中国与诊断相关的群体上编码的行为和驱动因素:一项混合方法研究
Wuping Zhou1, Chunchun Xu1, Lanyue Zhang1
1Department of Health Policy and Management, School of Public Health, Peking University, Beijing, China.
Social science & medicine (1982)
|December 25, 2024
概括
在中国的诊断相关集团 (DRG) 支付系统中,上加代码是普遍存在的,这是由于财务压力而导致的,导致医疗保健成本增加. 了解这些驱动因素是防止这种行为和改善系统的关键.
科学领域:
- 医疗保健服务研究 医疗服务研究
- 医疗保健经济学 医疗保健经济学
- 医学审计 医学审计
背景情况:
- 在诊断相关小组 (DRG) 支付中,Upcoding是一种有害的做法,受到越来越多的审查.
- 了解其流行率和驱动因素对于医疗保健支付系统的完整性至关重要.
研究的目的:
- 调查中国试点DRG支付实施期间的上代码的流行,类型和风险因素.
- 探索上代码行为的潜在驱动因素.
- 为减轻升级编码和增强DRG系统提供政策建议.
主要方法:
- 从DRG支付审计数据库 (2019年6月至2020年5月) 中对5157个重新抽象的医疗记录进行定量分析.
- 与DRG支付系统的10个主要利益相关者进行半结构化访谈的定性主题分析.
- 分析包括了Z市28家医院的数据.
主要成果:
- 发现了12.91% (666条记录) 的显著上升编码率,导致了45.27%的额外支付.
- 风险因素包括并发病,非手术室手术,内部医疗治疗,营利性医院和三级医院.
- 关键的驱动因素是财务/行政压力,对升级编码的负面态度,技术上的轻松,以及监管不足.
结论:
- 由于系统压力,DRG的上加代码在中国越来越令人担忧,导致医疗保健支出膨胀.
- 有效的预防需要解决财政激励,改善态度,加强技术保障和加强监督.
- 智能审计和成本管理支持是建议的政策干预措施.
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