从改变支付方式入手,求得医改的突破(1):上海市医疗费用“总量控制、结构调整”政策15年来效果及其启示

为验证总额预算下、按项目付费方式且合理化收费标准是实现医改突破的有效途径,研究以上海市上世纪九十年代中期出台的医疗费用"总量控制,结构调整"政策作为案例,引用政策实施前后近30年的全国卫生财务年报资料,通过纵向和同期不同地区横向比较发现,医疗费用从政策实施前的年均32.8%高速增长骤降至实施期间的12.5%,略低于期间GDP增长(14.7%),纳医疗费用在社会可承受范围之内,十年间为社会减少了2161.6亿元医疗费用负担,控费效果远超全国和同类城市平均水平。政策所取得的斐然成绩提示研究者和决策者,欲实现医疗费用的有效控制总额预算必不可少。但按项目付费方式下的高额医疗费用风险、物价部门难以协调又使得医疗机构潜在损失难以弥补等问题,均成为了现今看病贵等问题依然存在的桎梏。启示:合理设计总额预算指标以确保费用稳定增长,并需改现有按项目付费方式为预付制。     

ICD-10 anaphylaxis algorithm and the estimate of vaccine-attributable anaphylaxis incidence in Medicare

BackgroundAnaphylaxis is a rare, serious allergic reaction. Its identification in large healthcare databases can help better characterize this risk.ObjectiveTo create an ICD-10 anaphylaxis algorithm, estimate its positive predictive values (PPVs) in a post-vaccination risk window, and estimate vaccination-attributable anaphylaxis rates in the Medicare Fee For Service (FFS) population.MethodsAn anaphylaxis algorithm with core and extended portions was constructed analyzing ICD-10 anaphylaxis claims data in Medicare FFS from 2015 to 2017. Cases of post-vaccination anaphylaxis among Medicare FFS beneficiaries were then identified from October 1, 2015 to February 28, 2019 utilizing vaccine relevant anaphylaxis ICD-10 codes. Information from medical records was used to determine true anaphylaxis cases based on the Brighton Collaboration’s anaphylaxis case definition. PPVs were estimated for incident anaphylaxis and the subset of vaccine-attributable anaphylaxis within a 2-day post-vaccination risk window. Vaccine-attributable anaphylaxis rates in Medicare FFS were also estimated.ResultsThe study recorded 66,572,128 vaccinations among 21,685,119 unique Medicare FFS beneficiaries. The algorithm identified a total of 190 suspected anaphylaxis cases within the 2-day post-vaccination window; of these 117 (62%) satisfied the core algorithm, and 73 (38%) additional cases satisfied the extended algorithm. The core algorithm’s PPV was 66% (95% CI [56%, 76%]) for identifying incident anaphylaxis and 44% (95% CI [34%, 56%]) for vaccine-attributable anaphylaxis. The vaccine-attributable anaphylaxis incidence rate after any vaccination was 0.88 per million doses (95% CI [0.67, 1.16]).ConclusionThe ICD-10 claims algorithm for anaphylaxis allows the assessment of anaphylaxis risk in real-world data. The algorithm revealed vaccine-attributable anaphylaxis is rare among vaccinated Medicare FFS beneficiaries.     

无偿献血现行体制下血费返还弊端分析

指出目前的无偿献血体制下血费返还政策存在返还机制不健全,血费返还受益人中直系亲属界定不明确,血量返还不科学、不公平等问题。提出采供血机构应加强硬件建设和制度建设,在血费返还机制上尽快建立长效机制,实现资源共享,健全激励机制。同时,需合理布局,提供方便献血服务,保证血液质量,简化血费报销流程等。     

我国医疗服务价格项目技术难度和风险程度赋值的设计与应用

2012年版《全国医疗服务价格项目规范》于2012年5月4日由国家发展和改革委员会、卫生部和国家中医药管理局在2001年版和2007年版的基础上修订后联合颁布实施,本次修订过程中首次对基于医院资源消耗相对值的赋值进行研究和设计,将服务项目所需消耗的基本人力消耗和耗时、项目的技术、风险等体现医务人员技术劳务部分的要素作为定价因素在规范中发布,文章重点介绍了“技术难度”和“风险程度”赋值的设计及应用.     

《全国医疗服务价格项目规范工作手册》一次性医用耗材分类与编码的设计及应用

2012年版《全国医疗服务价格项目规范》历时近5年的研究于2012年5月4日由国家发展和改革委员会、卫生部、国家中医药管理局联合向全国颁布实施.新规范同时下发了工作手册征求意见稿,对文中涉及的全部一次性医用耗材进行了规范,出台了“一次性用医用耗材分类与编码”.文章详细介绍了该分类与编码的概念、范围及编码规则,对临床上允许收费的一次性医用耗材从收费角度进行规范化的管理和推进,帮助医疗机构加强一次性医用耗材的管理和使用,规范临床收费行为,推进2012年版《全国医疗服务价格项目规范》在全国执行.     

Reductions in Reimbursement and Relative Value Units for Interventional Radiology Procedures: Trends from 2011 to 2021 Compared with Those for Other Physician Specialties

PurposeTo compare recent trends in Medicare reimbursement and relative value units (RVUs) for interventional radiology (IR) procedures similar to those performed by non-IR specialties.Materials and MethodsData from the Centers for Medicare and Medicaid Services Physician Fee Schedule for facility reimbursement and RVU component values for 23 commonly performed single Current Procedural Terminology IR procedures were compared with similar procedures or procedures for similar indications performed by non-IR specialties between 2011 and 2021.ResultsThe work RVU component decreased in 18 of 23 (78.3%) IR procedures compared with 6 of 23 (26.1%) similar procedures performed by non-IR specialties. The largest change in single RVU component was a 19.2% reduction in practice expense RVU for IR compared with a 16.5% reduction for similar procedures performed by non-IR specialties.ConclusionsAs a specialty, IR experienced a disproportionately greater reduction in reimbursement and RVU valuation for a range of comparable procedures performed by non-IR specialties.     

Procedures With Longer Intraoperative Times Undervalue Surgeon Work in Total Joint Arthroplasty: A Large,Nationwide Database Study

BackgroundWork relative value units (wRVUs) measure a surgeon’s time and intensity required to perform the pre-service, intra-service, and post-service work of a surgical procedure and are commonly used to compare a physician’s work between different procedures. Previous literature across multiple specialties report that longer, often revision, operations are undervalued when compared to primary procedures. Our study aims to analyze the differences in intra-operative time, and its corresponding wRVU/h between the Medicare benchmarks and real-world time-stamped data for total joint arthroplasty procedures.MethodsThirteen primary and revision hip and knee arthroplasty procedures were identified, and intra-operative times were collected using the National Surgical Quality Improvement Program databases from 2014 to 2019. The Relative Value Scale Update Committee’s (RUC) estimated median intra-operative times for each procedure was compared to the calculated median intra-operative times from National Surgical Quality Improvement Program, as were their corresponding wRVU/h. Procedures were additionally stratified by “long” (>110 minutes) and “short” (≤110 minutes) intra-operative times.ResultsThe RUC over-estimated intra-operative time by 35.24% on average and this overestimation was more profound in longer operations than shorter operations (47.75% vs 15.22%, P = .011). The RUC intensity per unit time values (wRVU/h) between “long” and “short” procedures were significantly different (P < .001) and showed the undervaluation of intensity for the longer procedures by an average of 3.47 wRVU/h.ConclusionOur study provides further evidence that physician work is undervalued in revision total hip and knee surgeries.     

住院患者急性肾损伤的发病情况调查

目的 了解我国综合性医院住院患者急性肾损伤（AKI）的发病率、病因构成、预后，以及肾功能受损对住院费用和住院时间的影响。 方法 通过调查2004年9月1日至2005年8月31日复旦大学附属中山医院住院患者的肾功能检测结果，筛检出AKI患者，进行病史复习，总结分析患者的临床特征及其转归、肾功能受损的性质、导致肾功能不全的基础疾病等。 结果 观察期间共有住院患者37 365例次，其中1263例患者住院期间发生AKI，发病率为3.38%。观察期间住院患者总病死率为1.52%，其中AKI患者病死率为18.57%，经校正后AKI对患者住院病死率的OR值为10.08（P < 0.01）。Logistic回归分析提示高龄、Scr上升的百分比是AKI患者死亡的危险因素。 结论 住院患者AKI的发病较常见。患者Scr上升26.5 μmol/L即可增加死亡的风险，增加住院费用，延长住院天数。患者的预后同肾脏受损的程度相关，其病死率随Scr上升百分数的增加而增加