研究背景和目的：近年来，卫生费用快速增长，在合理控制医疗费用，合理使用医保基金方面，许多国家作了大量的探索，医疗费用支付方式的改革便是关键措施之一，采用诊断相关分组(Diagnosis Related Groups, DRGs)为基础的付费方式是许多国家的改革结果，并取得一定成效。为此，本文研究的主要问题是通过实证探讨医保与非医保患者医疗资源使用是否存在差异，在此基础上，尝试使用DRG分组方法对病例进行组合，初步探讨组合的可行性。本研究以X市7家公立三甲医院脑出血患者为例，比较医保和非医保患者差异，探讨医疗资源使用的相关因素，初步将病例进行组合作进一步观察，探讨组合的合理性，为当地推广DRGs，推进定价机制和医保支付方式改革提供参考。研究方法：数据来源于2015年12月到2017年6月X市7家公立三甲医院出院患者的病案首页，研究对象为主诊断是脑出血(ICD10:I61)的患者，选择出血部位是壳核、丘脑以及脑叶的患者，含内科治疗与外科治疗，外科治疗的主手术为颅内血肿清除术(ICD-9-CM:01.24)，共647例，数据清洗后剩余552例纳入分析。采用描述性统计、卡方检验、单因素分析及多元回归比较医保和非医保患者的差异，并探讨其它相关因素，采用卡方自动交互检测法(CHAID)进行病例组合。研究结果：（1）患者平均年龄55.49岁，平均住院天数18.06天，平均住院费用40194.42元，西药费及诊断费分别占39.01%和18.92%。（2）医保与非医保患者平均住院天数分别为20.12和16.84天，平均费用分别为45791.67和36913.26元，存在显著差异(P<0.001, P=0.024)，通过多元回归校正其他因素后依然显著。（3）年龄、患者来源、有无手术、有无抢救与住院天数回归结果显著；年龄、有无手术、入院情况、有无进ICU、出血部位与住院费用回归结果显著。（4）以费用为轴心将病例组合为5组，四组费用的变异系数小于0.8，一组为0.82，变异减低率(Reduction In Variance, RIV)为45.49%，非参数检验提示各组费用差异显著。研究结论与建议：（1）脑出血患者医疗资源使用较多，西药费及诊断费占费用比重最大。（2）医保患者医疗资源使用多于非医保患者，其他可能相关的因素有年龄、患者来源、入院情况、是否手术、有无抢救、有无进ICU及出血部位。（3）本研究的病例组合分组效果良好，有一定合理性。基于以上结论，建议开展更多相关大型研究，建立DRGs体系，规范病案首页填写，倡导健康管理与健康生活方式。

Background and Objectives: In recent years, health expenditures have grown rapidly. Many countries have made extensive explorations in the rational control of medical expenses and the rational use of health insurance funds. The reform of payment methods is one of the key measures and the use of diagnosis related groups （DRGs） is the result of reforms in many countries which have achieved good results. Therefore, the main problem of this paper is to empirically explore whether there is difference in the use of medical resources between patients with and without medical insurance. Based on this, the study try to use DRG method to combine cases and explore the feasibility of the case-mix. This study took an example of patients with intracerebral hemorrhage in 7 public hospitals in X City, and compared the difference between patients with and without medical insurance. The factors related to the use of medical resources were discussed. The cases were observed for in groups and the rationality of the case-mix was explored for local promotion. Then maybe some evidences were provided for establishment and development of local DRGs, reform of pricing mechanism and payment methods for medical insurance.Methods:Data were collected from the first page of the medical records of the discharged patients in 7 public hospitals in X city from December 2015 to June 2017. The study defined the patients who were first diagnosed as cerebral hemorrhage （ICD10: I61）, including medical treatment and surgical treatment, and the main surgical treatment was intracranial hematoma removal （ICD-9-CM:01.24）. A total of 647 patients were selected for the hemorrhage site, including the putamen, thalamus and lobar. After data cleaning, the remaining 552 cases were included in the analysis. Descriptive statistics, chi-square test, univariate analysis and multiple regression were used to compare the differences between patients with and without medical insurance, and explore other related factors. Chi-square automatic interaction detector （CHAID） was used for case mixing. Results:1） The average age of patients was 55.49 years old, the average length of stay was 18.06 days, the average hospitalization cost was 40194.42 yuan, and the drug costs and diagnostic expenses accounted for the highest of the costs, which were 39.01% and 18.92% respectively. 2） The average hospital stays in patients with and without medical insurance and non-medical patients were 20.12 and 16.84 days, respectively, and the average costs were 45,791.67 and 36,913.26 yuan, respectively. There was a significant difference （P＜0.001, P=0.024）, and it was still significant after multivariate regression was used to correct other factors. 3） The age, patient‘s source, surgery, rescue were significant in regression model of hospital stays. While age, surgery, admission status, presence or absence of ICU, hemorrhage sites were significant in regression model of costs. 4） Combine the cases into 5 groups with costs as the axis. The coefficient of variation of fees in four groups were less than 0.8, the one in the other group was 0.82, and the Reduction In Variance （RIV） is 45.49%. Non-parametric tests indicate the costs of each group were significantly different.Conclusions and Recommendations:1） The patients with cerebral hemorrhage use lots of medical resources, drug fees and diagnostic fees account for the largest proportion of costs. 2） Patients with medical insurance use more medical resources than non-medical insurance patients. Other possible related factors include age, patient source, hospital admission, surgery, rescue, ICU admission, and hemorrhage sites. 3） The case mix of this study has been verified that grouping is effective and reasonable. Based on the above conclusions, it is proposed to carry out more relevant large-scale studies, establish a DRGs system, standardize the filling out of the medical records, and advocate health management and healthy lifestyles.