Zhang Xinyu, Qian Mengcen, Yan Jiaqi, Wang Ruixin, Lyu Dawei, Ying Xiaohua, Tang Shenglan
School of Public Health, Fudan University, Shanghai, People's Republic of China.
Global Health Research Center, Duke Kunshan University, Kunshan, Jiangsu, People's Republic of China.
Risk Manag Healthc Policy. 2024 Dec 11;17:3113-3124. doi: 10.2147/RMHP.S488825. eCollection 2024.
China has developed and widely piloted a new case-based payment, ie, the "Diagnosis-Intervention Packet" (DIP) payment, which has a granular classification system. We evaluated the impact of DIP payment on the quality of care in a large pilot city in China and explored potential mechanisms of quality change.
The city started to implement DIP payment with a hospital-level cap on July 1, 2019. Using a 5% random sample of discharge records from July 2017 to June 2021, we employed a difference-in-differences approach to compare two mortality measures (in-hospital mortality, mortality of surgical patients), two readmission measures (all-cause readmission within 30 days, readmission with the same principal diagnosis within 30 days) and a patient safety measure (operation associated complications or adverse event) in 13 pilot hospitals and 27 non-pilot hospitals before and after DIP payment reform.
Of 122,637 discharge records included, 43,023 (35.1%) were from pilot hospitals. After DIP payment, the readmission rate within 30 days and readmission rate with the same principal diagnosis in pilot hospitals decreased significantly by 3.2 percentage points ( <0.001) and 1.8 percentage points ( <0.001), respectively. The in-hospital mortality rate, the mortality rate of surgical patients, and the rate of operation-associated complications or adverse events did not have significant changes. The decrease in quality measures was primarily driven by tertiary hospitals, was more obvious over time after the policy adoption, and was more pronounced in groups with higher intensity of care.
This study indicated that DIP payment with a cap in the study city was associated with improved quality of care among patients in pilot hospitals. The provider's behavior of increasing the intensity of care, especially for more severe patients, may partially contribute to the results.
中国已开发并广泛试点一种新的按病例付费方式，即“诊断-干预组合”（DIP）付费，其具有精细的分类系统。我们评估了DIP付费对中国一个大型试点城市医疗质量的影响，并探讨了质量变化的潜在机制。
该市于2019年7月1日开始实施DIP付费，并设定了医院层面的支付上限。利用2017年7月至2021年6月出院记录的5%随机样本，我们采用双重差分法比较了13家试点医院和27家非试点医院在DIP付费改革前后的两项死亡率指标（住院死亡率、手术患者死亡率）、两项再入院指标（30天内全因再入院、30天内同一主要诊断再入院）以及一项患者安全指标（手术相关并发症或不良事件）。
纳入的122,637份出院记录中，43,023份（35.1%）来自试点医院。实施DIP付费后，试点医院的30天内再入院率和同一主要诊断再入院率分别显著下降了3.2个百分点（<0.001）和1.8个百分点（<0.001）。住院死亡率、手术患者死亡率以及手术相关并发症或不良事件发生率没有显著变化。质量指标的下降主要由三级医院推动，在政策实施后随时间推移更为明显，且在护理强度较高的群体中更为显著。
本研究表明，研究城市实施的有支付上限的DIP付费与试点医院患者的医疗质量改善相关。医疗机构增加护理强度的行为，尤其是对病情较重患者，可能部分促成了这一结果。
