Payment standard measuring and calculating method and device based on disease group and disease category score

Abstract

The invention discloses a payment standard measuring and calculating method and device based on disease group and disease category scores, and relates to the technical field of medical technology, and the method comprises the steps: obtaining medical data of hospitals participating in DRG or DIP payment in a medical insurance overall planning region; screening out disease groups with clear clinical pathways and seriously distorted cost structures from the medical data; adjusting the disease group with severely distorted cost structure into a disease group with reasonable cost structure, and generating a disease group cost structure according with clinical pathway analysis according to the disease group with clear clinical pathway and reasonable cost structure; receiving an adjustment suggestion of a medical expert on the disease group cost structure, and adjusting the disease group cost structure to obtain a new cost structure; and aggregating the new cost structure according to the medical insurance directory cost, and analyzing differences according to statistics to obtain a final payment standard. According to the payment standard measuring and calculating method and device based on the disease group and disease category score provided by the invention, the influence of unreasonable cost on the payment standard is reduced, and the accuracy of the payment standard is improved.

Description

Technical Field

[0001] The present application relates to the field of medical technology, and specifically to a payment standard calculation method and device based on disease group and disease type scores. Background Art

[0002] DRG Diagnosis Related Groups (DRG) is a tool for classifying patients into several diagnostic groups for management based on factors such as disease diagnosis, treatment methods, comorbidities, complications, age, severity of symptoms, prognosis, and resource consumption. DIP Diagnosis-Intervention Packet uses big data to discover the common characteristics of "disease diagnosis + treatment methods" to classify patients. Both of them are classified into different groups based on factors such as the main diagnosis and treatment methods. It is also the main payment method currently adopted by various medical insurance pooling areas to pay medical institutions for the medical insurance pooling funds for inpatients, and they have common points in terms of payment scope, implementation technology, and payment standards.

[0003] According to statistics from the National Health Insurance Administration, by the end of 2023, more than 90% of the coordinated regions in the country have carried out DRG / DIP payment reforms. While basic results have been achieved, requirements for refinement and high quality have followed one after another. Therefore, it is necessary to further consider the impact of factors such as regional economic level, payment standards, and regulatory assessment on the quality of DRG / DIP payment. In the early stage of payment reform, the purpose is to promote it smoothly and quickly. The main work is to establish infrastructure, industry standards and basic specifications. When the architecture is completed, the focus of work will gradually shift to the goal of high-quality development. To achieve this goal, medical institutions need to change from passively accepting fund payments to recognizing and supporting payment reforms. Among them, accurate pricing of medical insurance is a key and difficult issue.

[0004] The DRG / DIP medical insurance payment standard is the standard amount of DRG / DIP disease group (disease type) fees that medical insurance institutions pay to hospitals under the DRG / DIP medical insurance payment method. The setting of payment standards is related to the efficiency and sustainability of the use of medical insurance funds, directly affects the income and cost control of medical institutions, determines the personal burden of patients when receiving medical services, and also affects the sales price of drugs and medical devices. Therefore, the payment standard is not only a measure to regulate the behavior of all parties, but also an important issue that needs to be urgently resolved in the reform of medical insurance payment methods.

[0005] For each paying city, the payment standards for DRG / DIP disease groups (diseases) are based on historical cost data and calculated using big data methods. Data processing and calculation are mostly done from a statistical perspective, and the irregular and unreasonable costs in historical clinical behaviors are basically not excluded. In the process of calculating payment standards, there are often problems such as uneven distribution of treatment costs for patients in the same disease group (disease), and inverted average costs in the same ADRG group (the upper level of DRG grouping, which is coarser than DRG granularity). Even if the payment costs are corrected by various data outlier processing, weight inversion adjustment, and adding various adjustment coefficients, they are often considered from a more macro and statistical perspective, and the problems caused by unreasonable costs are only a temporary solution. Because clinical medical problems are very complex, medical insurance policies are inevitably inconsistent with medical reality and lag behind clinical development. When the method processing at the data level reaches the extreme, it is possible to consider how to optimize the formulation of payment standards from the perspective of clinical pathways.

[0006] For example: The patent with publication number CN117151902B discloses a method for monitoring and warning of medical insurance payment risks for DRG and DIP through big data analysis. The risk monitoring model disclosed is a prediction model based on big data. The prediction model includes any big data training model based on machine learning. Each risk monitoring model is used to identify data or cases with medical insurance payment risks in DRG and DIP. Each risk monitoring model has one or more corresponding payment risk labels. It can be seen that this method uses payment risk labels for warning, and payment risk labels are also a relatively macro form of expression, which cannot accurately provide risk-based warnings.

[0007] In summary, it can be seen that patients will inevitably incur unreasonable expenses during the treatment process. Unreasonable expenses are generally divided into expenses that exceed normal medical standards, do not meet medical specifications, or are not approved by medical insurance. They are mainly manifested in repeated charges, charges exceeding standards, charges for decomposed items, irrelevant charges, and fraudulent charges. Under the condition of strong supervision, the most unreasonable charges for inpatient diagnosis and treatment are mainly those that do not meet medical specifications. Because medical insurance recognizes the rationality of past expenses when calculating payment standards, this part of the data is not reviewed and eliminated item by item. Therefore, when no elimination optimization is performed, even if the average cost and adjustment coefficient of the DRG / DIP disease group (disease type) are dynamically adjusted every year, there will be unreasonable costs that affect the calculation results, which ultimately affects the payment of medical insurance funds. Summary of the invention

[0008] To this end, the present application provides a payment standard calculation method and device based on disease group and disease type scores to solve the problem of inaccurate payment standards in the prior art.

[0009] In order to achieve the above objectives, this application provides the following technical solutions:

[0010] First, a payment standard calculation method based on disease group and disease type scores includes:

[0011] Obtain medical data of hospitals participating in DRG or DIP payment in the medical insurance pooling area through the medical insurance interface;

[0012] Screening out disease groups with clear clinical pathways and disease groups with severely distorted cost structures from the medical data; adjusting the disease groups with severely distorted cost structures to disease groups with reasonable cost structures;

[0013] Generate a disease group cost structure that complies with clinical pathway analysis based on the disease group with clear clinical pathway and the disease group with reasonable cost structure;

[0014] receiving the medical experts' suggestions for adjusting the fee structure of the disease group, and adjusting the fee structure of the disease group according to the suggestions for adjusting to obtain a new fee structure;

[0015] The new fee structure is aggregated according to the medical insurance catalogue costs, and the differences are analyzed based on statistics to obtain the final payment standard.

[0016] Preferably, the medical data includes basic patient information, hospitalization treatment information, medical fee information, medical insurance DRG or DIP grouping results, medical insurance settlement results, patient treatment details data and local medical insurance catalogue.

[0017] Preferably, the disease group with a clear clinical pathway is a disease group recommended by experts with many years of DRG or DIP practice experience, which is convenient for medical insurance payment management and easily accepted by hospitals.

[0018] Preferably, the disease groups with severely distorted cost structures include non-high-consumables disease groups with a high degree of deviation in consumables costs, and disease groups in which the treatment structures in the medical, surgical and non-surgical operation groups are far different from the cost structures corresponding to the actual treatment plans.

[0019] Preferably, a disease group cost structure that conforms to the clinical pathway analysis is generated based on the disease groups with clear clinical pathways and the disease groups with reasonable cost structures, specifically including: verifying the data details within the disease groups, and evaluating the cost differences within the disease groups, and then statistically processing the cost structure of the medical insurance settlement list, and calculating the cost composition of the disease groups, so as to generate a disease group cost structure that conforms to the clinical pathway analysis.

[0020] Preferably, the adjustment suggestion includes adjusting and deleting detailed data corresponding to the key points.

[0021] In the second aspect, a payment standard calculation device based on disease group and disease type scores includes:

[0022] The data acquisition module is used to obtain the medical data of DRG or DIP payment hospitals in the medical insurance pooling area through the medical insurance interface;

[0023] A disease group screening module is used to screen out disease groups with clear clinical pathways and disease groups with severely distorted cost structures from the medical data; and adjust the disease groups with severely distorted cost structures to disease groups with reasonable cost structures;

[0024] A data calculation module is used to generate a disease group cost structure that conforms to the clinical pathway analysis according to the disease group with clear clinical pathway and the disease group with reasonable cost structure;

[0025] An expert evaluation result receiving module is used to receive the adjustment suggestions of the medical experts on the fee structure of the patient group, and adjust the fee structure of the patient group according to the adjustment suggestions to obtain a new fee structure;

[0026] The data aggregation and statistical analysis module is used to aggregate the new fee structure according to the medical insurance catalogue fees, and obtain the final payment standard based on the statistical analysis differences.

[0027] Thirdly, a method for monitoring and early warning of medical insurance payment risks includes:

[0028] Obtaining health insurance payment data;

[0029] Determine whether the medical insurance payment data is greater than the payment standard; the payment standard is determined according to the payment standard calculation method based on disease group and disease type score;

[0030] If the medical insurance payment data is greater than the payment standard, an alarm is issued.

[0031] In a fourth aspect, a computer-readable storage medium stores a computer program, which, when executed by a processor, implements the steps of a payment standard calculation method based on disease group and disease type scores.

[0032] In a fifth aspect, a computer program product includes a computer program or instructions, which, when executed by a processor, implement the steps of a method for calculating payment standards based on disease group and disease type scores.

[0033] Compared with the prior art, this application has at least the following beneficial effects:

[0034] The present application provides a payment standard calculation method and device based on disease groups and disease type scores, by obtaining medical data of hospitals participating in DRG or DIP payment in the medical insurance pooling area; screening out disease groups with clear clinical pathways and severely distorted cost structures from the medical data; adjusting disease groups with severely distorted cost structures to disease groups with reasonable cost structures; generating a disease group cost structure that conforms to clinical pathway analysis based on disease groups with clear clinical pathways and reasonable cost structures; receiving medical experts' suggestions for adjusting the disease group cost structure, and adjusting the disease group cost structure according to the adjustment suggestions to obtain a new cost structure; aggregating the new cost structure according to the medical insurance catalog costs, and obtaining the final payment standard based on statistical analysis of the differences. The payment standard calculation method and device based on disease groups and disease type scores provided in the present application reduces the impact of unreasonable costs on the payment standard and improves the accuracy of the payment standard. BRIEF DESCRIPTION OF THE DRAWINGS

[0035] In order to more intuitively illustrate the prior art and the present application, exemplary drawings are given below. It should be understood that the specific shapes and structures shown in the drawings should not generally be regarded as limiting conditions for implementing the present application; for example, those skilled in the art are capable of easily making conventional adjustments or further optimizations to the addition / reduction / attribution division, specific shapes, positional relationships, connection methods, dimensional ratios, etc. of certain units (components) based on the technical concepts and exemplary drawings disclosed in the present application.

[0036] Figure 1 A basic flow chart of a payment standard calculation method based on disease group and disease type scores provided in Example 1 of the present application;

[0037] Figure 2 A flow chart of a method for calculating payment standards based on disease group and disease type scores provided in Example 1 of the present application. DETAILED DESCRIPTION

[0038] The present application is further described below in detail through specific embodiments in conjunction with the accompanying drawings.

[0039] In the description of this application: unless otherwise specified, "plurality" means two or more. The terms "first", "second", "third", etc. in this application are intended to distinguish the objects referred to, and do not have special meanings in terms of technical connotations (for example, they should not be understood as emphasizing the importance or order, etc.). Expressions such as "including", "comprising", "having", etc. also mean "not limited to" (certain units, components, materials, steps, etc.).

[0040] The terms such as "upper", "lower", "left", "right", "middle", etc. cited in this application are usually used to indicate the general relative position relationship for the purpose of intuitive understanding by referring to the drawings, and are not absolute limitations on the position relationship in the actual product.

[0041] In order to ensure that the payment and standard calculation of medical insurance funds are not divorced from clinical practice, reduce the impact of unreasonable expenses on payment standards, and increase the direction of medical insurance supervision, it is proposed to use the cost structure under the clinical pathway to correct the DRG / DIP disease group (disease type) payment standards and increase the supervision dimension in this direction. The specific requirements are:

[0042] 1. Balance of supply and demand within the region. The geography, economy and medical resources of a region remain stable for a long time. Even if there are population inflows and outflows and medical treatment in other places, the number of patients who need hospitalization, the composition of diseases and the cost of hospitalization are theoretically fixed. The medical insurance data in a region can represent the local area as a whole, and the data generated for statistical research is relatively stable.

[0043] 2. Consistency of DRG / DIP and clinical pathway goals. DRG / DIP grouping and clinical pathways are two different manifestations of unified standards. They are both management tools used to improve the quality of medical services and control costs, and improve efficiency and quality through unified payment rules and standardized medical service processes. The precise implementation of clinical pathways can standardize medical behavior and ensure that patients receive treatment that meets standards, thereby standardizing the costs of disease groups (disease types).

[0044] 3. There are diagnosis and treatment items and cost structures as data support. First, there is a mature mapping relationship between items and cost types. Whether it is the cost structure on the front page of the medical record with medical quality as the supervision direction, or the cost structure of the settlement list with the purpose of medical insurance payment, the items generated during the diagnosis and treatment process can be classified and processed; secondly, when the cost structure is found to be abnormal, the corresponding items can be traced, which is also convenient for clinical experts to find related items and evaluate the rationality; finally, the project cost is the project payment standard within the coordinated area, which is in line with the local medical insurance policy and price level, and provides support for the accuracy of the cost calculation.

[0045] Embodiment 1

[0046] See also Figure 1 and Figure 2 This embodiment provides a payment standard calculation method based on disease group and disease type scores, including:

[0047] S1: Obtain medical data of hospitals participating in DRG or DIP payment in the medical insurance pooling area through the medical insurance interface;

[0048] Specifically, obtain the relevant medical data of DRG / DIP payment hospitals in the medical insurance pooling area for 2-3 years, which is mainly divided into basic information, settlement information, cost details and medical insurance catalog. Medical data can come from medical insurance interfaces such as medical insurance information 4103, 5204 and 3605, including basic patient information (sensitive information desensitized), hospitalization diagnosis and treatment information, medical fee information, medical insurance DRG / DIP grouping results, medical insurance settlement results (including disease group weights, disease group average fees, benchmark points and other intermediate parameters), patient diagnosis and treatment details (charge item level) and local medical insurance catalog. Medical data is used to determine the cost structure of disease groups, standard cost adjustments, cost structure difference assessment and weight comparison, etc.

[0049] S2: Screen out the disease groups with clear clinical pathways and severely distorted cost structures from the medical data; adjust the disease groups with severely distorted cost structures to those with reasonable cost structures;

[0050] Specifically, in this step, within the medical insurance pooling area, based on historical medical data such as medical insurance and medical information, from the perspective of positive adjustment and reverse reasoning, the disease groups with clear clinical pathways and generally deformed regional medical behaviors are summarized.

[0051] Positive: Screen disease groups (diseases) with clear clinical pathways. The clarity of clinical pathways is usually closely related to their degree of standardization and widely recognized treatment plans. When associated with DRG / DIP, the relevant DRG / DIP disease groups usually include common diseases, surgeries and treatment procedures, and the treatment methods have been widely studied and verified to provide consistent treatment effects. Select disease groups (diseases) recommended by experts with many years of DRG / DIP practical experience, which are easy for medical insurance payment management and easy for hospitals to accept. Such disease groups have the characteristics of clear clinical pathways, relatively fixed treatment methods and relatively stable resource consumption.

[0052] Reverse: Make a preliminary judgment on the cost structure of each disease group, and select disease groups with severely distorted cost structures, such as non-high-consumables disease groups (disease types) with a high degree of deviation in consumable costs, and disease groups where the treatment structure under internal, surgical, and non-surgical operation groups is far from the cost structure corresponding to the actual treatment plan. After selecting disease groups with severely distorted cost structures, medical experts will make clinical professional judgments on whether the cost structure is really distorted (i.e., distorted). If the cost structure is really distorted, the disease groups with distorted cost structures will be adjusted to disease groups with reasonable cost structures.

[0053] S3: Generate a disease group cost structure that conforms to clinical pathway analysis based on disease groups with clear clinical pathways and reasonable cost structures;

[0054] Specifically, combined with clinical pathway guidelines and expert evaluations, a disease group cost structure that conforms to clinical pathway analysis is generated to locate the inevitability and rationality of each cost category in the clinical diagnosis and treatment process, facilitating clinical experts to make adjustments and transformations. Processing process: Conduct detailed data verification and intra-group cost difference assessment, statistically process the cost structure of the medical insurance settlement list, and calculate the cost composition of the disease group. Assess the similarities in resource consumption of cases in each DRG / DIP disease group (disease type), analyze the DRG / DIP cost structure, and find out the key points with large differences in composition, such as drugs, consumables, medical services, nursing, etc., evaluate the distribution of detailed items, locate the types of items that cause non-standard costs, and integrate with diagnosis, surgery and other treatment information so that experts can refer to the clinical pathway for corresponding adjustments.

[0055] S4: Receive the medical experts' suggestions for adjusting the cost structure of the disease group, and adjust the cost structure of the disease group according to the suggestions to obtain a new cost structure;

[0056] Specifically, the expert consultation method is used to ask the clinical expert team to evaluate the cost structure and key elements of the selected disease group, and to judge the rationality of the historical cost structure and amount in the clinical pathway, and to adjust and delete the detailed data corresponding to the key points, so as to obtain the medical experts' suggestions for adjusting the cost structure of the disease group. The medical experts' suggestions for adjusting the cost structure of the disease group are used to adjust the cost structure of the disease group, and a new cost structure and corresponding detailed items are obtained.

[0057] S5: Aggregate the new fee structure according to the medical insurance catalogue costs, and analyze the differences based on statistics to obtain the final payment standard.

[0058] Specifically, when data is aggregated, the structures and items adjusted by experts are used to generate new cost details and structures according to the prices in the medical insurance fee catalogue.

[0059] During the statistical analysis, we calculate the average cost and weight of the adjusted DRG / DIP disease groups (disease types), evaluate the difference with the historical average cost, the difference in weight before and after adjustment, and evaluate indicators such as contribution rate analysis and structural change, so as to determine the final payment standard weight.

[0060] This embodiment provides a payment standard calculation method based on disease group and disease type scores. In the medical insurance pooling area, based on historical medical data such as medical insurance and medical information, from the perspective of positive adjustment and reverse inference, the method summarizes the disease groups with clear clinical pathways and generally deformed regional medical behaviors, conducts a "DRG / DIP clinical pathway study" on doctors' diagnosis and treatment behaviors, analyzes the cost structure and item proportion of reasonable treatment of disease groups (disease types), and adjusts the payment standards and weights of disease groups (disease types) in combination with factors such as social and economic development and price level changes. This ensures that the payment and standard calculation of medical insurance funds are not separated from clinical practice, reduces the impact of unreasonable expenses on payment standards, and improves the accuracy of payment standards.

[0061] The payment standard calculation method based on disease group and disease type scores provided in this embodiment is of great significance to both medical insurance departments and medical institutions:

[0062] For the medical insurance department: The medical insurance department negotiates with medical institutions through the payment standards after the adjustment of the clinical pathway cost structure, which is more clinically based, more recognized for the disease group (disease type) standards for reasonable treatment, and reduces pricing disputes for the disease group (disease type) standards for unreasonable treatment, solving the dilemma of payment standard calculation being out of touch with the clinic, making the medical insurance department more persuasive when explaining to the hospital, which can improve the compliance of the hospital medical insurance reform to a certain extent and make the reform of the medical insurance payment method more efficient; secondly, the supervision direction can be refined to each cost structure, for example: the reason why the drug ratio cannot be higher than a certain percentage. In the past, supervision was based on the drug ratio level of the entire hospital. After structural research, the drug costs that should be spent under the clinical pathway of the disease group (disease type) can be used as evidence, which is more refined and more persuasive. Finally, a horizontal study of the service quality of hospitals in the region can be conducted. Due to the principle of homogeneity of DRG / DIP and clinical pathways, it can be used as a basis for horizontal comparison of medical institutions and regional diagnosis and treatment standards, enhancing the comparability between different medical institutions in the same DRG / DIP group, evaluating the differences in cost structures of various hospitals, and reducing the occurrence of unreasonable and non-standard treatments.

[0063] For medical institutions: The standardization and transparency of the clinical pathway cost structure can provide a reference for diagnosis, treatment and cost control for patients to a certain extent, enable medical institutions to pay more attention to the rational use of medical resources, thereby avoiding excessive concentration or waste of resources, and reducing the economic and psychological burden of treatment for patients.

[0064] Embodiment 2

[0065] This embodiment provides a payment standard calculation device based on disease group and disease type scores, including:

[0066] The data acquisition module is used to obtain the medical data of DRG or DIP payment hospitals in the medical insurance pooling area through the medical insurance interface;

[0067] A disease group screening module is used to screen out disease groups with clear clinical pathways and disease groups with severely distorted cost structures from the medical data; and adjust the disease groups with severely distorted cost structures to disease groups with reasonable cost structures;

[0068] A data calculation module is used to generate a disease group cost structure that conforms to the clinical pathway analysis according to the disease group with clear clinical pathway and the disease group with reasonable cost structure;

[0069] An expert evaluation result receiving module is used to receive the adjustment suggestions of the medical experts on the fee structure of the patient group, and adjust the fee structure of the patient group according to the adjustment suggestions to obtain a new fee structure;

[0070] The data aggregation and statistical analysis module is used to aggregate the new fee structure according to the medical insurance catalogue fees, and obtain the final payment standard based on the statistical analysis differences.

[0071] For the specific implementation content of each module in a payment standard calculation device based on disease groups and disease type scores, please refer to the above definition of a payment standard calculation method based on disease groups and disease type scores, which will not be repeated here.

[0072] Embodiment 3

[0073] This embodiment provides a method for monitoring and warning of medical insurance payment risks, including:

[0074] Obtaining health insurance payment data;

[0075] Determine whether the medical insurance payment data is greater than the payment standard; the payment standard is determined according to a payment standard calculation method based on disease group and disease type scores provided in Example 1;

[0076] If the medical insurance payment data is greater than the stated payment standard, an alarm will be issued.

[0077] From the perspective of self-management on the hospital side, a method for monitoring and early warning of medical insurance payment risks provided in this embodiment can monitor the patient's hospital stay days, drug cost ratio, drug and consumables costs, etc., and issue early warnings.

[0078] Embodiment 4

[0079] This embodiment provides a computer-readable storage medium having a computer program stored thereon. When the computer program is executed by a processor, the steps of a method for calculating payment standards based on disease group and disease type scores are implemented.

[0080] Embodiment 5

[0081] This embodiment provides a computer program product, including a computer program or instructions, which, when executed by a processor, implements the steps of a payment standard calculation method based on disease group and disease type scores.

[0082] The technical features of the above embodiments may be arbitrarily combined (as long as there is no contradiction in the combination of these technical features). To make the description concise, not all possible combinations of the technical features in the above embodiments are described; these embodiments that are not explicitly written should also be considered to be within the scope of this specification.

Claims

1. A payment standard calculation method based on disease group and disease type scores, characterized in that: include: Obtain medical data of hospitals participating in DRG or DIP payment in the medical insurance pooling area through the medical insurance interface; Screening out disease groups with clear clinical pathways and disease groups with severely distorted cost structures from the medical data; adjusting the disease groups with severely distorted cost structures to disease groups with reasonable cost structures; Generate a disease group cost structure that complies with clinical pathway analysis based on the disease group with clear clinical pathway and the disease group with reasonable cost structure; receiving the medical experts' suggestions for adjusting the fee structure of the disease group, and adjusting the fee structure of the disease group according to the suggestions for adjusting to obtain a new fee structure; The new fee structure is aggregated according to the medical insurance catalogue costs, and the differences are analyzed based on statistics to obtain the final payment standard.

2. The payment standard calculation method based on disease group and disease type scores according to claim 1 is characterized in that: The medical data includes basic patient information, hospitalization and treatment information, medical fee information, medical insurance DRG or DIP grouping results, medical insurance settlement results, patient treatment details and local medical insurance catalogue.

3. The payment standard calculation method based on disease group and disease type scores according to claim 1 is characterized in that: The disease groups with clear clinical pathways are recommended by experts with many years of DRG or DIP practice experience, are convenient for medical insurance payment management, and are easily accepted by hospitals.

4. The payment standard calculation method based on disease group and disease type scores according to claim 1 is characterized in that: The disease groups with seriously distorted cost structures include non-high-consumables disease groups where the consumables costs account for a relatively high degree of deviation, and disease groups where the treatment structures in the internal medicine, surgery and non-surgical operation groups are far from the cost structures corresponding to the actual treatment plans.

5. The payment standard calculation method based on disease group and disease type scores according to claim 1 is characterized in that: A disease group cost structure that conforms to the clinical pathway analysis is generated based on the disease groups with clear clinical pathways and the disease groups with reasonable cost structures, specifically including: verifying the data details within the disease groups, and evaluating the cost differences within the disease groups, and then statistically processing the cost structure of the medical insurance settlement list and calculating the cost composition of the disease groups, thereby generating a disease group cost structure that conforms to the clinical pathway analysis.

6. The payment standard calculation method based on disease group and disease type scores according to claim 1 is characterized in that: The adjustment suggestion includes adjusting and deleting the detailed data corresponding to the key points.

7. A payment standard calculation device based on disease group and disease type scores, characterized in that: include: The data acquisition module is used to obtain the medical data of DRG or DIP payment hospitals in the medical insurance pooling area through the medical insurance interface; A disease group screening module is used to screen out disease groups with clear clinical pathways and disease groups with severely distorted cost structures from the medical data; and adjust the disease groups with severely distorted cost structures to disease groups with reasonable cost structures; A data calculation module is used to generate a disease group cost structure that conforms to the clinical pathway analysis according to the disease group with clear clinical pathway and the disease group with reasonable cost structure; An expert evaluation result receiving module is used to receive the adjustment suggestions of the medical experts on the fee structure of the patient group, and adjust the fee structure of the patient group according to the adjustment suggestions to obtain a new fee structure; The data aggregation and statistical analysis module is used to aggregate the new fee structure according to the medical insurance catalogue fees, and obtain the final payment standard based on the statistical analysis differences.

8. A method for monitoring and early warning of medical insurance payment risks, characterized in that: include: Obtaining health insurance payment data; Determine whether the medical insurance payment data is greater than the payment standard; the payment standard is determined according to the payment standard calculation method based on disease group and disease type score according to any one of claims 1 to 6; If the medical insurance payment data is greater than the payment standard, an alarm is issued.

9. A computer-readable storage medium having a computer program stored thereon, characterized in that: When the computer program is executed by a processor, the steps of the method according to any one of claims 1 to 6 are implemented.

10. A computer program product comprising a computer program or instructions, characterized in that When the computer program or instruction is executed by a processor, the steps of the method according to any one of claims 1 to 6 are implemented.

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