Financial Outcomes of Clinical Practice Variation Under Prospective Payment Systems: A Billing-Data Audit
Keywords:
audit penagihan rumah sakit, biaya farmasi, INA-CBG, jalur klinis, margin keuangan, variasi praktik klinisAbstract
Di bawah sistem pembayaran prospektif INA-CBG, rumah sakit menanggung kerugian ketika biaya perawatan sebenarnya melebihi tarif tetap. Lama rawat inap (LOS) adalah indikator efisiensi yang umum, namun LOS yang sebanding mungkin tidak mencerminkan penggunaan sumber daya yang sebanding. Studi ini mengevaluasi variasi tingkat dokter dalam pengeluaran farmasi dan margin keuangan di antara episode rawat inap yang dikodekan sebagai K-4-17-I. Audit penagihan retrospektif dari 856 episode rawat inap gastroenteritis ringan atau nyeri perut yang dikodekan INA-CBG K-4-17-I selama tahun fiskal 2025 membandingkan LOS, tarif, total biaya sebenarnya, biaya farmasi, dan margin keuangan di tiga kelompok dokter anonim (A, B, C). Variabel miring dilaporkan sebagai median (IQR) dan dibandingkan dengan Kruskal-Wallis dengan pengujian post-hoc Dunn dan koreksi Bonferroni; regresi median dan model linier umum gamma-log disesuaikan untuk usia, jenis kelamin, diagnosis sekunder, dan LOS. Median LOS adalah 3 hari di semua kelompok; Hanya perbandingan B versus C yang lolos uji korelasi (p yang disesuaikan = 0,012, ε² = 0,010), perbedaan yang secara klinis tidak signifikan. Biaya farmasi dan margin keuangan berbeda secara signifikan (keduanya p < 0,001): biaya farmasi median adalah IDR 551.439 (C), 342.097 (A), dan 285.397 (B); margin median IDR 309.097 (B), -2.290 (A), dan -134.296 (C). Setelah penyesuaian, margin median IDR 237.522 dan 394.194 lebih rendah di A dan C daripada di B, dan biaya farmasi 1,18 dan 1,71 kali lebih tinggi (semua p < 0,001). Lama rawat inap yang sebanding tidak menjamin konsumsi sumber daya yang seragam; variasi biaya tetap ada setelah penyesuaian untuk campuran kasus yang tercatat dan mungkin tetap tidak terdeteksi ketika efisiensi dipantau hanya berdasarkan durasi rawat inap. Desain retrospektif menghalangi penentuan penyebab. Rumah sakit harus melengkapi pemantauan lama rawat inap (LOS) dengan audit biaya kelompok dokter secara agregat dan tata kelola jalur klinis yang terdigitalisasi.
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