Risk Governance of Payment Exceptions Under China's DRG/DIP Reform: A Structured Policy-Text Analysis of Special Case...

Under China's diagnosis-related group/diagnosis-intervention packet (DRG/DIP) payment reform, special case negotiation addresses clinically atypical cases that do not fit standard case-based payment rules but may also create payment misfit, fund leakage, discretionary review, delay, and accountability risks. This study examined whether policies translate these risks into enforceable governance rules.

A structured policy-text analysis examined 20 documents within one provincial policy chain: one national document, one provincial document, and 18 municipal documents covering all prefecture-level jurisdictions in the province. The municipal documents constituted a complete census within the selected province rather than a nationwide sample of Chinese provinces. A 30-node, five-domain framework used a 0-1-2 scale. Two coders worked independently, and final analyses used adjudicated scores.

Inter-coder agreement was 95.0% (Cohen's kappa, 0.899). Domain scores were highest for payment misfit risk control (0.797), discretion and capture risk control (0.786), and administrative burden and delay risk control (0.767), and lowest for accountability and equity risk control (0.512). Applicable scope, volume or proportion cap, and submission or review cycle were universally enforceable. The weakest or least consistently enforceable nodes concerned cross-area or fund responsibility, appeal or reconsideration, processing time limits, and special diseases, infectious diseases, or rare diseases. Vertical attenuation was highest for cross-area or fund responsibility (72.2%) and for processing time limits and special diseases, infectious diseases, or rare diseases (both 55.6%). Municipal documents formed balanced, boundary-heavy, procedure-heavy, and low-formalisation configurations.

Special case negotiation requires a minimum risk-governance package-a minimum set of enforceable procedural safeguards-combining eligibility boundaries, traceable review, appeal routes, and clear accountability. The analysis evaluates formal policy design rather than implementation outcomes. Functionally, the framework may inform risk audits of outlier, high-cost, new-technology, and other payment-exception mechanisms in DRG or other case-based payment systems internationally.