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目的运用DRGs技术评价医保患者住院服务效果和基金使用情况,为医保管理和DRGs-PPS进一步推广提供基础数据研究。方法抽取北京市某三甲医院2016年全部的住院病案首页数据、DRGs分组数据和医保结算数据,运用DRGs技术在Excel2010中建立数学模型,评价各临床科室的住院服务效果。结果该院整体医保住院DRGs评价效果较好,疾病诊疗范围覆盖534组DRGs,病组覆盖率67.94%,费用消耗指数和时间消耗指数分别为1.01和0.88,但CMI偏低,仅为0.72;重点学科眼科和耳鼻咽喉头颈外科CMI分别为0.41和0.82,眼科费用消耗指数和时间消耗指数分别为1.01和0.49,耳鼻喉咽喉头颈外科费用消耗指数和时间消耗指数分别为1.10和1.21。结论目前分组体系下的MDCC和MDCD组的分组情况和权重分配是该院重点学科和整体评价不理想的重要原因,分组方案在考虑复杂病例方面有待进一步论证,同时基础学科应有针对性的提升效率相关指标,建议医院推进DRGs管理和临床路径管理,增强成本控制意识,提高医保基金使用效率。
Objective To evaluate the effect of inpatient services and fund utilization of Medicare patients by DRGs technology and provide basic data research for health care management and further promotion of DRGs-PPS. Methods The data of all inpatient medical records, DRGs grouping data and medical insurance settlement data of a certain top three hospital in Beijing were collected. The mathematical model of DRGs was established in Excel2010 to evaluate the effect of inpatient services in various clinical departments. Results The hospitalized general medical insurance inpatient DRGs had a good evaluation. The disease coverage covered 534 DRGs, covering 67.94% of the patients. The cost-consuming index and time-consuming index were 1.01 and 0.88, respectively, but the CMI was low at only 0.72. Ophthalmology and otolaryngology head and neck surgery CMI were 0.41 and 0.82, ophthalmology cost and time consumption index were 1.01 and 0.49, otolaryngology and throat head and neck surgery cost and time consumption index were 1.10 and 1.21. Conclusion Currently, the grouping and weight distribution of MDCC and MDCD under the grouping system are the important reasons for the unsatisfactory evaluation of key disciplines and overall evaluation of the hospital. The grouping plan needs to be further demonstrated in considering complex cases, and the basic disciplines should be targeted to enhance Efficiency-related indicators, it is recommended that the hospital to promote DRGs management and clinical path management, enhance awareness of cost control and improve the efficiency of Medicare funds.