基于博弈理论的DRG付费与紧密型县域医共体总额付费政策协同研究  

Connection between DRG payment and total payment in compact county-level medical communities from the perspective of game theory

作　　者：孙诗洁 李绍华[1,2] 汤质如[1,2] 赵林海[1] 卢曼曼[1,2] SUN Shiji;LI Shaohua;TANG Zhiru;ZHAO Linhai;LU Manman(School of Health Management,Anhui Medical University,Hefei,Anhui 230032,China;不详)

机构地区：[1]安徽医科大学卫生管理学院,安徽合肥230032 [2]安徽医科大学安徽省医疗保障研究院

出　　处：《中国农村卫生事业管理》2025年第2期109-114,共6页Chinese Rural Health Service Administration

基　　金：安徽省高等学校省级自然科学研究计划项目(2022AH050711);安徽省医保局委托研究课题(YB2022W03)。

摘　　要：目的探究DRG付费与紧密型县域医共体总额付费政策不同协同模式对于医共体医疗行为的影响,为优化医保支付机制提供理论依据。方法构建医保部门与医共体之间的行为选择策略动态博弈模型,以按人头总额付费与DRG付费的不同协同模式(“内部付费”和“外部付费”)及医共体的医疗行为(“规范诊疗”与“不规范诊疗”)作为博弈策略,构建博弈矩阵,并分析各博弈行为的影响因素。结果“内部付费”模式下医共体年度DRG预算与“外部付费”模式下医共体DRG年度清算总额之间差额越小,对违规行为的追回资金和处罚力度越大时,医共体越倾向于“规范诊疗”。此外,医共体不规范诊疗引起的病人外流导致医疗成本的减少与医共体规范诊疗时应获得的收入之间的差额越大,医保部门对医共体“不规范诊疗”追回的违规资金和处罚力度越小,医保部门则更可能选择“外部付费”方式。结论通过实施“内部付费”的双预算管理模式可提高医共体“规范诊疗”概率,加强医共体自身监管动力,降低医保部门监管成本,提升工作效率。Objective To explore the impact of different synergistic modes of DRG payment and the total payment policies of the compact county-level medical communities on the medical behaviors of medical communities,so as to provide a theoretical basis for optimizing the medical insurance payment mechanism.Methods A dynamic game model of behavior selection strategy between the medical insurance department and medical communities was constructed,and the different collaborative modes of capitation payment and DRG payment(“internal payment”and“external payment”)and the medical behaviors of medical communities(“standardized diagnosis and treatment”and“non-standardized diagnosis and treatment”)were used as the game strategy to construct game matrix,and the influencing factors of each game behavior were analyzed.Results The smaller the difference between the annual DRG budget of medical communities under the“internal payment”model and the annual total DRG settlement amount of medical communities under the“external payment”model,the greater the recovery of funds and penalties for violations,the more inclined medical communities were to adopt“standardized diagnosis and treatment”.On the other hand,the greater the difference between the medical costs reduced by patient outflow due to non-standardized diagnosis and treatment and the income to be earned due to standardized diagnosis and treatment,the smaller the recovery of funds and penalties for violations by the medical insurance department,the more likely they were to choose the“external payment”model.Conclusions The implementation of the double budget management model of“internal payment”can improve the probability of“standardized diagnosis and treatment”in medical communities,which can strengthen the regulatory motivation of medical communities,reduce the supervision cost of the medical insurance department,and improve work efficiency.

关 键 词：紧密型县域医共体 博弈论 支付方式改革 疾病诊断相关分组 

分 类 号：R19[医药卫生—卫生事业管理]