DRG制度对医保监督医院医疗资源消耗行为的博弈分析

Game Analysis of DRG System on the Consumption Behavior of Medical Resources in Hospitals under Medical Insurance Supervision

目的用博弈论分析不同支付制度下医保对医院医疗资源消耗行为的监督。方法分别构建按项目付费下和按疾病诊断相关分组(DRG)付费下医保对医院医疗资源消耗行为的监督博弈模型并求解。结果在按项目付费下,医方会概率性选择过度医疗和正常诊疗。在DRG支付制度下,医方会概率性选择正面节约医疗和负面节约医疗。医方负面节约医疗的概率随着医保部门检查成本的增大而增大,随着医保罚款的增大而减小。医保开展检查的概率与医院开展正面节约医疗时技术优化的成本成正比,与医保部门的罚款成反比。结论DRG支付制度可纠正按项目付费下医疗机构的过度诊疗行为,促进医院节约医疗,医保的监督重点是防止医方的负面节约医疗。通过降低医保检查成本,提高医保处罚金额,可降低医方的违规概率。

Objective:To analyze the supervision of medical resource consumption by medical insurance under different payment systems with game theory.Method:The supervision game models of medical resource consumption behavior of medical insurance under project payment and DRG payment were constructed and solved respectively.Result:Under project based payment,the medical provider will have a probability of choosing between excessive medical treatment,and normal diagnosis and treatment.Under the DRG payment system,healthcare providers are likely to choose between positive and negative savings in healthcare.The probability of negative medical savings by the medical side increases with the increase of inspection costs by the medical insurance department,and decreases with the increase of medical insurance fines.The probability of medical insurance conducting inspections is directly proportional to the cost of technical optimization when hospitals carry out positive medical savings,and inversely proportional to the fines imposed by the medical insurance department.Conclusion:The DRG payment system can correct the excessive diagnosis and treatment behavior of medical institutions under project payment,and promote hospitals to save medical care.The focus of medical insurance supervision is to prevent negative medical savings from the medical side.By reducing the cost of medical insurance inspections and increasing the amount of medical insurance penalties,the probability of medical violations can be reduced.