基于单病种管理的医院住院病人费用控制的管理策略研究.doc

华中科技大学博士学位论文基于单病种管理的医院住院病人费用控制的管理策略研究姓名：陶红兵申请学位级别：博士专业：社会医学与卫生事业管理指导教师：方鹏骞20080501 华中科技大学博士学位论文基于单病种管理的医院住院病人费用控制的管理策略研究申请人姓名：陶红兵指导教师：方鹏骞教授中文摘要研究目的医疗费用控制是许多国家面临的共同问题，由于经济利益机制的作用，对医疗服务的价格规制方式决定了医疗机构(主要是医院)提供各种医疗服务所受激励的强度，这在很大程度上调节和规范着其行为，并且最终决定着医疗费用的高低。因此，采用适宜的规制方式对于控制医疗费用至关重要，医疗费用付费方式改革和研究成为医疗费用控制的主要问题之一。2000年以来，我国一些城市开始进行按病种支付制度的改革，对医院医疗费用的上涨速度起到了一定的抑制作用，但效果不甚理想，仍然面临着很多挑战。单病种医疗成本和费用控制的影响因素有哪些？医院单病种费用控制管理的影响因素有哪些？如何制定和实施住院病人单病种医疗费用控制管理策略？文献资料分析显示对这些问题的研究尚不够系统和全面，特别是住院病人医疗费用控制管理控制策略的系统研究尚未见报道。本研究采用定性与定量研究相结合的方法，通过住院医疗费用上涨的原因、控制现状和关键因素的研究以及医院医疗费用控制的理论评述，借鉴国内外医院医疗费用控制的实践经验，结合病种医疗成本的测算和费用影响因素的分析对管理控制的管理控制策略进行了系统研究，同时基于管理控制理论提出适合目前我国住院病人费用控制的管理控制系统框架，并通过样本医院的典型案例分析对管理控制系统的应用效果进行实证研究，为形成有效的病种费用控制的激励和约束机制，真正发挥病种费用控制在医疗费用控制方面的作用提供依据。III 华中科技大学博士学位论文研究方法1、文献研究方法采用非结构、非定量的文献法查阅专业杂志期刊、论文集以及网上检索等文字、图形、声音等相关文献资料，收集国内外对医院医疗服务过程中医疗费用控制有关文献资料。并对样本医院及相关政府部门的医疗费用控制相关的制度、具体方案和统计报表资料进行整理分析，对各种文献资料进行客观的、系统地归纳和总结。2、二手资料收集与分析对样本医院4个病种1341例病人的人口学特征、住院总费用和具体项目费用指标进行回顾性调查；样本医院实际开展的床位数、医院收入和医院支出项目费用；样本医院应用住院病人医疗费用管理控制系统后病种费用控制效果的相关指标收集；同时对湖北省某二级甲等医院的2006年医院实际开展的床位数、医院收入和医院支出项目费用和某病种的单病种费用测算的相关数据进行收集分析；对山东省某三级甲等医院2004- 2007年住院病人医疗费用管理控制系统后病种费用控制效果的相关指标进行调查。3、半结构深度访谈法在信息回顾和情报分析工作结果的基础上，根据事先确定的问题进行半结构式访谈，每个医院所在地区依据所在地区和部门采取分层随机抽样的方法，分别抽取卫生行政部门、卫生管理专家、医疗机构的医院管理人员和医疗专业人员 12- 16名，共36名人员进行半结构访谈，对医院医疗费用控制的关键环节和主要影响因素进行分析，并对深层次信息资料进行采集和挖掘。4、专题小组讨论每个样本地区抽取卫生经济和卫生管理专家、卫生行政部门的管理者、医疗机构的医院管理人员和医疗专业人员14- 16名，三个地区共46人次对医院住院医疗服务成本影响因素、住院医疗费用控制的影响因素、住院医疗服务的成本控制的策略和管理控制系统的相关问题进行研讨，对有关医院住院医疗成本管理的影响因素和管理策略进行一定广度和深度的挖掘。5、问卷调查法IV 华中科技大学博士学位论文通过文献资料的查阅和相关人员的访谈，对费用控制的相关制度和包括的主要内容进行了归纳总结。根据以上结果制定了费用控制制度调查表 ,随机抽取三个样本地区的卫生行政部门和样本医院的医院管理者和医务人员共 96人对制度的重要性进行问卷调查。6、专家咨询法通过Del phi专家咨询法，经过三轮专家咨询对病种费用标准费用的评价指标进行论证，确定医院成本控制的评价指标并应用模糊综合指数法对指标进行权重，同时对单病种费用的评价标准进行研究，构建医院成本费用控制的评价指标体系。7、统计分析方法单因素分析方法：方差分析和T检验对正态分布的病种费用资料进行比较分析；应用秩和检验对非正态分布的病种费用进行比较。多因素分析方法：运用多元线性回归分析对影响医院住院病人医疗费用的关键因素进行筛选。结果1、医疗费用控制问题分析与形势判别对医疗费用上涨的原因和费用控制问题进行文献分析，认为医疗费用上涨的原因可以分为两大类：一类是属于人口增加及人口老龄化、疾病结构的变化以及医疗新技术的应用等导致的医疗服务机构成本的理性增长造成医疗费用上涨，另一类是医疗保险制度的缺陷、医疗服务组织的结构与机制的不完善和医疗消费的非理性行为等非理性因素，后者需要通过供方制度的完善和服务的规范以及需方的合理引导进行控制。我国医疗费用控制的形势不容乐观，过去的多年我国卫生总费用的年平均增长率明显高于GDP的年平均增长率，如果医疗费用得不到合理的控制，今后 40年我国医疗费用开支将会大幅度地增长。2、医疗费用控制的特点与影响因素研究通过医疗费用控制的特点和不同的医疗费用支付方式对医疗费用控制的差异分析，提出医疗费用控制障碍的主要原因是由医疗服务市场的特殊性和费用支付方式决定的。影响医疗服务提供者费用和成本最直接的方式，就是改变支付制度，经过V 华中科技大学博士学位论文几种支付方式的比较提出实行病种费用控制是今后我国医疗费用控制策略的一个发展趋势。采用 wi l coxon非参检验和 t检验对 1341例病人不同疾病类型病人费用的差别进行比较分析，并应用多元线性回归分析筛选住院总费用的影响因素发现住院费用影响因素均与住院天数有关，表明要控制患者的住院费用首先需要控制住院时间。不同病种费用的人口学特征和相关指标的影响因素存在差异，阑尾炎和成人肺炎的住院医疗费用与病例分型和患者年龄相关，在制定费用控制标准时需要考虑病例分型和患者年龄。小儿肺炎与单纯剖腹产病人与病例分型和患者年龄不相关，与住院天数、药品比相关，在制定费用控制标准时不需考虑病例分型和患者年龄。3、医院住院医疗费用的成本预算研究通过文献资料的查阅对费用控制的相关制度进行了归纳总结，分析预算控制系统的基本框架。通过经济管理专家、医院管理者、医务人员等相关人员的半结构访谈、调查问卷和专题讨论，制定单病种成本费用测算表。确定了分摊方法和病种的临床路径以后，就可以进行具体病种成本测算工作。首先，制定测算病种的临床路径，确定住院天数。然后，对费用进行分离，区分出直接费用和间接费用，以临床路径为基础进行单病种成本测算。确定了决定间接成本的主要因素：住院天数。提出了住院医疗病种成本预算的基本步骤和方法，对病种成本测算的基本思路、病种的选择和测算方法进行了研究，以深圳某二级甲等医院的单纯剖腹产手术病人的标准成本测算的思路和基本方法进行了案例分析。4、医院住院医疗费用控制的评价研究病种费用标准费用的评价标准研究，通过Del phi专家咨询法确定医院成本控制的评价指标并采用模糊综合指数法确定每个指标的权重，建立医院成本费用控制的评价指标体系，并通过典型病种分析制定了费用控制标准。确定了单病种费用控制的评价指标包括：平均住院医疗费指标、费用结构指标和效率和效果指标3项一级指标和平均床位费、平均药费、平均检查费、平均治疗费、平均手术费、药品费用占总费用的比例、检查费用占总费用的比例、平均住院日、治VI 华中科技大学博士学位论文疗有效率、病种病人满意度等10项二级指标。同时对指标的权重和指标体系的应用进行了案例分析。5、医院住院病人费用控制的管理控制系统构建结合管理控制理论的阐述和医疗费用控制的特点分析，提出在单病种费用支付制度下，医院需要建立有效的医疗费用管理控制策略，使不重视费用控制的临床科室和医务人员的个人行为得到相应的遏制以保障医院的员工的工作目标和行为与医院的总体目标的实现保持一致，形成医院费用控制的长效机制。对实施病种预付制的医院进行费用控制主要环节和关键影响因素研究，总结了影响医院医疗费用控制的八个主要因素。其中包括：医院领导的观念转变、医疗保险支付方式的改变和医疗市场的压力、管理体系的完善和专职机构的设立、以医疗质量为中心的制度建设、科学地成本测算与合理的费用控制标准、动态的质量监督机制、科学的评价和有效的激励机制、医患双方的道德风险。在对医疗费用控制的特点和住院医疗费用单病种控制的影响因素进行分析以及住院医疗单病种费用控制成本测算与费用控制评价研究的基础上，借鉴企业的管理控制系统理论，结合医院单病种费用控制的特点构建适应我国单病种管理的住院医疗费用控制的管理控制系统的理论框架。包括制度控制系统、预算控制系统、考评控制系统和激励控制系统四大部分。6、医院住院病人病种费用控制系统的实证研究通过对山东省济宁市和武汉市两家三级甲等医院应用住院病人医疗费用控制系统具体过程和实施病种费用控制的的效果进行调查分析，发现医院实行单病种费用控制并应用住院病人病种费用控制系统后产生明显的社会效益和经济效益。单病种住院费用明显下降、医院病人总数增加，同时病人满意度和医院总体绩效明显提高。结论1、医疗费用的控制迄今仍是一个世界性的难题，医疗费用控制难度的主要原因是由医疗服务市场的特殊性和费用的支付方式决定的。单病种费用控制通过利益机制，可以达到既控制医疗费用，又保障医疗服务量的目的，实行病种费用控制是今后我国医VII 华中科技大学博士学位论文疗费用控制策略的一个发展趋势。应该积极探索实施医院住院病人的单病种费用控制策略。2、疾病特点和病人的人口学特征对不同病种的费用影响不同，因此需要针对医院的常见的病种开展病种费用的相关因素分析，制定不同的支付和费用控制评价标准。为医保部门、卫生行政部门提供科学依据。3、为了真正发挥病种费用控制的作用，根据本课题研究的住院医疗费用控制管理控制系统，不同医院应该结合自己医院的实际，建立科学合理的住院医疗费用控制管理控制系统，形成住院费用控制的激励和约束机制。4、在医疗服务需求质量弹性较低的情况下，医院提高服务质量的激励不足，可能出现为降低成本减少必需的服务问题，如治疗不足或者要求患者过早出院等。5、为了控制道德风险导致的费用增加，需要严格对医疗服务质量的规制，加强医疗服务的行政管理和法制建设，完善医疗服务质量保证体系。同时需要加强职业道德教育，加强医疗行为的自律性。另外还需要通过费用分摊机制减少患方的过度医疗消费行为导致的道德风险，以控制费用不合理的增加。关键词住院病人；医疗成本；费用控制；管理策略VIII 华中科技大学博士学位论文英文摘要Study on management strategy of the hospitalizationexpenses control based on single disease managementD.Candidate : Tao HongbingSupervisor : Prof.Fang PengqianABSTRACTObjectiveThe medical expense control is a common question which many countries face because ofthe economic interest mechanism.The way of price rules and regulations to medical servicedecided the size of intensity when medical organizations provide each kind of medical service, thisadjust is being standard their behavior, and decides the medical expense finally. Therefore, to usesuitable way of rules and regulations is very important to the control of medical expense. Therefore,the reform of medical expense payment way and the research are one of attention subjectmatters. Since 2000, some hospitals in Chinas cities started reform of payment system ofdisease type, which played a certain role of the rising expenses containment of hospital care,but the result was not ideal, is still faced the challenge from lots of problems. How manyfactors impact the medical expense and the medical expense containment of single disease?How many factors of management impact the effects of the implementation of singledisease expenses control? How to establish and implement a suitable management strategyof inpatient medical expenses containment for Chinas national conditions? Documentationshows that the study of these issues are still not systematic and comprehensive, especiallythe study on management and control system for hospitalization expenses containment hasnot yet been reported.Using qualitative and quantitative methods，the study combined with the theoreticalanalysis of the hospitalization expense containment, as well as the reasons, the research onthe status research and the key elements of the increasing of hospitalization expenses, andthe theory review of hospital care expenses containment, drawled on experiences onmedical expenses containment at home and abroad , studied the strategy of managementand containment by analyzing medical cost accounting and factors affecting the expenses.Based on management control theory, the study proposed the framework of managementand control system for the current China-inpatient. Through analyzing typical cases insampled hospitals, this study empirical research the application effect of management andcontrol system to provide the basis for forming an effective incentive and restrictivemechanisms and playing the real role of disease expenses containment in the diseasemedical expenses containment.IX 华中科技大学博士学位论文Methods 1.Literature research methodsUsing non-structural,non-quantitative methods to access the professional magazine,journals,essays and on-line retrieval text, graphics, sound and other relevant literature, collectingdata concerning expenses containment in the process of hospital medical services at homeand abroad,collating and analysising related systems about medical expenses containment,specific programmers and statistics data from sample hospitals and relevant governmentdepartments.Then all kinds of documents and information were summarized and concludedobjectively and systematically.2.Secondary data collection and analysisIn two sampled hospitals,retrospective survey from 1,341 patients four disease types ofinclude the demographic characteristics of patients, hospital expenses and the totalexpenses of the project specific indicators. the hospitals actual hospital beds, number ofhospital revenue and expenditure expenses of the project in sampled hospitals; collectingrelated indicators of hospitals expenses control after inpatient hospital medical expensesmanagement control system was used in sampled hospitals;at the same time,in a two-levelhospitals in Hubei Province, collect and analysis data in 2006 on the hospital beds, hospitalrevenue and hospital expenses and the expenses of the project of a single-species diseasecalculation of the expenses; in a three-level hospital in Shandong Province, investigaterelated indicators of hospitalization expenses containment after management and controlof hospitalization expenses control system was used from 2004 to 2007.3. Semi-structured depth interviewsOn the basis of the first part information and the results of intelligence analysis, visit andask 36 persons ,including the health sectors, health management experts, hospitalmanagement from medical institutions and medical professionals (12-16 persons),who arerandomly sampled from every hospital-located areas.Ask those persons pre-determinedquestions on the hospital medical expenses containment and the key links in the maininfluencing factors in semi-structured interviews and analysis those information, acquireand tap the in-depth information and data.4. Panel discussionsInvited 46 persons from three sample areas(about 14-16 persons from each samplearea),including experts in health economy and health management areas,managers fromhealth administration departments,the hospital management staff from medical institutionsand medical professionals,to discuss problems on the factors of the hospital medical servicecost, the factors of the hospitalization expenses containment, the strategy of hospital carecost control and control and management system.The factors impacting the costmanagement of hospital care and the management strategy were excavated in breadth anddepth.5. Survey methodThrough literature search and interviews with relevant staff, the study summarized relatedsystem of expenses containment and the major contents. According to the above results, thepapers developed questionnaire of expenses containment system, randomly selected 96people from medical insurance institutions, health administrative departments, hospitaladministrators and medical staff in three sampled areas, surveyed more than 30 people inX 华中科技大学博士学位论文each region by the questionnaire on importance of the system.6. Expert advice methodUsing Delphi expert advice method, the study demonstrated evaluation indexes of diseasestandard expenses in three rounds of expert advice, determined and studied the evaluationindexes of hospital cost containment, and established the evaluation index system ofhospital cost containment.7. Statistical methodsSingle factor analysis: Using T-test and variance analysis to analysis data in normaldistribution for comparative analysis; using rank sum test to analysis data in non-normaldistribution.Multivariate analysis methods: Using multiple linear regression analysis to screen the keyfactors impacting the hospitalization containment.Results1 Analysis on the medical expenses containment and discriminate the situationUsing literature studying, panel discussions and other methods, the study analyzed thereasons for the rising medical costs and cost control issues,and considered that the reasonsfor the increase of the health care expenses can be divided into two categories: One is thatthe growing population ,changes of the ageing of the national population and the diseasestructure, as well as the application of new medical technologies inresultedreasonable growth of medical services being followed the growth of medicalbyexpenses, and the other is the deficiencies of medical insurance system, the defects oforganizational structure and mechanism of medical services and non-rational behavior ofmedical expenses and other non-rational factors, the latter can be controlled by improvingsupply system and service standards as well as guiding reasonable behavior.The situation ofmedical expense control is unoptimistic in our country ,Over several years, average growth rate ofChinas health total expenses was significantly higher than the annual average growth rateof GDP, if medical expenses are not reasonable controlled, in the next 40 years Chinashealth care expenditure will increase relatively.2. The characteristics and influence factors of medical expenses containmentAnalyzing the characteristics of medical expenses containment and the difference analysisof medical expenses containment from different payment system of medical expenses, , thestudy pointed out the main reason for difficulty of medical expenses containment weredecided by the special nature of medical services market and the payment system ofmedical expenses. The most direct way impact the expenses and cost of medical serviceproviders is changing the payment system.After compared several payment systems, thestudy pointed out that implementing expenses containment of single disease will be a trendof Chinese medical expenses containment strategy in the future.Using non-wilcoxon test and t-test,the papers analyzed difference of the expenses betweenthe diseases of 1,354 patients. At the same time,Using multiple linear regression analysis toscreen the factors of the hospitalization expenses, the study found that hospitalizationexpenses were related to hospitalized days, indicating that we must firstly control thehospitalization time to control the hospitalization expenses.Besides,the study describedthere exist differences among demographic characteristics impacting different kinds ofdiseases expenses, Hospitalization expenditure of Appendicitis and Adult Pneumonia casesXI 华中科技大学博士学位论文is related to the case type and the patients age, so its necessary that case type and thepatients age should be considered to develop the standards of expenses containment. Onthe contrary, Children Pneumonia and Caesarean cases is not related to the case type andthe patients age, so its not required to consider case type and the patients age to developthe standards of expenses containment.3. Research on hospitalization cost budgetUsing literature studying,the study summarized the relevant systems of expensescontainment,and analyzed the basic framework of the budget control system.After analyzedthe suggestion from economic management experts, hospital managers and medicalpersonnel, and other relevant staff by semi-structured interview, questionnaire survey andsymposia,the study developed the table for cost estimates of single disease(seeAnnex).After determined the apportionment way and the clinical path of diseases,we cancarry out cost accounting work of specific kinds of diseases. Firstly, we should develop theclinical pathway of calculated disease,and determine the days of stay.Then, Its necessary toseparate the expenses, distinguish between direct expenses and indirect expenses,and carryout cost estimates of single disease based on the clinical path.The papers identified that the main factor impacting indirect cost is the days of stay,pointedout the basic steps and methods for estimating cost of hospitalization disease care, studiedthe basic ideas of the disease cost calculation, choices of disease types and calculationmethods.Using analysis methods of typical case,the papers analyzed the basic ideas andmethods of the standard cost expenses calculations for the simple Caesarean sectionpatients from a two-level hospitals in Shenzhen.4. Study on evaluation of hospitalization expenses containmentThe study researched the evaluation criteria of the disease standard cost, gave theevaluation index of hospital cost control by using the Delphi expert advice method,andweigh the indexes ,established the evaluation index system of hospital cost control.The evaluation indicators of single diseases expenses containment were determined asfollows: three One-level indexes including average hospitalization expenses index,expenses structure index and efficiency index and average bed fees, the averagedrugsexpenses, the average inspection fees, the average expenses of treatment, the averagesurgery fees, the proportions of drugsexpenses in total expenses, the proportion ofinspection fees in the total expenses, average hospital days, treatment efficiency andpatients satisfaction diseases such as ten Two-level indexes. At the same time, the weightof the index system and the application of the index system were ana