Research On The Mechanism Of Determination And Optimization Of The DRG Medical Insurance Payment Standard

Medical and health are closely related to the national economy and the people’s livelihood.The medical and health career in our country has always been widely paid attention by the government and academia.The health care and the public health of the residents are also increasingly paid attention by the public.The Outline of the"Healthy China 2030"Plan calls for improving the medical security system and the entire medical insurance system.By 2030,the national medical insurance system will be mature and finalized,and mechanisms for the negotiation,the consultation,and the risk sharing between medical insurance agencies and medical institutions should be improved.The state plans to extend DRG(Diagnosis Related Groups)/DIP(Diagnosis-Intervention Packet)payment to all eligible medical institutions that carry out inpatient services by the end of 2025.The outstanding feature of the payment method of DRG is to transfer the financial risk from the medical insurance to the hospital,to realize the balance of the interests of three parties of hospitals,medical insurance funds,and patients through the risk sharing.Through the negotiation and consultation and risk sharing mechanism between medical insurance institutions and medical institutions,hospitals are forced to strengthen the fine management,reduce costs and improve the hospital service efficiency.Then the length of hospital stay for patients can be shortened and the burden of the medical treatment for patients can be reduced.Funds have shifted from passive"buying"to"precise payment".The accurate payment of medical insurance institutions is how to scientifically determine the payment standard of DRG medical insurance.What factors should medical insurance institutions consider when scientifically determining the payment standard of DRG?What is the influencing mechanism between the payment standard of the medical insurance and the influencing factors?What impact will the reform of payment standards have on hospitals and patients?How to use the cost structure of the DRG disease group to determine and optimize the DRG medical insurance payment standard?All these questions are important scientific issues.Therefore,this paper mainly discusses the mechanism of determining and optimizing the payment standard of DRG.Based on analyzing the existing problems in the payment methods of the medical insurance,especially the payment standard of DRG,this paper uses the random variables and their probability distributions in a probability theory and mathematical statistics as well as empirical data tests to deeply analyze the influencing mechanism of the payment standard of DRG and various factors under the control of financial risks.The effects of the DRG payment standard reform have been analyzed by the regression,especially the effects of the DRG payment standard on the service efficiency of hospitals,and the medical burden of patients has been examined by the micro-data.At the same time,the basic scope of the DRG payment standard is determined by combining the cost structure of the DRG disease group.Finally,the policy implications of the DRG payment standard reform for the reform of the China’s medical and health system have been discussed.The specific research is as follows:(1)Analyzing the history of the medical insurance payment reform,it can be seen from the timeline of the development process that deep reasons for institutional changes in a medical insurance payment mode are that under the Chinese medical insurance system,medical institutions,patients,and medical insurance institutions are always in the constant game,and the game should form the result of the balance of the common interests of three parties at the end.Through SWOT analysis,advantages and opportunities of DRG can be seen,which is also one of the main reasons for the implementation of DRG in the country at present.However,it can also be seen that DRG has problems with the scientific and rational nature of payment standards.(2)Taking the DRG payment system as the research object,from the perspective of hospital balance of payments,random variables and their probability distributions are used to analyze the change mechanism of the DRG payment standard.This paper explores the influence of various key factors on the DRG payment standard,and mainly analyzes the influence of the expectation and the variance of the reimbursement cost,the loss probability of patient group k,the reimbursement ratio,the prevalence rate and population size on the payment standard of DRG,and builds a risk control model.Through the numerical simulation of the model,the research has found that:(1)the payment standard (?) will increase with the increase of the expectedμ_kof the reimbursable cost and the increase in the reimbursement ratioλ_k;(2)When the loss probability of hospital disease group k isβ<0.5,the payment standard will decrease with the increase ofβ;The payment standard will increase with the standard deviation of reimbursable costσ_k;The payment standard will decrease with the increase in the prevalence rate p_k.If 0.5<β<1,the payment standard will decrease with the increase ofβ,and the payment standard will decrease with the increase of the standard deviationσ_k of the reimbursable cost.(3)When the population size N is very small,the more patients are reimbursed,the more payment standards the medical insurance bureau pays to the hospital.When the population size N is very large,the payment standard is close toλ_kμ_k.(3)From two dimensions of the hospital and the patient,this paper has empirically tested the impact of the change of DRG medical insurance payment standards on the hospital service efficiency and the patient burden.The main findings are as follows:Firstly,there is a positive correlation between patient hospitalization days and medical insurance payment standards,indicating that the lower the payment standards,the shorter the duration of the patient stay.Secondly,there is a positive correlation between the medical insurance payment standard and the total cost of patients,that is,disease groups with good balances can appropriately reduce the medical insurance payment standard to control the total cost of patients.Thirdly,the medical insurance payment standard has a significant positive impact on the out-of-pocket ratio of patients,that is,the improvement of the medical insurance payment standard will lead to an increase in the out-of-pocket ratio of patients and increase the medical burden of patients.In other words,under the current medical environment conditions and policies,the lowering of DRG medical insurance payment standard is conducive to the improvement of the utilization rate of hospital resources and the reduction of the patient burden.(4)The cost structure data of the FV23 disease group(hypertension with general complications and comorbidities)from Hospital A in 2020 and 2021 has been used for mathematical statistical analysis.The results show that:under the condition that hospitals can guarantee the minimum compensation from medical insurance funds for the public welfare,the standard payment range is between 3748.36 RMB Yuan and7866.04 RMB Yuan in 2021,and between 3905.8 RMB Yuan and 7869.14 RMB Yuan in 2020.Both the upper and lower limits in 2021 are lower than those in 2020.This is in line with the direction of the national DRG reform.Based on ensuring the sustainable operation of hospitals for public welfare,the medical insurance payment is constantly refined and the hospital management is improved.(5)Based on the analysis and reference of typical national medical insurance payment methods and DRG payment standards,the following policy suggestions are put forward to determine and optimize the medical insurance payment standards with the idea of"setting the basis-setting the direction-dynamic adjustment":(1)From the perspective of the calculation basis of the medical insurance service price,it is mainly to solve the accuracy of the data information in the process of formulating the medical insurance payment standard,improve the information collection ability of hospitals and medical insurance institutions,the data sorting ability and the accuracy and reliability of the data information.(2)From the perspective of the unbiased direction of the adjustment of the DRG medical insurance payment standard,the rationality of the medical insurance payment standard should be considered in combination with the income and expenditure of various kinds of diseases in the hospital,the patient burden,and other factors,and the direction of the adjustment of the medical insurance payment standard should be determined from multiple perspectives and multiple indicators to improve the medical insurance payment standard.(3)From the perspective of the rationality of the formulation of the medical insurance payment standard,when formulating payment standards,it is necessary to analyze the specific situation of medical insurance payment standards for different disease groups based on the hospital data feedback.The medical insurance institutions should dynamically adjust the DRG medical insurance payment standard based on the data information to improve the rationality of the medical insurance payment standard.There are three main innovations in this paper:(1)The DRG medical insurance payment standard model is designed based on the probability theory and mathematical statistics.Existing kinds of literature are mainly based on the epidemiology and lack of management scientific methods.Existing domestic kinds of literature only use the game theory and the principal-agent theory to study medical insurance payment methods.Based on the probability theory and mathematical statistics,this paper constructs a model of the DRG medical insurance payment standard under the financial risk control and finds out the important influencing factors of the DRG medical insurance payment standard and the influencing mechanism of the DRG medical insurance payment standard.(2)Through the analysis of the influence of the reform of the DRG medical insurance payment standard and the analysis of the cost structure of the disease group,the influencing mechanism of the DRG medical insurance payment standard on hospitals and patients and the mechanism of the determination of the cost structure of the disease group on the DRG medical insurance payment standard has been revealed.(3)An analytical framework for determining the DRG medical insurance payment standard based on"three dimensions"has been constructed,and the scope of the DRG medical insurance payment standard has been determined based on this framework and combined with specific disease groups.Meanwhile,policy suggestions for improving the determination of the DRG medical insurance payment standard have been constructed based on the idea of determining the DRG medical insurance payment standard to ensure the accuracy of the medical insurance price measurement basis,ensure the unbiased direction of the adjustment of DRG medical insurance payment standards and improve the rationality of the formulation of DRG medical insurance payment standards.