pneumonia

Objective

Patients with unstable angina fall within a wide therapeutic and prognostic spectrum, and, in general, have access to specialty care and invasive procedures. Today, when hospital admissions for unstable angina outnumber those for myocardial infarction worldwide, and growing economic pressures are being placed on healthcare systems, cardiologists should re-examine clinical strategies for treating unstable angina in light of healthcare cost accounting. This study examines the number of patients with unstable angina hospitalised in our centre and the services supplied to them to determine the ‘real’ cost regarding diagnostic and therapeutic procedures for these patients compared with the reimbursement rates established by the diagnosis-related group (DRG) system.

Design and Setting

Apatient schedule was drawn up to prospectively register the number and types of cardiac processes carried out during hospitalisation for all patients with unstable angina in the period between 1 March and 30 May 1996. The time (in minutes) actually spent by both physicians and nurses for each process was carefully recorded in order to calculate the ‘activity budget’. An ‘economic budget’ was calculated for each cardiac process, taking into account salaries, materials, equipment maintenance, depreciation and indirect medical and nonmedical costs for hospitalisation in the coronary care unit and ward.

Results

53 out of 318 patients (16%) were discharged with a diagnosis of unstable angina. According to the DRG system, patients were allocated to 4 DRGs: DRG 140 (medically treated unstable angina; 18 patients); DRG 124 (unstable angina with angiography; 16 patients); DRG 122 (unstable angina evolving into myocardial infarction; 6 patients); DRG 112 (unstable angina with angioplasty; 13 patients). The mean cost for a hospitalised patient with unstable angina was 2911 euro (EUR): (DRG 140 = EUR1403.4; DRG 124 = EUR1462.2; DRG 122 = EUR3178.1; DRG 112 = EUR6658.3). The differences in costs were essentially related to the procedures involved in medical care; DRGs involving expensive cardiac processes had higher costs. Furthermore, these data show a marked discrepancy between ‘real’ costs and current DRG reimbursements.

Conclusions

The data show the standard management of unstable angina in our centre. Calculating the true costs of unstable angina is the first step towards maximising resources and optimising benefits. Our experience suggests that the use of this system is an essential means of creating an efficient management system for a cardiology unit. It should also be used to gather all the information necessary to establish whether reimbursement rates are covering real costs and to initiate the reduction of deficits or the utilisation of surpluses.

     

基于DRG的公立医院精细化成本管控实践探讨

分析DRG病种成本,可进一步优化医院成本管控。通过建立项目叠加法联合作业成本法的DRG病种成本核算方式,充分运用DRG病种成本核算结果进行同一病种不同学科间、同一病种不同治疗方式、临床路径入径和未入径、病种盈亏平衡等比较分析,以挖掘DRG成本管控难点。经实践,病案首页质量提高,DRG相关运营指标得以改善,医院运行效率和患者满意度进一步提高。为优化医院资源配置,帮助科室明确学科发展方向,提升医疗效率,建议制定临床科室个性化DRG管理方案,合理规避成本管控风险点,完善成本管理考核机制。     

Inpatient costs of endophthalmitis evaluated for the whole of France

Background

Endophthalmitis is a severe condition that requires hospitalization with at least day care. Information on the incidence rate, costs and consequences of endophthalmitis is scarce.

Objective

To estimate the number of patients with endophthalmitis hospitalized in France, as well as the average costs and hospital budget consequences.

Methods

French Programme de Médicalisation des Systèmes d’Information (PMSI) data for 2006, derived from the official DRG classification, were analysed. Data were extracted concerning the following primary diagnoses: ‘purulent endophthalmitis’, ‘other endophthalmitis’ and ‘endophthalmitis associated with another disease’. Two durations of hospitalization were compared: the actual duration and a weighted DRG duration. The cost of hospitalization was weighted by the average DRG cost + daily hospital costs × the difference between the actual and weighted DRG days in hospital. All costs are presented in €, year 2007 values.

Results

A total of 1518 patients (mean age 68.7 years; 47.1% male) experienced 1725 hospitalizations for endophthalmitis, including 1416 cases (82.1%) admitted to public hospitals. The majority of patients (79.1%) were classified by DRG codes that did not specify endophthalmitis (DRG 02M03Z). Most patients (1342) were given a drug injection and 510 underwent vitrectomy. Four patients died in hospital and 75 were transferred to other hospitals. The actual duration of hospitalization for endophthalmitis in public hospitals was 8.1 days (mean), whereas the average weighted DRG duration was 5.1 days, which underestimated the actual duration by 3 days. The average hospital cost was €3688 per patient, totalling €6 361 119 per annum for all public and private hospitalizations in France, including €223 723 as day care. If hospital funding was wholly based on DRG tariffs, the budget for endophthalmitis would be severely underestimated. The DRG inclusion of ’severe acute ocular infections’ as a proxy for endophthalmitis dramatically underestimated its true cost by approximately 30%.

Conclusion

For health economic evaluations, it is inappropriate to use DRG classifications as proxies for endophthalmitis. Expressed more generally, hospitalization cost analyses should not be based on any specific DRG, but always on the clinically relevant primary diagnosis. The PMSI clustering algorithm underestimates the hospital budgets required for endophthalmitis. Lastly, the PMSI (exhaustively reporting all hospitalizations) is best suited to capturing yearly endophthalmitis incidence rates, average costs and national health expenditure.     

A pharmacoeconomic evaluation of the effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes in Spain

To determine the 16-week health economic outcomes of short-term, intensive lipid-lowering therapy with atorvastatin in patients with acute coronary syndrome (ACS) using unit costs from Spain. The total expected cost per patient and the cost per inpatient event avoided were compared for patients on atorvastatin 80 mg daily versus placebo. The analysis was based on clinical outcome data from the MIRACL study. Clinical outcomes measured in this analysis included: death, cardiac arrest, nonfatal myocardial infarction (MI), fatal MI, angina pectoris, stroke, congestive heart failure (CHF), and surgical or percutaneous coronary revascularizations. Unit costs for outcomes were values using 2001 Diagnosis Related Group (DRG) costs in Spain. The cost of a follow-up visit was added to the cost of each outcome in both groups. In the atorvastatin group, monitoring costs were also added. All direct medical costs were taken from the perspective of the Spanish National Health System during a 16-week period. The hospital cost in the atorvastatin group was 1,921 per patient, compared to 1,853 in the placebo group. The incremental cost per patient in the atorvastatin group was 67.47, corresponding to a cost per inpatient event avoided of 1,760. The cost of atorvastatin for 16 weeks was 128. Forty-seven percent of this cost of atorvastatin was offset by the cost savings obtained through the reduction of number of events in the atorvastatin group. In Spain, the intensive short-term use of atorvastatin in patients with ACS has a favorable cost-effectiveness. The direct cost of the drug was largely offset by the associated reduction in costs for treating fewer cardiovascular events.     

新医改背景下公立医院实施成本管理的思考

目的探究新医改背景下公立医院成本管理的方法及意义。方法以河南省肿瘤医院为例,探究该医院常规管理过程中存在的问题,提出成本管理措施,改善医院管理现状,使其满足新医改背景下的成本管理要求。结果针对该院2018年1月前采取常规成本管理,2018年2月开始采取精细化成本管理方案,对公立医院采取成本管理措施后,管理成效明显优于常规管理方式,管理效率有效提升,医院成本缩减,经济效益提升,满足成本管理目标。结论新医改背景下公立医院采取有效的成本管理方式,自成本投入及输出的各项层面展开分析,多方面提出成本管理方法,各个科室及部门的精细化管理,有利于缩减无效的成本输出,满足成本管理目标。     

公立医院DRG病组成本-效益分析探索*

目的：为适应医改变化,提升医院精细化管理水平,进一步强化业财融合,为医院病种结构优化和专科发展方向提供参数依据,为DRG预付费改革提供数据参考。方法：运用作业成本法、项目叠加法和象限分析法,开展基于DRG病组的成本核算与效益分析。结果：生成院、科两级DRG病组及相关医疗、财务关键数据;通过院级专科和DRG病组的象限划分区别优劣类型,实施战略分析;随着病种并发症和伴随症的发生以及严重程度加深,住院平均天数、CMI升高,病种效益下降。结论：典型病组(专病)专科专治,效益更具优势;现行医疗服务项目价格与国家病种付费及分级诊疗改革方向存在差距;对DRG病组效益分析、象限分析和收支来源进行解读,呼吁杜绝医疗浪费、控制成本消耗,促进临床诊疗与经济运营的结合,获得临床科室的认可,起到了为临床提示病种结构优劣调整和专科建设发展方向的作用。