The Impact of A Fully Implemented DRG System on Community Hospital Finance - Analysis of a Regional Hospital

• Main Authors: Fu-Mei Yang, 楊馥美
• Other Authors: Hui-Chu Lang
• Format: Others
• Language: zh-TW
• Published: 2018
• Online Access: http://ndltd.ncl.edu.tw/handle/5vb4my

碩士 === 國立陽明大學 === 醫務管理研究所 === 106 === National Health Insurance (NHI) is the most essential part of our social security system, and is deeply cared for by the public. From the beginning of NHI implementation until the present, Taiwan has achieved the aim of this policy, "Universal Coverage and Healthcare Equality". Research Background and Purpose: With gradual changes in the medical environment and government policies, the NHI payment system has been revised many times. The changes in the payment system can have a direct impact on hospital finances. Originally Tw-DRGs payment system was planned to be gradually introduced over five years. However since the start of the system on 1 January 2010, it has been nearly six years, and only phases I and II have been introduced. Now Tw-DRGs phase III to V, which primarily focus on internal medicine, will soon be fully introduced. This will have a great impact on most internal medicine departments, which have yet to be introduced into the system. In addition, the National Health Insurance Administration (NHIA) has shifted the entire International Classification of Disease and NHI claims to ICD-10-CM/PCS version as of 1 January 2016. If Tw-DRGs is fully introduced now, the impact of the dual policies on hospital operation and financial management will require deeper analysis. Research Goal: To simulate the data distribution and variables of fixed-sum payment points and original actual NHI claim points from the claimed cases of the studied hospital, following the complete implementation of Tw-DRGs phases III to V. The research studies the projected changes in hospital finance and investigates the causes and influences of the changes, to serve as a reference for management and cost control for hospitals, in the light of changes to NHI policy. Research Method: Using a public regional hospital as the case study, this research employed a retrospective study with secondary data, and collected inpatient claims data between January 1 and December 31, 2015 from a regional hospital. With phase III to V DRG items, which have not been introduced into the system yet, the research simulated each inpatient case based on the NHIA Tw-DRGs payment system version 3.4, and compared data differences, distribution, and profit ratios of the resulting Tw-DRGs case payment and the actual NHI claims. The research analyzed and investigated the cost structure for each hospital department, and the factors influencing the NHI claims. The research utilized two statistical software packages Excel 2013 PivotTable and SPSS Ver. 22.0, and employed descriptive statistics, Chi-square test and binary logistic regression to analyze the influences of the profit ratios. Research Result: With a full implementation of TW-DRGs phases III to V, the overall profit ratio of NHI claims was -2.60%, and with a projected 990 cases in total (43.31%) in the deficit interval, the respective NHI claims was -19,445,293 points. There were a total of 1296 (56.69%) cases in the profit interval, and the respective NHI claims were 17,155,349 points. The hospital departments with negative profit ratios were mostly internal medicine departments. In addition, research on the logistic regression analysis found that the age, hospitalization period, hospital-acquired infections, and patient numbers of the long-term care units have a great influence on hospital profit and loss. Even though readmission with 14 days is not significantly meaningful, it can cause deficits in NHI claim points (OR=0.954＜1). Conclusion: Changes in payment system have a great impact on hospital finance and management. For the studied hospital, with a full implementation of TW-DRGs, it has shown an overall deficit in NHI claim points, mostly for internal medicine departments. Before executing the changes in the NHI payment system, preliminary financial budgeting and influence factor analysis can assist hospitals in taking suitable management action and financial control regarding the high-risk factors, as well as strengthen internal communication for departments with high margins in profit and loss. This will necessarily increase the quality of hospital medical services, while at the same time executing precise cost control to reduce operational risks, and allow for sustainable operation. Keywords: Tw-DRGs, NHI claims, data distribution, profit ratio