工业工程2025，Vol.28Issue(5)：35-42,8.DOI:10.3969/j.issn.1007-7375.250069
DIP制度下针对医方高编码行为的医保患三方演化博弈分析
Evolutionary Game Analysis of Hospitals,Insurers,and Patients with Focus on Upcoding Behavior under the Diagnosis-Intervention Packet System
摘要
Abstract
Against the backdrop of the diagnosis-intervention packet(DIP)payment reform,this paper explores the upcoding behavior of hospitals,and provides insights for the implementation of medical insurance payment reform.An extensible asymmetric dynamic evolutionary game model is developed and simulation analysis is conducted based on real-world cases to reveal the key factors of medical violations.Results show that increasing penalty intensity and expanding reputational damage are conducive to curbing the upcoding behavior of hospitals.Lowering regulatory cost while increasing penalty intensity and regulatory returns,encourages insurers to exercise strict supervision.Reducing complaint cost and improving complaint benefits provide protection for patient complaints.The probability of patient complaints increases with the probability of hospital upcoding,while hospital upcoding decreases as insurers intensify supervision,and insurer supervision strengthens with the decrease of patient complaints.The ultimate driving force of upcoding comes from extra benefits,which is independent of whether insurers or patients are in a supervisory state.Under the current management regulations of DIP in China,the internal motivation for hospital upcoding is insufficient,and there is no stable equilibrium point in reality.关键词
按病种分值付费/医保支付方式改革/高编码/三方演化博弈/仿真分析Key words
diagnosis-intervention packet(DIP)/medical insurance payment reform/up-coding behavior/tripartite evolutionary game/simulation analysis分类
预防医学引用本文复制引用
周天薇,张凤娥,周郑涵,牛奔..DIP制度下针对医方高编码行为的医保患三方演化博弈分析[J].工业工程,2025,28(5):35-42,8.基金项目
国家自然科学基金资助项目(72334004) （72334004）
广东省哲学社会科学十四五规划项目(GD22CGL35) （GD22CGL35）
广东省普通高校重点领域专项(2022ZDZX2054) （2022ZDZX2054）
