Cost-Utility Analysis of Liraglutide in Type 2 Diabetes Patients in China after Chinese Reformation of Medical Care System

Objectives: The cost-utility analysis of Liraglutide is aimed at evaluating whether Liraglutide is cost-effective or not after Chinese reformation on medical insurance. The analysis is based on the results of clinical trial conducted in Asia. Methods: We applied a Markov model to estimate the quality-adjusted life years, medical cost and incidence of diabetes-related complications for patients receiving the Liraglutide as an add-on to the metformin treatment. Baseline characteristics were taken from a China’s study while the treatment effect is from an Asian study. The related medical cost and utility score were obtained from a local study in China. Having set 30 years’ simulations, the incremental cost-effectiveness ratio was calculated comparing with glimepiride treatment. The ratio would be compared with the willingness to pay for a quality-adjusted-life-year (QALY) which is three times of the GDP per capita in Beijing. Sensitivity analysis was also performed. Result: During a period of 30 years, the base-case analysis which takes discount rate at 3% shows that Liraglutide 1.8 mg results in an average incremental cost of CNY 82,671.49, an improvement in 0.12 QALYs and a reduction of incidence of diabetes-related complications comparing to glimepiride. The associated incremental cost-effectiveness ratio is CNY 688,929.08. Conclusion: Long-term project shows that taking Liraglutide as an add-on to the metformin treatment will lead to increasing quality-adjusted life years and reduction of incidence of diabetes-related complications. When the price of Liraglutide is reduced by 43 percent in China’s yuan, Liraglutide will be cost-effective in China from the healthcare system perspective taking three times of GDP per capita as our WTP threshold.

Effects of Preoperative Risk Stratification on Direct In-hospital Costs for Chinese Patients with Coronary Artery Bypass Graft:A Single Center Analysis

The purpose of this study was to analyze the components of inpatient costs for coronary artery bypass graft(CABG)according to preoperative risk stratification and to provide evidence for improvement of diagnosis-related groups(DRGs)payment.All patients(n=458)receiving an isolated CABG between January 2014 and December 2016 in a tertiary referral center,in southwest China,were analyzed.Hospital mortality was predicted by the EuroSCORE Ⅱ for each patient. The patients were subdivided into two groups according to the observed mortality(1.97%,9/458):a high-risk group(group H,predicted mortality≥1.97%)and a low-risk group(group L,predicted mortality<1.97%).Clinical outcomes,resource use,in-hospital direct costs,and reimbursement expenses were compared between the two groups.Significant differences existed between group L and group H in postoperative mortality(0.4% vs.3.4%;P=0.02),postoperative complications(10.6% vs.45.7%;P<0.001),postoperative length of hospital stay(17.5±4.9 days vs.18.8±6.5 days,P=0.01),in-hospital costs($20 256±3096vs.$23 334±6332;P<0.001),and reimbursement expenses($7775±2627 vs.$9639±3917;P<0.001).In general,a higher EuroSCORE Ⅱ was significantly associated with a worse clinical outcome and increased costs.The CABG cost data provide evidence for improvement of DRGs payment. Key words:coronary artery bypass graft;risk stratification;hospital costs;medical insurance

An Analysis and Prediction of Health Insurance Costs Using Machine Learning-Based Regressor Techniques

One of the most significant annual expenses that a person has is their health insurance coverage. Health insurance accounts for one-third of GDP, and everyone needs medical treatment to varying degrees. Changes in medicine, pharmaceutical trends, and political factors are only a few of the many factors that cause annual fluctuations in healthcare costs. This paper describes how a system may analyse a person’s medical history to display their insurance plans and make predictions about their health insurance premiums. The performance of four ML models—XGBoost, Lasso, KNN, and Ridge—is evaluated using R2-score and RMSE. The analysis of medical health insurance cost prediction using Lasso regression, Ridge regression, and K-Nearest Neighbours (KNN), and XGBoost (XGB) highlights notable differences in performance. KNN has the lowest R2-score of 55.21 and an RMSE of 4431.1, indicating limited predictive ability. Ridge Regression improves on this by an R2-score of 78.38 but has a higher RMSE of 4652.06. Lasso Regression slightly edges out Ridge with an R2-score of 79.78, yet it suffers from an advanced RMSE of 5671.6. In contrast, XGBoost excels with the highest R2-score of 86.81 and the lowermost RMSE of 4450.4, demonstrating superior predictive accuracy and making it the most effective model for this task. The best method for accurately predicting health insurance premiums was XGBoost Regression. The findings beneficial for policymakers, insurers, and healthcare providers as they can use this information to allocate resources more efficiently and enhance cost-effectiveness in the healthcare industry.

Effects of Adalimumab Entering National Reimbursement on Medical Costs for Patients With Psoriasis:A 4-Year Single-Center Retrospective Study in China

Objective:Adalimumab(ADA)is expensive and rarely used among patients.However,its cost for moderate to severe chronic plaque psoriasis can now be reimbursed since its addition to the National Reimbursement Drug List(NRDL)in January 2020.Therefore,we conducted this study to estimate the medical cost of ADA and its influencing factors in patients with psoriasis using ADA and thus gain a better understanding of the effect of the NRDL adjustment in China.Methods:This retrospective study evaluated the medical cost of ADA before and after the addition of ADA to the NRDL(2018—2022)among 320 patients in a large professional dermatology specialty hospital.Descriptive analysis,Welch’s analysis of variance,and multiple regression analysis were used to evaluate the medical cost and influencing factors.Results:Before ADA was added to the NRDL,patients’mean total cost and ADA cost were¥24,243.56±16,346.53 and¥20,391.11±14,440.69,respectively.After ADA became covered by the NRDL,the above 2 expenses decreased to¥10,461.19±7,554.66 and¥8,775.27±7,092.16,respectively.This significant decrease in the cost of ADA resulted in a significant 110.5-times increase in ADA use.Statistically significant differences were found in the total cost,patient type(outpatient/inpatient),insurance status(yes/no),reimbursement status(before/after),and age.Medical insurance reimbursement(P<0.001,β=-0.468,before reimbursement=1,after reimbursement=2)was the most significant influencing factor,followed by patient type(P=0.018,β=-0.215,outpatient=1,inpatient=2)and age(P=0.0046,β=-0.174).Conclusion:Medical insurance reimbursement is the most important factor affecting patients’total cost of ADA by reducing the economic burden,enhancing the availability of ADA,and stimulating the need for treatment.

某三级专科医院DRG分组高倍率病例费用影响因素比较分析

[目的]基于天津市某三级专科医院DRG分组数据探讨专科医院DRG组高倍率病例影响因素,为医院进行有针对性的成本控制提供参考。[方法]收集某专科医院2022年10月1日-2023年9月30日上传的医保患者医保结算清单经分组器分组后正常入组数据,按照进入天津市医保局DRG分组器分组后的全市付费次均费用、平均住院天数计算入组病例费用的倍率,应用logistic回归分析高倍率病例的影响因素,采用灰色关联分析法分析高倍率病例各分项费用与住院总费用的关联度。[结果]入组病例总数为7829例,其中高倍率病例673例,占8.60%。Logistic回归结果显示,DRG合并并发症、15~60岁、非医嘱离院、实际住院天数长是高倍率病例产生的影响因素(P<0.05)。灰色关联结果显示,在10个高倍率的DRG组里,有5个DRG组的诊断费与其呈现最强的相关性,有3个DRG组的药品费与其呈现最强的相关性,有2个DRG组的综合服务费与其呈现最强的相关性。[结论]药品费、诊断费、综合服务费、合并并发症、15~60岁及住院天数长与高倍率住院费用的产生显著相关,是医院进行有指向性成本控制的重要因素。

我国药学服务收费探索与现状分析

目的 总结中国药学服务收费的探索历程及现状,并结合国外实践进行分析,为中国药学服务收费相关政策的进一步完善提供参考。方法 检索国家及各省卫生健康委员会、医疗保障局的官方网站,归纳中国药学服务收费相关政策的变革及各省最新的药学服务收费政策。同时检索中国国家知识基础设施(CNKI)、维普中文科技期刊数据库、Pubmed等数据库,总结关于药学服务收费相关研究。结果 国内关于药学服务成本测算和收费标准的研究较多,但多集中在药房调剂服务,对具体药学服务的技术劳务价值探讨较少,国外这方面研究相对较多。目前国内共8个省和1个直辖市公布了药学类医疗服务价格项目,收费项目、收费标准、医疗保险支付比例及监测评估指标各有差异。结论 将药学服务收费纳入国家医疗服务价格体系是对药学服务转型和药师价值的认可,但尚在起步阶段,仍有完善和改进空间。

2018—2022年天津市第二人民医院国家医保谈判药品使用情况分析

目的 了解天津市第二人民医院国家医保谈判药品(以下简称“谈判药品”)使用情况,为优化与调整医院药品目录提供参考。方法 回顾性分析该院2018年1月1日—2022年12月31日谈判药品的使用情况,比较谈判药品谈判前后药品单价、销售数量及销售金额、用药频度(DDDs)、日均费用(DDC)等变化情况。结果 2018—2022年医院使用的谈判药品品种从原来的5种增加至24种,分析比较的13个药品中有11个药品经谈判后单价降低,7个药品经谈判后纳入医保及医保门诊特定病支付目录。DDC平均降幅36.43%,DDDs平均增幅1 770.31%,该项政策施行提高了患者用药的可及性,销售数量显著增加。结论 通过降低药品单价、纳入医保支付范围等方式实现谈判药品销售数量显著增加。谈判药品经济性提高,有效减轻患者负担,促进医院用药合理化,提高药品可及性和效率。

日本个人医疗费用封顶制实践及启示

日本个人医疗费用封顶制以患者利益为主导,聚焦重大疾病保障;制度改革循序渐进,确保了医保基金可持续;自付限额以年龄和收入为划分维度,防止了泛福利化。这些实践经验对我国未来实施个人医疗费用封顶制具有一定的借鉴意义。我国应逐步优化基本医疗保障资源配置,设置与家庭收入相挂钩的自付限额,明确个人医疗费用封顶制的保障范围,创新医保支付方式和医疗过程监督机制。

基于医保结算的耗材精细化管理策略

目的探讨高效的医用耗材精细化管理模式和方法,助力公立医院高质量发展。方法从科室人均卫材费用、病组人均费用、医保结回率入手,对各科室疾病诊断相关分组病种消耗、耗材采购价格及院内流通等进行管控;以住院患者人均总费用、人均卫材费用为指标进行效果比对。结果住院患者人均总费用和人均卫材费用分别下降8.55%和5.85%。结论在基础建设、医护人员、床位数相对恒定的状态下,通过医用耗材的精细化管理,可有效降低患者就医负担,提高医保支付率,提升医院核心竞争力。

基于门诊病例分组的费用标准测定及门诊支付改革研究

目的:基于决策树原理测定门诊费用标准,为门诊医保支付改革提供定价参考。方法:采集2023年1—6月共41 371份肺恶性肿瘤门诊病例数据,利用决策树模型进行门诊病例分组并测定标准费用,在分类基础上对超线费用进行分析。结果:“是否用药”“是否治疗”“是否检验”等5个影响因素纳入分组规则,共形成8个门诊病例组合;研究得出的标准总费用对实际总费用的解释效果达到71.07%,10.76%的线外病例消耗了24.23%的医疗资源。结论:推进门诊医保支付改革,控制门诊医疗费用过快增长,从而完善医保基金长效平衡机制,实现医疗、医保、医药高质量协同发展。

某三级甲等医院第六批国家组织药品(胰岛素专项)带量采购实施成效与问题分析

目的探讨第六批国家组织药品(胰岛素专项)带量采购(简称胰岛素集采)在某三级甲等医院的实施成效,为后期其他生物类药物集采政策的调整提供参考。方法提取某三级甲等医院医院信息系统中胰岛素集采期间(2022年6月至2023年5月,集采后)与集采前同期(2021年6月至2022年5月,集采前)的胰岛素使用相关数据,对比集采前后胰岛素种类、单价、临床用量、用药频度(DDDs)、限定日费用(DDC)等的变化,计算该院胰岛素集采医保费用节省情况。结果集采后,该院国产胰岛素品规由8个增至15个,销售数量由52561支升至88098支;胰岛素价格大幅下降,平均降幅为46.68%;谷赖胰岛素注射液和精蛋白人胰岛素混合注射液(30R)的DDDs增长较多,增幅分别为33.12%,30.21%;精蛋白人胰岛素注射液和门冬胰岛素30注射液(笔芯)的DDDs下降较多,降幅分别为34.31%,24.25%;实施胰岛素集采后1年,该院共节省医保费用556.25万元。结论胰岛素集采政策的实施切实减轻了糖尿病患者的经济负担,实现了医保资金的有效利用。

按病种分值付费下医院医保精益管理对胃癌患者住院费用影响研究

[目的]通过胃癌相关病例医保数据,研究医保按病种分值付费(DIP)下精益管理模式对诊疗费用的影响,为医疗机构合理控制诊疗费用以应对医保支付方式改革提供参考。[方法]在大型三甲肿瘤专科医院实施一种创新化的医院医保精益管理模式,按DIP分组规则将胃癌病例分为化疗组GU13、根治性手术组GA13和操作治疗组GR29,以精益模式实施前后为节点运用回顾性数据分析法验证其实施效果。[结果]纳入研究病例4935例,GU13组次均住院总费用、药品费呈下降趋势(P<0.001);GR29组药品费、耗材费呈下降趋势(P<0.001);GA13组次均住院天数、手术治疗费、药品费呈下降趋势(P<0.001)。[结论]以专家为核心的精益管理模式,有效保障了医疗质量、助力了医疗费用管控、加强了成本控制。

Cost Analysis of Cervical Cancer Patients with Different Medical Payment Modes Based on Gamma Model within a Grade A Tertiary Hospital

Background： Cervical cancer shows a growing incidence and medical cost in recent years that has increased severe financial pressure on patients and medical insurance institutions. This study aimed to investigate the medical economic characteristics of cervical cancer patients with different payment modes within a Grade A tertiary hospital to provide evidence and suggestions for inpatient cost control and to verily the application of Gamma model in medical cost analysis. Methods： The basic and cost information of cervical cancer cases within a Grade A tertiary hospital in the year 2011-2016 were collected. The Gamma model was adopted to analyze the differences in each cost item between medical insured patient and uninsured patients. Meanwhile, the marginal means of different cost items were calculated to estimate the influence of payment modes toward different medical cost items among cervical cancer patients in the study. Results： A total of 1321 inpatients with cervical cancer between the 2011 and 2016 were collected through the medical records system. Of the 1321 cases~ 65.9% accounted for medical insured patients and 34.1% were uninsured patients. The total inpatient medical expenditure of insured patients was RMB 29,509.1 Yuan and uninsured patients was RMB 22,114.3 Yuan, respectively. Payment modes, therapeutic options as well as the recurrence and metastasis of tumor toward the inpatient medical expenditures between the two groups were statistically significant. To the specifics, drug costs accounted for 37.7% and 33.8% of the total, surgery costs accounted for 21.5% and 25.5%, treatment costs accounted for 18.7% and 16.4%, whereas the costs of imaging and laboratory examinations accounted for 16.4% and 15.2% for the insured patient and uninsured patients, respectively. As the effects of covariates were controlled, the total hospitalization costs, drug costs, treatment costs as well as imaging and laboratory exainination costs showed statistical significance. The total hospitalization costs, drug costs, treatment costs as well as imaging and laboratory examination costs of insured patient were 1.33, 1.42, 1.52, and 1.44 times of uninsured patients. Conclusions： The analysis of different payment modes toward the medical economic characteristics based on Gamma model is basically rational. Medical payment modes are having certain influence toward the hospitalization expenses of cervical cancer patients in an extent, as drug costs, treatment costs, and examination costs appear to be the main causes.

基于医保公平视野下不同级别公立医院老年骨质疏松性骨折住院费用对比分析

[目的]了解山西省公立医院老年骨质疏松性骨折患者的住院费用及不同医保类型住院费用的差别,为完善医保政策和合理控制医疗费用提供建议。[方法]选取山西省12个市区内10所三级医院和10所二级医院中符合调查要求的582例患者,由患者所在医院的骨科专职护士填写《患者出院结算费用明细表》,并运用秩和检验对其住院费用进行分析。[结果]二级医院与三级医院的总费用、手术费、检查费、化验费、护理费、医药费差异均有统计学意义(P<0.05);同一级别医院中不同医保类型患者统筹支付费用之间差异均无统计学意义(P>0.05);在三级医院中,城乡居民基本医疗保险患者的平均住院费用及自付费用、城镇职工基本医疗保险患者的自费费用均高于二级医院,差异有统计学意义(P<0.05)。[结论]我国医保政策整体效能良好,但仍需持续关注重点管控对象。

E-CHAID决策模型下骨髓增生异常综合征DRGs分组实际运行效果分析

目的 分析E-CHAID决策模型下骨髓增生异常综合征DRGs分组对住院费用的实际影响。方法 回顾性搜集2021年2月至2023年2月浙江省某三甲医院HIS系统中病案首页出院诊断首项为骨髓增生异常综合征的患者资料。对病案首页全部指标进行组间多元线性回归检验、Mann-Whitney U检验及Kruskal-Wallis H检验,以VIF(方差膨胀因子)<10、单因素筛选中P<0.05的指标为自变量,以住院费用为因变量,采用E-CHAID穷举算法建立DRGs分组决策树模型。以各DRGs病例组合“住院费用中位数+1.5倍标准差”为费用上限,计算各DRGs分组上限费用与所有病例上限费用之比,分析住院费用分布特征。结果 共纳入2 223例骨髓异常综合征患者。是否使用单克隆抗体、是否ICU入住、输血次数3个变量为E-CHAID决策树模型的分层分类变量节点,建立了12个节点,共生成7个终端节点,变异系数CV分别为0.40、0.15、0.23、0.21、0.25、0.51、0.46,各DRGs分组间Kruskal-Wallis H检验具备统计学意义(H=2 816.568,P<0.001)。2 223例患者中超出费用上限76例(3.42%),超上限费用患者的住院总花费为662 241.71万元,占DRGs总住院费用的1.40%;DRGs 1~7组相对权重分别为1.49、2.42、2.14、1.33、1.10、0.47、0.24。结论 E-CHAID决策模型下骨髓增生异常综合征DRGs分组异质性较强,组间分布合理,可为浙江省后续开展骨髓增生异常综合征等恶性血液疾病的地方性DRGs医疗付费改革提供一定依据。

基于项目人次权重的日间手术病种费用支付标准研究——以甘肃省为例

目的探讨48种典型日间手术病种费用支付标准,为广泛实施的日间手术提供一个科学、合理的医保支付标准,引导日间手术规范化实施。方法梳理和分析国内日间手术政策和标准临床路径,归纳48个病种日间手术的规范临床路径;分析甘肃省部分医疗机构医保结算数据,提取和分析数据特征;确定项目人次权重和比较历史样本数据得出日间手术费用支付标准。结果通过医保数据分析、项目权重确定及标准费用测算、组织专家研讨,最终得出科学合理的日间手术病种费用支付标准。结论基于项目人次权重的日间手术病种费用支付标准,能较全面地反映当前日间手术费用水平,对优化医疗卫生机构日间手术资源配置、保障医保基金安全以及推动日间手术规范化实施具有重要意义。

2020年—2022年某院国家医保谈判抗肿瘤药物的可及性及应用分析

目的探究纳入国家医保谈判(以下简称“国谈”)药品目录的抗肿瘤药物在泉州市第一医院(以下简称“某院”)的可及性及应用情况。方法收集2020年—2022年院内国谈抗肿瘤药物使用数据,分析品种数、使用金额、用药频度(DDDs)、日均治疗费用(DDC)及排序比(B/A)等的变化。结果某院国谈抗肿瘤药物可获得性逐年提高,配备品种数及使用量持续增长。其中单克隆抗体和蛋白激酶抑制剂使用金额占总使用金额的70%以上。戈舍瑞林、曲妥珠单抗和奥希替尼在其协议期内DDDs均稳居前3名,B/A均大于或等于1,DDC保持稳定,使用金额与用药频度同步性好。结论国谈抗肿瘤药物在某院的应用情况两年来呈合理上升趋势。医疗机构应优化国谈药品政策的落地实施,同时加强临床合理用药监管。

DIP付费下县级公立医院成本管控策略与实践

DIP付费改革影响着医院的综合运营管理和医疗服务质量。其目的在于促进医疗机构加强内部管理,控制不合理的医疗费用,减轻病人就医负担,保障医保基金安全。本文围绕当前医院面临的改革困境及亏损压力,医院DIP运营的总体情况展开论述,通过统计医院预估病种费用盈亏情况,结合实际案例对比分析,旨在找到一条应对DIP付费走出困境之路。积累推广县级公立医院以质控和运营为导向,以绩效激励为抓手,强化多部门MDT协作,坚持医疗质量与费用并重的实践经验,探索DIP付费下县级公立医院可持续健康发展模式。

DRG高倍率病例费用结构分析及相关影响因素研究

目的分析疾病诊断相关分组(diagnosis related groups,DRG)高倍率病例费用结构,研究影响住院费用的相关因素,合理利用DRG评价指标,为公立医院精细化管理和高质量发展提供参考。方法以2021年1月—2022年6月广西某三甲医院为样本,描述分析高倍率病例特征,运用SPSS 26.0统计学分析各因素对费用的影响。结果数据来源为从医保平台选取2021年1月—2022年6月DRG终审数据,高倍率病例6217例,占比5.76%,内科组与外科组在高倍率病例占比比较,差异无统计学意义(P>0.05)。在单因素分析中,权重、科室类别对高倍率病例住院费用有显著影响(P<0.05),而医保类别与高倍率费用无关(P>0.05)。结论权重递增结合费用倍数递减的方式制定高倍率病例认定标准是相对科学合理的,但同时应加大对违规入组病例审核力度,重视目前实际付费阶段存在的问题,转变传统医保按项目付费观念,多种付费方式相结合,合理利用DRG评价指标,以更好适应DRG支付方式改革。

基于DRGs的血液病患者住院费用影响研究

目的研究按疾病诊断相关分组(diagnosis related groups,DRGs)付费实施对血液病患者住院费用的影响,为医院进行医保精细化管理提供决策依据。方法从天津市某三甲医院医院信息系统(hospital information system,HIS)中选取2021年10月—2022年3月和2022年10月—2023年3月共21448例患者的病历资料,经过倾向得分匹配法进行匹配,筛选出8134例血液病患者,再利用双重差分法分析DRG付费对血液病患者住院费用的影响。结果实施DRGs付费后,血液病患者的检查费的中位数从6306.50元降至5038.50元,自付费用中位数从7607.17元降至6562.08元,材料费的中位数从305.70元降至286.88元。本研究进一步通过DID分析消除潜在混杂因素的影响,发现自付费用仍下降(P<0.05)。结论DRGs控费初见成效,有效降低了血液病患者的个人负担,医院应持续关注DRGs的长期效果。