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포괄수가제 도입이 청구 진단명에 미치는 영향 : 7개 질병군 대상으로
Since July the first, 2013, Korea has fully implemented mandatory seven diagnosis-related groups(DRGs) prospective payment system to every medical institution. Fee-for-service(FFS) and prospective payment system have different incentive mechanisms whose diagnosis codes can influence the decision about medical expenses. Thus, after the installment of prospective payment system, it is expected that diagnosis codes for insurance claims could have changed considerably. This research tries to analyze the effects of policy on changes in diagnosis coding patterns for claims from health care providers before and after applying mandatory 7 DRGs prospective payment system. For this purpose, the research selected and used the data of 7 DRGs among the whole inpatients from November 1, 2011 to December 31, 2014 from NHI Claims data of National Health Insurance(NHI). At the start of mandatory application, the whole claims were divided into two dataset. One was for the medical institutions that changed from FFS into prospective payment system. And the other was for the medical institutions that already used prospective payment system and have kept using it. The number of the former was 914 and the number of medical treatment was 1,248,448. And the number of the latter was 1,369 and the number of medical treatment was 2,548,878. Using it, the average number of using diagnosis codes by medical treatment and average severity scores using SCCL were analyzed. For the accurate comparison, after matching the characteristics of medical institutions by group of disease, additional analyses were carried out. Like the analysis of the whole institutions, the number of using diagnosis codes and changes in severity scores were examined, and DID multiple regression analysis was carried out in order to check whether these changes were the results of mandatory prospective payment system or not. Based on the matching data of medical institutions, after revising the changes over time before/after mandatory application, the results showed that the number of using diagnosis codes was a little reduced, such as 1.8 for hospitals and clinics and 2.0 for general hospitals. And the number of severity scores was also a little reduced, such as 0.37 points for hospitals and clinics and 0.75 points for general hospitals. When comparing the number of claims between FFS and prospective payment system, and analyzing diagnosis codes for 1,000 patients whose appearance frequency shows a lot differences, hospitals and general hospitals at FFS used K29, K59, and the codes for chronic diseases like diabetes and hypertension a lot and hospitals and clinics at FFS used R code a lot. However, the codes used a lot at prospective payment system were O82, D62, and Z35, and they were shown at hospitals and clinics more than general hospitals. Mandatory application of prospective payment system has have positive effects on the change in diagnosis coding patterns. At an early stage of applying prospective payment system, the number of using diagnosis codes and severity scores were reduced a lot, but they were still higher than those of hospitals which have applied prospective payment system continuously. However, a little increase in severity scores at the medical institutions which have used prospective payment system continuously suggests the possibility of upcoding. Therefore, ongoing management and monitoring from the government by long-term evaluation should be needed.
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