摘要：随着医疗改革的深入推进，疾病诊断相关分组（DRGs）付费模式在我国医疗体系中逐渐得到广泛应用。这一变革对医疗机构的经济管理科提出了全新的要求与挑战。本论文深入剖析经济管理科在 DRGs 体系下的各项职责，包括成本核算精细化、绩效评价科学化、医保管理专业化以及资
摘要： 随着医疗改革的深入推进，疾病诊断相关分组（DRGs）付费模式在我国医疗体系中逐渐得到广泛应用。这一变革对医疗机构的经济管理科提出了全新的要求与挑战。本论文深入剖析经济管理科在 DRGs 体系下的各项职责，包括成本核算精细化、绩效评价科学化、医保管理专业化以及资源配置合理化等方面。通过详细阐述各职责的内涵、实施路径与重要意义，并结合实际案例与数据进行分析，旨在为经济管理科在 DRGs 背景下的高效运作提供理论依据与实践指导，促进医疗机构在保障医疗质量的前提下实现经济管理的优化与可持续发展。
关键词：经济管理科；DRGs；成本核算；绩效评价；医保管理；资源配置
In recent years, the implementation of Diagnosis Related Groups (DRGs) payment system has become a crucial part of healthcare reform in many countries. This system aims to control medical costs, improve the efficiency of medical resource allocation, and promote the standardization and quality of medical services. In this context, the economic management department of medical institutions is facing unprecedented challenges and opportunities. It needs to adapt to the new payment model and adjust its functions and responsibilities accordingly. This paper focuses on exploring the various responsibilities of the economic management department under the DRGs system and how it can contribute to the overall development of medical institutions.（近年来，疾病诊断相关分组（DRGs）付费制度的实施已成为许多国家医疗改革的关键部分。该制度旨在控制医疗成本、提高医疗资源配置效率，并促进医疗服务的标准化与质量提升。在此背景下，医疗机构的经济管理科面临着前所未有的挑战与机遇。它需要适应新的付费模式，并相应地调整其职能与职责。本文重点探讨经济管理科在 DRGs 体系下的各项职责，以及它如何为医疗机构的整体发展做出贡献。）
DRGs is a patient classification system that groups patients with similar clinical characteristics and resource consumption into the same category for payment. It is based on factors such as patient diagnosis, age, gender, treatment procedures, and length of hospital stay. Each DRG group is assigned a specific payment rate, which is determined through a comprehensive analysis of historical cost data and actuarial methods. For example, patients with uncomplicated appendicitis may be grouped into one DRG, and those with more severe or complicated cases may be grouped into another. This way, hospitals are paid based on the DRG group to which the patient belongs rather than the actual cost of each individual service provided.（DRGs 是一种将具有相似临床特征和资源消耗的患者归为同一类进行付费的患者分类系统。它基于患者诊断、年龄、性别、治疗程序和住院时长等因素。每个 DRG 组都被分配一个特定的支付费率，这是通过对历史成本数据的综合分析和精算方法确定的。例如，患有单纯性阑尾炎的患者可能被归为一个 DRG 组，而病情更严重或复杂的患者则可能被归为另一个组。这样，医院根据患者所属的 DRG 组获得支付，而非基于所提供的每项个别服务的实际成本。）
Cost Control Imperative（成本控制的紧迫性）Under DRGs, hospitals face the risk of financial losses if their costs exceed the payment rate for a particular DRG. Therefore, the economic management department must focus on cost control more than ever. It needs to identify the key cost drivers within each DRG and implement strategies to reduce unnecessary expenditures. For instance, analyzing the cost of medical supplies, labor, and equipment usage for different DRG groups and finding ways to optimize these costs without compromising patient care.（在 DRGs 下，如果医院成本超过特定 DRG 的支付费率，就面临财务亏损风险。因此，经济管理科必须比以往更加注重成本控制。它需要识别每个 DRG 内的关键成本驱动因素，并实施策略减少不必要的支出。例如，分析不同 DRG 组的医疗用品、人力和设备使用成本，并在不影响患者护理的情况下寻找优化这些成本的方法。）Quality - Cost Balance（质量与成本的平衡）
While cost control is important, maintaining and improving the quality of medical services is equally crucial. The economic management department has to work in tandem with clinical departments to ensure that cost reduction measures do not lead to a decline in patient outcomes. This requires the establishment of quality indicators and performance evaluation systems that consider both cost and quality aspects. For example, monitoring the readmission rate, complication rate, and patient satisfaction within each DRG group to assess the overall performance of the hospital.（虽然成本控制很重要，但维持和提高医疗服务质量同样关键。经济管理科必须与临床科室协同工作，确保成本降低措施不会导致患者治疗效果下降。这需要建立同时考虑成本和质量方面的质量指标和绩效评价系统。例如，监测每个 DRG 组内的再入院率、并发症发生率和患者满意度，以评估医院的整体绩效。）Reimbursement Uncertainty（报销的不确定性）
The payment rate under DRGs is fixed, but the actual cost of treating patients may vary. The economic management department needs to manage the uncertainty associated with reimbursement. This involves accurate cost estimation and documentation, as well as effective communication with insurance companies and other payers. For example, ensuring that all relevant cost data is properly recorded and submitted to the payer to avoid disputes and ensure timely reimbursement.（DRGs 下的支付费率是固定的，但治疗患者的实际成本可能会有所不同。经济管理科需要管理与报销相关的不确定性。这涉及准确的成本估算和记录，以及与保险公司和其他支付方的有效沟通。例如，确保所有相关成本数据都被正确记录并提交给支付方，以避免纠纷并确保及时报销。）
The economic management department is responsible for accurately allocating both direct and indirect costs to each DRG group. Direct costs such as drugs, medical supplies, and physician fees are relatively easier to track and assign. However, indirect costs like hospital overheads, administrative expenses, and equipment depreciation need to be allocated based on appropriate cost drivers. For example, using the square footage of the space occupied by a particular department or the number of hours of equipment usage for a specific DRG as a basis for allocating indirect costs. This ensures a more accurate reflection of the true cost of treating patients within each DRG.（经济管理科负责将直接和间接成本精确分配到每个 DRG 组。药物、医疗用品和医生费用等直接成本相对较易追踪和分配。然而，医院管理费用、行政开支和设备折旧等间接成本需要基于合适的成本驱动因素进行分配。例如，使用特定部门占用的空间面积或特定 DRG 使用设备的小时数作为分配间接成本的依据。这确保更准确地反映每个 DRG 内治疗患者的真实成本。）Cost Variance Analysis（成本差异分析）
Regularly conduct cost variance analysis between the actual cost of treating patients within a DRG group and the expected DRG payment rate. Identify the sources of cost variances, whether it is due to higher than expected resource consumption, inefficiencies in the treatment process, or other factors. For example, if a particular DRG group shows a significant cost overrun, analyze whether it is because of longer than average hospital stays, excessive use of high - cost medical procedures, or other reasons. Based on the analysis, develop targeted cost control strategies.（定期对 DRG 组内治疗患者的实际成本与预期 DRG 支付费率进行成本差异分析。识别成本差异的来源，无论是由于资源消耗高于预期、治疗过程中的低效率还是其他因素。例如，如果某个 DRG 组出现显著成本超支，分析是否是因为住院时长高于平均水平、过度使用高成本医疗程序或其他原因。基于分析结果，制定有针对性的成本控制策略。）DRG - Based Performance Metrics（基于 DRGs 的绩效指标）
Establish a comprehensive set of performance metrics based on DRGs. These metrics should include not only financial indicators such as cost per case, revenue per DRG, and profit margin but also clinical quality indicators like mortality rate, complication rate, and readmission rate within a specific time period. For example, calculate the average cost per case for a particular DRG group and compare it with the national or regional average to assess the hospital's cost management performance. At the same time, monitor the mortality rate for a specific DRG to evaluate the quality of medical care provided.（基于 DRGs 建立一套全面的绩效指标。这些指标不仅应包括财务指标，如每例成本、每个 DRG 的收入和利润率，还应包括临床质量指标，如特定时间段内的死亡率、并发症发生率和再入院率。例如，计算特定 DRG 组的每例平均成本，并与国家或地区平均水平进行比较，以评估医院的成本管理绩效。同时，监测特定 DRG 的死亡率，以评估所提供医疗服务的质量。）Incentive Mechanism Design（激励机制设计）
Design an incentive mechanism that links the performance of clinical departments and individual physicians to the DRG - based performance metrics. Provide financial and non - financial incentives for those who achieve good performance in both cost control and quality improvement. For example, offer bonuses or additional resources to departments that consistently meet or exceed the target cost per case and have low complication and readmission rates. This encourages clinical staff to actively participate in DRGs - related cost control and quality enhancement efforts.（设计一种激励机制，将临床科室和个体医生的绩效与基于 DRGs 的绩效指标相联系。为那些在成本控制和质量改进方面表现良好的人员提供财务和非财务激励。例如，向那些持续达到或低于目标每例成本且并发症和再入院率低的科室提供奖金或额外资源。这鼓励临床工作人员积极参与 DRGs 相关的成本控制和质量提升工作。）DRG Coding and Documentation Accuracy（DRG 编码与记录准确性）
Ensure the accurate coding and documentation of patient diagnoses, procedures, and other relevant information for proper DRG assignment. This is crucial as incorrect coding can lead to inappropriate payment or even disputes with insurance companies. The economic management department should work with medical coders and clinical staff to train them on the proper coding practices and conduct regular audits to ensure compliance. For example, if a patient's diagnosis is not coded accurately, it may result in the patient being assigned to the wrong DRG group, leading to either underpayment or overpayment.（确保患者诊断、治疗程序和其他相关信息的准确编码与记录，以进行正确的 DRG 分组。这至关重要，因为错误编码可能导致不当支付甚至与保险公司的纠纷。经济管理科应与医疗编码员和临床工作人员合作，对他们进行正确编码实践的培训，并定期进行审计以确保合规。例如，如果患者的诊断编码不准确，可能导致患者被分配到错误的 DRG 组，从而导致支付不足或支付过多。）Reimbursement Negotiation and Management（报销谈判与管理）
Engage in reimbursement negotiation with insurance companies and other payers based on the DRG payment system. This involves understanding the payer's policies and requirements, presenting the hospital's cost and quality data in a favorable light, and advocating for a reasonable payment rate. At the same time, manage the reimbursement process, including submitting claims in a timely manner, following up on claim status, and resolving any disputes that may arise. For example, during the negotiation process, provide evidence of the hospital's efforts in cost control and quality improvement to justify a higher payment rate.（基于 DRG 支付系统与保险公司和其他支付方进行报销谈判。这涉及了解支付方的政策和要求，以有利的方式呈现医院的成本和质量数据，并争取合理的支付费率。同时，管理报销流程，包括及时提交索赔、跟踪索赔状态并解决可能出现的任何纠纷。例如，在谈判过程中，提供医院在成本控制和质量改进方面努力的证据，以证明更高支付费率的合理性。）Bed Capacity and Staffing Allocation（床位与人员配置分配）
Based on the historical data and projected demand of different DRG groups, optimize the allocation of bed capacity and staffing resources. For example, if a particular DRG group is expected to have an increasing number of patients in the future, allocate more beds and appropriate nursing and medical staff to that area. This ensures that resources are allocated where they are most needed and avoids over - or under - allocation of resources.（根据不同 DRG 组的历史数据和预计需求，优化床位容量和人员配置资源的分配。例如，如果某个特定 DRG 组预计未来患者数量会增加，则为该区域分配更多床位以及合适的护理和医疗人员。这确保资源被分配到最需要的地方，避免资源的过度或不足分配。）Medical Equipment and Supply Procurement（医疗设备与物资采购）
Make informed decisions about the procurement of medical equipment and supplies based on the needs of different DRG groups. Analyze the cost - effectiveness of different equipment and supply options and consider their impact on the overall cost and quality of patient care. For example, if a new medical device can significantly reduce the length of hospital stay for a particular DRG group and has a reasonable cost - benefit ratio, it may be a worthy investment.（基于不同 DRG 组的需求，就医疗设备和物资采购做出明智决策。分析不同设备和物资选项的成本效益，并考虑它们对患者护理总成本和质量的影响。例如，如果一种新的医疗设备能够显著缩短特定 DRG 组的住院时长且具有合理的成本效益比，那么它可能是一项值得的投资。）
A large comprehensive hospital implemented a detailed cost accounting and control system under DRGs. The economic management department first conducted a comprehensive review of all cost elements and established a cost allocation model based on activity - based costing. For each DRG group, they analyzed the direct costs such as drugs, laboratory tests, and surgical supplies, as well as the indirect costs like departmental overheads and equipment depreciation. They also set up a cost variance analysis mechanism to monitor and address any significant cost deviations.（一家大型综合医院在 DRGs 下实施了详细的成本核算与控制系统。经济管理科首先对所有成本要素进行了全面审查，并基于作业成本法建立了成本分配模型。对于每个 DRG 组，他们分析了药物、实验室检查和手术用品等直接成本，以及部门管理费用和设备折旧等间接成本。他们还建立了成本差异分析机制，以监测和解决任何显著的成本偏差。）Results and Analysis（结果与分析）
After one year of implementation, the hospital saw a significant reduction in the cost per case for several major DRG groups. For example, the cost per case for patients with coronary artery bypass grafting (CABG) decreased by 10% due to more efficient use of medical supplies and optimized surgical procedures. The overall cost variance was also reduced, indicating better cost control. At the same time, the hospital was able to maintain the quality of care, as evidenced by stable mortality and complication rates within the DRG groups.（实施一年后，该医院几个主要 DRG 组的每例成本显著降低。例如，由于更有效地使用医疗用品和优化手术程序，冠状动脉旁路移植术（CABG）患者的每例成本降低了 10%。总体成本差异也有所减少，表明成本控制得到改善。同时，医院能够维持医疗服务质量，DRG 组内稳定的死亡率和并发症发生率就是证明。）Case Description（案例描述）
A specialty hospital focused on orthopedics developed a DRG - based performance evaluation and incentive system. The economic management department defined a set of performance metrics, including cost per case, implant cost per procedure, and patient satisfaction. They also established an incentive mechanism that rewarded departments and surgeons who achieved good performance in both cost control and quality improvement. For example, a department that had a lower than average cost per case for total hip replacement and a high patient satisfaction rate received a bonus equal to 5% of their annual budget.（一家专注于骨科的专科医院开发了基于 DRGs 的绩效评价与激励系统。经济管理科定义了一套绩效指标，包括每例成本、每次手术植入物成本和患者满意度。他们还建立了一种激励机制，奖励在成本控制和质量改进方面表现良好的科室和外科医生。例如，一个全髋关节置换术每例成本低于平均水平且患者满意度高的科室获得了相当于其年度预算 5% 的奖金。）Results and Analysis（结果与分析）
Over a period of two years, the hospital observed an improvement in both cost management and patient outcomes. The average cost per case for orthopedic surgeries decreased by 8%, mainly due to a reduction in implant costs and more efficient use of operating room time. The patient satisfaction rate also increased from 85% to 90%, indicating that the incentive mechanism effectively motivated the clinical staff to balance cost and quality.（在两年的时间里，该医院在成本管理和患者治疗效果方面都有所改善。骨科手术的每例平均成本降低了 8%，主要是由于植入物成本降低和手术室时间更有效利用。患者满意度也从 85% 提高到 90%，表明激励机制有效地激励了临床工作人员平衡成本和质量。）数据准确性与完整性
The success of DRGs implementation heavily depends on accurate and complete data. However, in practice, there may be issues with incorrect coding, missing data, or inconsistent data entry. The economic management department needs to work with other departments to improve data quality. This can be achieved through staff training, regular data audits, and the implementation of data validation tools. For example, providing training to medical coders and physicians on the proper coding of DRGs and conducting monthly audits to check for data errors.（DRGs 实施的成功在很大程度上取决于准确和完整的数据。然而，在实践中，可能存在编码错误、数据缺失或数据录入不一致等问题。经济管理科需要与其他部门合作来提高数据质量。这可以通过员工培训、定期数据审计以及数据验证工具的实施来实现。例如，为医疗编码员和医生提供关于 DRGs 正确编码的培训，并每月进行审计以检查数据错误。）信息系统 Integration and Upgrades（信息系统集成与升级）
Existing hospital information systems may not be fully compatible with DRGs requirements. The economic management department needs to coordinate with the IT department to ensure seamless integration and necessary upgrades. This may involve integrating cost accounting modules, performance evaluation systems, and DRG coding and billing functions. For example, upgrading the hospital's electronic medical record system to automatically capture and classify data according to DRG criteria and enabling real - time cost tracking and reporting.（现有的医院信息系统可能无法完全满足 DRGs 的要求。经济管理科需要与信息技术部门协调，以确保无缝集成和必要的升级。这可能涉及整合成本核算模块、绩效评价系统以及 DRG 编码和计费功能。例如，升级医院的电子病历系统，使其能够根据 DRG 标准自动捕获和分类数据，并实现实时成本跟踪和报告。）Cost - Quality Trade - off Misunderstanding（成本 - 质量权衡误解）
Clinical departments may sometimes perceive cost control efforts under DRGs as compromising patient care quality. The economic management department needs to have effective communication and education initiatives to clarify that cost control and quality improvement can be achieved simultaneously. This can be done through regular seminars, case studies, and sharing success stories of other hospitals. For example, presenting a case where a reduction in unnecessary tests and procedures led to both cost savings and improved patient outcomes due to shorter hospital stays and fewer complications.（临床科室有时可能会认为 DRGs 下的成本控制努力会损害患者护理质量。经济管理科需要开展有效的沟通和教育活动，以阐明成本控制和质量改进可以同时实现。这可以通过定期研讨会、案例研究以及分享其他医院的成功案例来实现。例如，展示一个减少不必要的检查和程序的案例，由于住院时间缩短和并发症减少，既节省了成本又改善了患者的治疗效果。）Data Sharing and Coordination Difficulties（数据共享与协调困难）
Sharing and coordinating data between economic management and clinical departments can be a challenge. Different departments may use different data formats and systems. The economic management department should establish standardized data sharing protocols and platforms. For example, creating a centralized data repository where both economic and clinical data can be accessed and analyzed in a unified manner, facilitating better decision - making and resource allocation.（经济管理科与临床科室之间的数据共享和协调可能是一个挑战。不同部门可能使用不同的数据格式和系统。经济管理科应建立标准化的数据共享协议和平台。例如，创建一个集中式数据存储库，使经济和临床数据能够以统一的方式访问和分析，促进更好的决策和资源分配。）DRG Payment Rate Adjustments（DRG 支付费率调整）
The payment rates under DRGs may change over time due to policy reforms or actuarial reassessments. The economic management department needs to closely monitor policy changes and adjust its cost management and pricing strategies accordingly. This may involve conducting sensitivity analyses to predict the impact of payment rate changes on hospital revenues and costs. For example, if the payment rate for a particular DRG is expected to decrease, the department can explore options such as process optimization, supply chain management improvements, or renegotiating with suppliers to maintain profitability.（DRGs 下的支付费率可能会因政策改革或精算重新评估而随时间变化。经济管理科需要密切监测政策变化，并相应地调整其成本管理和定价策略。这可能涉及进行敏感性分析，以预测支付费率变化对医院收入和成本的影响。例如，如果某个特定 DRG 的支付费率预计会降低，该部门可以探索诸如流程优化、供应链管理改进或与供应商重新谈判等选项，以维持盈利能力。）Regulatory Compliance Burden（监管合规负担）
Increasing regulatory requirements related to DRGs, such as data reporting, quality monitoring, and compliance audits, can place a significant burden on the economic management department. The department needs to allocate sufficient resources and develop efficient compliance management processes. This may include hiring dedicated compliance officers, implementing automated reporting tools, and establishing internal control mechanisms to ensure compliance with all relevant regulations. For example, using software that automatically generates regulatory reports based on the hospital's DRG data and conducts internal audits to identify and address any compliance issues before external audits.（与 DRGs 相关的监管要求不断增加，如数据报告、质量监测和合规审计等，可能会给经济管理科带来沉重负担。该部门需要分配足够的资源并开发高效的合规管理流程。这可能包括雇用专门的合规官员、实施自动化报告工具以及建立内部控制机制，以确保遵守所有相关法规。例如，使用能够根据医院的 DRG 数据自动生成监管报告的软件，并进行内部审计，以便在外部审计之前识别和解决任何合规问题。）
The implementation of DRGs has brought about profound changes and challenges to the economic management department of medical institutions. Through fulfilling responsibilities such as refined cost accounting, scientific performance evaluation, professional medical insurance management, and rational resource allocation, and by effectively addressing challenges such as data quality, clinical collaboration, and external policy changes, the economic management department can contribute to the sustainable development of medical institutions under the DRGs payment system. It is essential for the economic management department to continuously adapt and innovate in its management strategies and methods to ensure the optimization of economic management and the provision of high - quality medical services in the context of healthcare reform.（DRGs 的实施给医疗机构的经济管理科带来了深刻的变化和挑战。通过履行精细化成本核算、科学化绩效评价、专业化医保管理和合理化资源配置等职责，并有效应对数据质量、临床协作和外部政策变化等挑战，经济管理科能够在 DRGs 支付系统下为医疗机构的可持续发展做出贡献。经济管理科在医疗改革背景下不断适应和创新其管理策略和方法，以确保经济管理的优化和高质量医疗服务的提供至关重要。）
来源：医学顾事
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