Analysis of differences and similarities in the grouping of inpatient cases by DRG grouping for medical insurance payment and performance evaluation of a province
10.3760/cma.j.cn111325-20240529-00437
- VernacularTitle:某省医保支付与绩效评价DRG分组器对住院病例分组的异同分析
- Author:
Yan XU
1
;
Sai HE
;
Lin CAI
Author Information
1. 云南省第三人民医院病案统计科，昆明 650011
- Publication Type:Journal Article
- Keywords:
Diagnosis related groups;
Relative weight;
Primary diagnosis;
Ambiguity group;
China healthcare security diagnosis related groups
- From:
Chinese Journal of Hospital Administration
2025;41(3):229-233
- CountryChina
- Language:Chinese
-
Abstract:
Objective:To compare and analyze the inpatient case grouping results of the medical insurance payment DRG grouping based on CHS-DRG (the medical insurance grouping) and the medical quality performance evaluation DRG grouping (the performance grouping), providing references for hospitals to carry out DRG application practice.Methods:Hospitalized cases were selected from a tertiary hospital in Yunnan Province that completed medical insurance settlement in December 2023. Their medical record homepage data were upload to the medical insurance grouping and the performance grouping respectively. Two DRG grouping results were obtained. The grouping weights, surgical operation grouping, and ambiguous group cases were compared and analyzed.Results:3 053 cases were included. The DRG weight of medical insurance payment was positively correlated with the DRG weight of performance evaluation ( rs=0.57, P<0.001), and the DRG weight of performance evaluation was generally higher than that of medical insurance payment ( Z=-25.49, P<0.001); Compared with the medical insurance grouping, the performance grouping generated fewer surgical groups and more operational and internal medicine groups (χ 2=7.01, P=0.030). The consistency of surgical operation grouping between the two groupings was high ( K=0.78, P<0.001), but the surgical operation groups of 111 patients were inconsistent. The medical insurance grouping generated 104 ambiguous cases, while the performance grouping generated no ambiguous cases. Conclusions:There was a certain difference in the grouping results between the two DRG grouping. Medical institutions should coordinate the handling of differences in grouping weights, surgical operation grouping, and ambiguity groups among different DRG grouping, strengthen the review and quality control of medical record front pages, and achieve collaborative win-win outcomes for different management goals.
