| The reform of medical insurance payment methods is a crucial link in deepening the reform of the medical and health system.Since the National Medical Insurance Administration and other four ministries launched the pilot of Diagnosis Related Groups(DRG)payment in 30 cities across the country in 2019,in November 2021,the National Medical Insurance Administration proposed to promote DRG or DiagnosisIntervention Packet(DIP)payment reform in all pooling areas nationwide by the end of 2024.However,studies show that although DRG payment is conducive to optimizing the allocation of medical resources and controlling the unreasonable growth of medical expenses,doctors may engage in strategic behaviors that violate the norms of the DRG payment system during the implementation process.These behaviors not only hinder the improvement of medical quality and efficiency but also lead to unreasonable expenditure of medical insurance funds.Therefore,avoiding doctors’ strategic behaviors in the DRG payment system has become an urgent problem to be solved.This study first adopts a combination of qualitative and quantitative research methods to identify the main types of strategic behavior by doctors in the DRG payment system.Then,taking the limited rationality hypothesis of doctors as the logical starting point,it introduces the planned behavior theory from the field of social psychology to construct a theoretical model of strategic behavior by doctors,and through empirical research,reveals the mechanism of strategic behavior.Finally,based on the results of empirical research,it sorts out the intervention paths of strategic behavior and proposes targeted preventive measures.The main work and innovations of this study are as follows:Firstly,this study uses the interrupted time series analysis method to focus on a city where the national DRG payment system was piloted.It analyzes indicators such as standardized hospitalization costs,length of hospital stay,the proportion of cases in the DRG group with severe complications or comorbidities,the proportion of mild cases with weights less than 1,and the rate of unplanned readmissions within 14 days after the implementation of the DRG payment system,to clarify the changes in doctor behavior before and after the implementation of the DRG payment system.Then,based on the definition of strategic behavior,unstructured questionnaires are designed to conduct in-depth interviews with doctors,and grounded theory is used to analyze the interview data.Six types of strategic behaviors are identified in the DRG payment system: cherry picking,upcoding,overtreatment,hospitalization decomposition,reducing medical services,and shifting costs.Among these,upcoding,cherry picking,and hospitalization decomposition account for 87.7% of the total,being the main types of strategic behavior.Quantitative research based on medical system databases and qualitative research through doctor interviews complement each other and more comprehensively identify the types of strategic behavior by doctors in the DRG payment system.Secondly,this study begins with the premise of bounded rationality in doctors,drawing upon the Theory of Planned Behavior to formulate a theoretical model of doctors’ strategic behavior within the context of the DRG payment system.Through empirical research,it investigates the influence of various economic and socio-psychological elements such as doctors’ beliefs,behavioral attitudes,subjective norms,perceived behavioral control,and intentions on the path of strategic behavior.This approach provides a more comprehensive understanding of the occurrence mechanisms underlying strategic behavior within the DRG payment system.The results show that:(1)the model has good adaptability,with a chi-square degree of freedom ratio of 2.575 and a root-mean-square error of approximation(RMSEA)of 0.072;(2)the influence of doctors’ strategic behavior intentions on behaviors is most significant,with a path coefficient of 0.606;(3)behavioral attitude,subjective norms,and perceived behavioral control are the main factors affecting doctors’ strategic behavior intentions,with path coefficients of-0.159,-0.120,and-0.093,respectively;(4)there are significant correlations between behavioral beliefs,normative beliefs,control beliefs,and behavioral attitude,subjective norms,and perceived behavioral control,respectively;(5)the occurrence mechanisms of the three main types of strategic behaviors,namely upcoding,cherry picking,and hospitalization decomposition,are similar,but the degrees of influence of factors such as beliefs,behavioral attitudes,subjective norms,perceived behavioral control,and behavioral intentions on different types of strategic behaviors vary.Lastly,this study adopts a comprehensive approach,utilizing literature review and expert consultation to construct a "1+3+3" prevention system for doctors’ strategic behavior in the DRG payment system.Based on the research results of the occurrence mechanisms for various strategic behaviors,such as upcoding,cherry picking,and hospitalization decomposition,the study analyzes salient beliefs and proposes specific preventive measures.For example,to prevent upcoding behavior,it is essential to increase doctors’ awareness of the potential damage to medical insurance fund efficiency,patient care quality,and their own reputation.Regarding cherry picking behavior,the roles of department heads and hospital management should be fully utilized,while also strengthening the responsibilities of higher-level authorities.As for hospitalization decomposition behavior,prevention can be achieved through improving DRG grouping rules,strengthening DRG supervision,establishing negotiation and consultation mechanisms between medical insurance and hospitals,and promoting clinical pathways.In summary,this study first identifies the types of strategic behavior among doctors in the DRG payment system.Then,by incorporating the theory of planned behavior,it uncovers the mechanisms behind strategic behavior from the perspective of individual doctors.Lastly,a prevention system for doctors’ strategic behavior is developed based on the research findings,along with specific countermeasures.This study expands the application of the theory of planned behavior in related fields to a certain extent and provides valuable decision-making support for effectively preventing strategic behavior.19 figures,38 tables,280 references... |
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