区域点数法总额预算和按病种分值付费对医生医疗服务行为影响的经济学实验研究

An economics experiment study on the impact of diagnosis-intervention packet under the regional global budget on physicians’behaviors

目的:分析区域点数法总额预算和按病种分值付费(DIP)的支付方式对医生医疗服务行为的影响,为医院医保质量管理提供依据。方法:运用经济学实验,将招募的48名医学生随机分到4人一组的实验小组中,测试其在DIP付费下为不同疾病严重程度的患者选择提供的医疗服务数量。实验小组中的受试者通过医疗服务点数来竞争固定的总支付额,每组分别进行10轮实验。将本实验中DIP付费结果与按项目付费(FFS)和按疾病诊断相关分组(DRG)付费两种支付方式进行比较。结果:DIP付费下,随着实验轮次的增加,受试者平均医疗服务点数呈上升趋势,点数价值及净收益呈下降趋势。DIP付费下医生对轻症和中症患者存在一定程度的供给过度,但相比FFS过度服务的情况有所缓解;对于重症患者,无论是服务量还是患者健康效益方面,DIP付费都优于DRG付费。结论:DIP付费可能存在促进医保和医疗协同发展的优势,也可能存在过度服务及资源浪费的问题;DIP付费下医疗机构应从医疗机构医保管理、医疗服务管理以及受益和满意度等方面加强医保质量监管。

Objective:This study was designed to analyze the impact of diagnosis-intervention packet(DIP)payment based on the regional global budget on physicians’supply of medical services and provide a reference for managing the medical insurance quality of medical institutions.Methods:This study used an economics experiment,and 48 recruited medical students were randomly assigned to experimental groups of 4 to test the quantities of medical services they chose to provide for patients with different disease severity under DIP.Four subjects in each experimental group were assigned fixed total payments based on the points they earned through providing medical services.Each group was given 10 rounds of the experiment.Besides,this study compared physicians’behaviors under three payment methods,including DIP,fee for service(FFS),and diagnosis-related groups(DRG)in two experiments.Results:With the increase of the experiment rounds,the average medical service points of the subjects showed an upward trend,while the average value of points and the average net income showed a trend of decrease,respectively.The DIP payment incentivized physicians to provide more than the optimal quantity for mild and moderate patients,but there was less over-provision under DIP than under FFS.For severe patients,the DIP payment was superior to the DRG payment both in terms of quantity and patient health benefit.Conclusion:The DIP payment may have the advantage of promoting the coordinated development of medical insurance and medical services,but it may also have the problem of over-provision and resource waste.Medical institutions should strengthen medical insurance quality supervision under the DIP payment in terms of medical insurance management,medical service management,patient benefit and satisfaction.