Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
Department of Medical Insurance Management, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
Front Public Health. 2024 Sep 18;12:1437272. doi: 10.3389/fpubh.2024.1437272. eCollection 2024.
To investigate the cost homogeneity within the Diagnosis-Related Group (DRG) "major operation of pancreas and liver, with general complications or comorbidities" (HB13), its cost-influencing factors, and to propose suggestions for better grouping efficacy.
Medical and insurance settlement data of inpatients covered by the DRG payment system at the author's institution were collected from March 15, 2022 to December 31, 2023. The cost homogeneity of group HB13 was assessed using the coefficient of variation (CV). Clinical factors that may have an impact on hospitalization cost for patients undergoing pancreatic surgery were identified through a semi-structured interview administered to the pancreatic surgeons in author's department, their significance was analyzed using multiple linear regression, along with their impact on the cost of different service categories. A proposal to subdivide HB13 was made and evaluated by CV and t-test.
The CV of the HB13 group was 0.4. Robotic-assisted surgery and pancreaticoduodenectomy were two independent factors that significantly affected the total cost. Patients undergoing robotic-assisted surgery have an average increase of 41,873 CNY in total cost, primarily derived from operation fee. Patients undergoing pancreaticoduodenectomy have an average increase of 37,487 CNY in total cost, with significant increases across all service categories. HB13 was subdivided based on whether pancreaticoduodenectomy was performed. The newly formed groups exhibited lower CVs than the original HB13.
The cost homogeneity of HB13 was lower than that of other DRG groups in author's department. It is recommended to introduce a supplementary payment for patients requiring robotic-assisted surgery, to guarantee their access to this advanced technology. It is recommended to establish a new group with higher payment standard for patients undergoing pancreaticoduodenectomy. A tiered CV criterion for the evaluation of grouping efficacy is recommended to increase intra-group homogeneity, facilitating a better allocation of health insurance funds, and the prevention of unintended negative outcomes such as service cuts and cherry-picking.
探讨诊断相关分组（DRG）“胰腺和肝脏大手术，伴有一般并发症或合并症”（HB13）内的费用同质性，分析其费用影响因素，并提出分组效果优化建议。
收集作者单位 DRG 支付系统覆盖的住院患者的医疗和保险结算数据，时间为 2022 年 3 月 15 日至 2023 年 12 月 31 日。采用变异系数（CV）评估 HB13 组的费用同质性。通过对作者所在科室的胰腺外科医生进行半结构式访谈，确定可能影响胰腺手术患者住院费用的临床因素，采用多元线性回归分析其意义，并分析其对不同服务类别费用的影响。提出了 HB13 的细分建议，并通过 CV 和 t 检验进行评估。
HB13 组的 CV 为 0.4。机器人辅助手术和胰十二指肠切除术是两个独立影响总费用的因素。接受机器人辅助手术的患者总费用平均增加 41873 元，主要来自手术费用。接受胰十二指肠切除术的患者总费用平均增加 37487 元，所有服务类别均显著增加。根据是否进行胰十二指肠切除术对 HB13 进行细分。新形成的组的 CV 低于原始 HB13。
作者单位 HB13 的费用同质性低于其他 DRG 组。建议对需要机器人辅助手术的患者引入补充支付，以保证他们能够获得这项先进技术。建议为接受胰十二指肠切除术的患者建立新的分组，支付标准更高。建议建立分层 CV 标准来评估分组效果，以提高组内同质性，更好地分配医疗保险资金，并防止服务削减和选择性治疗等意外的负面结果。
