Determination Of Medical Service Scope For Public Hospitals In Multi-attribute Decision Making Model Under DRG Payment Method

[Purpose]The purpose of this study was to establish a multi-attribute decision making model with patients in different diagnosis-related groups(DRGs)regarded as samples and each level of health institutes as alternatives that making decision of which level of health institutes is the most proper choice for patients in each DRG,in order to discriminate the boundary of medical services offered by different levels of institutes.[Methods](1)Literature research method.Based on the principles of importance,accessibility,relevance and sensitivity,the author integrated and summarized the relevant research articles and policy documents,to form an alternative index pool for judging the suitability of inpatient medical services in different levels of medical institutions.(2)Delphi method.Twenty experts with experience of research,education,or practice in health care management and clinical practice were selected.Delphi method was applied to consult experts on the construction of evaluation indicators and dimensions of the suitability of medical service in different levels of hospitals.Through the consultation form,experts were invited to score the recognition degree of each dimension and index,and put forward suggestions for revision.The indicator system for suitability evaluation of inpatient medical service scope at different levels of medical institutions for each DRG group was established based on the expert consultation progress.(3)Entropy weight method.Entropy weight method is used to aggregate the attribute values in the decision model and give weight to attribute indexes.In the multi-attributed decision making(MADM)model for each DRG,entropy method were applied in weighting attributes,in order to give higher weight for attributes with more significant difference among schemes.(4)Ideal solution method.In this paper,Technique for Order Preference by Similarity to an Ideal Solution(TOPSIS)is used to compare the schemes in the decision model to find the best scheme.The optimal decision scheme is ranked according to the superior degree of each alternative scheme,and the vector that is both closest to the ideal scheme and farthest from the negative ideal scheme is taken as the optimal decision scheme.(5)Data collection.This study collected data from 17 secondary and tertiary public hospitals in a city of Henan Province from 2019 to 2020.The data contain administrative data of inpatients' medical records and medical insurance settlement lists of sample hospitals,mainly including 385369 observations after matching the medical records and insurance settlement lists,and 577 CHS-DRG related information corresponding to the sample data.(6)Panel discussion.In this study,after making decisions on 125 DRG groups in the sample area by using the decision model,health administrators,clinical medical personnel and hospital administrators in the sample area were invited to have thematic group discussions to discuss whether the results of the model were consistent with the development level of medical services in the sample area.To explore the DRG group whose hospital level is too high when the best decision plan should promote patient subsidence,and the DRG group whose hospital level is too low when the best decision plan should not promote patient subsidence,as well as the possible reasons behind it,and then to add restrictions to the applicable conditions of the model and optimize the model.[Results]1.Establish of indicator system for the suitability of inpatient medical service scope.Based on the definition and part of elements from VBHC theory,this study collects and collates relevant information by combing the relevant literature,combining with ICD-10 disease classification and code national clinical version 2.0 and the transparency and evaluation of medical institutions' performance from The Agency for Healthcare Research and Quality,and preliminarily constructs the dimension and index pool of medical service scope evaluation.Through two rounds of Delphi expert consultation,the paper conducts the evaluation of medical service scope at all kinds of objective to evaluate the language expression and recognition degree,and to make statistical analysis by mean,rank sum and coefficient of variation.After repeated discussion by the research group,the items were screened and modified.Finally,the evaluation index system of medical service scope was formed,including two dimensions of health results(27 items)and resource utilization(2items),with a total of 29 items.The items of the index system reflect the requirements of reducing resource consumption and pursuing health outcomes in the VBHC theory.Besides the traditional mortality and infection rate,the evaluation of health outcomes added the prevalence of in-hospital adverse events.Compared with the previous research,this study paid core attention on the actual clinical health outcomes of patients that getting closed with clinical practice.2.Determine medical scope by DRGs and MADM model in each groupThis study transformed the problem of defining the scope of inpatient medical services in public hospitals into the decision-making problem of selecting the hospital type with the highest value of medical services for the same type of patients.According to the DRG grouping principle,the patients were classified according to the difficulty and complexity of treatment.Based on the analysis framework of MADM,the general objective of value medicine was decomposed.Combined with the evaluation index system of the suitability of inpatient medical service scope,the decision matrix was formed.The entropy weighting method and TOPSIS method commonly used in MADM analysis were performed as the decision attribute weighting method and the ranking method for the scheme.The patients in each DRG group were taken as the analysis objects,the indicator system constructed by expert consultation was taken as the decision criteria,and the hospitals of different levels were taken as the alternatives.The model can find the optimal solution that is the most suitable type of medical institutions for each DRG group of patients.In order to achieve the purpose of this paper,we can judge and distinguish the scope of in-patient medical services of public hospitals.3.Discrimination of inpatient service scope of sample hospitalsIn this study,we empirically analyzed 385369 medical record front pages and medical insurance settlement list records of 17 hospitals in the sample area,made multi-attribute decision-making for 125 DRG groups with at least two types of hospitals meeting the requirement of 100 cases,analyzed the differences in medical service achievements and costs of different types of hospitals,and took three DRG groups as examples to show how to build multi-attribute decision-making model and solve the problem.In order to judge whether the decision-making results are consistent with the actual situation,the best decision-making scheme of each DRG group in the sample data is solved.The results show that 28 groups are the best decision-making scheme in Grade 3A hospital,49 groups are the best scheme in grade 3B hospital and 28 groups are the best scheme in grade II hospital In order to identify the scope of inpatient services of secondary and tertiary public hospitals in the sample area,and provide evidence support for promoting patient subsidence and implementing hierarchical diagnosis and treatment policy in the area.[Conclusions]1.The study uses DRG grouping to classify patients according to the difficulty and complexity of treatment,and puts forward the analysis idea of distinguishing and defining the scope of medical services of different levels of medical institutions from the perspective of patients through decision analysis.The problem of distinguishing the scope of medical services between different institutions and refining the functional positioning is transformed into the analysis of patients in each DRG group,taking different levels of medical institutions as the analysis object.Thus,the medical services provided by different levels of medical institutions are comparable in terms of quality,efficiency and patient safety,so that the problem of defining the service scope of medical institutions is no longer limited to judging from the perspective of case coverage and the overall performance indicators of medical institutions,but can be solved more finely to determine which type of patients should be encouraged for lower referral.It is suitable for the implementation of hierarchical diagnosis and treatment system in lower level hospitals,which expands the relevant research ideas.2.To judge whether the scope of inpatient medical services of different levels of medical institutions is appropriate,application of VBHC framework with comprehensively evaluate the medical services of hospitals at various levels are necessary.Based on the definition and some elements of value medicine theory,this study constructed an index system for each DRG group to comprehensively evaluate the clinical health results and medical resource utilization of medical services provided by different levels of medical institutions.Compared with the previous research on DRG grouping to promote the implementation of hierarchical diagnosis and treatment,the consideration of the risk of adverse events during hospitalization is added,so the evaluation is more comprehensive and can better reflect the differences of clinical health results in the whole process of treatment.This index can provide reference for policy makers of health administrative departments and managers of medical institutions in the evaluation and assessment of medical services of medical institutions at all levels,so that the application of value medical theory is not limited to health technology evaluation and other research fields,but also can provide reference for the implementation of relevant policy-making of hierarchical diagnosis and treatment,as well as the self-evaluation of medical institutions to provide evidence for the assessment and planning of development direction.3.Decision analysis model can be used to solve the problem of fine functional positioning of hospitals at all levels from the perspective of patients.In the past researches,the purpose of applying decision analysis to the implementation of hierarchical diagnosis and treatment system is to reflect the wishes and preferences of decision-makers,and select the most suitable scheme from different alternatives.This study uses the relevant elements of value medical theory as the goal and criterion of MADM,extracts the relevant information of clinical health results from the diagnosis information of the front page of medical records,and weakens the influence of decision-makers' wishes and preferences on the choice of treatment by objective weighting method,so as to build the model more close to the actual health situation of patients and the cost and time expenditure.Therefore,it can objectively reflect the best choice of patients in each DRG group,rather than the willingness of patients.The model of this study could be used by policy makers of health administrative departments on promoting lower referral of patients and implementing the hierarchical diagnosis and treatment policy.They can transform the original problem of distinguishing and defining medical service scope from the perspective of medical institutions into the decision-making problem of analyzing the best choice of treatment for various types of patients,whether through administrative orders or with the help of medical insurance payment lever,the lower referral of part of patients could be more specifically on the premise of ensuring medical quality and patient safety,which may help in saving total health expenditure and improve the allocation efficiency of medical resources.[Innovation and Deficiency]1.InnovationThis study uses MADM model,from the perspective of value medicine,from the perspective of clinical health outcomes of medical services and medical resource utilization,to build decision-making goals and criteria,for each DRG group of patients in different types of medical institutions to make decisions.Through this method,the original problem of distinguishing and defining the scope of medical services of different levels or levels of medical institutions is transformed into a decision-making problem of selecting the best type of medical institutions for all kinds of patients from the perspective of patients,which expands the analytical thinking for the related research on defining the scope of medical services.On the one hand,the DRG group is used to classify patients' condition characteristics according to the complexity of the disease,so that different levels of medical institutions can be compared;on the other hand,the adverse events including infection and postoperative complications during the hospitalization of patients are successfully included in the evaluation of various alternatives,that is,different levels of medical institutions.In addition,this study synthesizes each evaluation index to obtain the optimal solution,which enriches the evaluation methods of whether medical institutions at all levels are suitable for carrying out relevant medical services in similar studies.This study constructs a MADM model to evaluate the suitability of inpatient medical services from the perspective of clinical health outcomes and resource utilization.The model takes the historical data as the attribute value,and gives weight to each attribute by objective weighting method.Therefore,the attribute weight of the model is not unchangeable,but changes with the level of each attribute of various hospitals in each DRG group.It automatically selects the attribute values with large level differences between different levels of medical institutions,and gives higher weight.Therefore,the model has a certain adaptability to the changes of the analysis object.From the results of the empirical analysis,we can see that it is not a decision-making model only for one or several types of patients,but suitable for all DRG groups that meet the conditions of hospitalization.As a result,the model has a certain application value in the similar research or practice of judging and defining the scope of inpatient medical services in different levels of medical institutions.2.DeficiencyThis study draws on the elements of clinical health outcomes and resource utilization of VBHC.However,due to the need to compare different levels of medical institutions,the more widely recognized quality adjusted life years are not used.This is mainly due to the fact that patients may visit many medical institutions with different level of institutes during the survival period,and it is difficult to distinguish the impact of each hospital on the final outcome.Therefore,we use the clinical health outcomes that are more closely related to the cause and effect of this hospitalization as the evaluation criteria for the "results" of medical services.In addition,the sample of empirical analysis comes from 17 secondary and tertiary public hospitals in a prefecture level city of Henan Province.Therefore,the scope of inpatient medical services of different levels of medical institutions obtained from empirical analysis is only applicable to the sample areas.Thus the conclusions of the empirical analysis part of this study should not be used directly.