A Study On Social Health Insurance Diagnosis Related Groups Payment In China

Since the end of the 20th century,the dramatic rise in the medical and health care costs has become the common challenges faced by countries around the world,and this challenge will persist in quite long period in the future.Controlling the rapid growth of medical expenses and improving the effective use of medical and health resources has become the focus of research in the field of health care in the world.International medical security reform practice has proved that only relying on the demanders' cost sharing is difficult to effectively control the steady growth of medical expenses,and the health insurance provider payment methods,because of their functions in the effective utilization of medical resources,the allocation of resources and cost control,have attracted much attention.In the cases of the rest of the world and our country,hospital-care costs account for a significant share of the total health care expenditures in a country.In order to improve the efficiency of hospital medical service,control the hospital medical service fees,DRGs payment method has been widely used and achieved good results.On the current stage,the health care,social health insurance management departments and scientific research institutions are doing the research for the full implementation of DRGs payment methodThis paper mainly completes the research work in the following aspects:?To defined the theory and practical significance of implementing the DRGs payment method.?To Analyse the concept and the background of existing DRGs payment method,grouping method,the evolution of DRGs versions,the pricing method of DRGs payment,the effects of DRGs payment implementation.?To review and analyse the practices of DRGs payment in the typical countries of foreign countries(the United States and Germany),and to summarize six experiences of implementing DRGs payment methods.? Based on DRGs payment experiences of typical foreign countries,using incomplete information static game and dynamic game analysis method,the impact of DRGs payment methods implementation are analysed.?Based on foreign experiences,game analysis and empirical analysis,this paper puts forward the countermeasures and suggestions for implementing the DRGs payment in China.Through the above research,this paper draws the following main conclusions:First,the general pricing method for DRGs is a method of delaying average cost pricing based on annual dynamic adjustment.In general,DRGs pricing follows seven steps:First,data collection and analysis.Step 2,to build the DRGs group.Step 3,the clinical cases are grouped into the DRGs groups.Step 4,to calculate the DRGs cost weight.Step five:to calculate the base rate.Step 6,to calculate the payment for a DRG group.Step 7,adjustment factors.To adjust the final DRGs payments according to the needs of the health care department.In addition,countries and regions adjust the payment based on factors such as economic development,in order to ensure the fairness and efficiency of DRGs payment.Second,based on the typical foreign countries(the United States and Germany)experiences,our country should draw lessons from the following six aspects in the implementation of DRGs payment:?To emphasize the responsibility of the government in the medical insurance;?Reasonable setting of the relevant indicators for the DRGs payment;?To adjust the DRGs cost weight and base rate dynamically to ensure the fairness of DRGs payment;?To focus on obtaining and organizing the high-quality first page data of medical record and cost data;?To pay attention to the training of professional DRGs coding talents;?To pay attention to the examination of medical expenses.Third,the conclusions of the dynamic game of DRGs payment method are as follows:? Under the Fee for Service method,medical institutions can maximize their utility by providing higher quality than normal diagnosis and treatment,which also means that they tend to adopt the strategy of "excessive diagnosis and treatment",which leads to the waste of medical resources and other problems.?Under the DRGs payment method,hospitals are more inclined to save costs,and this payment method solves the problem of medical resource waste caused by Fee for Service method to some extent.However,from another point of view,there will also be the "diagnosis and treatment insufficient" because of cost control,and then affect the quality of diagnosis and treatment.? In the implementation of DRGs payment mode,we should pay attention to its existing problems while giving full play to the advantages of the payment mode,improve the relevant supporting systems,such as public hospital cost accounting system,medical quality supervision mechanism,etc.Fourth,the empirical analysis of DRGs payment method concluded that for radical lung cancer and community-acquired pneumonia,the total cost of treatment in the intervention group showed a decreasing trend,and the decrease degree of the total cost of treatment for internal disease was lower than that for surgical disease.The results of the empirical analysis show that the implementation of DRGs has a certain degree of control on the total medical costs of the two diseases.By adding important control variables,the robustness test of the analysis results of the differential model is carried out.The results are consistent with the original conclusion,which shows that the analysis results of the differential model are robust.Fifth,Based on the results of game analysis and the typical foreign countries'experiences,this paper argues that:government supervision should follow the principle of incentive compatibility,the policies should not only achieve the regulatory goal,but also consider the benefits and long-term development of the regulatory object,so as to fundamentally solve the problems that exist in the social health insurance in our country,so as to realize the ultimate goal of universal health coverage in China.The specific measures and suggestions are as follows:?Define the main responsibility of the government in the reform of health care reform;? To establish the quality control system of the medical record first page;?To establish a standardized public hospital cost accounting system;?To improve a medical quality supervision mechanism;? To improve the compensation mechanism for public hospitals.