Health Care Commissioner Medical Insurance Profit and Loss DRGs Gastric Cancer Gastrointestinal Surgery
南京市医疗保险研究会基础课题（NJYB2022JC006）；南京大学中国医院改革发展研究院面上课题（NDYG2022015）；南京大学中国医院改革发展研究院培育课题（NDYG2022051）
目的：探讨医保专员干预管理在疾病诊断相关分组（diagnosis-related groups，DRGs）支付模式下医保的盈亏情况，为优化诊疗过程及控制不合理的医疗收费提供管理依据和决策参考。方法：收集南京市某三甲医院2022年1月-7月胃肠外科胃癌住院病例医保DRGs系统数据，根据有无医保专员干预管理分为干预组和对照组，统计分析医保专员干预管理对该病种在DRGs中盈亏情况的影响，评估管理效果。结果：本研究共收集206例患者信息，其中干预组127例，对照组79例。干预组盈余多于对照组（P=0.025），DRGs分组中干预组严重并发症或合并症（Major Complication or Comorbidity，MCC）组和并发症或合并症（Complication or Comorbidity，CC）组的入组人数显著多于对照组（P=0.007）。随着干预的进行，胃癌手术患者贡献的病例组合指数（case mix index，CMI）值呈上升趋势，医保结余呈现正增长趋势。结论：通过医保专员的干预可明显增加DRGs中胃癌组医保节余费用，指导胃癌病种合理化分配费用，优化资源配置，进一步管控医疗成本，降低患者住院费用。
Objective：To explore the profit and loss of medical insurance under the payment mode of DRGs（diagnosis-related groups），and to provide a management basis and decision-making reference for optimizing the diagnosis and treatment process and controlling unreasonable medical fees. Methods：To collect the medical insurance DRGs system data of inpatients with gastric cancer in the department of gastrointestinal surgeryin a certain tertiary grade Ahospital in Nanjing from January to July 2022. They were divided into an intervention group and a control group according to the intervention and management of the medical insurance commissioner，the profit and loss of DRGs were analyzed statistically，and the management effect was evaluated. Results：A total of 206 patients were collected，including 127 patients in the intervention group and 79 patients in the control group. The intervention group had more surplus than the control group（P=0.025），and the number of participants of MCC（Major Complication or Comorbidity）and CC（Complication or Comorbidity）group in the DRGs subgroup was significantly morethanin intervention group than that in the controlgroup（P=0.007）. With the intervention going forward，the CMI（case mix index）of patients with gastric cancer after operation showed an upward trend，and the balance of medical insurance showed a positive trend. Conclusion：The intervention of medical insurance commissioner can obviously increase thehealth insurance surplus of gastric cancer groups in DRGs，guide the rational allocation of the cost of gastric cancer，optimize the allocation of resources，further control the medical cost and reduce the hospitalization cost of patients.