| Recently, the cost of health care is growing at a high rate in our country. The annual growth rate is faster than that of the revenue growth. Meanwhile, the actual mechanism of reimbursement for hospitals is unreasonable, resulting in the waste of healthcare resources.The cost of outpatient has experienced a rapid growth and it is still growing at a high rate. In 1995, 1996 and 1997, the cost of outpatient amounted to 39.707 billion, 48.185 billion and 56.916 billion respectively. The proportion is 48.13%, 47.68% and 47.93% of total health care expenditure.In 1998, the State Council issued a regulation on establishing a basic medical care system for employees in urban areas, which was put into effect in 2000. The dramatic increasing tendency of health care cost, to some extent, has been controlled, but the growth rate of cost is still higher than that of the economic development. The conflict between income and expenditure of the medical care fund is still serious. In such circumstances, how to reimburse the cost of health care for hospitals becomes a focus. On one hand, we have to restrain the increase of health care, on the other hand we must protect the benefit of assurance beneficiary so as to treat patients well and timely. At present, the method to reimburse the outpatient cost for hospitals is on the basis of items. The total payment for hospitals figured out by means of multiplying the cases of outpatient and the mean fee per service. This method can benefit the competition among hospitals and is convenient to be implemented. The method has showed some serious defects such as stimulating health demand, inducing excessive consumption of health providers and leading to waste of healthcare resources.Case mix is a measurement unit of hospital output. It can be applied in health policy-making, administration and health economic research. In addition, the case mix can be used in reimbursement for hospitals.Because of the increase of ambulatory cost, the study of case mix is focused more on outpatient, community care, family care, psychiatric and rehabilitation. The APGs system of USA has become a foundation of Medicare payment.This study described and analyzed the reality of outpatient cost first and then screened out the relational factors of outpatient cost using ANOVA and stepwise regression. The result indicated that the relational factors was age, sex, visit department, first visit or not, visit type, etc. On the basis of these factors, the paper used the AID algorithm to construct a case mix scheme suited to our hospitals.Because the cost engine of outpatient is the significant health examination and therapy, the general idea of case mix for outpatient is as follows: the therapies or examinations that are inexpensive or frequently provided are packaged into the case mix groups for the medical visit payment. However, other services that are expensive or infrequently performed, are paid as separate case mix groups. This method can not only control healthcare cost by giving providers the incentive, but also reimburse hospitals accurately and limit the providers' risk. Visits must be divided into two different types: patients with medical visit or patients with significant therapy or examination only.19605 medical visits were divided into 17 mutually exclusive categories called Major Diagnostic Categories by ICD-9. According to clinical character and cost homogeneity, these 17 MDCs were divided into 56 sub-categories, which was formed as case mix scheme by such variables as type of the disease, medical specialty, age, sex, first visit or not, clinical type.Patients who only experienced significant therapy or examination were divided into 7 major categories by ICD-9-CM. The 7 major categories were classified into 16 subordinate groups according to variables such as type of equipment, laboratory department or type, site, contrast media, complexity.This paper constructed a case mix classification scheme of 89 groups with 73 medical visit groups and 16 significant therapy or examina...
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