基于RBRVS的地域重点疾病护理成本核算研究

Nursing cost accounting, at a macro level, could be used to assess the nursing cost management in the hospital scientifically and rationally, and to provide data support for the reform of medical payment patterns and the adjustment of the medical service cost. It could also be used, at the micro level, to help the hospital take full advantage of limited nursing resources, improve the nursing quality and raise its management towards nursing service. However, a general survey of the studies on nursing cost accounting revealed that some studies, based on the theoretical study, were in lack of empirical and clinical research; some studies chose accounting indices from a narrow range and thus the research results were not complete; some studies ignored the discrepancy of the nursing labor cost in terms of labor intensity, technical difficulty and the degree of risk and some studies ignored the particularity of the share of the indirect nursing cost. In this study, the principle of Resource-Based Relative Value Scale and Time-driven activity based costing will be used for the first time in China to check the nursing cost. By the way of the stratified sampling, eight hospitals of four different levels in Gansu province will be sampled, scientific and suitable methods of checking nursing cost of nursing items and regional priority diseases will be explored. The study aims to bring out three results: the nursing items cost, the single disease nursing cost and the methods of nursing cost accounting. Among the three, the nursing items cost lays the foundation of the nursing service price and provide a reference for the policy of the nursing cost management. Single disease nursing cost can provide reference for the standard of the single disease expense and the method of the nursing cost accounting can offer methodological guidance for medical items and medical cost accounting.

护理成本核算，宏观上可以科学合理地评价医院护理成本管控水平，为医保支付方式改革、医疗服务价格调整等提供数据支撑；微观上可以引导医院充分利用有限的护理资源，提高护理服务质量，提升护理管理水平。然而，纵观当前的护理成本核算研究，部分从理论出发，缺乏实践研究和临床研究；部分选择核算指标范围狭窄，成本核算内容不全面；部分忽略了护理人力成本在劳动强度、技术难度和风险程度等的差别；部分忽略了护理间接成本分摊的特殊性。本研究在国内首次引进RBRVS的原理与时间驱动作业成本法进行护理成本核算，通过分层抽样选择甘肃省8家不同等级医院，探索科学、合理的、适合我国国情的护理项目以及地域重点疾病的护理成本核算方法。本研究的结果，护理项目成本是制定护理服务价格的依据，为护理成本管理提供决策依据；单病种护理成本可为制定单病种费用标准提供参考；护理成本核算方法可为医疗项目成本核算及医院成本核算研究提供思路和方法学指导。

护理成本核算是制定护理服务价格及医保付费标准的依据，有助于提升护理管理水平和护理服务质量。然而目前我国开展的护理成本核算相关研究，综述和理论探讨多、试验和应用研究少；讲必要性和意义的多，谈如何进行核算的少。因此，为了准确核算护理成本，为临床护理项目收费及单病种收费提供依据，本研究对临床常见基础护理项目和地域重点疾病进行了护理成本核算研究。首先，从成本核算角度确定了84项基础护理项目，并将其分为“核算项目”（65项）和“分摊项目”（19项）；然后，基于RBRVS测算了单项目护理人力成本；再次，利用TDABC法对护理间接成本和分摊项目成本进行了成本分摊；最后，测算了核算项目的直接成本和总成本。在此基础上，核算并对比了不同等级医院胃恶性肿瘤、胆囊结石、老年性白内障以及输尿管结石5个单病种的护理成本。研究结果显示，单项目及单病种护理成本核算结果与甘肃省现行收费比较，现行收费项目少、标准低，如单项目护理成本最高者为“超声引导下PICC置管术”（172.90元），而临床实际收费75元；单病种护理成本以“胆囊结石”为例，其护理成本为5029.59元，临床实际平均收费4592元；在单病种护理成本中，人力成本、材料成本和间接成本分别占49.40%、37.32%和13.28%，说明人力成本是护理成本的主要组成部分，体现了护理服务高劳务、低物质消耗的特点。因此，从政府宏观层面来说，成本核算可以科学合理地评价医院护理成本管控水平，为医保支付方式改革、财政补偿政策创新、医疗服务价格调整等提供数据支撑；从医院微观角度讲，成本核算可以引导医院将成本管控和精细化管理相结合，充分利用有限的护理资源，提高护理服务质量，提升管理水平。