运用DRGs的产能和效率提高医保支付管理科学性

Using the Productivity and Efficiency of Diagnosis-related Groups to Improve the Scientificity of the Management of Medical Insurance Payment

目的意义:引入诊断相关组(DRGs)这一管理工具对昆明市定点医疗机构的医疗服务进行评价,为定额结算打下基础。方法 :采集2015年昆明地区6家三级医疗机构病案首页数据,共546422份。使用DRGs的产能和效率2个维度相关指标分析。结论 :采用DRGs工具,实现同一病组不同医疗机构之间可以进行比较,应用权重对资源消耗进行度量,以此评价医疗机构医疗保险基金使用情况,提高了医疗保险基金支付管理的科学性和合理性。

Purpose and significance： Using the management tool of diagnosis-related groups（DRGs） to evaluate medical services in the designated hospitals of Kunming, therefore to lay foundation for Prospective Payment System（PPS）. Methods： Collecting first-page of 546,422 discharged cases of six three-level hospitals of Kunming, and using two relevant dimensions, i.e., productivity and effi ciency of DRGs, to conduct analysis. Conclusion： Using DRGs made the data comparable, and applying a weight analysis to measure consumption of resources in the same disease group among hospitals to evaluate the use of medical insurance fund has improved the scientifi c and rational management of the medical insurance fund.