本报讯（通讯员崔瑶）"本来一次手术就能解决的事，却让我分两次住院，前前后后折腾了半个多月， 身体遭罪不说，心里更堵得慌。"近日，面对前来回访的山西省清徐县检察院检察官，刘女士回忆起几 个月前的就医经历，语气里仍带着几分无奈。如今，随着该县医保基金监管领域专项治理的深入推 进，"一日住院、次日出院、隔日再入院"的乱象已基本消除。就医环境的清爽变化，让像刘女士一样的 患者安心多了。 变化，始于一次公益诉讼检察监督。2025年9月，清徐县检察院检察官在履职中发现，辖区部分医疗机 构疑似存在"分解住院"行为，即将应一次连续住院完成的诊疗过程，人为分解成两次或多次住院，以套 取医保基金。初步摸排后，该院于当月依法立案。 承办检察官调取了该县医保结算数据、医院住院记录和患者就诊信息，运用大数据法律监督模型，通过 数据比对，重点筛查"短期内重复住院""同病种多次住院""住院间隔时间过短"等异常情形，精准锁定80 条疑似分解住院线索。 "分解住院不仅违反医保政策，更增加了患者经济负担和身体痛苦。"承办检察官指出，一些医疗机构为 规避医保支付限额、追求业务指标，采取分解住院的方式套取医保基金，严重损害了医保基金安全和群 众利益 ...

Core Viewpoint - The article discusses the complexities and challenges surrounding the issue of "decomposed hospitalization" in the healthcare system, particularly in the context of the DRG/DIP payment reform, highlighting the increase in readmission rates and the ambiguity in defining and regulating such practices [3][4][5]. Summary by Sections Hospitalization Costs and Readmission Rates - In 2024, the average personal burden of hospitalization costs is expected to decrease by 5%, while the total number of individuals enjoying hospitalization benefits is projected to increase by 4.48% [3][4]. - The decline in average costs raises questions about whether it reflects genuine improvements in medical service efficiency or if it is a result of hospitals engaging in practices like low-standard admissions and decomposed hospitalizations [4]. DRG/DIP Reform and Its Impacts - Since the implementation of DRG/DIP payment reforms, there has been a notable increase in the "readmission rate," which rose from 11% before the reform to 14.41% in 2023 in a specific province [7][8]. - The increase in readmission rates is linked to the financial pressures hospitals face under the DRG system, leading to practices that may not align with the intended cost-control objectives of the reform [9][10]. Challenges in Defining and Regulating Decomposed Hospitalization - There is no clear definition or standard for "decomposed hospitalization," making it difficult for regulatory bodies to monitor and enforce compliance effectively [14][15]. - The ambiguity in defining decomposed hospitalization allows hospitals to exploit loopholes, such as changing primary diagnoses to avoid penalties for repeat admissions [10][12]. Regulatory Approaches and Observations - Some regions have adopted a data-driven approach to flag potential cases of decomposed hospitalization, marking instances of readmission within a specific timeframe as "suspected decomposed hospitalization" [21][22]. - Effective governance of decomposed hospitalization requires not only stringent monitoring but also appropriate compensation policies to address the underlying financial incentives that drive such practices [22][23]. Variability in Readmission Rates Across Hospital Types - Readmission rates tend to be higher in secondary hospitals compared to tertiary hospitals, indicating that the financial pressures and motivations for decomposed hospitalization may vary significantly based on the type of institution [24].

Core Insights - The average out-of-pocket expense for hospital stays is expected to decrease by 5% in 2024, indicating a potential improvement in healthcare cost management [1] - However, the total number of hospitalizations is projected to increase by 4.48%, raising concerns about whether the decrease in average costs reflects genuine efficiency improvements or potential manipulation of hospitalization practices [2][3] Group 1: Hospitalization Trends - The increase in hospitalization rates alongside a decrease in average costs suggests a complex relationship that may involve questionable practices such as low-standard admissions and fragmented hospital stays [2][3] - The "15-day unplanned readmission rate" is proposed as a metric to assess the severity of fragmented hospitalizations, although its application is contentious [2][4] Group 2: Regulatory Challenges - The ambiguity in defining and regulating fragmented hospitalizations complicates oversight, as overly strict regulations may lack flexibility while lenient standards could allow for exploitation [3][10] - The lack of a clear definition for fragmented hospitalizations hampers effective regulation, with existing guidelines providing limited clarity [10][11] Group 3: Data Monitoring and Analysis - Research indicates that the readmission rate has risen significantly post-DRG/DIP reform, suggesting a correlation with increased fragmented hospitalizations [4][5] - Monitoring practices have evolved, with a focus on dynamic indicators rather than fixed thresholds for readmissions, reflecting the complexities of hospital practices [11][16] Group 4: Local Insights and Variability - Local healthcare officials recognize that fragmented hospitalizations are likely to increase under DRG payment systems, as hospitals seek to mitigate financial losses from cost overruns [7][17] - The effectiveness of managing readmission rates varies significantly across regions, with some areas achieving notable reductions while others struggle with high rates [14][18]