DRG下低码高编的制度环境、逻辑动机及形成机制:一个“压力—矛盾”转移视角  

The System Circumstances, Motivation Logic and Mechanisms of DRG Upcoding in China: A "Stress-Contradiction" Transition Perspective

作　　者：李浩 陶红兵[1] LI Hao;TAO Hongbing

机构地区：[1]华中科技大学同济医学院医药卫生管理学院,湖北武汉430030

出　　处：《社会保障研究》2022年第6期64-77,共14页Social Security Studies

基　　金：国家自然科学基金面上项目“人头总额预付下紧密医疗联合体整合服务供方行为的激励机制研究”(7207041637);中央高校基本科研业务费资助(编号:YCJJ202204018)的阶段性研究成果。

摘　　要：低码高编是引入DRG付费的系统性难题。基于委托代理理论和组织内部“共谋现象”的制度逻辑,探讨低码高编行为形成的政策环境和支付制度基础,剖析其逻辑动机,并从“结构—过程—结果”维度构建低码高编形成机制的分析框架,进一步从“压力—矛盾”转移视角解释低码高编有别于其他DRG负向行为的关键要素,研究发现:DRG制度基础与原理导致低码高编行为监管的成本更高、专业性更强;低码高编所要达成的目标是多重交织的,该行为能同时满足医院经济与绩效目标;以低码高编形式的逐利行为与医生职业精神可以形成一套自洽的逻辑,进而避免角色认知偏差;低码高编行为在组织内部有其稳定的结构性与机制性基础,医生与组织目标能够通过“压力—矛盾”转移路径保持高度统一。基于此,可分别从医疗机构、医保机构层面对DRG进行改革。Upcoding has been a systematic problem since the introduction of the DRG system.Based on the principal-agent theory and the logic of the "conspiracy phenomenon",this article discusses the policy environment and the basis of payment system of DRG upcoding, analyzes the motivation of upcoding behaviors, and constructs an analytical framework of the formation mechanism of upcoding from the dimension of "Structure-Process-Outcome".Furthermore, from the perspective of a "Stress-Contradiction" transition, this article explains the key elements of upcoding behavior that is different from other DRG negative behaviors.Findings from this research indicate as follow: The foundation and principle of DRG system lead to higher cost and more professional regulation of upcoding behaviors;The goals of upcoding are multiple intertwined and this behavior can meet the economic and performance goals of the hospital at the same time;The profit-seeking behavior in the form of upcoding can generate a set of self-consistent logic with the professional spirit of doctors, so as to avoid the cognitive deviation of roles;The behavior of upcoding has its stable structural and institutional basis in the organization, and doctors and organizational goals can maintain a high degree of unity through the "pressure-contradiction" transition path.Based on this, suggestions on DRG reform are put forward from the level of medical institutions and medical insurance institutions.

关 键 词：DRG 低码高编 委托代理理论 道德风险 共谋行为 

分 类 号：R197.1[医药卫生—卫生事业管理] F842.684[医药卫生—公共卫生与预防医学]