Taking a DRG payment system reform pilot city in China as a research sample, we empirically analyzed the changes in the number of cases, the composition ratio of each DRG group under the same ADRG group before, after the implementation of DRG. Interrupted time series analysis was performed in the DRG group with severe comorbidities or complications. The results showed that there were upcoding behaviors in hospitals of the pilot city, which must be regulated. We can strengthen the training, learning of medical record, diagnostic coding, ensure the healthy operation of DRG
Key words
DRG payment /
upcoding /
medical insurance supervision
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References
[1] BERTA P, CALLEA G, MARTINI G, et al.The effects of upcoding, cream skimming and readmissions on the Italian hospitals efficiency: a population-based investigation[J]. Economic Modelling, 2010, 27(4): 812-821.
[2] Coustasse A, Layton W, Nelson L, Walker V. UPCODING MEDICARE: IS HEALTHCARE FRAUD AND ABUSE INCREASING? Perspect Health Inf Manag.2021 Oct 1;18(4):1f.
[3] Phillips & Cohen “Upcoding & Unbundling: Healthcare Medicare Fraud.” [EB/OL].Fighting for Whistleblowers for 30 Years.2018 https://www.phillipsandcohen.com/upcoding-unbundling-fragmentation/.
[4] Geruso M, Layton T. Upcoding: Evidence from Medicare on Squishy Risk Adjustment. J Polit Econ.2020 Mar;12(3):984-1026. doi: 10.1086/704756. Epub 2020 Jan 29.
[5] 黄昊,张丽,王颖,等.主要诊断选择对DRG入组和权重变化的影响[J] . 中华医院管理杂志,2020,36(02): 108-112.
[6] 方金鸣,刘玲,彭义香,等.DRG支付下典型病组的低码高编和医疗资源消耗分析[J].卫生经济研究,2022,39(04):33-36.
[7] Schaffer A L, Dobbins T A, Pearson S A.Interrupted time series analysis using autoregressive integrated moving average (ARIMA) models: a guide for evaluating large-scale health interventions[J]. BMC Medical Research Methodology,2021,21(1).
[8] Fretheim A,Zhang F,Ross-Degnan D,et al.A reanalysis of cluster randomized trials showed interrupted time-series studies were valuable in health system evaluation[J].J Clin Epidemiol, 2015,68(3):324-333.
[9] 张静秋,江芹,郎婧婧,等.DRG付费改革的医院实施效果对照研究[J].中国卫生经济,2021, 40(07): 44-47.
[10] Silverman E, Skinner J.Medicare upcoding and hospital ownership[J].Journal of Health Economics,2004, 23(2): 369-389.
[11] Simborg D W.DRG creep: a new hospital-acquired disease[J].N Engl J Med,1981, 304(26): 1602-1604.
[12] 李伶俐,吴佩佩,姚奕婷,等.C-DRG收付费制度下的医院医保管理实践与思考[J].中国卫生经济,2019, 38(12): 21-22.
[13] 周吴平,简伟研.以智能审核应对DRG高靠分组问题[J].中国医疗保险,2022(06):44-47.
