Evolutionary Game Analysis of Hospitals,Insurers,and Patients with Focus on Upcoding Behavior under the Diagnosis-Intervention Packet System
ZHOU Tianwei
ZHANG Fenge
ZHOU Zhenghan
NIU Ben
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.
Keywords：diagnosis-intervention packet(DIP)medical insurance payment reformup-coding behaviortripartite evolutionary gamesimulation analysis
Publication Date：2025-10-30
Online Publishing Date：2025-11-19(First online date of this platform, not the publication date of the document)
Pages：8( 35-42 )