Muñoz E, Goldstein J, Benacquista T, Mulloy K, Wise L
Department of Surgery, Long Island Jewish Medical Center, New Hyde Park, NY 11042.
Arch Intern Med. 1989 Feb;149(2):417-20. doi: 10.1001/archinte.1989.00390020117025.
There are many health policy issues related to diagnosis-related group (DRG) hospital payment. Previous work by our group had suggested that some DRGs did not adequately comorbidities. Despite recommendations by federal advisory committees, the secretary of Health and Human Services has proposed no major changes to DRGs along these lines. We analyze resource consumption in any of the 88 non-complicating condition (CC)-stratified medical DRGs using the DRG prospective "all payor system" in effect at our hospital. Analysis of 12,340 medical patients by payor (Medicare, Medicaid, Blue Cross, and commercial insurance) in these non-CC-stratified medical DRGs for a three-year period demonstrated that patients with more CCs per DRG for each payor generated higher total hospital costs, a longer hospital length of stay, a greater percentage of procedures per patient, higher financial risk under DRG payment, and a higher mortality, compared with patients in these same DRGs with fewer CCs. These findings suggest that new prospective DRG all payor systems may be inequitable to certain groups of patients or types of hospitals vis-à-vis the non-CC-stratified medical DRGs. Health policy leaders should be encouraged to stratify many medical DRGs by the numbers and types of CCs to more equitably reimburse hospitals under DRG all payor systems.
有许多与诊断相关分组（DRG）医院支付相关的卫生政策问题。我们团队之前的研究表明，一些DRG未能充分考虑合并症情况。尽管联邦咨询委员会提出了建议，但卫生与公众服务部部长并未提议对DRG进行此类重大变革。我们使用我院现行的DRG前瞻性“全付费方系统”，分析了88个无并发症情况（CC）分层的医疗DRG中任何一个的资源消耗情况。在三年期间，对这些非CC分层医疗DRG中按付费方（医疗保险、医疗补助、蓝十字和商业保险）分类的12340名内科患者进行分析，结果表明，与同一DRG中合并症较少的患者相比，每个付费方每个DRG中合并症较多的患者产生的医院总成本更高、住院时间更长、每位患者的手术比例更高、DRG支付下的财务风险更高且死亡率更高。这些发现表明，相对于非CC分层的医疗DRG而言，新的前瞻性DRG全付费方系统可能对某些患者群体或医院类型不公平。应鼓励卫生政策领导人根据合并症的数量和类型对许多医疗DRG进行分层，以便在DRG全付费方系统下更公平地补偿医院。
