基于DIP、DRG的医保大数据后评价体系研究

The Assumption of Building Post-evaluation System of Medical Insurance Big Data Based on DIP and DRG Research and Analysis

在医疗过程中,如何准确、有效地利用患者的基本信息数据、临床数据和业务数据为医保提供有价值的指导至关重要。为深化医改,国家在多个地方推出了DIP和DRG两种不同的支付方式进行试点。文章对广东省某家三级医院(实行DIP支付方式)分别基于DIP和DRG两种支付方式进行了研究,以探索构建医保大数据后评价体系。文章主要运用SWOT方法和工具分析两种支付方式对疾病的分类、疾病的权重、CMI、标准分值、病种费用(即成本)等评价指标,分析病种的权重和盈亏,再通过与医院监测指标数据统计(临床路径和单病种)评价指标联动分析,探索构建医疗保险大数据后评价体系,以实现监测疾病结构和费用监控评价目标,加快医院精细化管理。

At present,we are in the era of big data.In the course of medical behavior how to accurately and effectively use patients'basic information data,clinical data and business data to provide valuable guidance.In order to deepen the focus of medical reform,the country has launched two different payment methods,DIP and DRG,in several places for trial.In this paper,a tertiary hospital in Guangdong Province(implementing DIP payment mode)conducted research on DIP and DRG two payment modes respectively.SWOT method and tools were used to analyze the classification of diseases,the weight of diseases,CMI,standard score,cost of diseases and other factors,and the weight,profit and loss of diseases were analyzed.It is also envisaged to construct the medical insurance big data post-evaluation system to achieve the objectives of monitoring disease structure and cost monitoring and evaluation,and accelerate the hospital's fine management.