The Study Of Computing 16 Regular Diseases DRGs Payment Rates In Beijing Area

Objectives and SignificanceSince implementing the reform and open policy, China's health industry has been developing at top speed, medical establishment, medical technology and medical quality all made rapid progress. But health expenditure and health price increase sharply, it leads to the occurrence of lopsided consumption and affects the development of national economy. Plebes are discontented with the rise in health care. Stabilizing health price complied with the scientific developing philosophy is a crucial ingredient to build a harmonious country.Based on the health economic analysis of providers'behavior characteristics in Various payment systems, the aims of this study are as follows: firstly, to find out the reasons for the rise in health price; secondly, to draw up genuine case-mix plans of DRGs using medical record information available in China; thirdly, integrating hospital present financial situation with the conceivable reform tendency, to explore the theories and methodologies on computing DRGs payment rates, and try to give advice and references on health reform.Research MethodsQualitative and quantitative approaches were applied in this study. Use the elementary theories and models in the fields of positive economics, new classical economics and information economics to compare providers'behavior in various payment systems. Judgmental sampling was used to collect data. Set up case database and filter database with Oracle software. Descriptive analysis, comparative analysis, single-variable statistic analysis, multi-variable analysis, multiple linear regression analysis were adopted when analyzing case data. Evidence based medical method and qualitative interview were adopted to mix cases with SAS8.0 software. Receiver operating characteristic curve, the value of coefficient variable and Kruskal-Wallis test were used to verify the result of case-mix. Compute DRGs payment rates with the theories and methods of the economics of regulation and health economics.Research ContentsThe main content of this study includes:1. The difference between providers'behavior characteristics in different payment systems, placing emphasis on the distinction between fee-for-service payment system and prospective payment system;2. The necessity and feasibility of applying DRGs-PPS in the general health care;3. The case-mix plan with the front pages of the inpatient medical records, which limited 16 regular diseases;4. The method of formulate DRGs payment system rates according the related economic rules, which should conform to China'hospital financial situation as well as balance rights and interests amongst government, health care insurance agents and patients.Main ResultsBecause of the peculiarity of health industry and profit motive, providers'orientation is distinction from administrative agency's all the while. Various payment systems create powerful incentives upon to the behavior of providers. Each payment system regulates and directs medical behavior of providers and results in different financial outcomes and then differences will be occurred in cost containment, resources allocation as well as quality. None of payment systems is perfect, administrative agency should adopt a multilevel and mixed payment system to solve the main embarrassments in various health care. It would utilize the merts of payment systems and avoid the negative effects caused by single payment system. DRGs-PPS is fit for general health care, its prominent virtue is what check the health care expense inflation.Statistic results indicate that hospitalization charge is mostly decided by procedures, primary diagnoses, complications and comorbidities, ages and payment system. 86415 eligible cases were classified in 97 groups. Among 14 major diagnosis categories, the maximum R2- value is 0.37, the minimum R2- value is 0.02, 8 major diagnosis categories R2- value are above 0.1, average R2- value is 0.11. The receiver operating characteristic curve is quiet distinctive in a major diagnosis category, which shows grouping nodes are reasonable. P- value are below 0.0001 in Kruskal-Wallis test, which demonstrates inpatients in different groups are heterogeneous. The values of variance coefficient are below 1 in 80 groups, it indicates cases in the same group are homogenous. The result demonstrates that the patients in the same group have the same pattern in clinical condition and health resources consumption. Patients in different groups are different in health resources consumption. In addition, this classifying method complies with the principle that there should not be repeated cases among different groups. Consequently, the case-mix scheme in this study is reasonable. Furthermore, the case-mix scheme combines the statistic results and clinical experts'suggestions, thus, it would be more acceptable.During transition period, the computing DRGs payment rates bases on hospitalization charges is a second-best optimization. This study brings forward a formulation that DRGs payment rates could be calculated on the basis of both the area standardized average of hospitalization charge and hospital customary average of hospitalization charge, moreover use incremental financial allocation and hospital price index as adjusting multipliers. Having verified, the average error rate is 6.49%, the maximum error rate is 28.32%, the minimum error rate is 0.03%. It demonstrates the case-mix scheme and the formulation of DRGs payment rate are reasonable. Furthermore, hypothesis calculation suggests the formulation can reflect the macro-economic policies.Policy RecommendationsOn the basis of results, put forward recommendations as follows:1. Payment system's reform is an important measure to reduce health price administrative agency should introduce DRGs-PPS to general health care.2. According to Price Law, the competent authorities call providers, health care insurance agents and patients'delegates together to set DRGs payment rates through public rate hearing.3. The development of hospital information systems is uneven, inpatient medical records are not full and clear, therefore DRGs prospective payment system could be adopted to pay the charge of regular diseases firstly. In addition, payment system's reform would pursue by region.4. Set a period of transition, so that providers could adapt themselves to the new payment system, governors could collect sufficient cost information. After transition, DRGs payment rates computed on the basis of operating costs and average investment income rate.5. Standardize medical information, changing the current information managing model which is scattering and self-deciding. Establish a unified and professional managing model in order to let information flow with high fidelity and smoothly.6. Health competent authorities lay down related standards strictly, which includes the primary diagnosis, the standard of admittance to hospital, the standard of leaving hospital and the standard of transferring. In addition, authorities could monitor and control mortality, the structure of diseases and medical incomes in order to prevent providers'moral hazard and adverse selection.Innovation points in this study1. Use the elementary theories and models in the fields of new classical economics and the theory of yardstick competition to compare providers'behavior in various payment systems.2. According to AP-DRGs and advise of clinical experts, estabalish the data-bases of diagnoses defined as major complication or comorbidities, complication or comorbidities, and operation.3.Make a thorough study on the hospitalization charge structure of each DRGs. On the basis of analysis, calculate the weighted average hospitalization charge, in that, the DRGs payment rates are more representative.4.Combine the principle of prospective payment system based on DRGs with hospital financial situation, the formulate balance rights and interests among government, health care insurance agents and patients.