| Summary: | 碩士 === 高雄醫學大學 === 醫務管理學研究所碩士在職專班 === 96 === Background: The Bureau of National Health Insurance（BNHI） had planed to implement theTw-DRGs ( Taiwan Diagnosis Related Groups) payment system under the global budget system in 2008. However, under the objection of the medical group and other aspects, the plans was abolished on December, 2007, and declared to continue negotiation with the medical group. Under this development, it’s important to perform an evidence-base research to prove the feasibility of the system, then providing a good strategy of medical quality control for Bureau of National Health Insurance . Therefore, Our study chose one of the original first stage’s 6 MDC( Maior diagnosis categry) , MDC11（urogenital system） including the two groups of DRG320 and DRG321, as the research’s object .The characteristics of MDC11 including the the commonest medical payment claims of the 6 MDCs(49%), the highest proportions of healthcare expenses (38%). We aimed to explore the Tw-DRGs payment system’s structure applicability, medical resource distribution, rationality of expense and explored the factors that affect the medical resource expense.
Methods：Using the inpations medical payment claimed data of the bureau of national health insurance, Kao-Ping branch, we tried to introduce the Tw-DRGs payment system into the DRG with the variations between different healthcare stratums, and analyzed how to deal the outlier of our study to validation structure of payment. Using the average of medical cost, rates of returning to emergency department (ED) within three days and readmission within fourteen days as indicators, we analyzed the challenges that the medical providers may face in the future. Moreover, using the variants of the popularity, clinical specialty, hospital peculiarity, we explored the aspects of future monitor and inspection.
Results：First, the application of the Tw-DRG paymentstructure: 1. The comprehensiveness of disease’s category: The CV value of DRG320 was 38.1% with DRG321 value <22.7% after introducing the system. 2. After introducing the system, the case falling into the area of fixed payment in DRG320 was 91% with DRG320 96%. 3. Different severity of diseases with different payment: After introducing, the average of medical cost was increasing in DRG320 and decreasing in DRG321. The statistic average inpatient days were lower than public announcement in DRG 320 and 321, but both of the average inpatient days were higher than the reference value of announcement. The rate of transfer was 6.5%, with the higher rate in the regional hospital and the patients admitted within 0-2 days. Second, the reasonableness of medical resource distribution and expense: There was a significant difference of average medical cost in the age and stratums of hospital. Rate of returning to ED within 3 days was <1.8%, and readmission with the same disease was <0.4%. Readmission rate of whole diseases within 14 days was 6.0% in DRG 320 and 2.8% in DRG 321. Third, the impact factors of medical cost: Both the important factors of DRG 320 and 321 were including days of inpatient, the status of discharge, the stratum of hospital, base rate and numbers of secondary coding.
Discussion and Suggestions：First, it’s positive of lower CV value in the category of diseases. With the stable payment system, after being introduced, it’s proper because more money was deposited into the more severity patients of DRG 320 group. The principle of payment system was equalization; the whole expense of medicine was not increasing. Therefore, the Tw-DRG payment system was applicable. For the negative revenue hospitals, they should start to increase the efficiency and use standardized procedures. Hospitals with more budget should be monitored the quality of care. The hospitals having higher length of inpatient should be enforced to be supervised. Second, although there was a difference between age in the average medical cost, the package payment of DRG could complement each others that the hospital could not have difference treatment of patients with different payment. The clinical pathways should be established and increasing the quality of care. There was a difference in the average medical cost of different stratum of hospital, which revealed that the medical centers should release the lower CV value patients of DRG 320 and 321, and transferred to community hospital to decrease wasting of medical resource and establishing the diversion. Community hospital should increase the ability of care and the regional hospitals should increase its efficiency. Overall, the distribution of medical resource was reasonable. Third, the most important factors affected the medical cost was average days of inpatient and it should be the first priority of hospital management and the key point of investigation by bureau. We suggest using the quality control and resource redistribution to investigate the length of inpatient and develop associated strategy. Medical providers could using the clinical pathways and concept of prime of cost with proving suggestion to government and create a triple-wining situation.
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