[Reliability of health insurance claim statistical data based on the principal diagnosis method].
[Reliability of health insurance claim statistical data based on the principal diagnosis method].
复制标题
DOI：
10.1265/jjh.63.29
复制
发表时间：
2008-01-01
期刊：
影响因子：
--
通讯作者：
Une, Hiroshi
中科院分区：
文献类型：
--
作者：
Tanihara, Shinichi;Yamagata, Zentaro;Une, Hiroshi
目的：在日本，对特定疾病的医疗费用的估计是基于这样的假设：即使健康保险索赔实际上包括多项诊断，给定索赔中的所有医疗费用都花在主要诊断上。因此，本研究的目的是评估这种方法的有效性。方法：日本国民医疗保险计划目前使用的医疗费用和基于国际疾病分类的诊断，是从2004年5月长野县冈谷市国家老年医疗保险的8471例门诊医疗费用报销中获得的。我们计算了每种特定疾病的发生频率，并仅使用索赔中的主要诊断和10种诊断(主要诊断和9种附加诊断)来估计特定于疾病的医疗费用。结果：主诊断法反映疾病频度的比例因诊断的不同而不同。高血压占59.7%，糖尿病占33.3%。高血压和糖尿病分别占所有医疗费用的18.32%和5.38%，按主要诊断方法确定。然而，在使用10种诊断方法时，高血压和糖尿病分别占所有医疗费用的8.50%和5.16%。结论：上述主要诊断方法被认为高估了经常被选为主要诊断的疾病的医疗费用。
OBJECTIVE: The estimation of disease-specific medical expenses in Japan is based on the assumption that all medical care expenses in a given claim are spent on the principal diagnosis even though health insurance claims actually include multiple diagnoses. The purpose of this study was therefore to evaluate the validity of this methodology.METHODS: Medical expenses and the diagnosis based on the International Classification of Diseases, which are presently used for the Japanese National Health Insurance program, were obtained from 8471 outpatient medical expense claims from the National Health Insurance for Medical services for the Aged in Okaya city, Nagano Prefecture in May 2004. We calculated the frequency of each specific disease and estimated the disease-specific medical expenses using only the principal diagnosis in a claim and 10 diagnoses (principal diagnosis and nine additional diagnoses). Disease-specific medical expenses using 10 diagnoses was estimated according to the Proportional Disease Magnitude method.RESULTS: The proportion that the principal diagnosis method reflected the frequency based on the method using ten diagnoses differed depending on the diagnosis. The proportion for hypertension was 59.7%, whereas it was 33.3% for diabetes mellitus. Hypertension and diabetes mellitus were estimated to be 18.32% and 5.38%, respectively, of all medical care expenses, as determined using the principal diagnosis method. However, when using ten diagnoses, hypertension and diabetes mellitus were estimated to be 8.50% and 5.16%, respectively, of all medical care expenses.CONCLUSIONS: The above described principal diagnosis method is therefore considered to overestimate the medical care expenses of diseases that are often selected as the principal diagnosis.