Jencks S F, Dobson A
N Engl J Med. 1987 Sep 10;317(11):679-86. doi: 10.1056/NEJM198709103171106.
We review case-mix adjustment, which is the process of adjusting for differences in the cases treated in different hospitals so that their costs or outcomes can be compared. We examine the Medicare payment system, which rests on case-mix adjustment, and identify areas, including outlier payments, in which payment accuracy might be improved without better measurement of the severity of illness. There is no available measure of severity of illness that would produce a large improvement in the accuracy of Medicare payments if used to supplement or replace the system of diagnosis-related groups. Evidence regarding whether better measurement of severity would substantially change the distribution of payments across hospitals is mixed. Considerable evidence suggests that the intensity of medically appropriate treatment for patients in the same diagnosis-related group varies substantially for reasons other than the severity of illness. Despite great demand for measures of the quality of care, important technical problems must be solved before we can be confident that differences in case-mix-adjusted outcomes reflect differences in the quality of care.
我们回顾了病例组合调整，这是针对不同医院所治疗病例的差异进行调整的过程，以便能够比较它们的成本或治疗结果。我们审视了基于病例组合调整的医疗保险支付系统，并确定了包括异常值支付在内的一些领域，在这些领域中，即便没有对疾病严重程度进行更完善的衡量，支付准确性仍有可能得到提高。目前没有一种疾病严重程度衡量方法，若用于补充或取代诊断相关分组系统，能在医疗保险支付准确性上带来大幅提升。关于更完善的严重程度衡量是否会显著改变各医院间支付分配的证据并不一致。大量证据表明，同一诊断相关组内患者获得的合理医疗治疗强度，会因疾病严重程度以外的原因而有很大差异。尽管对医疗质量衡量标准有巨大需求，但在我们能够确信病例组合调整后的结果差异反映了医疗质量差异之前，必须先解决一些重要的技术问题。
