DRG预付费视角下医保结算清单与病案首页差异性分析

Analysis on the Difference Between Medical Insurance Settlement List and Medical Record Home Page from the Perspective of DRG Prepayment

目的通过比较病案首页作为DRG支付凭证的差异,为完善预付费支付制度、提高支付凭证信息准确性提供理论参考。方法以新疆维吾尔自治区3所三级医院2020年10月—2021年10月间的27.04万份病案首页信息资料、17.45万份医保信息资料为研究对象,比较两者内容与结构差异,运用国家医疗保障疾病诊断相关分组(China Healthcare Security Diagnosis Related Groups,CHS-DRG)方案,分析导致两者DRG分组结果差异的原因,分别探讨两者作为医保支付凭证为付费带来的影响。结果医保结算清单由193类信息构成,病案首页由123类信息构成。病案资料与医保资料分别覆盖了26个和25个主要诊断分类(Major Diagnostic Category,MDC)病案资料的疾病诊断相关分组核心组(Adjacent Diagnosis Related Groups,ADRG)、疾病诊断相关分组(Diagnosis Related Groups,DRG)组数、DRG总量分别为374分、698分、46924.85分,医保资料变异系数(Coefficient of Variation,CV)大于1,组别占比低于病案资料(P<0.05)。病案资料病例组合指数(Case Mix Index,CMI)大于医保资料,专科医院CMI>综合医院CMI>兵团医院CMI(P<0.05)、病案资料一般并发症或合并症(Complication&Comorbidity,CC)组(P<0.05)、严重并发症或合并症(Major Complication&Comorbidity,MCC)组病例数量构成均高于医保资料(P<0.05);病案资料出院患者数、平均年龄、少数民族占比大于医保资料(P<0.05),性别比小于医保资料(P>0.05)。结论医保结算清单填写容错率低,付费准确性高;病案首页诊疗信息全面,付费精准性低。医保资料纳入标准高于病案资料,分组结果低于病案资料;医保资料评价结果应用于支付更为精准。

Objective To compare the differences between the first page of medical records as DRG payment voucher,so as to provide theoretical reference for improving the prepayment system and the accuracy of payment voucher information.Methods Taking 270400 first page information materials of medical records and 174500 co-pies of medical insurance information from three tertiary hospitals in Xinjiang Uygur Autonomous Region from October 2020 to October 2021 as the research object,this paper compared the constituent elements,used the China Healthcare Security Diagnosis Related Groups(CHS-DRG)grouping scheme,analyzed the reasons for the difference of DRG grouping results,and discussed the impact of medical insurance payment vouchers on payment.Results The medical insurance settlement list consisted of 193 types of information,and the first page of medical records consisted of 123 types of information.Medical record data and medical insurance data covered 26 and 25 Major Diagnostic Ca-tegory(MDCs)respectively.The number of Adjacent Diagnosis Related Groups(ADRG),Diagnosis Related Groups(DRG)groups and total DRG of medical record data were 374,698 and 46924.85 respectively.The proportion of medical insurance data coefficient of variation>1 group was lower than that of medical record data(P<0.05).The Case Mix Index(CMI)of medical record data was greater than that of medical insurance data.The CMI of special hospital was greater than that of general hospital,which was greater than corps hospital(P<0.05).The number of cases of Complication&Comorbidity(CC)group(P<0.05)and Major Complication&Comorbidity(MCC)group in medical record data were higher than those of medical insurance data(P<0.05).The number of discharged patients,average age and the proportion of ethnic minorities in medical record data were greater than those from medical insurance data(P<0.05),and the sex ratio was lower than that in medical insurance data(P>0.05).Conclusion The medical insurance settlement list has low fault tolerance rate,high payment accuracy,while the diagnosis and treatment information on the first page of medical records were comprehensive with low payment accuracy.The inclusion standard of medical insurance data was higher than that of medical record data,and the grouping result was lower than that of medical record data.The evaluation results of medical insurance data are more accurate when applied to payment.