背景与目的：DRG支付背景下的医院运营管理正逐步向精细化迈进，控费压力下医院对于DRG病种成本的管控愈发重要。科学的DRG成本核算为医院节降成本、探寻结余空间提供了数据支撑，而基于临床路径的协同管控融入了临床视角，可帮助医院在管控中兼顾成本合理与医疗规范。DRG成本相较于费用更能够反映真实资源消耗，也能够为支付标准及价格制定提供依据。因此，本文以C医院2023年的经皮肾镜手术（PCNL）病种为例开展DRG成本核算与分析，并试探究引起该病种DRG超支的原因，探讨可行的DRG成本管控思路。方法：（1）基于项目叠加法核算PCNL病种实际DRG成本；（2）基于C医院现行PCNL临床路径及相关诊疗指南和专家共识，将路径医嘱转化为成本项目，归集临床路径下的标准DRG成本及费用；（3）实证分析PCNL手术患者成本及费用的影响因素，识别高成本/费用患者的主要特征；（4）对具备复杂特征的患者特例进行个案讨论与分析，梳理各类重要特征下的成本项目叠加。结果：（1）2023年C医院PCNL病种实际DRG成本低于费用，但二者均高于DRG支付标准；（2）2023年C医院PCNL病种实际DRG成本高于临床路径标准成本，但临床路径标准费用与DRG支付标准相近；（3）影响C医院PCNL患者成本及费用的主要因素包括二期PCNL情况、手术方式、术中建立通道数目及合并泌尿系感染情况；（4）行二期PCNL、使用创新手术方式（NAES）、术中建立多通道及合并泌尿系感染的特例均有各特征下相应的成本项目叠加。结论与建议：C医院的PCNL病种作为业内领先的卓越专科病种，所收治患者具备多种复杂特征，病种的实际成本超出当前DRG支付标准及未考虑复杂情形的现行临床路径标准成本水平。在对PCNL病种的DRG成本管控中，医院端应从明确复杂特例的指征、规范高值耗材使用等诊疗行为入手，精准把控非合理的成本超支；支付/政策端需充分结合临床实际，通过分组优化、除外管理及政策联动等方式补偿合理超支；商业端则需正确看待DRG支付，通过探寻多元支付方式、调整适配的准入策略等扩展新技术生存空间。
Background and objective: The operation and management of hospitals under the background of DRG payment is gradually moving towards refinement. The management of DRG costs by hospitals under the pressure of cost control is becoming more and more important. Scientific DRG cost accounting provides data support for hospitals to save costs and explore room for savings. Clinical pathway-based collaborative management incorporates a clinical perspective, which can help hospitals balance cost rationality and medical standardization. DRG costs are more reflective of true resource consumption than patient expenses and can provide a basis for payment rates and price setting. Therefore, this paper carries out DRG cost accounting and analysis using percutaneous nephrolithotomy （PCNL） cases in Hospital C in 2023 as an example, and tries to explore the causes of DRG overruns in these cases and discusses feasible DRG cost control ideas.Methods: （1） Use the bottom-up approach to account for actual DRG costs for PCNL patients. （2） Based on the current PCNL clinical pathway of Hospital C and related guidelines and expert consensus, convert clinical prescriptions into cost items, and summarize standard DRG costs and patient expenses under the clinical pathway. （3） Empirically analyze the factors influencing the costs and patient expenses of PCNL patients and identify the main characteristics of patients with high costs and patient expenses. （4） Discuss the special cases with complex characteristics, and sort out the cost item overlays for each important characteristic.Results: （1） The actual DRG costs are lower than patient expenses for PCNL of Hospital C in 2023, but both are higher than DRG payment rates. （2） The actual DRG costs are higher than standardized costs based on clinical pathway, but the standardized costs are similar to DRG payment rates. （3） The main factors affecting the costs and patient expenses for PCNL in Hospital C include the status of staged PCNL, the surgical approach, the number of intraoperative channels created and the presence of coexisting urinary tract infections. （4） The exceptional patients undergoing second-stage PCNL, using an innovative surgical approach （NAES）, intraoperative creation of multiple channels, and comorbid urinary tract infections had the corresponding cost items stacked under each characteristic respectively.Conclusions: PCNL in Hospital C industry-leading, with patients admitted with multiple complex characteristics, and the actual DRG costs for PCNL exceeds both the current DRG payment rates and the standard cost levels based on current clinical pathways that do not account for complexity. In the DRG cost management and control for PCNL, hospitals should start from clarifying the indications of complex exceptions, standardizing the use of high-value consumables and other clinical behaviors, and accurately controlling non-reasonable cost overruns. The payment or policy side needs to fully integrate with the actual clinical situation, and compensate for the reasonable overruns through DRG grouping optimization, exclusion management, and policy linkages. The commercial side needs to face up to the DRG payment policy, and expand the living space for new technologies by exploring diversified payment modes, and adjusting the adapted market access strategies.
