Economic and Technical Aspects of DRG-Based Tariff Setting for Medical Services

Introduction. The study analyzes the economic and technical aspects of setting tariffs for medical services based on Diagnosis-Related Groups (DRG) in Russia and foreign countries. The implementation of a DRGbased tariff system is associated with serious challenges in all countries of the world, including technical difficulties in case classification and tariff calculation, insufficient data infrastructure, and risks to the financial stability of healthcare providers, etc. Successful implementation requires careful planning, investment in data systems, and adaptation to each country's specific healthcare context. Objective. To assess the prospects for introducing DRG into medical practice and to classify the difficulties encountered in different countries when establishing DRG-based tariffs. Materials and methods. The main sources of information were regulatory legal acts in Russian and global healthcare, as well as relevant Russian and foreign scientific publications. The principal research methods employed were systematic review, critical review, comparative analysis, and content analysis. Results and conclusion. The analysis of DRG-based tariff setting for medical services reveals a number of challenges in its implementation, which can be divided into the following categories: problems of DRG classification and pricing, country-specific implementation issues, economic and financial problems, and concerns regarding quality and access to health care. International experience shows significant diversity in the characteristics and effectiveness of DRG systems. Countries have developed different approaches to address the limitations of basic DRG systems, including the use of additional payment mechanisms for high-tech, specialized, and low-volume medical care. These additional mechanisms include payments for individual services, additional charges for certain services, and alternative payment models for certain types of care. The implications of the challenges associated with DRG implementation go beyond technical issues of health financing and concern broader issues of health system design and operation. The data suggest that successful implementation of DRG requires significant investments in infrastructure, training, and ongoing system maintenance that may exceed initial expectations.

1. Avksentyeva M.V., Salakhutdinova S.K. Clinical and statistical groups (CSG) as a new method of payment for inpatient and inpatient-replacing care in the Russian Federation. Drug Bulletin. 2016;10(2):31-36. EDN: WZUBPB. (In Russ.)

2. Verulava T., Jorbenadze R. The Impact of DRG-Based Payment Reform on the Efficiency of Medical Care for Patients with Myocardial Infarction: Evidence from Georgia. Hospital Topics. 2024:1-6. https://doi.org/10.1080/00185868.2024.2433243

3. Barouni M., Ahmadian L., Mohsenbeigi H.S., Elham. Challenges and Adverse Outcomes of Implementing Reimbursement Mechanisms Based on the Diagnosis-Related Group Classification System: A systematic review. Sultan Qaboos University Medical Journal. 2020;20:e260-270. https://doi.org/10.18295/squmj.2020.20.03.004

4. Trippoli S., Messori A., Borselli M. et al. Relationship Between Price and Diagnosis-Related Group Tariff for Medical Devices Assessed by a Regional Health Technology Assessment Committee. Cureus. 2022;14(3):e23092. https://doi.org/10.7759/cureus.23092

5. Mehmood A., Ahmed Z., Ghailan K. et al. Implementation of Healthcare Financing Based on Diagnosis-related Group in Three WHO Regions; Western Pacific, South East Asia and Eastern Mediterranean: A Systematic Review. Journal of Health Management. 2023;25(3):404-413. https://doi.org/10.1177/09720634231168250

6. Zhang J., Liu J., Qu L., Duan Z. How does the dual policy-the C-DRG-based reimbursement system and subsidy policy for appropriate Traditional Chinese Medicine (TCM) techniques-influence physicians’ choice of disease treatment methods in TCM hospitals? Health Economics Review. 2025;15(1):48. https://doi.org/10.1186/s13561-025-00643-6

7. Zhao C., Wang C., Shen C., Wang Q. Diagnosis-related group (DRG)-based case-mix funding system, a promising alternative for fee for service payment in China. BioScience Trends. 2018;12(2):109-115. https://doi.org/10.5582/BST.2017.01289

8. Kotherová Z., Caithamlová M., Nemec J., Dolejšová K. The Use of Diagnosis-Related Group-Based Reimbursement in the Czech Hospital Care System. International Journal of Environmental Research and Public Health. 2021;18(10):5463. https://doi.org/10.3390/ijerph18105463

9. Agri F., Möller W., Deslarzes P. et al. Cost Analysis of Outpatient Colectomy in a Tertiary Center: A Projected Medico-Economic Evaluation. Health Services Insights. 2024;17:11786329241284400. https://doi.org/10.1177/11786329241284400

10. Lüthi H.J., Widmer P.K. DRG system design: A financial risk perspective. Operations Research for Health Care. 2017;13:28-36. https://doi.org/10.1016/j.orhc.2017.03.002

11. Xie X., Cui T., Ying X. et al. Development of a novel hospital payment system – Big data diagnosis & intervention Packet. Health Policy OPEN. 2022;3:100066. https://doi.org/10.1016/j.hpopen.2022.100066

12. LoPresti M., Igarashi A. Value-based reimbursement under the inpatient prospective payment system in Japan: a review of Japan’s diagnosis procedure combination/per-diem payment system. Journal of Medical Economics. 2024;27(1):1515-1529. https://doi.org/10.1080/13696998.2024.2427502

13. Ryan S.P., Plate J.F., Goltz D.E. et al. Should Medical Severity-Diagnosis Related Group Classification Be Utilized for Reimbursement? An Analysis of Elixhauser Comorbidities and Cost of Care. The Journal of Arthroplasty. 2019;34(7):1312-1316. https://doi.org/10.1016/j.arth.2019.02.045

14. Mihailovic N., Kocic S., Jakovljevic M. Review of Diagnosis-Related Group-Based Financing of Hospital Care. Health Services Research and Managerial Epidemiology. 2016;3:2333392816647892. https://doi.org/10.1177/2333392816647892

15. Zheleznyakova I.A., Volkova O.A., Rumyantseva E.I. et al. Methodology of forming a model of diagnosis-related groups for cases of medical care using surgery performed by laparoscopic access. Farmakoekonomika. Modern pharmacoeconomics and pharmacoepidemiology. 2024;17(2):137-151. https://doi.org/10.17749/2070-4909/farmakoekonomika.2024.241

16. Chang W.F., Yan X.Y., Ling H., Liu T., Luo A.J. A study of the types and manifestations of physicians’ unintended behaviors in the DRG payment system. Frontiers in Public Health. 2023;11:1141981. https://doi.org/10.3389/fpubh.2023.1141981

17. Quentin W., Stephani V., Berenson R.A. et al. How Denmark, England, Estonia, France, Germany, and the USA Pay for Variable, Specialized and Low Volume Care: A Cross-country Comparison of In-patient Payment Systems. International Journal of Health Policy and Management. 2022;11(8):1377-1388. https://doi.org/10.34172/ijhpm.2022.6536

18. Avksentyeva M.V., Petrovsky A.V., Zheleznyakova I.A. et al. Development of diagnosis-related groups for malignant neoplasms diagnostics and treatment in the Russian Federation. Medical Technologies. Assessment and Choice. 2021;43(3):12-20. https://doi.org/10.17116/medtech20214303112

19. Asadi F., Sabahi A., Ramezanghorbani N., Emami H. Challenges of implementing diagnostic-related groups and healthcare promotion in Iran: a strategic applied research. Health Science Reports. 2023;6(2):e1115. https://doi.org/10.1002/hsr2.1115

20. Batko K., Ślęzak A. The use of Big Data Analytics in healthcare. Journal of Big Data. 2022;9(1):3. https://doi.org/10.1186/s40537-021-00553-4

21. Gay S.E., Line K.W., Collar A., Reynaldo G. Inpatient Coding System and Opportunities for Documentation Optimization: An Interactive Session for Internal Medicine Residents. MedEdPORTAL. 2022;18:11219. https://doi.org/10.15766/mep_2374-8265.11219