摘要
研究目的:
改革开放以来,我国医疗卫生行业高速发展,医疗服务机构、医疗服务技术、医疗服务质量都得到显著的发展。但另一方面,医疗费用大幅增长,由此造成的消费支出畸形结构妨碍了国民经济的正常发展,引起民众的诸多不满。如何按照科学发展观,缓解看病贵的现象是构建和谐社会的重要内容。
本研究旨从卫生经济学视野,分析不同支付方式下医疗服务提供者的行为特征,从支付方式角度探讨医疗费用上涨的原因;探询利用出院病历首页进行病例组合的方法;在此基础上,结合当前医院财务收入现状和未来医疗卫生改革的方向,初步病例费率测算的方法,冀望能给相关领域的改革提供帮助和建议。
研究方法:
采用定性与定量相结合的方法,通过文献研究,从微观经济学的角度,用实证经济学分析方法和区域比较竞争理论,分析、比较不同支付方式下医院的行为特点;资料收集采用判断式抽样方法;用Oracle软件建立病例数据库和病例分组筛选库;资料处理和分析采用描述性分析法、比较分析法、单因素分析法、多因素分析法、多元逐步线形回归分析法;用循证医学的方法和专家咨询法,结合统计分析的结果,用SAS8.0软件进行病例组合,采用ROC曲线、变异系数、Kruskal-Wallis等非参数检验方法验证结果;病种费率研究采用管制经济学和卫生经济学分析方法。
研究内容:
本文围绕DRGs预付费制实行的必要性、可行性及病种费率测算方法开展探讨和研究,主要内容包括:不同支付方式下医疗服务提供者的行为特点,重点对比分析按医疗服务项目付费和诊断相关组合预付费制两种支付方式下医疗服务供方行为以及医疗服务价格;利用出院病历首页资料,对剖宫产、股骨骨折等16种常见疾病进行病例组合;遵循诊断相关组合预付费制和相关经济学的原理,结合我国医院收支实际情况,制定兼顾政府、医疗机构及患者三方利益的病种费率测算方案。
主要研究结果:
医疗服务领域的特殊性,以及利益机制的作用,各种医疗费用支付方式均不能使医疗服务提供方的价值取向与管制者完全一致;不同支付方式给医疗服务提供者产生不同的经济诱因,导致不同的经济后果,支付方式改革是抑制医疗费用快速增长的治本措施之一。没有一种医疗费用支付方式是完美无暇的,管制者必须针对不同时期医疗卫生领域凸现的主要矛盾,采用不同组合方式的多层次、混合支付体系,才更有利于消除单一支付体系的负面效应而保留综合优势。诊断相关组合预付费制适用于基本医疗服务领域,能有效抑制医疗费用的通胀。
统计分析表明影响住院费用的主要因素有:手术类型、首要诊断及重要的次要诊断、并发症合并症或重要并发症合并症、年龄、医疗保险类型等。86415份合格病例分成97个病种组合。各主要诊断类目中,R2值最大为0.37,最小为0.02,8个类目的R2值大于0.1,平均值为0.11;不同病种组合ROC曲线存在区别,各组之间的费用有差异,分组节点选取合理;所有病种组合的Kruskal-Wallis检验结果均为P<0.0001,组合间费用差异有统计学意义;组合中,80个病种组合的变异系数小于1,占总组合数的84.21%,其中CV最小为28.65%,最大为199.01%,显示组内同质性较好。病例组合满足组内临床特征及资源消耗相似,组间资源消耗存在差别,各组合间病例没有重复的分类原则,说明本研究的分组是合理的。同时,病例组合既充分尊重临床专家的建议,又不违背数理统计的原则,结果更易于被医生接受。
过渡期内,测算基于住院费用的病种费率可作为一种次优选择。本研究以地区标准平均费用、医院惯例平均费用为费率测算基数,并以财政拨款的增量和住院费用价格指数作为费率调节因子,计算病种费率。经检验,22所医院中,预测医疗收入与实际收入误差最大为28.32%,最小为0.03%;误差小于10%的医院有17所,占医院总数的77.27%;整体误差合计6.49%。说明病例组合及费率测算公式是合理的。同时,假设性检验显示,费率测算公式能将国家财政拨款等宏观经济政策与病种费率的调节有机地结合起来。
政策建议:
综合研究成果,提出以下政策建议:在基础医疗服务领域引入诊断相关组合预付费制,按《价格法》要求组织卫生行政主管部门、医疗机构、医疗保险机构、患者通过听政程序,共同制定病种费率。针对我国医院信息化建设参差不齐、病案质量不高的现状,应分地区、从常见病入手逐步推行诊断相关组合预付费制,并设立过渡期,一方面使医院转变经营方式,另一方面管制者可收集足够的相关信息,按价格学的原理制定病种费率。统一医疗信息的标准和规范,改变分散管理、自成体系,信息缺漏或交叉重叠的信息管理格局,形成统一的、专业化的信息网络,确保信息质量的不断提高。卫生行政管理当局要严格制定首要诊断确认的标准,严格院际间转院程序和出、入院标准,控制推诿危重病人现象的发生。此外,还可通过死亡率、病种结构、医疗业务收支状况等指标防范各种“逆向选择”和“道德风险”的发生。
研究创新:
本研究以医疗服务费用支付方式及其特点为切入点,用新古典经济学和区域比较竞争理论,着重分析了按医疗服务项目付费和诊断相关组合预付费制方式下医院的行为特点,这在国内同类研究中较为罕见。将定量与定性研究相结合,针对我国医院管理水平现状,对原有病例组合方法进行改进,建立并发症、合并症及重要并发症、合并症筛选字典库和排除字典库,建立手术操作分类编码字典库,明确相应分组节点定义,为今后相关研究提供了参考和借鉴。将诊断相关组合预付费制费率制定的原理与我国实际相结合,提出兼顾政府、医疗机构和患者三方利益的病种费率测算方案,相对原有方法和理论提出的改进观点:一是按各病种组合住院费用的各类费用构成,采用加权平均的方法确定病种费用均值,增加例均费用的代表性;二是设置过渡期,以地区基准费率和医院惯例标准平均费用测算医院基准费率;三是增加基准费率调节因子,切实体现国家财政增量投入在平抑医疗费用中应有的作用。
Objectives and Significance
Since implementing the reform and open policy, China’s health industry has been developing at top speed, medical establishment, medical technology and medical quality all made rapid progress. But health expenditure and health price increase sharply, it leads to the occurrence of lopsided consumption and affects the development of national economy. Plebes are discontented with the rise in health care. Stabilizing health price complied with the scientific developing philosophy is a crucial ingredient to build a harmonious country.
Based on the health economic analysis of providers’behavior characteristics in Various payment systems, the aims of this study are as follows: firstly, to find out the reasons for the rise in health price; secondly, to draw up genuine case-mix plans of DRGs using medical record information available in China; thirdly, integrating hospital present financial situation with the conceivable reform tendency, to explore the theories and methodologies on computing DRGs payment rates, and try to give advice and references on health reform.
Research Methods
Qualitative and quantitative approaches were applied in this study. Use the elementary theories and models in the fields of positive economics, new classical economics and information economics to compare providers’behavior in various payment systems. Judgmental sampling was used to collect data. Set up case database and filter database with Oracle software. Descriptive analysis, comparative analysis, single-variable statistic analysis, multi-variable analysis, multiple linear regression analysis were adopted when analyzing case data. Evidence based medical method and qualitative interview were adopted to mix cases with SAS8.0 software. Receiver operating characteristic curve, the value of coefficient variable and Kruskal-Wallis test were used to verify the result of case-mix. Compute DRGs payment rates with the theories and methods of the economics of regulation and health economics.
Research Contents
The main content of this study includes:
1. The difference between providers’behavior characteristics in different payment systems, placing emphasis on the distinction between fee-for-service payment system and prospective payment system;
2. The necessity and feasibility of applying DRGs-PPS in the general health care;
3. The case-mix plan with the front pages of the inpatient medical records, which limited 16 regular diseases;
4. The method of formulate DRGs payment system rates according the related economic rules, which should conform to China’hospital financial situation as well as balance rights and interests amongst government, health care insurance agents and patients.
Main Results
Because of the peculiarity of health industry and profit motive, providers’orientation is distinction from administrative agency’s all the while. Various payment systems create powerful incentives upon to the behavior of providers. Each payment system regulates and directs medical behavior of providers and results in different financial outcomes and then differences will be occurred in cost containment, resources allocation as well as quality. None of payment systems is perfect, administrative agency should adopt a multilevel and mixed payment system to solve the main embarrassments in various health care. It would utilize the merts of payment systems and avoid the negative effects caused by single payment system. DRGs-PPS is fit for general health care, its prominent virtue is what check the health care expense inflation.
Statistic results indicate that hospitalization charge is mostly decided by procedures, primary diagnoses, complications and comorbidities, ages and payment system. 86415 eligible cases were classified in 97 groups. Among 14 major diagnosis categories, the maximum R2- value is 0.37, the minimum R2- value is 0.02, 8 major diagnosis categories R2- value are above 0.1, average R2- value is 0.11. The receiver operating characteristic curve is quiet distinctive in a major diagnosis category, which shows grouping nodes are reasonable. P- value are below 0.0001 in Kruskal-Wallis test, which demonstrates inpatients in different groups are heterogeneous. The values of variance coefficient are below 1 in 80 groups, it indicates cases in the same group are homogenous. The result demonstrates that the patients in the same group have the same pattern in clinical condition and health resources consumption. Patients in different groups are different in health resources consumption. In addition, this classifying method complies with the principle that there should not be repeated cases among different groups. Consequently, the case-mix scheme in this study is reasonable. Furthermore, the case-mix scheme combines the statistic results and clinical experts’suggestions, thus, it would be more acceptable.
During transition period, the computing DRGs payment rates bases on hospitalization charges is a second-best optimization. This study brings forward a formulation that DRGs payment rates could be calculated on the basis of both the area standardized average of hospitalization charge and hospital customary average of hospitalization charge, moreover use incremental financial allocation and hospital price index as adjusting multipliers. Having verified, the average error rate is 6.49%, the maximum error rate is 28.32%, the minimum error rate is 0.03%. It demonstrates the case-mix scheme and the formulation of DRGs payment rate are reasonable. Furthermore, hypothesis calculation suggests the formulation can reflect the macro-economic policies.
Policy Recommendations
On the basis of results, put forward recommendations as follows:
1. Payment system’s reform is an important measure to reduce health price administrative agency should introduce DRGs-PPS to general health care.
2. According to Price Law, the competent authorities call providers, health care insurance agents and patients’delegates together to set DRGs payment rates through public rate hearing.
3. The development of hospital information systems is uneven, inpatient medical records are not full and clear, therefore DRGs prospective payment system could be adopted to pay the charge of regular diseases firstly. In addition, payment system’s reform would pursue by region.
4. Set a period of transition, so that providers could adapt themselves to the new payment system, governors could collect sufficient cost information. After transition, DRGs payment rates computed on the basis of operating costs and average investment income rate.
5. Standardize medical information, changing the current information managing model which is scattering and self-deciding. Establish a unified and professional managing model in order to let information flow with high fidelity and smoothly.
6. Health competent authorities lay down related standards strictly, which includes the primary diagnosis, the standard of admittance to hospital, the standard of leaving hospital and the standard of transferring. In addition, authorities could monitor and control mortality, the structure of diseases and medical incomes in order to prevent providers’moral hazard and adverse selection.
Innovation points in this study
1. Use the elementary theories and models in the fields of new classical economics and the theory of yardstick competition to compare providers’behavior in various payment systems.
2. According to AP-DRGs and advise of clinical experts, estabalish the data-bases of diagnoses defined as major complication or comorbidities, complication or comorbidities, and operation.
3.Make a thorough study on the hospitalization charge structure of each DRGs. On the basis of analysis, calculate the weighted average hospitalization charge, in that, the DRGs payment rates are more representative.
4.Combine the principle of prospective payment system based on DRGs with hospital financial situation, the formulate balance rights and interests among government, health care insurance agents and patients.
引文
[1]陈佳贵,王延中.中国社会保障发展报告.北京:社会科学文献出版社,2004.45-47.
[2]杜乐勋,张文鸣,张大伟.中国医疗卫生事业发展报告.北京:社会科学文献出版社,2004.45-48.
[3]卫生部统计信息中心.国家卫生服务研究系列报告之一:中国卫生服务调查研究——2003年第三次国家卫生服务调查分析报告.北京:中国协和医科大学出版社.2004.1-78.
[4]国家统计局:《中国统计摘要--2004》.北京:中国统计出版社. 2004.
[5]吴敬琏.中国政府在市场经济转型中的作用[J].河北学刊,2004,24(4):39-46.
[6]虞云耀.社会主义和谐社会的基本特征[J].前线,2005(4):6-8.
[7]卫生部.中国卫生服务调查研究[M].北京:中国协和医科大学出版社,2004.10-47.
[8]林仕威.谈谈医疗服务价格的监管调控[J].广西市场与价格,2001(11):30-32.
[9]赵郁馨,蔡仁华.中国卫生总费用研究报告(2004).北京:卫生部内部资料,2005.15-1.
[10]国家计委,卫生部.关于改革医疗服务价格管理的意见的通知.计价格(2000)962号,2000-7-20.
[11]周荣慧.北京地区部分护理服务项目价格与实际成本的对比与分析.护理管理杂志.2005,5(7):35-36.
[12]陈晓阳,刘则杨等.阑尾切除手术配合的护理成本核算方法研究.中国医院管理.2005,6(25):35-26.
[13]孟庆跃,郑振玉.医疗服务价格扭曲的测量及其分析.中国卫生资源.2003,6(9):225-227.
[14]孟庆跃.医疗服务价格政策中的假设和假设检验.中国卫生事业管理.2003,9:528-541.
[15]郑大喜.医疗服务价格调整与医疗费用控制的关系研究.医学与哲学.2005,26(9):14-18.
[16]陈宁姗,刘兴柱,董树山等.医疗服务收费中存在的问题及改革建议.卫生经济研究.1996,89(4):35-36.
[17]卫生部统计信息中心.卫生改革专题调查研究.北京:中国协和医科医学出版社,2004.56-57.
[18]郝模,章滨云,罗力等.上海市医疗费用“总量控制、结构调整”政策评价及思考课题概述.中国医院管理,2002,22(9):1-5.
[19]白常凯,章滨云,张勇等.医疗费用“总量控制、结构调整”政策与医院支付方式变化[J].中国医院管理,22(9):18-20.
[20]张馨.公共财政论纲[M].北京:经济科学出版社,1999.12-14.
[21]保罗·萨缪尔森,威廉·诺德豪斯.经济学(下)[M].北京:中国展望出版社,1992.135-137.
[22]赵杰.政府主导或是医疗市场化.瞭望新闻刊,2005,6(26):5.
[23]郑大喜.“灯塔经济”与医改的“穷人经济学”[J].医学与哲学,2006,27(8):14-17.
[24]杜乐勋.从看病贵看我国医疗收费价格的合理调控[J].中国卫生经济.23(6):5-8.
[25] John Black. Oxford Dictionary of Economics. Landon: Oxford University Press,1997.521.
[26]中华人民共和国价格法.北京:法律出版社,2002.10.
[27]林仕威.谈谈医疗服务价格的监管调控[J].广西市场与价格,2001,11:30-32.
[28] Paul J. Feldstein, Congressional Voting Behavior on Hospital Legislation: An Exploratory Study[J],Journal of Health Politics,Policy and Law,1984,8(4).
[29] Paul J. Feldstein. Health care economics[M],5th ed.Albany, New York:Delmar,1998.
[30]肯尼斯·阿罗.不确定性和医疗保障的福利经济学.比较,24:73-98.
[31] Gaynor,M..Issues in the Industrial Organization of the Marker for Physician Services[J].Journal of Economics and Management Strategy,1994,3(1):211-255.
[32] Holmstrom, Bengt. The Provision of Service in a Market Economy[M],New York:Cambridge University Press,1985.
[33] Zweifel,P. and Breyer. Health Economics[M],Oxford,U.K.:Oxford University Press,1997.
[34] Murthy N R V,Ukpolo V.Aggregate Health Care Expenditure in the United States:Evidence from Cointegration Test[J].Applied Economics,1992,26(8): 797-802.
[35]邓晨珂.不同支付方式对医疗费用的影响.食品与药品,2007,9(1):61-63.
[36] Shain,Max,and Milton I. Romer,Hospital Cost Relate to the Supply of Beds.Modern Hospital,1957,92:71-73.
[37] Sherman Folland,Allen C. Goodman,Miron Stano.The Economics of Health and Health Care[M].第三版.王健,孟庆跃译.北京:中国人民大学出版社,2004.525.
[38] Stephen M.Shortel,Arnold D.Kaluzn.Health Management (M).王健译.北京:北京大学出版社,2005.132.
[39]程晓明.医疗保险学[M].上海:复旦大学出版社,2003.8
[40] Josep, Figueras, Ray Robinson. Purchasing to improve health systems performance[M],Open University Press, Buckingham Philadephia,2005.
[41] Gordon, Margaret S. Social Security Policies in Industrial Countries. Cambridge: Cambridge University Press,1988.
[42] Smith, S.,et al., The next ten years of health spending:What does the future hold? Health Affairs,1998, (17):128-140.
[43]关朝红.几种医疗保险结算方式的分析比较.中国卫生事业管理,1999,5(131):235-236.
[44]李洪珍,庄雅稚.德国社会医疗保险制度介评.国外医学,2003,20(4):159-161.
[45] Sherman Folland,Allen C. Goodman,Miron Stano.The Economics of Health and Health Care[M].第三版.王健,孟庆跃译.北京:中国人民大学出版社,2004.582-584.
[46]王鸿勇.不同医疗费用支付方式的利弊分析及适宜制度选择[J].国外医学.卫生经济分册,1988,15(1):1-5.
[47]王鸿勇.国际医疗保险模式和改革发展比较分析[J].国外医学,16(2):49-64.
[48]鲁盛康,朱士俊.按医疗服务项目付费制与诊断相关分组预付费制的利弊分析,中华医院管理杂志,23(10):661-663.
[49] Iglehart, J.K. The American health care system:Expenditures. New England Journal of Medicine, 1999,340(1):70-76.
[50] Rosenberg, Marjorie A, Browne, Mark J. The impact of the inpatient prospective payment system and DRGs: A survey of the literature. North American Actuarial Journal.Oct,2001.
[51]朱士俊,鲍玉荣.医疗费用支付方式改革-DRGs简介.中华医院管理杂志,2006,22:664-665.
[52] Ministry of Health, Labor and Welfare. Trend of medical expenditures in medical facilities October 2003.
[53] Soonman Kwon. Payment system reform for health care providers in Korea. Health Policy And Planning,18(1): 84–92.
[54]龚舒琴.对镇江市医疗保险医疗费用支付方式效应的回顾性分析[J].江苏卫生事业管理,2004,15(3):49-51.
[55]武广华,朱志忠等.病种质量管理与病种付费方式.济宁:内部资料,2006.
[56]刘景峰.单病种限价收费的乐与恼.医药经济报,2007,9:1.
[57]艾自胜,高歌,潘军燕.国际医疗保险支付制度理论研究及对我国的借鉴作用[J].中国农村卫生事管理.2001,21(1):40-42.
[58]陈佳贵,王延中.中国社会保障发展报告.北京:社会科学文献出版社,2004.54-56.
[59]杜乐勋,张文鸣,张大伟.中国医疗卫生事业发展报告.北京:社会科学文献出版社,2004.55-58.
[60] Folland,Sherman T.,Miron Stano,“Sources of Small Area Variations in the Use of Medical Care”,Journal of Health Economics 8(1989):85-107.
[61]贺卫,伍山林.制度经济学.北京:机械工业出版社,2003.101-102.
[62] Shleifer , Andrei. A Theory of Yardstick Competition. Rand Journal ofEconomics,1985(16):319-327.
[63] Machado AM.医院成本核算.The International Hospital Federation,1993,26(3):12-14.
[64]程晓明.医疗保险学[M].上海:复旦大学出版社,2003.8.
[65]世界卫生组织编.疾病和有关健康问题的国际统计分类:第十次修订本(第一版).北京:人民卫生出版社,2000.3.
[66]马鹃.DRGs在医院改革中应用的可行性研究.中国卫生事业管理.1991,10:145.
[67] Hornbrook M.C. Hospital case mix:its definition, measurement and use:partΙ.The Conceptual Framework. Medical Care Review.1982,39(1):7.
[68] Vladeck,B.C. Medicare Hospital Payment by Diagnosis Related Groups. Annals of Internal Medicine.1984,100(4):576.
[69]张音,徐勇勇等.军队医院开展病例组合研究的必要性和可行性.解放军医院管理杂志.1998,5(1):75.
[70] NCMO.Project Progress Report. NHS Executive.1997 issue 12.
[71]王晓京,朱士俊.医疗费用支付方式的比较.中华医院管理杂志[J],2006,22(7):481-483.
[72]朱士俊,鲍玉荣.医疗费用支付方式改革——DRGs简介.中华医院管理杂志[J],2006,22(7):664-665.
[73] Joseph S.G Mark C H.,Daniel Z L. Staging of disease.JMMA,1984,251(5):637.
[74] Stephen F. Jencks,et al. Refining Case Mix Adjustment. New England, 1987,317:679.
[75]丁涵章等主编.《现代医院管理全书》.杭州:杭州出版社,1999.8.
[76] Joseph C. Young, et al. Identifying Injuries and Trauma Severity. The Journal of Trauma. 1990,30:1220.
[77] Wanda W. Young, et al. PMCs—An Alternative to DRGs for Trauma Care Reimbursement. The Journal of Trauma. 1991, 31:459.
[78] J. William Thomas,et al. Application of Severity Measurement System for Hospital Quality Management. Hospital & Health Services Administration. 1990,221.
[79] William Knaus, et al. Development of APACHE. Critical Care Medicine. 1989,17:181.
[80] William A. Knaus, et al. APACHEⅡA Severity of Disease Classification System. Critical Care Medicine,1985,13:818.
[81] Lisa Lessoni,et al. A Description and Clinical Assessment of the Computerized Severity Index. QRB,Feb,1992,44.
[82]刘丹红,陈平等.临床疾病严重度评价标准.中国医院统计,2002,9(2):78-80.
[83]黄慧英.诊断相关分类法在北京地区医院管理中的可行性研究.中华医院管理杂志,1994,10(3):131.
[84]马骏.DRGs系统新模式的研究.中国医院管理,1994,14(9):10～13.
[85]黄慧英.诊断相关分类法DRGs在美国的发展.中华医院管理志,1992,8(7):433.
[86]蔡乐,万崇华,王军等.住院费用构成及影响因素分析.中国医院统计,1999,6(4):206.
[87]张鹭鹭,胡善联.医疗需求强度的测量.解放军医院管理志,1998 ,5(1):73-75.
[88]张力,王文中等.病例分型的特点和技术要点.中华医院管理杂志,2000, 16(7):392-393.
[89]马骏.DRGs系统新模式的研究[J].中国医院管理,1994,14(9):10-13.
[90]张力,马健,李淑惠等.病种质量费用监控方法研究.中国医院管理,1998, 203(6):27 .
[91]张力,马健,董军等.病例组合综合质量评价微机判定系统的设计与应用.解放军医院管理杂志, 1999,6(6):438.
[92]徐勇勇,赵清波,阎玉霞等.我国病例组合方案研究概述.中华医院管理杂志,2001,17(10):586-588.
[93]徐勇勇,张音,潘峰等.基于我国病案首页的病例组合方案与病例组合指数.中华医院管理杂志,2001,17(1):34-36.
[94]阎玉霞,潘峰等.住院病人内外科治疗的病例组合研究.中华医院管理杂志,2001,17(10):588-592.
[95]朱滨海.研究和实施DRGs时应考虑的若干问题.中华医院管理杂志,2006,22(7):456-460.
[96]刘俊田等编.现代医院管理发展与研究.北京:北京出版社.2002.213.
[97]小贾尔斯·伯吉斯.管制和反垄断经济学[M].上海:上海财经大学出版社.2003.56.
[98] Tyler J. Brannen. DRG-based per diem payment system matches costs more accurately - Cover Story. Healthcare Financial Management, 1999, April:42-46.
[99] Price, K.F.: Pricing Medicare's diagnosis-related groups: Charges versus estimated costs. Health Care Financing Review ,Fall 1989,11(1):79-90.
[100] Cotterill, P., Bobula, J., and Connerton, R.: Comparison of alternative relative weights for diagnosis-related groups. Health Care Financing Review ,1986, 7(3):37-51.
[101] R.F Coulam, G.L. Gaumer. Medicare’s prospective payment system:a critical appraisal. Health Care Financing Review,1991,Annual Supplement.
[102] Grace M. Care, Peter D. Jacobson,Gerald F. Kominski,Mark J. Perry.Use of diagnosis-relater groups by non-Medicare payers-Medicare Payment Systems:Moving Toward the Future.Health Care Financing Review.Winter,1994.
[103] Rogowski, J.R., and Byrne, D.J.: Comparison and evaluation of alternative DRG weight recalibration methods. Health Care Financing Review ,Winter 1990,12(2): 87-101.
[104] Kala Sue Bush.Keys for Unlocking the Medicare/Medicaid Reimbursement Mystery [J].Journal of Health Care Compliance.May/Jun 2005,7(3):71-73.
[105]汪丁丁.医生、医院、医疗体制改革[J].财经,2005,21:43-47.
[106]杜乐勋.从看病贵看我国医疗收费价格的合理调控.中国卫生经济,2004,23(9):5-8.
[107]雒敏.试论现行医院会计制度中存在的问题及对策.中国卫生事业管理,2006,212(2):88-89.
[108]郑大喜.医疗保险支付制度改革与医院成本核算发展趋势探讨.中华医院管理杂志,2005,21(6):382-385.
[109] Grace M. Carter, Donna O. Farley. A longitudinal comparison of charge-basedweights with cost-based weights. Health Care Financing Review,Sprin,1992.
[110]《北京地区医院按DRGs付费和临床路径的应用研究》中期报告.北京:内部资料.
[111]高晓凤,曾庆.病例组合的研究现状及问题.中国医院统计,2004,11(3):53-56.
[112]张仁伟,胡善联.90年代我国若干经济指标动态分析.中华医院管理杂志,2002,18(7):428-430.
[113]中华人民共和国国家统计局.中华人民共和国2004年国民经济和社会发展统计公报. 2005年.
[114] Karen Davis. Paying for Care Episodes and Care Coordination[J]. The New England Journal of Medicine.2007,356(11)1166-1168.
[115] AL Plough, SR Salem,et al. Case mix in end-stage renal disease. Differences between patients in hospital-based and free-standing treatment facilities.JAMA, 1984,310(3):1432-1436.
[116]万崇华,蔡乐等.疾病诊断相关组DRGs研究的现状、问题及对策.中国医院统计,2001,8(6):112-116.
[117]彭佩云.谈医疗制度改革.健康报,1995年5月9日.
[118]龚舒琴,尹明芳.进一步完善医保医疗费用支付方式的对策与措施研究.中国卫生经济,2004,23(4):33-34.
[119] Doyal, L. & Gough, I(1991).A Theory of Human Need. The Guilford, New York,1991:170.
[120] Reliability of Hospital Discharge Abstracts, Report of a Study by the Institute of Medicine, National Academy of Science, Washington DC, February, 1977.
[121] Guterman S. Dobson A. Impact of the Medicare prospective payment system for hospitals[J]. Health Care Financing Review.1986,7(3):97-114.
[122]陈政,陈立今等.从有偿服务看公立医疗卫生机构的运作效率.中国卫生资源,2004,7(5):198-201.
[123] Richard H. Shachtman, Steven M. Snapinn, Dana Quade, et al. A Method for Constructing Case-Mix Iddexes with Application to Hospital Length of Stay.Health Services Research, 1986,20(2):737-762.
[124] Freund, D., et al. Analysis of length of stay differences between investor-owned and voluntary hospitals. Inquiry, Spring 1985,22(1):33.
[125]张淳海,方沈应,徐德忠.某综合医院住院患者住院费用及其相关因素分析.解放军预防医学杂志,2000;2(18):100.
[126]尚磊,周鑫.住院病人单病种住院费用调查及相关因素分析.中国医院统计,1996;3(2):75-77.
[127]王少利,胡牧,杨芳等.北京三所三甲医院循环系统住院病人DRGs分组及质量评价.中国医院,2006,10(7):33-37.
[1]中华人民共和国卫生部. 2004年中国卫生事业发展统计公报,2005.
[2]郝模.论三项改革联动和公立医院管理体制改革.中华医院管理杂志,2002,18(1):4-7.
[3] Jean M,Caroline M.DRG Information System,healthcare reforms and Innovation of management in the western countries. Casemix,2002, (4):16-19.
[4] Baker,J. Medicare payment system for hospital inpatients: diagnosis- related groups. J-Health-Care-Finance,2002,(28):1-13.
[5] Hugh Sanderson. Measuring Case Mix.BMJ,1992,(6)304-315.
[6]胜彦婷.美国医院与医疗保险.中华医院管理杂志,2002,18(1):61-62.
[7]辛衍涛.对美国卫生保健改革的历史回顾.国外医学·医院管理分册,1997;14(2):66-69.
[8]黄慧英.美国诊断相关分类法的综合介绍.国外医学·医院管理分册,1990;7(4):145-147.
[9]黄慧英.诊断相关分类法DRGs在美国的发展.中国医院管理,1992;8(7):433-436.
[10] Feeter RB.按诊断分类定额的付款制度.国外医学·卫生经济分册,1988,5(2):404-407.
[11]汪建新,冼雄,梁志诚等.美国卫生费用持续上涨的原因及控制措施.中国卫生事业管理,2001,161(11):696-699.
[12]李国鸿.国外健康保险的主要模式.中国医院管理,1992;12(8):54-56.
[13]石本忠义.按疾病分类定额付款和世界医疗保险制度的动向.国外医学·卫生经济分册,1989;6(3):34-36.
[14]万崇华,蔡乐,许传志等.疾病诊断相关分组DRGs研究的现状、问题及对策.中国医院统计,2001;8(2):112-115.
[15]二木立.DRG方式的背景影响和引进日本的可能性.国外医学·卫生经济分册,1990;7(1)34-36.
[16]黄慧英.诊断相关分类法在北京地区医院管理中的可行性研究.中华医院管理杂志,1994;10(3):131-135.
[17]马竣.DRGs系统新模式的研究.中国医院管理,1994;14(9):10-13.
[18]徐勇勇,张音等.基于我国病案首页的病例组合方案与病例组合指数.中华医院管理杂志,2001;17(1):34-37.
[19]张力,马健,李淑惠等.病种质量费用监控方法研究.中国医院管理,1998,203(6):27-29.
[20]张力,马健,董军等.病例组合综合质量评价微机判定系统的设计与应用.解放军医院管理杂志,1999,6(6):438-440.
[21]胡向阳.病例组合概念及其应用.中华医院管理杂志,1994,10(2):736-739.
[22]徐勇勇,赵清波.我国病例组合方案研究概述.中华医院管理杂志,2001,17(10):586-588.
[23]阎玉霞,徐勇勇.住院病人病例组合方法的探讨.中国医院统计,2001,8(3)131-134.
[24] Young WW,et al.PMCs-An alternative to DRGs for Trauma care reimbursement. The Journal of trauma,1991,31:459-467.
[25] Jencks SF ,Dobson A. Redefining Case-Mix Adjustment . N Engl J Med ,1987 ,11 :679-689.
[26]蔡乐,万崇华等.消化系统疾病住院费用的影响因素分析.中国医院统计,2000 ,7 (1):11-13.
[27]蔡乐,万崇华,王军等.住院费用构成及影响因素分析.中国医院统计,1999 ,6 (4):206-209.
[28]张鹭鹭,胡善联.医疗需求强度的测量.解放军医院管理杂志,1998 ,5 (1) :73-75.
[29]傅征,王耀宗等.病例分型研究概述.中华医院管理杂志.2000,16(7):389-391.
[30]吴清平,张璐,腾国召,等.医院内各病区医疗质量横向分析的比较探讨.中华医院管理杂志,1999 ,15(2):78-79.
[31]周凤琼,廖振尔.综合指数法用于我院医疗质量评价效果分析.中华医院管理杂志,2000 ,16(3):109-110.
[32]马骏,刘兵,主编.实用医院质量管理学.天津:社会科学院出版社,1999. 122-150.