Tw-DRGs 4.0實施對某區域醫院敗血症醫療費用之影響

The Impact of the Implementation of Tw-DRGs 4.0 on the Sepsis Inpatients at a Regional Hospital

近年來健保署陸續實施的400多項DRGs，已對醫院財務及管理造成衝擊，為了解Tw-DRGs 4.0實施之敗血症DRG對醫院申報費用的影響，本研究除試算個案醫院與之前3.4版之差異外，且進一步分析不同主治醫師間藥費支出對醫療費用之影響。本研究蒐集北部某區域醫院1,035名敗血症病患之住院醫療費用清單明細檔，採次級資料回溯研究及進行統計檢定。研究發現Tw-DRGs 3.4版之DRG41601之給付費用（佔總案件數96.9％），醫院原本虧損9,504,428元，而採用Tw-DRG 4.0版後，醫院減少虧損至2,475,277元；若加上Tw-DRGs 4.0版敗血症病危和死亡患者採核實申報，醫院給付比Tw-DRGs 3.4版增加2,973,048元，則醫院整體給付費用反由虧轉盈。另比較不同主治醫師間藥費支出發現：DRG 41601及41603在統計上均有顯著差異（p＜0.002；p＜0.006），且Scheffe事後檢定亦顯示個別主治醫師之藥費支出顯著影響醫療費用。本研究發現實施4.0版敗血症DRGs，對個案醫院申報費用較有利，其虧損費用可大幅減少6,835,826元，且主治醫師若能減少藥費支出，有利敗血症病患醫療費用控管。故建議健保署在導入新的DRGs項目時，應審視疾病嚴重度，給予不同DRG給付，以利往後DRG新項目之順利推行。而各級醫院應加強病歷書寫及診斷編碼，並有效管控藥費支出，以平衡醫療品質和成本管理，以達永續經營目的。

In recent years, National Health Insurance (NHI) launched, one after another, more than 400 items in total of DRGs, which have apparently affected hospitals’ financial affair and management. To explore the impact on sepsis inpatients’ hospital reimbursement ex-penses by the DRG4.0, this study not only compared the payments with those under the former version 3.4, but also further analyzed the drug expense differences among various attending physicians that affected the overall medical payments. We collected 1,035 sepsis inpatients’ detailed medical expense records from a regional hospital in northern Taiwan between January 1, 2017 and June 30, 2019. This retrospective study of secondary data was done by using Excel Pivot Table, Paired Sample t-test, and One-way ANOVA. Comparing the payments of Tw-DRGs 3.4 and 4.0, it was found that the hospital orig-inally lost NT$9, 504,428 in DRG 41601 (96.9% of all cases) under the version 3.4, but the loss was reduced to NT$2,475,227 in the version 4.0. In addition, the critically ill and dead patients paid by fee for service in the Tw-DRGs 4.0, and its payment was increased by NT$2,973,048. Overall, the hospital’s NHI expenses turned from loss to surplus. Lastly, the attending physicians’ drugs expenses had a significant statistical difference in DRG 41601 and DRG 41603 respectively (p<0.002; p<0.006), and the Scheffe posterior test results also showed that drug expenses of different attending physicians significantly affected their re-spective medical payments. We found out this very hospital would favor the sepsis DRGs 4.0 because its loss could be greatly reduced by NT$6,835,826, and the medical expenses could be better controlled if attending physicians managed their drug usage more appropriately. Therefore, we’d like to recommend that when the NHI administration is introducing new DRGs, it will have to review the disease severity based on the number of comorbidities or complications, and to assign different DRGs payments to fulfill the future phase-in implementation. Concurrently, the hospitals of various levels should all strengthen their medical record writing and coding skill, and medical expense control to effectively reach an ideal balance between medical quality and cost management for achieving everlasting NHI sustainability.