DRG支付制度下住院醫療服務財務風險監控模式—決策支援系統之應用

A Financial Risk Monitoring Model of Inpatient Services in the PPS/DRGs Reimbursement System — Application of a Decision Support System

洪瀅琇(Ying-Hsiu Houng)

指導教授 ： 陳金淵

長榮大學/健康科學學院/醫務管理學研究所/碩士(2006年)

https://doi.org/10.6833/CJCU.2006.00067

摘要

面對即將實施的住院診斷關聯群支付制度，醫療機構必須設法將DRG服務項目的醫療費用控制在給付金額以下，以降低財務風險，確保營運服務之順暢進行。就同一DRG而言，醫療費用的變異主要受到醫師醫療行為的影響，而醫療行為通常決定於短時間之內，因此本研究擬發展DRG支付制度下住院醫療服務財務風險監控的決策支援系統，希望能夠協助醫院及醫師迅速、精確地掌握執行某一DRG服務項目可能產生的財務風險，並經由潛在風險費用項目之建議，提供醫師進行費用控管之參考，期能有效降低財務風險。
本研究自行開發系統，在Windows XP作業環境下，利用Visual Basic 6.0為前端系統開發工具，後端則以Microsoft Access 2003為資料庫管理系統。系統之建置使用某一區域教學醫院2002年1月至2004年7月住院醫療服務健保申報資料（共37,031筆），並根據中央健康保險局公告之第二版DRG編碼原則進行轉碼以及給付費用之計算。而財務風險之計算則使用以「點數」為單位的「差額」(ΔR)及各主要費用項目，希望能讓使用者對所造成之財務風險有更為具體之感受──當ΔR為正數，表示該項服務出現溢酬；反之，出現負數則為損失。此外，本系統亦提供標準化指標「差額佔定額費用比率（ΔR/R）」，作為各個醫師與標竿醫師間比較之用。
本系統為一資料庫系統，協助醫師瞭解執行某一DRG個案可能產生之財務風險，並藉由歷史資料，提供標竿醫師之財務風險表現及相關費用項目，作為潛在費用控制之參考建議。當主治醫師收治病患時，該醫師以輸入病患DRG碼及醫師代碼的方式進行查詢分析，主要分析功能包含醫院整體財務風險、全院單一DRG財務風險、特定DRG下該醫師之財務風險、特定DRG下標竿醫師之財務風險（頂標、前標、均標）以及潛在費用控制之相關建議。
藉由本系統之運用，期冀可以提升醫療服務提供者對於營運財務之風險觀念，也希望透過醫療團隊成員之直接參與費用控制，得以強化財務控管機制，降低醫院整體之財務風險。

關鍵字

住院服務 ； 診斷關聯群 ； 財務風險 ； 風險監控 ； 決策支援系統

並列摘要

Facing the impending DRG payment system, hospitals must try to control medical expenses to reduce financial risks, and make sure services are provided in a cost-effective way. For each specific DRG, the differences of medical expenses are influenced mainly by doctors' medical behaviors. However, doctors usually need to make medical decisions within a short period of time. Therefore, this study aimed to develop a decision support system to help monitor inpatient services' financial risks under the DRG payment system. It's expected that not only may the decision support system help quantify probable financial risk of each DRG service quickly and precisely, but also will propose appropriate approaches to reducing financial risk through identification of problematic expense items.
This study developed the decision support system of its own, which used Visual Basic 6.0 as the front-end system developing tool and Microsoft Access 2003 as the database management system under Windows XP. The financial risk assessment mechanism uses claims data as modeling base of a regional teaching hospital's inpatient services between 2002 January and 2004 July (37,031 cases). Based on the Bureau of National Health Insurance's second version DRG coding algorithms, the system converses ICD-9 codes into DRGs and computes corresponding reimbursement fees. Then, it computes the difference (ΔR) between actual medical expense (R') and DRG reimbursement (R), and calculates the ratio of the difference to the DRG reimbursement (ΔR/R), which serves as the comparison basis among doctors and between any doctor of interest and the benchmarker. Briefly, when ΔR is positive, it means the service provided generates profits; otherwise, it incurs a loss.
The proposed decision support system is expected to help doctors better understand what the financial risk might be for any specific DRG service. It provides doctors with financial risk indicators and corresponding expense items based on historical data to serve as reference for potential expense control. After admitting a patient, the doctor proceeds query analysis by inputting a DRG code and his/her doctor ID code, and then the system will generate relevant information such as hospital-wide all-DRGs inpatient financial risk, and financial risks for specific DRG, or specific doctor of concern and his/her benchmarkers (99th percentile, 75th percentile, and 50th percentile). Relevant suggestions of potential expense control are provided.
The developed system is expected to improve the concept of financial risks for health care providers. It is also expected to reinforce the expense control mechanism through the direct participation of health care team members in financial risks monitoring activities.

並列關鍵字

inpatient services ； diagnosis-related groups ； financial risk ； risk monitor ； decision support system

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