随着医疗技术的发展及人口老龄化的加剧，我国医疗费用呈逐年上升态势， 并对医保基金的平稳运行带来较大压力。2017年12月1日，浙江省二级以上的 公立医院在107个病种内试行按病种收费改革。在新的医改政策影响下，医院的 经济运营面临巨大挑战，当病种成本高于相应的病种定额结算标准时，医院就会 发生亏损，医院要维持良好的运营，须尽快开展对单病种成本的研究，探求其影 响因素，做好单病种成本管理和控制，降低运营成本，提高医院的绩效水平。 本研究针对我国医疗机构实施单病种收费后存在的医疗结余下降、成本控制 困难等问题，选取某省级三甲医院2018年1月1日至2018年12月31日实行单 病种定额结算的全部住院患者医疗费用，剔除申请出组、信息不全和住院费用异 常病例,最终得到有效分析数据共计1007例，通过科室全成本核算与临床路径相 结合的方法测算单病种成本，使用SPSS20.0及SPSSMODELER18.0软件拟合 通径模型、CHAID决策树模型对临床路径下医院单病种成本的影响因素进行分 析。 通过对样本医院临床路径下单病种成本测算发现，医技科室的执行收入大幅 高于科室成本，而临床科室反之；通过对单病种成本构成分析发现，卫生耗材、 药品、化验、检查成本在病种成本中占比超过六成，而体现医务人员劳务价值的 医疗服务成本占比不到四成。反映出医疗服务价格存在一定不合理性。检查和检 验项目的医疗收费偏高，而手术、护理、治疗等项目的医疗收费偏低。 通径模型结果提示，平均住院日因素正向影响单病种成本。卫生耗材费占比 因素对病种成本的影响具有双面性。一方面，该变量直接正向影响单病种成本； 另一方面，通过平均住院日间接负向影响病种成本；从总效应来看，卫生耗材费 占比高会增加病种医疗成本。药费占比因素可直接正向影响单病种成本，但对平 均住院日没有影响。临床路径表单化管理直接负向影响单病种成本，不存在间接 影响作用。临床特征中的病种变量是影响医院单病种成本最重要的因素；是否恶 性变量对单病种成本没有直接影响，而是通过平均住院日间接正向影响病种成 本。社会人口学特征的性别变量可直接、间接负向影响单病种成本。另外，通过 CHAID决策树模型确定了8种单病种结算模式下的病例成本组合，并可得出每 临床路径下医院单病种成本影响因素研究——基于z医院1007例肿瘤类单病种数据 III 个病例组中病种成本超过医保结算标准的例数，模型预测准确率超八成。病例成 本组合的分类规则可以有效地指导医院制定合理的病种成本管控方案。 根据实证研究结果，本文分别从医疗机构管理层面及政府政策制定层面，探 索控制单病种成本，节约有限的医疗资源的可操作路径。 本研究丰富了以往学者对病种成本影响因素的研究方法，提供新的研究思 路。为医保部门制定合理的单病种结算标准、财政部门制定针对医疗机构的财政 补助政策提供理论依据和方法支持。有利于完善医院全成本核算的管理理论，对 构建基于病种成本核算的医院成本核算的方法体系提供借鉴。本研究通过对医院 临床路径下单病种成本影响因素的分析，有利于为医院管理者制定成本管控方案 提供科学依据，做到精准管理。通过科室全成本核算与临床路径相结合的方法测 算病种成本，有利于医院控制成本，提高绩效水平。为医疗机构与医保部门双方 建立合理的谈判机制提供定价参考，有利于单病种定额结算政策的推行。通过政 府、医院双方视角的病种成本控制策略研究，有利于抑制病种医疗成本的增长， 减轻患者的就医负担，节约有限的医疗资源。 关键词：病种成本，单病种定额结算，临床路径，数据挖掘 浙江工业大学硕士学位论文 IV Studyontheinfluencingfactorsofhospitalsingledisease costunderclinicalpathway——basedonthedataof1007 casesoftumordiseaseinZhospital ABSTRACT Withthedevelopmentofmedicaltechnologyandtheaggravationofpopulationaging, China'smedicalexpensesarerisingyearbyyear,whichbringsgreatpressuretothesmooth operationofthemedicalinsurancefund.OnDec1,2017,Healthinsurancepaymentreformhas beenimplementedinhospitalsinzhejiangprovince.Underthenewhealthcarereformpolicy influence,thehospital'seconomicoperationfaceshugechallenges.Ontheresearchofthecostof singlediseasesmustbecarriedoutassoonaspossible,toexploretheinfluencefactorsofcostof singlediseases,completesthecostmanagementandcontrolofsinglediseases,reduceoperating costs,improvethelevelofhospitalperformance. Thisstudyaimingatsinglediseasesfeeaftermedicalinstitutionsformedicaltreatmentof surplusdecline,costcontroldifficultproblems,selecting1007casesinaprovincialhospitalasthe researchsample,throughcostaccountingmethodmeasuringthemedicalcostofsingle diseases.SPSS20.0andSPSSMODELER18.0softwarewereusedtofitthepathmodeland CHAIDdecisiontreemodeltoanalyzetheinfluencingfactorsofhospitalsinglediseasemedical costunderclinicalpathway. Throughthecalculationofthemedicalcostinsamplehospital,itisfoundthatthe executiveincomeofthemedicaltechnologydepartmentismuchhigherthanthedepartmentcost, whiletheclinicaldepartmentisonthecontrary.Throughtheanalysisofthecoststructureofsingle diseases,itwasfoundthatthecostofmedicalconsumables,drugs,laboratorytestsand examinationsaccountsformorethan60%ofthecostofdiseases,whilethecostofmedical servicesreflectingthelaborvalueofmedicalpersonnelaccountsforlessthan40%.Itreflectsthe irrationalityofthepriceofmedicalservices.Themedicalfeesforinspectionandinspectionitems arerelativelyhigh,whilethemedicalfeesforoperation,nursing,treatmentandotheritems reflectingthevalueofmedicalpersonnel'sservicesarerelativelylow. Theresultsofthepathmodelindicatethattheaveragelengthofhospitalstaycandirectly affectthecostofdiseasespecies,Theinfluenceoftheproportionofmedicalconsumablesonthe costofdiseasespeciesistwo-sided.Ontheonehand,thisvariabledirectlypositivelyaffectsthe costofsinglediseasespecies.Ontheotherhand,theaveragelengthofhospitalstayindirectly negativelyaffectsthediseasespeciescost.Intermsoftheoveralleffect,thehighproportionof medicalconsumableswillincreasethemedicalcostofdiseases.Theproportionofdrugcost directlyaffectsthemedicalcostofsingledisease.Theformalizedmanagementofclinicalpathway hasadirectnegativeeffectonthecostofsingledisease,buthasnoeffectontheaverageannual hospitalstay.Inaddition,diseasetypeisthemostimportantfactorinfluencingthemedicalcostof singlediseasetypeinhospital.Gendervariablesofdemographicandsociologicalfactorscan directlyandindirectlynegativelyaffectthecostofsingledisease.TheCHAIDdecisiontreemodel wasusedtodeterminethecasecostcombinationunderthesettlementmodeof8singledisease species,thenumberofexceedingthestandardcasesineachgroupcanbeobtained.Theprediction accuracyofthemodelexceeded80%.Theclassificationrulesofcasecostcombinationcan effectivelyguidehospitalstodevelopreasonablediseasecostcontrolplans. Accordingtotheresultsoftheempiricalstudy,thisstudydevelopedcontrolstrategiesfrom themanagementlevelofmedicalinstitutionsandthegovernmentpolicyformulationlevelonthe controllableinfluencingfactorsofthemedicalcostofsinglediseaseintheclinicalpathwayof hospitals. Thisstudyenrichespreviousscholars'researchmethodsoninfluencingfactorsofdisease 临床路径下医院单病种成本影响因素研究——基于Z医院1007例肿瘤类单病种数据 V speciescostandmedicalcostcontrolofdiseasespecies,andprovidesnewresearchideas.It providestheoreticalbasisandmethodsupportfortheestablishmentofreasonablesingle-disease settlementstandardsforthemedicalinsurancedepartmentsandtheformulationoffinancial subsidypoliciesformedicalinstitutionsbythefinancialdepartments.Itisbeneficialtoimprove themanagementtheoryoftotalhospitalcostaccountingandprovidereferenceforconstructingthe methodsystemofhospitalcostaccountingbasedondiseasespeciescostaccounting.Throughthe analysisoftheinfluencingfactorsofthemedicalcostofthesinglediseaseintheclinicalpathway ofthehospital,thisstudyprovidesascientificbasisforthehospitalmanagerstoformulatethecost controlplanandachieveaccuratemanagement.Throughtheformulationofthestandarddisease speciescostbasedonclinicalpathway,itisbeneficialforhospitalstocontrolthecost,improvethe performancelevel.Itprovidespricingreferencefortheestablishmentofreasonablenegotiation mechanismbetweenthemedicalinstitutionsandthemedicalinsurancedepartment,andprovides datasupportfortheestablishmentofsettlementstandardforthemedicalinsurancedepartment, whichisconducivetotheimplementationofquotasettlementpolicyforsingledisease.Through thestudyofdiseasecostcontrolstrategiesfromtheperspectivesofthegovernmentandthe hospital,itisbeneficialtorestrainthegrowthofmedicalcostofdisease,reducetheburdenof medicaltreatmentforpatients,andsavelimitedmedicalresources. KEYWORDS:Diseasecost,SingleDiseasePayment,Clinicalpathway,Datamining 浙江工业大学硕士学位论文 VI 目录 摘要...II ABSTRACT.......................IV 插图清单......................