Analysis of the Impact Mechanism of DRG pricing and payment reform Integration Reform——Taking Quanzhou and Sanming in Fujian as examples

Corresponding author: XIANG Li, xllyf@126.com

DOI: 10.12201/bmr.202311.00001

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  Abstract: The integration reform of DRG pricing and payment is still a key aspect of deepening the reform of medical insurance payment methods, but it is still in the stage of local pilot exploration, and its impact mechanism needs to be explored. This study is based on game theory, starting from three stakeholders: patients, medical insurance departments, and medical institutions, and using the reform models of Quanzhou and Sanming in Fujian Province as examples to analyze the operating modes. Research has found that the difference in fee standards for patient testing is an important factor affecting the results of the reform, and the one size fits all fee standards for patient testing can easily exacerbate the risk of self-payment by patients. Under reasonable budget control and payment standards, it helps to alleviate the burden of medical insurance fund expenditure。Reform can motivate medical institutions to save medical costs, but it is still necessary to prevent unreasonable medical behavior. It is recommended that the medical insurance department set a self-payment ratio based on the actual medical expenses incurred, with the DRG payment standard as the upper limit. Reasonably formulate the annual budget, coordinate the dynamic adjustment mechanism of medical service prices and centralized procurement of drug consumables, and promote the reasonable determination of payment standards. Strengthen regulatory mechanisms to prevent medicare upcoding.

  Key words: DRG；pricing and payment reform; Medical insurance payment method; Impact mechanism; Fujian; 

  Submit time: 17 November 2023

  Copyright: The copyright holder for this preprint is the author/funder, who has granted biomedRxiv a license to display the preprint in perpetuity.
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