Muñoz E, Zahtz G, Goldstein J, Benacquista T, Mulloy K, Wise L
Department of Otolaryngology, Long Island Jewish Medical Center, New Hyde Park, NY 11042.
Arch Otolaryngol Head Neck Surg. 1988 Nov;114(11):1317-20. doi: 10.1001/archotol.1988.01860230111037.
The Medicare diagnosis related group (DRG) prospective payment model is changing hospital payment. Currently many states are using DRG prospective "All Payor Systems" for hospital reimbursement. In All Payor Systems, Medicare, Medicaid, Blue Cross, and other commercial insurers pay by the DRG mode; New York State has been All Payor since Jan 1, 1988. This study simulated DRG All Payor methods on a large sample (N = 1074) of adult otolaryngology patients for a two-year period using both federal and New York DRG reimbursement now in effect. Both Medicare and Medicaid patients had (on average) a longer hospital stay and total hospital cost compared with patients from Blue Cross and other commercial payors. Medicare and Medicaid patients also had a greater severity of illness compared with patients from Blue Cross or other payors. All payors (ie, Medicaid, Blue Cross, and commercial insurers), except Medicare, generated financial risk under the DRG All Payor scheme. These data suggest that state and private payors may be underreimbursing for the care of the hospitalized otolaryngology patient using the DRG prospective hospital payment scheme. Health care financing policy described in this study may limit both the access and/or the quality of care for many otolaryngology patients in the future.
医疗保险诊断相关分组（DRG）前瞻性支付模式正在改变医院的支付方式。目前，许多州正在使用DRG前瞻性“全支付方系统”来进行医院报销。在全支付方系统中，医疗保险、医疗补助、蓝十字以及其他商业保险公司均按照DRG模式进行支付；纽约州自1988年1月1日起就采用了全支付方系统。本研究使用现行的联邦和纽约DRG报销方式，对1074例成年耳鼻喉科患者的大样本进行了为期两年的DRG全支付方方法模拟。与蓝十字和其他商业支付方的患者相比，医疗保险和医疗补助患者的平均住院时间更长，住院总费用更高。与蓝十字或其他支付方的患者相比，医疗保险和医疗补助患者的病情也更严重。除医疗保险外，所有支付方（即医疗补助、蓝十字和商业保险公司）在DRG全支付方方案下都产生了财务风险。这些数据表明，使用DRG前瞻性医院支付方案时，州和私人支付方可能对住院耳鼻喉科患者的护理报销不足。本研究中描述的医疗保健融资政策未来可能会限制许多耳鼻喉科患者获得医疗服务的机会和/或医疗服务质量。
