Tw-DRG支付制度下住院醫療服務之財務收益探討-以南部某三家醫學中心六個主要診斷類別(MDC)為例

Study of the Financial Income Benefit of Inpatient Medical Care Services Under the Tw-DRG payment system–Using Three Medical Centers and Six Major Diagnosis Categories (MDC) in Southern Taiwan as Example

李逢君(Feng- Chun Lee)

指導教授 ： 張永源

高雄醫學大學/健康科學院/醫務管理學研究所碩士在職專班/碩士(2007年)

摘要

摘 要
研究目的
本研究欲探討南部三家醫學中心於第一年導入之六個主要診斷類別（MDC3、MDC9、MDC11、MDC13、MDC23、MDC24）下之年度財務收益情形，並進一步探討影響住院醫療費用之重要因子。

研究方法
本研究為一回溯性的研究，以2004-2006年南部某三家醫學中心「住院醫療費用清單明細檔」之次級資料(secondary data)，透過DRG編審服務與支付公式計算共83,060筆為研究對象，探討年度與醫院別財務收益、病例組合指標(CMI)、每人次平均住院醫療費用、平均住院日、診斷編碼數與合併(併發)症編碼數情形。

研究結果
六個MDC年度財務收益指標會同時受到醫院別的不同而有顯著差異者為MDC3、MDC9、MDC11與MDC13；主要臨床專科對治療其專科疾患之MDC財務控制較非主要專科為佳。
除MDC24外，餘MDC之診斷編碼數呈現逐年成長情形；MDC3、MDC9、MDC11、MDC13合併(併發)症編碼數亦呈現逐年成長趨勢；病例組合指標(CMI)、每人次平均住院醫療費用與平均住院日變項，在不同的年度與醫院別中不同的MDC各有其消長及交互影
響情形。

經控制年齡與性別等變項後研究顯示平均住院日、住院病例組合指標(CMI)、診斷編碼數與合併(併發)症編碼數為影響住院醫療費用之重要因子，R2解釋力達61.8%。
結構方程模式顯示醫療資源耗用(平均住院日、住院病例組合指標)與編碼(診斷編碼數、合併(併發)症編碼數)可顯著預測醫療費用，而醫療費用又可顯著預測財務收益指標。

結論與建議
六個MDC以第三版DRG支付原則試算其財務收益指標介於0.01~0.06；多數MDC之病例組合指標(CMI)、診斷與合併(併發)症編碼數有逐年上升情形；複迴歸分析顯示平均住院日、病例組合指標、診斷編碼數與合併(併發)症編碼數為住院醫療費用之重要影響因子；結構方程模式研究顯示醫療資源耗用與編碼可顯著預測醫療費用，而醫療費用又可顯著預測財務收益指標。

未來台灣實施DRG時，醫院管理者應在維持醫療品質前提下，合理控制住院日並加強疾病分類人員訓練，而制度者亦應建立配套審查模式，確保民眾得到適切之醫療照護。

關鍵字

DRG ； 主要診斷類別(MDC) ； 平均住院日 ； 住院醫療費用 ； 財務收益

並列摘要

Abstract
Objectives
The aim of this research was to investigate the annual income of three southern medical centers for the first year in which six major diagnostic categories were introduced (MDC3, MDC9, MDC11, MDC13, MDC23, MDC24). It also aimed to investigate the important factors influencing the costs of hospitalization.

Methods
As a retrospective study, this research including the 2004~2006 “Hospitalization Treatment Costs” files of three southern medical centers, investigate cases of 83,060 from the DRG review service and disbursement formula to study financial income by year and by hospital, the Case Mix Index (CMI), the average per person cost of hospitalization, the average number of days of hospitalization, diagnosis encoding and comorbidity(complication) disease encoding.

Results
Of the six annual MDC financial income indices, MDC3, MDC9, MDC11and MDC13 had the greatest influence on different hospitals. In different hospitals and different areas of specialization, That main clinical areas of specialization have a greater influence on MDC financial control than non-specialist areas. Except for MDC24, the diagnosis encoding of the other MDCs showed a situation of annual increase. MDC3, MDC9, MDC11 and MDC13 comorbidity(complication) disease encoding also showed a tendency to increase on an annual basis. For the Case Mix Index (CMI), the average cost per person of hospitalization, and the average number of days of hospitalization in different years and hospitals, different MDC’s had different interactive influences.
After controlling for differences in age and gender, the research shows that the average number of days of hospitalization, the Case Mix Index (CMI), the diagnostic encoding, and the comorbidity(complication) disease encoding are all important factors influencing the cost of hospitalization, with R2 reaching 61.8%.；AMOS showed that Utilization (average number of days of hospitalization and hospitalization Case Mix Index) and Coding (analysis encoding and comorbidity(complication) disease encoding) may be used to forecast medical expenses, and the medical costs may be used to forecast financial income targets.

Discussion and Suggestions
According to the third version of the DRG disbursement framework, the financial income index for the six MDCs falls between 0.01~0.06. Duplicate regression analysis demonstrated that the average number of days of hospitalization, the Case Mix Index, the diagnostic encoding and the comorbidity(complication) disease encoding are all important factors influencing the cost of hospitalization. The hospital superintendent should regard the service quality of medical care, control the length of days of patient in reasonable, and improve the coder of hospital with constant practice during the implementation of DRG in the future. The medical superintendent by the government should also establish the investigation system to survey the results of DRG and be sure the appropriate medical care of our people.

並列關鍵字

DRG ； Major Diagnosis Category (MDC) ； average number of days of hospitalization ； the cost of hospitalization ； financial income

參考文獻

中文部份

于美德(2002)， 心導管檢查醫療資源耗用分析，國立陽明大學醫務管理研究所碩士論文。

朱光興(2003)，1997~2000年全國外科麻醉醫療費用改變情形之探討—以四項論病例計酬手術為例，高雄醫學大學公共衛生學研究所碩士論文。

呂嵐欽、林慧雯、張瀞文、陳俊賢、朱子斌、李友專、邱文達(2005)，他山之石可以攻錯—DRG制度之國際比較；健康保險期刊，2(1)：40-46。

李嫦娥(2005) ，住院消化系統疾病患者對醫療資源耗用之研究，輔仁大學應用統計學研究所碩士論文。