Rimler Simcha B, Gale Brian D, Reede Deborah L
From the Department of Radiology, SUNY Downstate Medical Center, Box 1278, 450 Clarkson Ave, Brooklyn, NY 11203.
Radiographics. 2015 Oct;35(6):1825-34. doi: 10.1148/rg.2015150043.
To understand the complex system of reimbursement for health care services, it is helpful to have a working knowledge of the historic context of diagnosis-related groups (DRGs), as well as their utility and increasing relevance. Congress implemented the DRG system in 1983 in response to rapidly increasing health care costs. The DRG system was designed to control hospital reimbursements by replacing retrospective payments with prospective payments for hospital charges. This article explains how these payments are calculated. Every inpatient admission is classified into one of several hundred DRGs that are based on the diagnosis, complications, and comorbidities. The Centers for Medicare & Medicaid Services (CMS) assigns each DRG a weight that the CMS uses in conjunction with hospital-specific data to determine reimbursement. A population's DRGs represent the resources needed to treat the medical disorders of that population. Hospital administrators use this information to budget and plan for the future. The Affordable Care Act and other recent legislation affect medical reimbursement by altering the DRG system. Radiologic procedures in particular are affected. This legislation will give DRGs an even larger role in determining reimbursements in the coming years.
要理解医疗服务报销的复杂系统，了解诊断相关分组（DRG）的历史背景、其效用及日益增加的相关性会有所帮助。国会于1983年实施了DRG系统，以应对迅速增长的医疗成本。DRG系统旨在通过用对医院收费的预付费取代后付费来控制医院报销。本文解释了这些费用是如何计算的。每次住院都被归类到基于诊断、并发症和合并症的几百个DRG之一。医疗保险和医疗补助服务中心（CMS）为每个DRG分配一个权重，CMS将该权重与医院特定数据结合使用来确定报销金额。一个人群的DRG代表治疗该人群医疗疾病所需的资源。医院管理人员利用这些信息进行预算和未来规划。《平价医疗法案》及其他近期立法通过改变DRG系统影响医疗报销。特别是放射学程序受到影响。这项立法将使DRG在未来几年确定报销金额方面发挥更大作用。
