基于疾病分组的医保住院补偿范围研究

Abstract

Objective: As the emerging of medical insurance payment reform, the payment scope will turn form the catalog of drugs, treatments and facilities to whole payment upon disease or disease groups. In this paper, the rational reimbursement scope and rate for NRCMS are studied via Diagnosis Related Groups(DRG) tools. Methods: Information of the first page of medical records for short-term hospitalized patients (length of stay< 60 days) enrolled in NCMS in Beijing was collected, and was analyzed based on the DRG tools. Together with the information collected through interviewing key informants and scholars in medical insurance studies, this study was able to put a recommended frame to the disease groups that should be covered by NCMS for short-term hospitalization, and to project the simulating reimbursement rate based on our recommended frame. Results: A final number of 638,191 medical cases entered final analyses, covering 26 MDC and 697 DRG. At the first step of drawing our recommended disease frame covered by NCMS, we use expenditure and discharge volume as criteria. At the second step, the frame was revised according to comments from experts in clinical medicine, based on the inclusion criteria that include clinical value and essentiality, rationality as well as cost-effectiveness. 664 groups of DRG were included in the final recommended frame for short-term hospitalization reimbursement. Among the excluded 34 groups, 13 groups that have low cost, relatively short length of stay, high medicine cost and are mainly internal diseases were categorized into the sector as outpatient service insurance; 8 groups that have high cost, severe syndromes and difficult treatment plans were categorized into the sector as “severe disease insurance”; 12 groups that are much less vital and out of basic healthcare were excluded out of the insurance sector. Based on the NCMS data in 2014, we ran a simulation analysis and calculated out the actual reimbursement rate for short-term hospitalization was 48.69%. Conclusion: This study provided an innovative sight into the researches on hospitalization reimbursement rate under NCMS. It analyzed the health data by DRG that is good for not only making the use of NCMS fund more controllable, but also ben e fiting more NCMS users through rational reimbursement. Where the medical insurance payment reform adopted, the methods in this paper are suitable for determine the scope of inpatient payment and calculate the reimbursement rate.