1、,DRG沿革及理論簡介,回溯性支付制度（Retrospective Payment System; RPS）：,1965 Medicare established, USA Congress adopted the private health insurance sectors “retrospective cost-based reimbursement” system to pay for hospital services. Medicare made interim payments Hospital filed cost report Reconciled with allowab
2、le costs,Two factors were blamed :,Payment methodologies that paid providers based on their charges for providing services and consequently created an incentive to provide more services. Increased in costly medical technology.,In Response to payment growth:,Congress adopted a Prospective Payment Sys
3、tem (PPS) to curtail the amount of resources the Federal government spent on medical care for the elderly and disables. Social Security Amendments of 1983 mandated the PPS for hospital, effective in Oct. of Fiscal Year 1983.,前瞻性支付制度（Prospective Payment System; PPS）：,A method of payment for health ca
4、re services in which the amount of payment for services is set prior to the delivery of those services and the hospital (or other provider) is at least partially at risk for losses or stands to gain from surpluses that accrue in the payment period. Prospective payment rates may be per service, per c
5、apita, per diem, or per case rates.,前瞻性支付制度（Prospective Payment System; PPS）：,保險人在即將來臨的會計年度前，預先訂定診療報酬費率，以預定的費率支付醫療院所提供給保險對象的醫療費用。Per diem：按日計酬制Per capita：按人計酬制Case Payment：論病例計酬DRG：按疾病診斷關聯群付費Global Budget：總額預算制,DRG概念形成,Concept of Case Mix Complexity Severity of illness Prognosis Treatment Difficulty
6、 Need for intervention Resource Intensity,DRGs分類基礎 :,Principal Diagnosis (why the patient was admitted) Complications and Comorbidities (CCs other secondary diagnoses) Surgical Procedures Age Gender Discharge Disposition (routine, transferred, or expired ),10 highest volume Medicare DRGS:,30% of tot
7、al Medicare patients DRG 127 (5.99%), DRG 089 (3.85%) DRG 014 (3.18%), DRG 430 (3.18%) DRG 088 (3.11%), DRG 209 (2.78%) DRG 140 (2.33%), DRG 182 (2.09%) DRG 174 (2.07%), DRG 296 (1.93%),Medicare DRGs 發展(1),1960+ 美國耶魯大學Robert Fetter及John Thompsom 研發 1970+ New Jersey試用為住院費用支付的依據 1977 Health Care Finan
8、cing Administration 成立 (2001 改名為 Centers for Medicare & Medicaid Services),Medicare DRGs發展(2),第一版DRGs以ICDA-8為分類基礎 23個MDC, 383 DRGs 缺點:資料不夠代表性、無法複製、缺乏臨床一致性、資源耗用不具同質性、疾病嚴重度不敏感、其他組群太多等。,Medicare DRGs發展(3),1983 第二版DRGs以ICD-9-CM為分類基礎 23 MDC, 470 DRGs 美國國會通過自1983年10月1日正式以DRGs作為Medicare住院醫療費用的給付依據 1990 第八版
9、DRGs - 25 MDC,25 MDC (1),25 MDC (2),Pre MDC,Heart Transplant Liver Transplant Bone Marrow Transplant Lung Transplant Tracheostomy氣管造口術 and Laryngectomy喉頭切除術,其他 DRGs 發展(1),Refined DRG (RDRG) 1989耶魯大學將所有符合 合併症、併發症定義之次診斷標示出136種次診斷群，再將每一次診斷群組歸類到不同的合併症、併發症等級。 外科系病人-非CC、中度CC、主要CC、嚴重級CC 內科系病人-非CC、中度CC或主要CC
10、、嚴重級CC,其他 DRGs 發展(2),All Patient DRG (AP-DRG) 1987 New York State Department of Health (NYDH)與3M Health Information Systems (3M HIS)共同發展出適用於所有年齡層及範圍更廣泛的給付系統。 此系統把CCs再分為合併症/併發症及主要合併症/併發症(Major CCs)，共發展出60個Major CCs,其他 DRGs 發展(3),Severity DRG (SDRG) 1993年HCFA參考AP-DRG主要合併症/併發症列表，將次診斷再分類1. Non-CC非合併症併發症
11、2. Non-major CC非主要合併症/併 發症3. Major CC主要合併症併發症 共發展出652個DRG,其他 DRGs 發展(4),All Patient Refined DRG (APR-DRG) 內容包括:1. 基本的APR-DRG2. 病情嚴重情形:輕微的、中度的、主要的及最嚴重的3. 死亡率的風險度:輕微的、中度的、主要的及最嚴重的 共發展出1530個APR-DRG,其他 DRGs 發展(5),International Refined DRG (IR-DRG) 3M 內容包括:1.無合併症併發症 (Without CC)2.合併症/併發症 (With CC)3.主要合併症
12、併發症 (With Major CC ) 共發展出923個IR-DRG,其他 DRGs 發展(6),Australian National Diagnosis Related Groups (AN-DRG)1992-1996 3M & CommonwealthVersion 1.0, 2.0, 2.1, 3.0, 3.1 Australian Refined Diagnosis Related Groups (AR-DRG)1997-Version 3.2, 4.0, 4.1, 4.2, 5.0,DRG-based Payments,DRG payment = Relative weight
13、X Rate Rate is defined by Federal regulations and is updated annually to reflect inflation, technical adjustments, and budgetary constrains.,計算公式某DRG平均費用 某DRG權值 =所有個案平均費用,相對權值(Relative Weight),解讀: 數值越高反映該病例組合之資源耗用越高,計算公式所有個案RW總和 某醫院CMI =所有個案數,病例組合指標 (Case Mix Index),解讀:數值越高反應該醫院收治個案病情複雜程度越高或所需耗用之醫療資
14、源越多,計算公式該院所有個案平均費用 Base rate =該院之CMI,Hospital Base Rate,解讀: 數值偏高必須檢討該病例組合之資源耗用是否浪費 數值偏低必須檢討該院所收治病患之病情嚴重度是否較輕,計算公式所有個案平均費用 Base rate =整體之CMI,Overall Base Rate,Transient Ischemic Attack (TIA, Mini-Stroke) 缺血性中風 Pleurisy 肋膜炎;胸膜炎 COPD: characterised by difficulty breathing, wheezing and a chronic cough
15、CVD: cardiovascular disease,Keys to a financially successful DRG Program,Length of stay Service utilization (test/procedures) Early discharges Preadmission testing,Medical Record must be:,Comprehensive and complete Timely Legible Well documented,我國住院病例組合,以美國CMS ( Centers for Medicare & Medicaid Serv
16、ices, 原HCFA) DRG18版為基礎，發展本土化之499個DRGs 自92年起推廣試辦 進行第二版之研議與修訂,實施DRG疾病分類與申報的因應措施,出院病歷 整 理,出院病歷 審 查,詳閱相關 診斷與處置,疾病分類 編 碼,檢視費用明細 與主次要診斷,DRG 編審,DRG 建檔與申報,病歷是否 已完成,病歷補寫,否,是,是否 完備,否,是,強化團隊合作,病人基本資料、繳費身份、就診項目建檔務必正確完整 前線人員收費醫令、帳目正確完整 加強前線人員健保相關資訊之訓練 降低未完成病歷比率、定期稽催 協助即時完成診斷與手術編碼 病歷各項記載與電腦鍵入資料及實際作業相符 推動醫療科部常態性病歷記錄審查,
