| Objective:In the context of continuous reform of the medical and health care system,the reform of medical insurance payment method has become a key link,the purpose of which is mainly to control excessive cost growth,rationalize the allocation of medical resources,and achieve a win-win situation for doctors,patients and insurance.At present,the payment method is still in the pilot stage,and its implementation status and effect evaluation have further exploration value.Therefore,based on the background of the reform of China’s value-based payment method,this study investigates the current situation of value-based payment by disease type and conducts an empirical study on the evaluation of its effects.It explores the main focus and difficulties in the current implementation under the value-based payment by disease,analyzes its change mechanism,finds the influencing factors,and proposes improvement countermeasures to consolidate the strong points and make up for the shortcomings,so as to provide a reference basis for promoting the development of health insurance payment methods and improving related policies in the future.Methods:1.Literature research.Using the keywords "medical insurance payment","DIP","medical insurance" and other keywords,we searched relevant literature in Pub Med,Zhiwang and other domestic and foreign literature databases,screened and read literature with highly relevant content to the content of this study,sorted out and summarized the development history of DIP payment reform,relevant research methods,evaluation indicators and evaluation results at home and abroad,and provided references for the design and analysis of this study.2.Qualitative research in-depth interview method.By designing a semi-structured interview outline for the current situation of DIP implementation in the study area and the subsequent positive and negative impacts,16 people,including health insurance institution personnel and medical personnel,were organized to conduct interviews,and the current situation of DIP implementation and the positive and negative impacts of implementation were analyzed using thematic analysis,and targeted suggestions were made for unintended effects by combining stakeholder theory and game theory.3.Quantitative questionnaire survey method.A self-designed questionnaire on the reform of medical institutions under DIP payment reform was used to reflect the changes in medical institutions in the study area after the implementation of DIP payment,and statistical descriptive analysis was used to respond to the impact of medical institutions in terms of organizational structure,case home management,and performance evaluation after the implementation of DIP payment.4.Policy effect evaluation method.By constructing a generalized linear model,we conducted a comparative analysis of the policy effect indicators such as medical cost indicators and medical efficiency on patients with chronic obstructive pulmonary disease and different subgroups of patients before and after the implementation of DIP payment reform,selected the variables that might affect medical cost and medical efficiency related variables as control variables,and focused on the trends of the policy effect indicators before and after DIP payment reform.Results:1.Survey results on the current status of DIP payment implementation in the survey areaThe process of implementing DIP payment in the survey area mainly includes reorganization of the organizational structure,identification of disease types,determination of disease type scores,determination of medical institution coefficients,adoption of monthly budget and annual settlement,and related health insurance fund supervision measures.At present,there are 6792 disease types in the core category and 566 disease types in the comprehensive category;the disease type score is based on acute appendicitis with limited peritonitis + laparoscopic appendectomy as the benchmark disease type,Other diseases and benchmark diseases as a proportional relationship to calculate the score;by the technical level of medical institutions at all levels,disease structure,type of specialties,resource consumption and other comprehensive factors to determine the coefficient of different medical institutions;supporting the corresponding annual assessment,disease type score supervision and other measures.2.Positive and negative impact results under DIP payment reform in the study areaFrom the results of questionnaires and interviews,the expected effects under DIP payment reform are reflected in the following points:(1)to a certain extent,medical insurance institutions have a guiding role and promote the balance of income and expenditure of medical insurance funds;(2)medical institutions strengthen the quality of filling out the first page of medical cases and the accuracy of coding;(3)hospitals’ cost control awareness and cost control ability gradually improve;(4)hospitals improve clinical pathway management,and the coverage rate of clinical pathways greatly increases,which promotes the standardized management of clinical treatment.However,DIP payments also cause some negative effects,mainly:(1)medical institutions and medical staff to obtain more profits,control medical costs and at the same time reduce the necessary medical services,resulting in the problem of insufficient patient care;(2)some of the patients admitted to hospitals with serious illnesses are not compensated for a long period of time,and hospitals are in a long-term loss,which must bring huge financial pressure on medical institutions;(3)New technology or new projects generate a lot of high medical costs,which is a new challenge for medical institutions;(4)medical institutions will admit more patients with difficult and complicated diseases,and reduce the behavior of multi-morbidity and other low-point diseases to obtain more medical insurance compensation funds,which is also known as the "punch point" problem.3.Empirical study of changes in medical costs,medical efficiency and other indicators before and after DIP payment reform(1)Setting the non-implemented DIP payment phase as the reference block,the results of the analysis based on a generalized linear model for patients with chronic obstructive pulmonary disease showed a statistically significant and decreasing trend than the total average per hospitalization costs,out-of-pocket costs,the percentage of out-of-pocket costs,and the average hospitalization days after the implementation of DIP.The out-of-pocket costs,average hospitalization days,and total average next hospitalization costs decreased by 7.87%,1.78%,and 3.05%,respectively,with better control of out-of-pocket costs.(2)The analysis of cost indicators for different subgroups of patients with chronic obstructive pulmonary disease using a generalized linear model showed that for patients with chronic obstructive pulmonary disease with lower respiratory tract infections,the average total per hospitalization cost,average per out-of-pocket cost,average per Medicare reimbursement cost,and the percentage of out-of-pocket cost all showed a decreasing trend after the implementation of DIP,with the largest decrease in average per out-of-pocket cost,followed by the average total per hospitalization cost.For patients with acute exacerbation,the average inpatient total cost,average inpatient out-of-pocket cost,average inpatient out-of-pocket ratio,and average number of days in hospital decreased by 1.69%,6.95%,2.96%,and 0.60%,respectively;for patients with other specific chronic obstructive pulmonary disease,the decreasing trend in average inpatient out-of-pocket cost and average inpatient health insurance reimbursement was more obvious.Conclusion:DIP payment reform,the pilot areas carrying out DIP payments will implement DIP payment models adapted to the development of the region based on a variety of factors such as regional economic development,type of disease,level of medical development,and health insurance fund coordination,etc.The implementation of DIP payments in the research areas will help to reduce the average number of hospital days and have a more pronounced effect on medical cost control under the premise of attaching importance to medical quality,and the cost control effect for patients with milder conditions is better than that for patients with more severe conditions;Under the DIP payment implementation fusion,the medical side actively improves the medical quality evaluation system,enhances cost control,and pays attention to the standardization standard of the first page of medical cases;the medical insurance side guides the medical side’s behavior by adjusting DIP payment standards,setting DIP patient group rules,and supervising and controlling for shirking patients,punching point behavior,transferring costs to outpatient clinics,and applying high score codes.DIP payment reform has changed the relationship between doctors,patients and insurance,with the medical side gradually shifting to aim for cost minimization.Patients may worry about inadequate treatment while relieving their medical burden,and health insurance institutions gradually reversing the status quo of passive payment,prompting medical institutions to refine their reform and internal development,improving the sharing mechanism between health insurance and medical institutions,and building and improving a patient health-centered medical and health service system. |
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