Research on the Influencing Factors of Hospital Medical Insurance Settlement Rate Under the DRG Payment Method Reform——An Empirical Analysis from the Perspective of Hospitals
Objective:From the perspective of hospitals,this paper analyzes the factors affecting the settlement rate of medical insurance under the DRG payment method reform and provides an empirical basis for improving the service quality and efficiency of hospitals.Methods:Taking the 12 hospitals in City S that have implemented the DRG payment method reform as research samples,the medical insurance settlement list data of DRG payment cases from 2022 were collected through the medical insurance settlement system,including patients'personal information,disease diagnosis and treatment information,grouping and hospitalization cost information.A patient-hospital panel dataset was constructed,which takes the medical insurance settlement rate of a single patient group in a hospital as the dependent variable,selects independent variables from the three dimensions of cost characteristics,hospital characteristics and case type characteristics,and takes patient age and the adjustment coefficient of the patient group as the control variables,distinguishes the two types of medical insurance,i.e.residents and employees,and analyzes the influencing factors of the medical insurance settlement rate by the fixed effect model between patient groups.Results:In the cost characteristic dimension,the average inpatient cost(βresidents=-51.70,P<0.01;βemployee=-39.18,P<0.01),the proportion of drug costs(βresidents=-0.77,P<0.01;βemployee=-0.43,P<0.01)was negatively correlated with the settlement rate,and the proportion of expenses within the policy scope(βresidents=1.12,P<0.01;βemployee=0.71,P<0.01)was positively correlated with settlement rate.In the characteristic dimension of hospital,the tertiary hospital was higher than the secondary hospital(βresidents=7.79,P<0.01;βemployee=9.33,P<0.01),private hospitals was higher than public hospitals(βresidents=22.16,P<0.01;βemployee=13.83,P<0.01)the settlement rate was higher.In the characteristic dimension of case type,the proportion of extremely low-cost cases(βresidents=0.09,P<0.10;βemployee=0.10,P<0.05),the proportion of patients hospitalized for more than 60 days(βresidents=1.30,P<0.01;βemployee=0.88,P<0.01)were positively correlated with the settlement rate,while the proportion of extremely high-cost cases(βresidents=-0.21,P<0.10;βemployee=-0.29,P<0.01)was negatively correlated with settlement rate.Conclusion:Reducing the medical expenses and optimizing the cost structure,such as increasing the proportion of expenses within the policy scope and reducing the proportion of drug expenses,are conducive to increasing the settlement rate.Secondary hospitals and public hospitals should improve medical efficiency and internal management efficiency of hospitals to improve DRG settlement rate.In addition,the medical insurance departments need to further optimize the settlement rules of different types of cases,and guide the diagnosis and treatment behavior of hospitals to be more reasonable and efficient.
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