A Study of Patients with Higher Medical Expenses in DRG 124 - A Regional Hospital as Case

Diagnostic Related Group (DRG) is a prospective payment system to classify hospitalization cases into groups with predefined payment in order to control medical expenses. National Health Insurance Bureau of Taiwan (NHI) implements 155 items of DRG since 2010, and will complete it in five years. When a hospital encounters the payment system, it needs to control its cost. But it cannot just reduce the outcome or increase overloading of stuffs to affect service quality, also cannot discharge patients early to raise medical disputes or return soon. It should study the major outcomes to refine itself or to make suggestions to the NHI. This paper studies expensive tests of DRG124: with cardiac catheterization and complex diagnosis, focus on patients in 2010 and 2011 whose medical expense is higher, tracks back their medical records and analyses data with such medical histories. Methods developed in this study can also be applied to other DRGs to improve performance of hospitals. Study finds that medical expenses relating to source of patients, hospitalized days and related expenses, principle diagnosis and test items. Patients with heart failures, emergency admission and stay ICU will be the higher expense group. For patients and hospitals, it is important to screen related syndromes and control the progress actively. For NHI, we suggest that to divide into two DRGs according to disease of coronary artery syndrome (4111, 4140) or heart failure (42X.) to clear the reasonable expense class.