I-DRG, okanye iqela lokuxilonga oluhambelana nokuxilongwa, indlela iMagaretheri kunye neenkampani ze-inshorensi zempilo zibeka iindleko zokubhedlele izibhedlele kwaye ziqikelele ukuba zinjani ukuhlawula isihlala esibhedlele isiguli. Esikhundleni sokuhlawula isibhedlele kwento esetyenzisayo yokunyamekela isigulane esibhedlele, iMirare ihlawula isibhedlele isixa esicwangcisiweyo esekelwe kwi-DRG yesigulane okanye ukuxilongwa.
Ukuba isibhedlele siyaphatha isigulane ngelixa ichitha imali engaphantsi kwe-DRG yentlawulo, yenza inzuzo. Ukuba isibhedlele sichitha ngaphezu kwe-DRG intlawulo yokuphatha isigulane, ilahlekelwa yimali.
Imvelaphi
Kwiminyaka edlulileyo, xa uhlala esibhedlele, isibhedlele yayiza kuthumela i-bill ye-Medicare okanye inkampani yakho ye-inshorensi ebandakanya iintlawulo zonke ii-Band-Aid, i-X-ray, i-swab yotywala, i-bedpan, kunye ne-aspirin, kunye necala lokulala usuku ngalunye usibhedlele. Oku kwakhuthaza izibhedlele ukuba zigcine esibhedlele ixesha elide kunokwenzeka kwaye zenze okungangoko kunokwenzeka xa usibhedlele. Emva kwakho konke, ixesha elide usesikhungweni, imali eyongezelelweyo isibhedlele esenziwe kwiimali zecala. Iinkqubo ezininzi ozenzileyo ngexesha lobhedlele, i-Band-Aids, i-X-ray kunye ne-alcohol swabs oyisebenzisileyo.
Njengoko iindleko zokunakekelwa kwempilo zenyuka, urhulumente wafuna indlela yokulawula iindleko ngelixa ekhuthaza izibhedlele ukuba zibonelele ngempumelelo.
Yintoni eyabangela ukuba i-DRG.
Ukususela kuma-1980, ii-DRG zatshintshile indlela i-Medicare ehlawula ngayo izibhedlele. Esikhundleni sokuhlawula imihla ngemihla usibhedlele kunye neNcediso yoLuntu oluyisebenzisayo, i-Medicare ihlawula isamba esisodwa kwisibhedlele sakho esisekelwe kwi-DRG yakho, esekelwe kwisifo sakho (kubandakanya ukuxilongwa kwesekondari, ukuba kuyasebenza), nawuphi na ugqirha iinkqubo ezibandakanyekayo, kunye nobudala bakho kunye nesini.
Iingcamango kukuba i-DRG nganye ibandakanya izigulane ezinezifo ezifanayo zonyango, kwaye ukunakekelwa kwabo kudinga inani elifanayo lemithombo yokunyanga. Ukuphuhlisa le nkqubo kwakungekho lula, njengoko kuchazwe ngamaziko e-Medicare kunye neeNkonzo zeMedicaid .
Inkqubo ye-DRG ijoliswe ekujoliseni ngokulinganayo izibhengezo zebhedlele, kungakhathaliseki ukuba isibhedlele siphi na okanye zeziphi izigulane ezithathayo. Kodwa ukungaphumeleli kusekho kwinkqubo, iholele ezinye izibhedlele ukuba zijolise kwiinkonzo kwiinkonzo eziphelela kwiimida eziphezulu, ngaphandle kokusetyenziswa kwe-DGRs.
Umthetho ononophelo wokuNakekelwa koMninimandla wokuThuthukiswa kweMpilo uqaliswe kwiinguqulelo ezintsha zokuhlawula i-Medicare, kubandakanywa iintlawulo ezixhamliweyo kunye neeNkxaso zoNakekelo eziNoxanduva (ACOs). Kodwa i-DGRs isakha isiseko senkqubo yokuhlawula isibhedlele saseMedare.
Iimali ze-DRG zokuhlawula zibalwa njani
I-Medicare iqala ngokubala iindleko eziqhelekileyo zezibonelelo eziyimfuneko ukunyanga izigulane zeMedare kwi-DRG ethile. Ireyithi yesiseko ihlaziywa ngokusekelwe kwimiba eyahlukeneyo, kubandakanywa nesalathiso semvuzo endaweni ethile (isibhedlele e-NYC ihlawula umvuzo ophezulu ngaphezu kwesibhedlele kwiphandle yasemaphandleni yaseKansas, umzekelo, kwaye kubonakaliswa kwinqanaba lokuhlawula isibhedlele ngasinye i-DRG efanayo).
Izibhedlele zaseAlaska neHawaii, nokuba inxalenye engabonakaliyo yexabiso le-DRG yokuhlawula isiseko ihlaziywe yindleko yokuphila.
Kukho ukulungiswa kwintlawulo yesiseko se-DRG ukuba isibhedlele senza isibalo esikhulu sezigulane ezingaqinisekwanga, okanye ukuba sisibhedlele sokufundisa.
Indlela i-DRG isebenza ngayo
Inguqu elula ihamba kanje: UMnu Koff noMnu Flemm bobabini babemkelwa esibhedlele esifanayo kunyango lwe- pneumonia . UMnu Koff waphathwa kwaye wakhululwa ngeentsuku ezimbini. Ukuhlala esibhedlele sikaMnu Flemm kwahlala iintsuku ezili-10.
Ekubeni uMnu Koff kunye noMnu Flemm benokuxilongwa okufanayo, bane-DRG efanayo. Ngokusekelwe kuloo-DRG, i-Medicare ihlawula isibhedlele isixa esifanayo kuMnu Koff njengoko yenzayo kuMnu. Flemm nangona isibhedlele sichitha imali engaphezulu kweentsuku ezili-10 zokunyamekela kuMnu. Flemm kunokuba unikezele ngenyameko iintsuku ezimbini kuMnu Koff.
Nge-DRG, i-Medicare ihlawula i-hospital hospital based on the diagnosis isigulane esibhedlele ukunyanga, kungekhona isiseko esibhedlele esiphathe ngayo isigulane, ixesha elide isigulane esibhedlele, okanye ubuninzi bebhedlele esetyenziselwa ukunyamekela isigulane .
Kwimeko kaMnu Koff, isibhedlele sinokuba nenzuzo encinci. Inkokhelo esekelwe kwi-DRG mhlawumbi ikhudlwana kuneendleko zangempela zokuhlala kukaMnu Koff.
Kwimeko kaMnu Flemm, isibhedlele mhlawumbi silahlekelwe yimali. Ngokuqinisekileyo kwendleko yesibhedlele ngakumbi ukunyamekela uMnu. Flemm iintsuku ezili-10 kuneentlawulo ezisekelwe kwi-DRG efunyenwe.
Impembelelo ye-DRG
Inkqubo yokuhlawula i-DRG ikhuthaza izibhedlele ukuba zisebenzise ngakumbi ekuphatheni izigulane kwaye zisuse inzuzo yezibhedlele ukunyanga izigulane . Nangona kunjalo, le ngxondorha ejikeleze kabini njengezibhedlele ngoku zizimisele ukukhupha izigulane ngokukhawuleza kwaye ngamanye amaxesha zityholwa ukukhupha izigulane ekhaya ngaphambi kokuba ziphile ngokwaneleyo ukuya ekhaya ngokukhuselekileyo.
Ngoku i-Medicare inomthetho kwindawo ehlawulisa isibhedlele ngemali ukuba isigulane siphinde singeniswe esibhedlele ngesifo esifanayo kwisithuba seentsuku ezingama-30 zokukhutshwa. Oku kuthetha ukuthintela izibhedlele ukuba zikhuphe izigulane ngaphambi kokuba ziphile ngokwaneleyo ukuba zikhutshwe.
Ukongezelela, kwezinye ii-DRG, isibhedlele kufuneka yabelane ngenxalenye yentlawulo ye-DRG kunye nesibonelelo sokuhlaziya okanye umboneleli wezempilo ekhaya xa ikhupha isigulane kwisibonelelo sokuhlala esibhedlele okanye kunye nenkxaso yezempilo yasekhaya.
Ukususela ekubeni isiguli singasuswa kwisibhedlele ngokukhawuleza kunye neenkonzo zesibonelelo sokuhlala esibhedlele okanye ukunakekelwa kwezempilo ekhaya, isibhedlele sizimisele ukwenza njalo kuba kunokwenzeka ukuba inenzuzo evela kwi-DRG yokuhlawula. Nangona kunjalo, i-Medicare idinga isibhedlele ukwabelana ngenxalenye yentlawulo ye-DRG kunye nesibonelelo sokuhlala okanye umboneleli wezempilo ukuncedisa iindleko ezongezelelweyo ezihambelana nezo nkonzo.
Jonga uluhlu lwe-DRG
Uludwe lwamanje lwe-DRG (njengoko ngo-2017) lufumaneka apha.
Funda ngakumbi malunga nee-DRG
I-DRG ichonga njani Isibhedlele esifumana ngayo sihlawulwa?
> Imithombo:
> Amasebe e-Medicare kunye neeNkonzo zeMedicaid, i-PPS engenakwi-TB.
> Amasebe e-Medicare kunye neenkonzo zeMedicaid, ukuCwangciswa noPhuhliso lweQela eliDityanisiweyo . Oktobha 2016.
> Amasebe e-Medicare kunye neeNkonzo zeMedicaid, iNkqubo yokuNcitshiswa kweziBhedlela. Epreli 2016.
> I-New England Journal of Medicine Catalyst. Ukuphucula iziKhuthazo zeZibhedlele ngeZindleko zeZindleko ezingcono. Ngo-Apreli 10, 2017.