按病种分值付费下医疗机构冲量行为博弈分析&#x02014;&#x02014;基于利益相关者理论

郭宇超; 敖晔

doi:10.19546/j.issn.1674-3830.2025.5.004

中国医疗保险 ›› 2025, Vol. 0 ›› Issue (5) : 26-32. DOI: 10.19546/j.issn.1674-3830.2025.5.004

观察思考

按病种分值付费下医疗机构冲量行为博弈分析——基于利益相关者理论

郭宇超, 敖晔

作者信息 +

Game Analysis of the Excessive Expansion of Hospital Service Volume of Medical Institutions Under the DIP Payment Method——Based on the Stakeholder Theory

Author information +

文章历史 +

摘要

目的: 探讨DIP改革下医疗机构冲量行为产生的原因及风险隐患,为优化医保支付制度改革提供参考。方法: 基于利益相关者理论,构建医保DIP下医、保、患三方博弈模型,通过均衡解计算揭示不同约束条件下各主体的策略选择和行为冲突。结果: 医疗机构能够显著影响患者的就医选择;DIP支付下医疗机构有采取冲量策略的动机和意愿;医保机构有力监管可以降低医疗机构不合理冲量行为发生概率。结论: 通过建立信息披露机制、落实医联体与分级诊疗制度、完善医保监管机制来形成三方博弈的良性互动,实现医保基金的持续健康运行。

Abstract

Objective: The paper explores the causes and potential risks of excessive expansion of hospital service volume under the DIP reform, to provide references for optimizing the medical insurance payment system reform. Methods: Based on the stakeholder theory, a game model among medical institutions, medical insurance institutions, and patients under the DIP payment method was constructed. The equilibrium solutions were calculated to reveal the strategy choices and behavioral conflicts of each subject under different constraints. Results: Medical institutions can significantly influence patients' medical choices. medical institutions have the motivation and willingness to adopt excessive expansion of service volume strategies under the DIP payment method, and strict supervision by medical insurance institutions can reduce the probability of unreasonable excessive expansion of service volume. Conclusion: By establishing an information disclosure mechanism, implementing the medical alliance and hierarchical medical treatment system, and improving the medical insurance supervision mechanism, a positive interaction among the three parties in the game can be formed to ensure the sustainable and healthy operation of medical insurance funds.

导出引用

郭宇超, 敖晔. 按病种分值付费下医疗机构冲量行为博弈分析——基于利益相关者理论[J]. 中国医疗保险. 2025, 0(5): 26-32 https://doi.org/10.19546/j.issn.1674-3830.2025.5.004

Game Analysis of the Excessive Expansion of Hospital Service Volume of Medical Institutions Under the DIP Payment Method——Based on the Stakeholder Theory[J]. China Health Insurance. 2025, 0(5): 26-32 https://doi.org/10.19546/j.issn.1674-3830.2025.5.004

中图分类号： F840.684 C913.7

参考文献

[1] 应亚珍.DIP与DRG:相同与差异[J].中国医疗保险,2021(01):39-42.
[2] 廖藏宜.DRG/DIP付费的医疗服务冲量行为思辨[J].中国人力资源社会保障,2022(04):57.
[3] 张映钰,乐煦,曾茜.广州市基于大数据的病种分值付费实施路径与成效[J].中国医疗保险,2020(09):47-51.
[4] 傅卫,江芹,于丽华,等.DRG与DIP比较及对医疗机构的影响分析[J].中国卫生经济,2020,39(12):13-16.
[5] 李秋莎,杨春晓,赵兹旋,等.我国按病种分值付费(DIP)政策研究——基于国家、省、市三级的比较分析[J].中国卫生政策研究,2022,15(07):8-15.
[6] 芦丰,宋静,孙晓阳,等.淮安市按病种分值付费的实证研究[J].南京医科大学学报(社会科学版),2014,14(04):280-283.
[7] TASSOS P.The relevance of Nash equilibrium to paychiatric disorders[J].Theoretical medicine & bioethics, 2011 (32): 245-258.
[8] CLARKSON M E.A stakeholder framework for analyzing and evaluating corporate social performance[J].Academy of management review, 1995, 20(1): 92-117.
[9] 赵炜,梁宝方,周燕,等.病种点数付费方式改革对医院运行影响的分析[J].中国医院管理,2022,42(07):21-24.
[10] 张博,刘涛,龚福玲.总额控制下的按病种分值付费评价——基于银川市的实践[J].中国医疗保险,2016(07):35-38.
[11] 黄茜.长沙市基本医疗保险支付方式改革研究[D].长沙:湖南大学,2019.
[12] 李乐乐,唐馨怡.政策扩散理论视角下我国DRG政策演变及扩散机制研究——基于2009—2022年DRG政策的量化文本分析[J].社会保障研究,2023(02):62-74.
[13] 蔡滨,徐敏薇,张莹,等.博弈论视角下公立医院回归公益性改革研究[J].医学与哲学(A),2013,34(02):62-64.
[14] JJRGES H, KKBERLEIN-NEU J.First do no harm-then do not cheat: DRG upcoding in German neonatology[J].CESifo working paper series, 2013.
[15] 杨玉婷,乔丽名,王筱慧,等.上海市三级综合医院总额预付制相关指标分析[J].解放军医院管理杂志,2013,20(11):1026-1028.
[16] 林坤河,刘宵,黄雨萌,等.区域点数法总额预算下医疗机构“冲点”行为分析——以DIP支付方式为例[J].中国卫生政策研究,2022,15(05):40-46.
[17] 韦薇.广东省基本医疗保险按病种分值付费政策研究[D].广州:暨南大学,2020.
[18] 许速,邬惊雷,谢桦,等.基于大数据的病种分值付费研究:来自上海和广州经验[J].中华医院管理杂志,2021,37(03):186-190.
[19] 潘宏伟,邹俐爱,张远妮,等.区域比较视角下广东省专业公共卫生机构卫生资源配置公平性研究[J].中国卫生经济,2023,42(02):46-52.
[20] 刘春雨,龚超,薄云鹊,等.基于基尼系数和聚集度的天津市卫生资源配置公平性分析[J].中国医院,2022,26(09):32-35.