CAJ | 학술논문

目的:弄清综合性医院普外科手术病人的医疗费用构成及不合理费用现况.方法:随机抽取上海某区六家医院普外科手术病历779份,采用双人检查法,以临床诊疗路径及相关医政、医保法律法规为依据,对住院费用清单及病历记录进行逐项检查,统计医疗费用构成及不合理费用的特点.结果:五种手术医保基金支付的费用占总费用的平均比例为82.72%±12.95%.不合理费用占医保基金支付费用的平均比例为12.61%±10.10%.不合理费用均值为1479±2225元.术前阶段,不合理化验频次及金额居前,分别为:3.02±2.81次、173±218元;术后72小时内,不合理用药和不合理收费频次及金额居前,分别为:2.53±1.79次、584±570元和2.90±1.94次、251±455元;术后72小时至出院阶段,不合理用药频次及金额居前,分别为:1.91±2.21次、754±1681元.比较不同医院间不合理费用占比发现,最高为17.21%±11.23%,最低为2.96%±4.69%,差异有统计学意义.结论:医疗保险监管应在规范医疗行为中区别病种、不同环节与不同医院,增强监管的针对性.
목적:롱청종합성의원보외과수술병인적의료비용구성급불합리비용현황.방법:수궤추취상해모구륙가의원보외과수술병력779빈,채용쌍인검사법,이림상진료로경급상관의정、의보법율법규위의거,대주원비용청단급병력기록진행축항검사,통계의료비용구성급불합리비용적특점.결과:오충수술의보기금지부적비용점총비용적평균비례위82.72%±12.95%.불합리비용점의보기금지부비용적평균비례위12.61%±10.10%.불합리비용균치위1479±2225원.술전계단,불합이화험빈차급금액거전,분별위:3.02±2.81차、173±218원;술후72소시내,불합리용약화불합리수비빈차급금액거전,분별위:2.53±1.79차、584±570원화2.90±1.94차、251±455원;술후72소시지출원계단,불합리용약빈차급금액거전,분별위:1.91±2.21차、754±1681원.비교불동의원간불합리비용점비발현,최고위17.21%±11.23%,최저위2.96%±4.69%,차이유통계학의의.결론:의료보험감관응재규범의료행위중구별병충、불동배절여불동의원,증강감관적침대성.
Objective to identify the medical cost structure and unreasonable expenditure of general surgery inpatients among general hospital. Method Randomly selected 779 inpatients’ medical records from six hospitals in Baosian district Shanghai, and used the double check method to check the List of hospitalization record and it’s cost, and to describe the characteristics of medical expenditure structure and unreasonable charge, on the basis of clinical treatment path and associated medical, insurance laws and regulations. Result Five kinds of operation of medical insurance fund occupied 82.72%± 12.95% of the total cost. Unreasonable expense accounting for the health insurance fund to pay the cost of the average ratio was 12.61%± 10.10%. The mean value of unreasonable cost was 1479 ±2225 Yuan. In preoperative stage, unreasonable test frequency and cost are in the forefront, as 3.02 ±2.81times, 173 ±218 Yuan;during the 72 hours after the operation, irrational drug use and the unreasonable charge frequency and costs are in the forefront, as 2.53±1.79times, 584±570Yuan and 2.90±1.94times, 251±455Yuan, beyond 72 hours after the operation, irrational drug use frequency and costs are in the forefront, as 1.91±2.21times, 754±1681Yuan. When comparing the ratio of unreasonable costs among six hospitals, the highest is 17.21%±11.23%, and the lowest is 2.96%±4.69%. The difference was statistically significant. Conclusion Medical insurance supervision should regulate doctors’ behavior based on different links, various diseases and hospitals, to strengthen the pertinence in supervision.