从肝癌手术患者住院费用的构成分析探讨医保DRGs新付费模式的推行

Investigation on the implementation of the new payment model of DRGs in medical insurance from the analysis of the composition of hospitalization expenses of patients undergoing liver cancer operation

目的探讨目前医保按项目付费模式下肝癌手术患者住院费用的构成,为医保DRGs新付费模式的精准推行提供参考依据。方法收集2016年1月至2019年12月陕西省某三甲医院312例肝癌手术患者的出院病历资料,选择有差异的单因素(包含患者的性别、年龄、手术方式、术前合并症、术后近期并发症、医保类型)作为自变量,住院天数的对数值作为因变量,采用Maximum likelihood法作出参数评估,推导出各变量间的路径系数。依据其效应分解值的大小评估各因素对住院费用的影响程度。结果影响住院费用的最主要因素是住院天数,路径系数为0.55。其他因素依次为手术方式、术后近期并发症、术前合并症、年龄、医保类型。结论大型公立医院应对基于DRGs的支付方式改革的发展策略:强化医院内部管理,加快病床周转,减少平均住院日,降低诊疗成本(包括高值耗材的合理应用),推行精细化DRGs付费模式,可在充分保障医疗质量的前提下合理控制肝癌手术患者的诊疗费用,同时减轻患者的经济负担。

Objective To investigation the composition of hospitalization expenses of patients undergoing liver cancer operation under the current project-based payment model of medical insurance,and to provide reference for the accurate implementation of the new payment model of DRGs in medical insurance.Methods The discharge medical records of 312 patients undergoing liver cancer operation admitted to a tertiary hospital in Shaanxi province from January 2016 to December 2019 were collected.Single factors with differences(including patients'gender,age,operation methods,preoperative complications,recent postoperative complications and types of medical insurance)were selected as independent variables,and logarithmic values of hospitalization days were taken as dependent variables.Maximum likelihood method was used to evaluate the parameters,and the path coefficients among the variables were obtained and then the effects were decomposed.The impacts degree of each factor on hospitalization expenses were reflected from the size of total effect value.Results The hospitalization days was the most important factor impacting hospitalization expenses,and the path coefficient was 0.55.The other impacting factors were sequentially as operation methods,recent postoperative complications,preoperative complications,ages and types of medical insurance.Conclusion The development strategies of large public hospitals to deal with DRGs-based payment reform include strengthening hospital internal management,speeding up turnover of hospital beds,reducing average hospitalization days,reducing diagnosis and treatment costs(including rational application of high-value consumables),and implementing refined DRGs payment model.On the premise of fully guaranteeing the medical quality,the diagnosis and treatment expenses of patients undergoing liver cancer operation can be reasonably controlled.At the same time,the economic burden of patients can be alleviated.