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研究生:林玲珠
研究生(外文):Ling-chu Lin
論文名稱:東區區域級以上醫院於台灣版DRGs權重公告前後呼吸系統疾病群變化分析
論文名稱(外文):The changes analysis of the respiratory system disease pattern inthe hospital of the east district area of Taiwan during Taiwan’s DRGs weight announcemen
指導教授:朱正一朱正一引用關係
學位類別:碩士
校院名稱:慈濟大學
系所名稱:公共衛生研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
畢業學年度:94
語文別:中文
論文頁數:101
中文關鍵詞:高報代碼疾病分類診斷關聯群
外文關鍵詞:ICD-9-CM codingUpcodingDRGs
相關次數:
  • 被引用被引用:10
  • 點閱點閱:372
  • 評分評分:系統版面圖檔系統版面圖檔系統版面圖檔系統版面圖檔系統版面圖檔
  • 下載下載:58
  • 收藏至我的研究室書目清單書目收藏:3
此制度,積極提升疾病分類員的地位,採購代碼選取的輔助軟體,以避免遺漏重要的疾病分類碼造成收入的損失。文獻顯示美國在DRGs 支付制度正式實施前,醫院申報的疾病群產生改變,支付費用較高的疾病群件數有明顯上升的趨勢。美國聯邦政府評估實施DRGs 後的影響,亦發現醫院的疾病代碼有取巧行為造成錯誤的支付,因此要求審查機構透過檔案分析與專案研究,針對容易造成不當支付的高風險DRGs 指標列為審查重點。
本研究目的為探討我國即將實施DRGs 前的疾病群的變化。以東區區域級以上醫院因MDC 4呼吸系統疾病住院個案為研究對象,分析2003 年至2004 年台灣版DRGs 權重公告前後高風險DRGs、病例組合指標、次診斷數、平均住院日等變項,於不同醫院層級、科別的件數與佔率之年度差異。研究資料採用醫院申報健保局的「住院醫療費用清單明細檔」資料,經健保局提供的第二代醫療資訊服務系統轉換DRGs 碼。經描述性與分析性統計分析,結果顯示區域醫院無論在高風險DRGs、病例組合指標、次診斷數、平均住院日等變項,2003-2004 年前後差異分析皆達顯著;醫學中心則除了高風險DRG79(呼吸道感染)呈顯著下降外,其他皆無顯著改變;科別分析結果顯
示胸腔內科與一般內科於病例組合指標、次診斷數、平均住院日之2003-2004 年度差異亦皆達顯III著;高風險DRGs 中僅胸腔內科的DRG87(呼吸衰竭)及一般內科的DRG475(使用呼吸器的診斷)達顯著差異。由以上研究結果顯示,DRGs 權重公告後東區區域醫院的疾病群的確有顯著的改變。
本研究建議健保局於即將實施DRGs 支付制度前,應提早建立完整的審查制度,且健保總局下的各分局亦應同步提昇檔案分析的能力。未來健保局對於審查規劃,除了設定高風險DRGs 指標之外,應考量不同層級與屬性醫院間的差異,於參考國外實施多年的經驗同時,應思考我國已實施多項給付制度的特殊環境。對於醫院的因應作業,本研究建議以落實病歷診斷書寫的品質及遵循疾病分類編碼準則為首要工作,唯有臨床醫師將所有耗用醫療資源的診斷完整記錄,且疾病分類員能提供正確的代碼,達到病歷內容與申報資料一致,才能因應健保局的審查作業並為醫院爭取最大的利益。
The aging of populations and the continuing development of medical technology have caused
an increase in the cost of medical care services in many countries that have implemented national health insurance, including Taiwan. In July of 2002, the National Health Insurance of Taiwan implemented a global budgeting system for all hospital payments. It was hoped that such a system would control the growth of medical expenses within a certain expected range.However, in the absence of reasonable
payment bases and effective utilization management and control mechanics, the outcome of implementing this new payment system has been difficult to measure. Therefore, the National Health Insurance (NHI) studied the possibility of implementing DRGs (diagnoses related groups) for all in-patient payments in 2006.
The new payment system had an immense impact on the insured, the insurers, and the medical
service providers. Hospitals responded by purchasing auxiliary software that minimized the “miscoding”of a patient into a DRG that might result in a loss of income. In fact, the experience of the American DRGs (implemented in 1983) revealed changes in disease patterns were happening even before the introduction of DRGs. High paid DRGs exhibited significant upward trends. The Federal government investigated the impact of the DRGs and found the situation of creeping which caused payment errors.
Consequently, through file analysis and special projects, high-risk DRGs were reviewed.
This research aims at analyzing the change of disease patterns in regional hospitals and one
medical center in eastern Taiwan from 2003 to 2004, during the DRGs announcement period. We will use hospital claimed data to study the index of MDC 4 respiratory system, the index of complication and comorbidity,average of coding number, average length of stay, and case-mixed index to see if there has been a significant variance among different levels of hospitals and departments.
The study found the impacts varied in hospitals with different characteristics. The regional
hospitals had significant differences in the respiratory system disease pattern and CMI from 2003 to 2004 during the DRGs announcement. The medical center had no significant difference, except in high-risk DRG79.
Foreseeing the coming of DRGs, all of hospitals should improve the quality of medical
records, expedite the quality of coding, and monitor the high risk DRGs. NHI should pay attention to the different kinds of hospitals impacts and consider our country have implemented multiple payment system.
Futhermore, establishing a system of evaluation and quality control would improve the accuracy of claim ICD-9-CM code and reduce the payment error.
第一章 緒論-------------------------------------------------------------------------1
第一節 研究緣起------------------------------------------------------------------1
第二節 研究目的------------------------------------------------------------------4
第三節 名詞解釋------------------------------------------------------------------5
第二章 文獻探討---------------------------------------------------------------------8
第一節 診斷關聯群DRGs 與疾病分類-------------------------------------------------8
第二節 疾病統計與呼吸系統架構---------------------------------------------------13
第三節 美國實施DRG 影響與我國論病例計酬現況-------------------------------------16
第四節 台灣DRGs 版本與應用------------------------------------------------------28
第五節 疾病分類品質-------------------------------------------------------------30
第三章 研究方法--------------------------------------------------------------------33
第一節 研究架構-----------------------------------------------------------------33
第二節 研究假說-----------------------------------------------------------------34
第三節 資料來源與處理-----------------------------------------------------------35
第四節 資料分析-----------------------------------------------------------------39
第四章 研究結果--------------------------------------------------------------------40
第一節 DRGs 的基本資料統計------------------------------------------------------40
第二節 高風險DRGs 資料描述性統計------------------------------------------------46
第三節 資源耗用相關指標之描述性統計表-------------------------------------------53
第四節 高風險DRGs 與各層級各科別年度分析性統計----------------------------------56
第五節 疾病嚴重度相關指標與各層級各科別年度分析性統計---------------------------62
第五章 討論與建議------------------------------------------------------------------64
第一節 監測高風險DRGs 於我國的適用性--------------------------------------------64
第二節 病例組合指標值CMI 醫療費用與編碼相關探討---------------------------------72
第三節 次診斷數於層級間差異分析及編碼準則---------------------------------------74
第四節 平均住院日上升的相關因素-------------------------------------------------76
第五節 建議---------------------------------------------------------------------77
第六節 研究限制-----------------------------------------------------------------83
參考文獻---------------------------------------------------------------------------84
附錄一、MDC 4 呼吸系統主診斷件數統計表-----------------------------------------附錄一
VII
表目錄
表2.4.1、2002-2004 年各層級醫療院所CMI 值 -----------------------------------------29
表3.3.1、高風險單一DRGs-----------------------------------------------------------36
表3.3.2、高風險成對DRGs-----------------------------------------------------------37
表3.3.3、高風險合併症群組DRGs-----------------------------------------------------37
表4.1.1、MDC4 呼吸系統2003-2004 年各DRG 件數統計-----------------------------------41
表4.1.2、MDC4 呼吸系統2003—2004 年權重統計表--------------------------------------43
表4.1.3、MDC 4 呼吸系統高權重之DRG 統計表------------------------------------------44
表4.1.4、MDC4 呼吸系統各層級與各科件數統計表---------------------------------------45
表4.2.1、MDC4 呼吸系統高風險單一DRGs 件數差異率------------------------------------46
表4.2.2、MDC 4 呼吸系統各層級高風險單一DRGs 件數差異率-----------------------------46
表4.2.3、MDC 4 呼吸系統之高風險成對DRGs 件數統計表---------------------------------47
表4.2.4、MDC 4 呼吸系統各層級高風險成對DRGs 件數統計表-----------------------------48
表4.2.5、MDC 4 呼吸系統高風險合併症群組DRGs 件數統計表-----------------------------49
表4.2.6、MDC 4 呼吸系統各層級高風險合併症群組DRGs 件數統計表-----------------------50
表4.2.7、MDC 4 呼吸系統各科高風險DRG 件數統計表------------------------------------51
表4.3.1、MDC 4 呼吸系統各層級與各科CMI 統計表--------------------------------------54
表4.3.2、MDC 4 呼吸系統各層級與各科次診斷數統計表----------------------------------55
表4.3.3、MDC 4 呼吸系統各層級與各科平均住院日數統計表------------------------------55
表4.3.4、MDC 4 呼吸系統各層級與各科件平均費用統計表--------------------------------55
表4.4.1、醫學中心與區域醫院之高風險單一DRGs 與年度卡方分析表----------------------56
表4.4.2、醫學中心與區域醫院之高風險成對DRGs 與年度卡方分析表----------------------57
表4.4.3、醫學中心與區域醫院之高風險合併症群DRGs 與年度卡方分析表------------------58
表4.4.4、醫學中心與區域醫院之高風險單一DRGs 與年度卡方分析表----------------------59
表4.4.5、醫學中心與區域醫院之高風險成對DRGs 與年度卡方分析表----------------------60
表4.4.6、醫學中心與區域醫院之高風險合併症群DRGs 與年度卡方分析表------------------61
VIII
表目錄(續)
表4.5.1、MDC4 呼吸系統各層級之CMI、診斷數、平均住院日與年度之分析-----------------62
表4.5.2、MDC4 呼吸系統各科CMI、診斷數、平均住院日與年度之分析---------------------63
圖目錄
圖3.1.1、依醫院及科別分析其年度差異之研究架構-------------------------------------33
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85
黃于珊、施驊真 (2004),疾病分類品性與效率;病歷管理期刊,4(2) : 58-64。
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魏秀美(2004),某醫學中心申報與疾病分類一致性研究;陽明大學醫務管理研究所碩士論文。
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溫信財(2005),中央健康保險局委託研究計畫DOH94-NH-1003;建立本土版之DRGs 疾病分類準

溫信財、潘德樑、謝惠閔、徐均宏(2004),美國ICD-9-CM 編碼指引之介紹;病歷管理期刊,4(2):
67-102。
溫信財(2005),疾病分類編碼與診斷關係群(DRGs)-美國之經驗;病歷管理期刊,5(1):46-54。
溫信財(2005),Government Insurance Oversight in the United States. DRGs 制度之因應研討會,台北
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鄭茉莉等(2004),ICD-9-CM 分類彙編(修定版),台灣病歷管理協會。
86
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行政院衛生署(2004),全民健保與醫療品質,二代健保規劃叢書系列-4。
第四次健保局支付委員會會議(2002.10),擴大實施論病例計酬項目草案。
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Peer Review Organization for Indiana and Kentucky.
Health Care Excel (1999). The Payment Error Prevention Program,DRG Validation.The Medicare Peer
Review Organization for Indiana and Kentucky.
Health and Human Services(1999.6). Office of Inspector General,Targets Hospitals in Septicemia
Upcoding ,www.dhhs.gov/progorg/oei/whatsnew.html.
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