基于DRGs技术分析异地医保直接结算患者费用情况

Analyzes the Cost of Direct Settlement of Long-Distance Medical Insurance based on DRGs Technology

目的实施异地医保直接结算实现后,分析异地医保直接结算患者费用情况、病种以及对于医院运营的影响。方法基于BJ-DRGs技术,分析北京市某三级医院2017年4月至2018年3月全部出院病例100 383例,根据结算方式将病例分为"异地医保"和"自费结算"组,采用倾向性评分方法,比较两种结算方式下的整体费用差异以及其所含病组的差异。结果 2017年4月至2018年3月,该院共完成异地医保直接结算病例3286例,纳入DRGs分析的病例3257例,排除29例,覆盖20个MDC诊疗群、259个病组,CMI为0.73,费用消耗指数为1.09,时间消耗指数为1.01。两种结算方式例均费用具有统计学差异(P<0.05),CB39病组是异地医保病例中例数最多的病组,同时例均费用比自费结算病例低8.62%,而CR19病组例均费用比自费结算病例高出30.75%。结论异地医保直接结算量不断增加,工作压力随之而来,管理部门要关注智能审核系统及人力资源配比情况;宣传工作、系统功能和转诊模式上仍需继续改进;加强学科发展,关注异地医保直接结算病例的医疗资源消耗和个别病组的费用及构成的合理性,深入分析,保证医保基金合理使用。

Objective After the implementation of the direct settlement of the long-distance medical insurance, the costs, diseases and the impact on the operation of the hospital are analyzed. Methods BJ-DRGs technology, based on the analysis of a large tertiary care hospital of Beijing in April 2017 to March 2018 cases, 100383 cases of hospital, cases according to the method of payment is divided into ＂long distance medical care＂ and ＂at his own expense settlement＂ group, propensity score methods, comparing two settlement under the way of the overall cost differences and differences in its disease group. Results Between April 2017 and March 2015, the institute has accomplished a long-distance coverage directly to settle cases 3286 cases, into the DRGs analysis of cases in 3257 cases, 29 cases, covers 20 MDC diagnosis and treatment group, 259 group, CMI 0.73, cost consumption index is 1.09, time consumption index of 1.01. CB39 disease group is the most common disease group with the largest number of cases in different places, and the average cost is 8.62% lower than that of the self-fee settlement, while the total cost of CR19 cases is 30.75% higher than that of self-fee settlement. Conclusion The amount of direct settlement of medical insurance in different places is increasing, and the pressure of work comes with it. Management should pay attention to the situation of Intelligent Audit system and human resource matching. Advocacy, system functionality and referral models still need to be improved. Strengthen discipline development, pay attention to the consumption of medical resources and the rationality of the cost and composition of individual patient groups in the direct settlement of medical Insurance cases in different places. In-depth analysis to ensure reasonable use of health insurance funds.