医保DRGs与公立医院管理的价值协同机制探析

目的：通过整理和分析H医院DRGs付费方式改革与成效，尝试构建DRGs与医院管理的协同理论模型。方法：通过对H医院的管理文件进行梳理，理清DRGs与医院内部管理改革的逻辑关系；调取医院2017年9月-2018年12月的运行数据，选择发生占比前五位疾病为目标病种，通过医疗费用等指标评估改革成效。结果：临床路径人次覆盖率由45.32%上升到了60.74%，病案首页填报完整率由95.31%提升至99.01%，住院人次增长16.28%，医务人员人均绩效工资涨幅23.19%；排除医疗服务价格调整的影响，代表性疾病次均费用波动性下降，降幅为100~300元。结论：通过医保DRGs与医院协同管理系统环，H医院以效率提升、质量维持和成本降低验证了DRGs能够协同医院管理实现价值共创。

Analysis of the value synergetic mechanism between DRGs of health insurance and public hospitals management

Objective:Through reorganizing the reform measures and analyzing the effectiveness of the DRGs payment methods in H hospital, this paper considers assessing whether the DRGs reform brings value to medical insurance and hospitals, and constructs a synergistic theoretical model of DRGs and hospital management. Methods:Through the management documents of H hospital, the logical relationship between DRGs and hospital internal management reform was clarified. Meanwhile, the 2017.9-2018.12 period''s hospital operational data were retrieved, and the top five diseases were selected as the target diseases to evaluate the effectiveness of the reforms through indicators such as medical expenses. Results:The coverage rate of clinical pathways increased from 45.30% to 60.08%. The complete rate of report on the front page of the medical record increased from 95.31% to 99%, the number of hospitalized patients increased by 16.28%, and the per capita performance salary of medical staff increased by 23.19%. The effect of price adjustment on medical services was excluded. The average cost of major diseases received a decrease of 100~300 yuan. Conclusions:Through the combination of medical insurance DRGs and hospital collaborative management system loop, H hospital has verified that DRGs can achieve the value creation in collaboration with hospital management with efficiency improvement, quality maintenance and cost reduction, respectively.