太生病了不是真的吗? 在医疗保险的患者驱动支付模式中评估潜在的问题诊断编码实践
Harsha Amaravadi1, Rachel A Prusynski1,2, Paul A Fishman1
1Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA.
患者驱动支付模式 (PDPM) 在熟练护理设施 (SNFs) 中增加了诊断编码,特别是在营利性设施中. 需要进一步评估,以确保准确的临床复杂性文档,以确保医疗保险支付的准确性.
科学领域:
- 医疗保健服务研究 医疗服务研究
- 卫生经济学 卫生经济学
- 老年学是指老年学的学科.
背景情况:
- 患者驱动支付模式 (PDPM) 由医疗保险实施,以改革熟练护理设施 (SNF) 的报销.
- PDPM将SNF支付与患者特征联系起来,强调通过诊断文档捕捉到的临床复杂性.
- 了解PDPM对SNF诊断文档的影响对于支付准确性和患者护理至关重要.
研究的目的:
- 在实施医疗保险的患者驱动支付模式 (PDPM) 之后,量化熟练护理机构 (SNF) 诊断文档的变化.
- 评估PDPM与诊断数量,临床复杂性得分以及特定疾病的记录之间的关联.
- 根据SNF的利状况,检查文档变化的变化.
主要方法:
- 采用差异差异方法的准实验性设计.
- 分析使用了2018-2021年100%的传统医疗保险索赔数据,覆盖了超过480万例从医院到SNF的病例.
- 固定效应线性模型和通用线性模型被用来估计PDPM的影响和SNF利状况的变化.
主要成果:
- PDPM与诊断人数增加7.1%和Elixhauser并发症指数得分增加13.6%有关.
- 与非营利性设施相比,营利性SNF的诊断 (2.8%) 和Elixhauser点 (4%) 的相对增加更大.
- 记录特定疾病的概率,如慢性肺病,复杂糖尿病,心力衰竭,肥胖和体重减轻,在PDPM后显著增加.
结论:
- 实施PDPM导致SNF的编码强度增加,在营利性设施中观察到更高的编码率.
- 需要评估这种增加的文档是否准确地反映了临床复杂性,或者代表了夸张的编码.
- 持续监测SNF诊断编码行为对于保持医疗保险支付准确性至关重要.
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