Game Analysis And Empirical Research Of Stakeholders In The DRG Payment

[Purpose]Based on the background of DRG reform of medical insurance and stakeholder theory,this study constructs game models and evolutionary game models analyze the changes of medical treatment behaviors of hospitals,medical insurance and patients in the DRG system theoretically and empirically,analyzes the change mechanism,and finds out the key influencing factors.It provides a reference for formulating and perfecting medical insurance policies,guiding stakeholders to perform their duties according to the expected goals,and promoting the rational use of medical resources.[Methods]1.Literature research.According to the logical relationship of keywords such as "stakeholders","DRG" and "game",the search steps were arranged,and the search formula was scientifically compiled.Searching in Pub Med,CNKI and other major databases at home and abroad,reading 511 highly relevant literatures.The research methods,evaluation indicators and application results of DRG payment reform,game behavior and medical insurance management at home and abroad were summarized,which provided the basis for the design and analysis of this study.2.Collection of secondary data.Collect the policies of DRG payment reform and hospital operation in the survey area,and collect the data of DRG and medical record homepage from 2017 to 2020,including 13 indicators of medical resource consumption,4indicators of medical service quality,2 indicators of two-way referral,indicators of medical resource consumption of 5 disease groups,and the number of patients with different weights in 5 disease groups.3.Expert consultation.Sixteen experts in medical insurance,hospital management and health management were selected for expert consultation on the determination of core stakeholders in this study,and the stakeholder matrix was scored to determine the core stakeholders in this study.4.Thematic group discussion.In this study,16 people,including health administrators,medical insurance personnel,heads of research hospitals and experts in DRG field,were organized to form a special group.Focusing on the demands and behaviors of stakeholders,special discussions and brainstorming were conducted to sort out the demands and behavior items,and questionnaires were designed for hospitals,medical insurance and patients respectively.5.Interview with key insiders.According to the actual situation before and after the reform of DRG payment in the survey area,52 insiders,including medical insurance managers,hospital managers,clinicians and patients of 8 hospitals,were interviewed to analyze the causes of various behaviors and phenomena before and after the reform of DRG.6.Questionnaire survey.A self-designed questionnaire was used to investigate the demands and behaviors of hospitals,medical insurance and patients in sample areas.According to the number of questionnaire items,the minimum sample size of factor analysis was calculated,and 258 valid questionnaires for hospitals,138 valid questionnaires for insurers and 302 valid questionnaires for patients were collected.7.Methods of data analysis.Through repeated measurement variance analysis and interruption time series analysis,the indexes of medical resource consumption and medical service ability before and after the reform were compared.Through factor analysis,the common factors are extracted from the demands and behaviors of hospitals,medical insurance and patients,and the medical people are classified by cluster analysis.Through the analysis of game model,find out the equilibrium solution and influencing factors of various behaviors of stakeholders.The evolution characteristics of the system under different parameters are explored through simulation experiments with evolutionary game model.[Results]1.Definition of core stakeholders in medical insurance payment reform and analysis of their relationship.The core stakeholders of medical insurance payment reform are hospitals,medical insurance and patients.The interests of hospitals are "DRG system design is scientific and reasonable","DRG promotes the ability improvement of medical institutions","medical insurance institutions ensure open and transparent system",and "DRG promotes scientific and fair evaluation of medical insurance to medical institutions".There are 28 behaviors of hospitals,which are divided into positive behavior and negative behavior.Medical staff are divided into "adaptive group" and "reverse group".The interests of medical insurance are "promoting the service ability of medical institutions","improving the handling ability of medical insurance institutions","improving the medical evaluation ability of medical insurance institutions" and "improving the fund supervision ability of medical insurance institutions".There are nine actions of the medical insurance,which could be divided into three categories: "adjusting DRG policy"," supervision and assessment" and "consulting with the hospital".The patient’s demands are "medical service quality improvement","medical service price reduction" and "medical service information transparency".There are seven types of patients’ behavior.In the DRG reform,the reasons for conflict include the selfish departmentalism of stakeholders,opportunistic behavior in pursuit of the maximization of interests,failure to establish effective communication mechanisms,incomplete supervisory systems,which leads to game behavior.2.Construction and solution of stakeholder game model in DRG reform(1)The game between hospitals.From the game of medical resource consumption,DRG reform can promote the transformation from excessive medical treatment to saving medical treatment at hospital level.However,at the doctor level,due to the incentives from pharmaceutical companies,doctors may still choose over-treatment.From the perspective of the game of medical service ability,DRG reform can promote departments to choose to improve their medical service ability and obtain greater profits.According to the game of graded diagnosis and treatment,under the DRG system,it is more in line with the interests of medical institutions to carry out graded diagnosis and treatment.(2)The game between hospitals and medical insurance.According to the game between the consumption of medical resources and the quota setting of medical insurance patients,under the DRG reform,the hospitals choose to save medical care,while the insurers choose to reduce the quota,and the game is repeated.The final result is that the hospitals reduce the medical expenses to a lower state and form adverse selection.According to the game of DRG point method medical service quantity,the behavior of increasing points caused by hospital competition under point method is inevitable,and the whole benefit is reduced by point method,and medical institutions bear most of the risk of overspending.Judging from the bargaining game between hospitals and medical insurance in pricing DRG groups,the game is beneficial to insurers who bid first,forming a first-Mover advantage,and hospitals can choose to delay negotiation time or increase negotiation times to gain more benefits.From the monitoring game of the insurer on the consumption of medical resources,DRG reform may lead to positive or negative medical saving.Reducing the inspection cost of medical insurance department and increasing the penalty amount of medical insurance can reduce the probability of negative medical saving in hospitals.According to the supervision game of the insurer on the behavior of up-coding,if the probability of up-coding in hospitals is consistent under the fee-for-service payment and DRG payment,the inspection probability of medical insurance under DRG payment will be greater,which reflects that the motivation of upcoding is enhanced.Reducing the cost of medical insurance inspection and increasing the penalty amount of medical insurance departments can restrain the up-coding in hospitals.(3)The game between hospitals and patients.According to the supervision game between hospitals and patients,under the reform of DRG,reducing the cost of patients’ complaints and strengthening punishment can reduce the probability of negative medical saving such as insufficient medical services in hospitals.From the reputation model of repeated games between doctors and patients,reputation is an important means to strengthen mutual trust in incomplete and asymmetric information.(4)The game between the medical insurance and the patient.Under the DRG system,the benefits of hospitals and the benefits of patients’ insurance fraud will oppose each other,completely blocking the possibility of collusion between doctors and patients.3.Evolutionary game model of stakeholders under the DRG system.(1)The evolutionary game of medical resource consumption shows that under the DRG payment system,even if the initial proportion of over-medical treatment reaches 99%,the medical saving strategy can cover more than 95% of the population after only 6 simulation cycles.(2)The evolutionary game of medical service ability shows that under the DRG payment system,even if the initial proportion of hospitals choosing to improve medical service ability is 1%,the strategy of improving medical service ability can cover more than 95% of the population after only 6 simulation cycles.(3)The evolutionary game model of graded diagnosis and treatment shows that under the reform of DRG payment,all hospital groups quickly choose to transfer out patients.4.Empirical study on stakeholder game after DRG payment reform(1)From the perspective of the consumption of medical resources in a city,after the reform,the consumption of medical resources at the municipal level decreased( < 0.05),the medical efficiency was improved( < 0.05),the medical service capacity was optimized( < 0.05),and the implementation of two-way referral was promoted.(2)According to the analysis of typical DRG groups,after the reform,the consumption of medical resources has been significantly reduced and the medical efficiency has been improved in five DRG groups( < 0.05),while the five disease groups have up-coding( < 0.05),and the groups which implement the point method have the behavior trend of increasing points.(3)According to the situation of six hospitals,the secondary and tertiary hospitals can reduce the consumption of medical resources and improve the efficiency of diagnosis and treatment.The goals of tertiary hospitals are more consistent,which are improving the difficulty of diagnosis and treatment and the coverage of patients( < 0.05).There are differences in the goals of secondary hospitals.Some try to improve the difficulty of diagnosis and treatment and the scope of disease groups( < 0.05),while others expand the treatment of mild disease groups and increase the number of diagnosis and treatment( <0.05).The DRG group of typical hospitals suffered serious losses,which indicated that medical institutions could not adapt to the precise control of DRG payment reform for the time being.The research discussion supplemented the data analysis.(4)The empirical data and investigation are consistent with the conclusions of game model and evolutionary game model,which proves the correctness and practicability of the game model and evolutionary game model constructed in this study.[Conclusions]The results show that under the DRG system,the demands and behaviors of hospitals,medical insurance and patients are quite different from those of the past,and hospitals will focus on saving medical care and continuously improving medical ability.It will be more active to carry out graded diagnosis and treatment,and hospitals of different grades will develop differently.The insurer will lead the behavior of hospitals by adjusting DRG payment standards and setting DRG disease group rules,to completely reverse the passive payment status.The supervision of medical insurance will focus on the negative reduction of medical treatment,up-coding and the behavior of increasing points.DRG system has completely changed the relationship among hospitals,medical insurance and patients.DRG system has changed hospitals from pursuing the maximization of income to pursuing the minimization of cost,changed patients from worrying about over-treatment to worrying about insufficient medical services,changed medical insurance from passive payment to strategic purchase,and changed medical institutions from passive cooperation to active cooperation.Many factors can influence the outcome of the game.Reducing the proportion of drug consumables in total expenses,improving the proportion of hospital performance distribution,reducing the proportion of patients paying,and squeezing out the rebate profits in drug circulation can promote doctors to carry out reduced medical care;Reducing technical costs will promote doctors to improve their medical service capabilities;Reducing the cost of graded diagnosis and treatment will promote doctors to carry out graded diagnosis and treatment.Hospitals can gain more profit proportion by delaying time or increasing the number of negotiations in the bargaining negotiation of payment standard.Reducing the cost of medical insurance inspection and increasing the punishment degree of medical insurance departments can restrain the up-coding and negatively reduced treatment probability of hospitals.We should optimize relevant policies,change the key direction of hospital operation,guide the connotative development of hospitals,improve the negotiation mechanism and risk sharing mechanism between medical insurance and hospitals,promote the scientific supervision of medical insurance,build an integrated medical and health service system and promote the realization of value-based medical care.[Innovation and Deficiency]Innovation1.This research systematically constructs the research framework of stakeholders’ role orientation,demands and behaviors,mutual relationship and interest conflict,which is innovative.2.The game behaviors of hospitals,medical insurance and patients under the reform of DRG payment in China are comprehensively constructed,and the typical group behaviors are analyzed through the evolutionary game model,which is very innovative.3.The result of the game model is proved to be correct,which is innovative.Deficiency and prospects1.The questionnaire survey only involves the survey area,and the universality of the conclusion needs to be verified in further research.2.The time after the reform of DRG payment is short,and the long-term trend needs further study.