Gansu Qingyang: DRG paid reform allows the masses to see a doctor more affordable

Recently, the reporter found that when visiting the major hospitals in Qingyang City, it was found that patients with medical insurance settlement windows were discharged and discharged from hospitalization and medical reimbursement. Uncle Zhang, who is processing the settlement of the medical insurance settlement window of the Municipal People's Hospital, told reporters that he was diagnosed with chronic diseases and needed hospitalization and medicine all year round. In the past two years, the medical insurance environment has been greatly improved. They are all reasonable, and the cost of reimbursement is also very high. I will never worry about the hospitalization and buying medicine anymore.

The problem of "difficulty in hospitalization" and "expensive medical treatment" can be effectively relieved. In recent years, Qingyang has continuously deepened the reform of DRG medical insurance payment methods and innovation in the supervision of medical insurance funds.

The reporter learned from the Municipal Medical Security Bureau that since Qingyang City has become a national pilot city of the DRG paid in medical insurance in 2019, the average hospitalization costs of various pilot medical institutions have decreased significantly, the quality of medical data management has been continuously improved, and the growth of unreasonable medical expenses has been controlled. The three parties of "medical, insurance, and affected" are win -win.

"Previously, paid by service projects was the most widely used basic medical insurance payment method in major hospitals. When patients were hospitalized, each inspection and prescription order of the doctor was a hospital's income." The Municipal Medical Security Bureau Relevant persons in charge told reporters that although this payment method is in line with the actual situation of my country's medical and health system in the past, its problems are also very obvious. As some hospitals provide more medical projects to obtain revenue, excessive medical behavior such as "big prescriptions" and "big inspection" has led to the rapid growth of medical expenses. The medical insurance fund spends more money.

The DRG paid system is to formulate payment standards for groups related to the diagnosis of various diseases and prepaid medical expenses. In DRG paid, each case will correspond to different diagnostic related groups according to different diagnosis, different treatment methods, and patient characteristics. On this basis, medical insurance no longer pays medical institutions in accordance with the actual expenses of the patient in the hospital (that is, according to the service items), but pays in accordance with the paid standards of the diagnostic relevant group entered by the case.

"This kind of payment method is more scientific than in the past according to the project service, and it is more efficient. The drugs, medical consumables and examinations used by patients have become the cost of diagnosis and treatment services, not the means of obtaining the income of the hospital." The person in charge said.

Qingyang Second People's Hospital was identified as a national DRG payment method reform pilot unit in 2019. In September 2021, the actual payment of DRG was launched. After entering the actual paid stage, the hospital has improved measures such as improving work mechanisms, strengthening information guarantee, improving the quality of the medical case, and optimizing data indicators. The DRG paid system has initially showed its effectiveness in the management efficiency and service quality of medical institutions.

As of April this year, there were 487 DRG diseases in Qingyang Second People's Hospital, with a coverage rate of 81%. There were 12,784 medical insurance compensation, and 11,193 cases were included in DRG settlement. A total of 58.979 million yuan in medical insurance funds, 47.82 million yuan of DRG payment cases, and 81.1%of the fund coverage. Patients' average hospital hospitalization costs were 6492 yuan, a year -on -year decrease of 18%, and a 6%decrease from the previous month.

"DRG paid is aimed at the settlement between medical insurance and hospitals. Patients may not feel obvious in the early stage, but for the hospital, it is a thorough reform." Yao Zhirui, Dean of the Second People's Hospital of the Municipal Second Municipal People's Hospital, said that at the DRG paid model in DRG paid model Below, the hospital's medical income is no longer a simple charge. In terms of management, the hospital must follow the principles of reasonable medication, reasonable treatment, reasonable examination, and reasonable charging. This requires the hospital to take the initiative to change, thereby reducing medical expenses, saving medical funds, and allowing patients to reduce the burden of medical care and achieve a win -win situation for patients, hospitals, and medical insurance.

It is understood that the reform of the DRG paid system is a complex system project, involving a wide range of policies, strong policy, and difficult technical. To this end, the city has established a leadership group of the DRG paid system reform of the medical insurance, and issued the "Implementation Plan for the Pilot Work of the DRG Paid State Payment of Qingyang City". The specific tasks of the project will be carried out in depth the reform of the DRG paid system reform. With the help of experts in DRG's national pilot technology guidance group, integrate local business backbones, set up a team of experts, and use responsible guarantee mechanisms, industry main promotion, and hospital active collaborative mechanisms to effectively promote the extensive development of DRG paid work.

At the same time, the Qingyang Medical Security Bureau and the Municipal Health and Health Commission invited experts who engaged in medical insurance and medical insurance management inside and outside the province to carry out various forms of medical insurance DRG paid business knowledge, settlement methods and business systems for local hospitals and medical insurance related personnel. Operation training has laid a solid foundation for DRG paid to fully develop applications in medical insurance.

From September 1, 2021, 12 medical institutions in Qingyang City have entered the actual payment, achieving the normal operation of the monthly settlement, completed the annual liquidation, and the total liquidation payment was 224 million yuan. In 2022, the number of actual paid institutions expanded to 13, and the proportion of medical insurance funds reached 62.8%. Medical institutions reached 92%according to DRG paid disease. The existing cases of medical institutions covered the DRG disease group 94.5%. According to the "Implementation Plan for the DRG Three -Year Action Plan of Qingyang City", by the end of this year or early next year, there will be 26 medical institutions in our city. above. This also means that Qingyang City's era of overpayment systems that caused over -payment in accordance with the project paid by the project, the extensive development of the hospital, the passive purchase of medical insurance, and the patient's treatment were over. Far -affecting medical insurance ecological changes.

DRG paid reform has improved the city's medical insurance data standardization level and the level of data decision management management level of medical insurance departments. It has formed normalized monitoring and supervision of medical insurance funds, and has achieved obvious results in promoting the improvement of fund use efficiency and improving governance capacity.

In 2021, Qingyang Urban and Rural Residents' Medical Insurance Fund was 136 million yuan in the current period. The total control of the medical insurance department's medical institution also shifted to the control of the medical group. The awareness of actively controlling fees for various medical institutions increased significantly. The average hospitalization fee of 13 fixed -point medical institutions dropped from September to December 2021 to 5748.8 yuan from 5805.55 yuan to 5748.8 yuan, with an average. The decrease of 56.75 yuan, some medical institutions decreased by more than 500 yuan, and the average hospitalization period, the proportion of medical institutions, and the proportion of consumables all decreased significantly.

According to the relevant person in charge of the Qingyang Medical Security Bureau, DRG paid reform has obvious guidance on the development concept of medical institutions and medical management models, the quality of medical services has gradually improved, the burden of seeing a doctor is further alleviated, the effectiveness of medical insurance funds and the medical treatment patients to seek medical treatment Experience and sense of gain have been significantly improved. In accordance with the requirements of the "Three -Year Action Plan for the Reform of DRG Payment Methods", our city will continue to optimize and improve the DRG payment plan, expand the scope of DRG payment implementation, improve and improve the diversified diversification of DRG payments, and supplement by bed day and head payment. Composite payment methods, comprehensively improve the quality of operation of DRG payment methods, and promote the reform of the city's medical insurance payment methods in depth.

(Author: Huang Fei)

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