Kominski G F, Schoenman J A
Department of Health Services, UCLA School of Public Health 90024-1772.
Med Care. 1990 Aug;28(8):657-71. doi: 10.1097/00005650-199008000-00001.
The Medicare prospective payment system (PPS) pays hospitals a fixed payment for patients in 474 categories of diagnosis-related groups (DRGs). Since the beginning of PPS, many DRGs have been modified to improve the accuracy of patient classification and the equity of hospital payments. There are continuing problems, however, in classifying surgical patients who have no procedure related to their reason for admission. Until recently, these patients were classified into a single miscellaneous category (DRG 468) and paid the same amount, despite considerable variation in their clinical conditions and resource use. Three options for improving the payment and classification of such cases were examined. Improvements are possible using each of the options examined. The greatest improvement, however, was achieved by reassigning patients to existing surgical DRGs, because patients with the same surgery tend to have similar costs, regardless of their original reason for entering the hospital. This change in assignment methodology would increase payments to teaching hospitals, where the most costly DRG 468 cases are concentrated. It also would remove potential incentives to deny access to or withhold appropriate treatments from patients needing high-cost surgical procedures. It was concluded that this change should be implemented for hospital payment under PPS.
医疗保险预付费系统（PPS）根据474种诊断相关分组（DRG）为医院的患者支付固定费用。自PPS实施以来，许多DRG已被修改，以提高患者分类的准确性和医院支付的公平性。然而，在对那些入院原因与手术无关的外科患者进行分类方面，仍然存在问题。直到最近，这些患者都被归入一个单一的杂项类别（DRG 468），并获得相同的支付金额，尽管他们的临床状况和资源使用情况存在很大差异。研究了三种改进此类病例支付和分类的方案。采用所研究的每种方案都有可能实现改进。然而，通过将患者重新分配到现有的外科DRG中，取得了最大的改进，因为接受相同手术的患者往往具有相似的费用，无论他们最初的入院原因是什么。这种分配方法的改变将增加对教学医院的支付，因为最昂贵的DRG 468病例集中在这些医院。这也将消除拒绝为需要高成本手术的患者提供治疗或扣留适当治疗的潜在动机。得出的结论是，这种改变应在PPS下用于医院支付。
