Patients have dropped by 4.4%monthly at their own expense. How to break the reform of medical insurance payment?

The 21st Century Business Herald reporter You Fang Ming Shanwei reported that medical insurance payment is a key mechanism for ensuring that the masses get high -quality medical services and improve the efficiency of fund use. In November 2021, the National Medical Insurance Bureau issued the "Notice on the Three -Year Action Plan for the Reform of DRG/DIP Payment Methods". During the "Fourteenth Five -Year Plan" period, DRG (paid according to the relevant groups of disease diagnosis) and DIP (paid by the disease scores based ) Two prepaid methods will be merged with dual tracks, replacing the post -payment system that was originally paid by the project. The medical insurance payment method of the disease group or disease will set the payment "ceiling" to transform the hospital's income in the traditional era into the cost of the DRG/DIP era, and force the hospital Funding effectiveness.

As the first local city -level city, the national "two diseases" (diabetes, hypertension) outpatient drug protection special action demonstration cities in the country to launch a national medical insurance information platform, in recent years, Shanwei City, Guangdong Province has taken out its own reform of medical insurance payment methods. The road of characteristic innovation.

In August 2020, on the basis of exploring DIP paid in advance, Shanwei City took the initiative to apply for DRG paid reform pilots, becoming the only DRG paid provincial pilot city in Guangdong Province, and began to explore DIP and DRG integration reform paths. In January 2022, the DRG paid reform of Shanwei City entered the actual payment stage.

The effectiveness of reform shows that the average cost of hospitalization in Shanwei medical institutions continues to decline, the increase in the rate of negative expenses at their own expense of patients has decreased simultaneously, the number of medical institutions with positive balances has continued to increase, the illegal acts of medical insurance are gradually decreased, and the three -party win -win results of medical insurance, hospitals, and patients The reform pattern is initially formed.

Recently, the scientific research team of Associate Professor Liao Zangyi of China University of Political Science and Law and the Shanwei Municipal Medical Insurance Bureau jointly organized the high -quality development of medical insurance and Shanwei City DIP and DRG Integration Reform Symposium was held in Shanwei City. Li Jintang, a member of the Party Group and Deputy Director of the Guangdong Medical Insurance Bureau, expressed his hope to create a "Guangdong Shanwei Model" that can be used for reference, replication, and promotion to provide advanced experience and typical demonstration for the province to promote the reform of DRG payment methods.

During the meeting, Chen Liangchuan, the party secretary and director of the Shanwei Medical Insurance Bureau, accepted an exclusive interview with the 21st Century Business Herald reporter to introduce the course of the reform of the reform of the medical insurance payment method and work experience.

DIP and DRG fusion reform "crab"

"21st Century": Please briefly introduce the process of the fusion reform of DIP and DRG in Shanwei City.

Chen Liangchuan: Since 2018, Shanwei City has begun to implement the payment system according to the disease score. In the actual operation, Shanwei City collected more than 400,000 medical data and a relatively sound local disease spectrum, and accumulated some experience in medical insurance information coding, technical grouping, score negotiation, policy formulation, etc. During the period, many rounds of inspections of pilot cities such as Foshan, Xiamen, and Jinhua City, believed that the DRG points method paid the actual situation of Shanwei City.

In order to better realize precise payment and precision management of medical insurance, Shanwei City launched DIP and DRG integration exploration in 2020. In August of the same year, the Guangdong Provincial Medical Insurance Bureau listed Shanwei as the only provincial pilot city in Guangdong Province's DRG paid reform. After two years of practice, Shanwei City has achieved the path transformation target of DIP paid to DRG points.

"21st Century": What specific work did Shanwei City carry out during the advancement of DRG paid reform?

Chen Liangchuan: The specific work can be summarized with "four one".

The first is to complete the system design and establish a complete medical insurance payment system. Shanwei City has formed a "1+X" medical insurance payment system. The core of which is the incentive and restraint mechanism of "total control, balance reserves, reasonable overwear" in accordance with the DRG point method. According to the liquidation interval, the fixed -point medical institutions are paid, and the target management mechanism is used to stimulate the enthusiasm of the quality and efficiency of medical institutions.

Specifically, at the end of the annual liquidation, the total reimbursement of the reimbursement of the inpatient medical insurance fund of designated medical institutions is compared with the annual total amount calculated by the DRG point method. The rest of the hospital's balance is too large, and policy risks such as pushing refusal and inadequate treatment have been generated. The total reimbursement of medical insurance in accordance with actual medical insurance funds in the hospital is the total annual payment.

If the total reimbursement of the inpatient medical insurance fund is 70%and 90%of the total annual payment, the medical insurance is based on 110%of the total reimbursement of the actual medical insurance fund as the total annual payment. Its 10%excess reward encourages the cost of controlling medical institutions.

If the total reimbursement of the actual medical insurance fund exceeds 90%of the total annual payment, the medical insurance is based on the established "ceiling" as the total annual payment, and the medical institution obtains the balance of the balance.

In addition, Shanwei City has also been equipped with four policy documents, including special diseases, medical community reforms, day surgery, and traditional Chinese medicine. Solving cases that cannot be admitted to group or compensation for over -lunar cases due to technological innovation and treatment of difficulty in treating difficulties, and exploring policy ways to connect medical communities in physical reforms, day surgery and support the development of traditional Chinese medicine inheritance and innovation and DRG paid reform.

The second is to complete the system construction and formulate a scientific DRG details plan. Scientific grouping is the prerequisite for DRG accurate payment, while data quality is the core of scientific grouping. Since the implementation of DRG paid reform, Shanwei City has carried out 3 rounds of historical data cleaning and 2 rounds of simulation operation data analysis on the medical case data and settlement list of designated medical institutions in the past three years. Technical standards, combined with local clinical reality, form a localized DRG details solution. The third is to complete policy adaptation and build an efficient and practical medical insurance settlement platform. Shanwei City is the first prefecture -level city in the country to launch a national medical insurance information platform. It has some experience in medical insurance informatization and standardization.

With the support of the National New Health Technology Service Team, the "last mile" of DRG paid in Shanwei City was officially opened. At the end of 2021, the local DRG platform of Shanwei realized the docking with the provincial platform, and the hospital settlement data returned to the local system. It was unimpeded with the hospital's publicity feedback on the group results. At present, Shanwei City is stepping up to connect with the national information platform, do a good job of localization policy adaptation of the DRG module of payment management subsystems, and strive to transition to the national information platform to settle simultaneously as soon as possible.

The fourth is to complete the team building and form a professional expert team. At the beginning of the start of DRG's paid reform, Shanwei hired well -known domestic scholars such as Liu Aimin, Qiu Yulin, Xia Sujian, Liao Zangyi, Wei Xiaolei, and experts from the National DIP Technology Guidance Group for DRG Paid Reform.

Medical Insurance suffers from the three parties to win -win

"21st Century": From the perspective of medical insurance, hospitals, and patients, how did the reform achieve?

Chen Liangchuan: From the perspective of medical insurance, the sustainability of the medical insurance fund is guaranteed. The total budget management of the medical insurance fund has been strengthened. From July 2021 to June 2022, the monthly point value remained stable and basically maintained in the range of 70 yuan to 80 yuan. It provided medical institutions with the expected point value standard for reference. Controlled.

The second is the initial results of the medical group control. In the first half of 2022, 325 DRG group costs were reduced or flat, accounting for 80.64%of the total cost, accounting for 62.5%of the total pathogenesis; 37.5%.

Third, the illegal violations of medical insurance have gradually decreased. The decomposition of hospitalization and frequent transfer of hospitalization have decreased. According to the analysis of 10 disease group cases that are prone to resolving hospitalization and frequent transfer of hospitalization according to the analysis of stroke stroke, renal failure, it is found that the number of people in hospitals declined. Essence

From the perspective of hospitals, the number of medical institutions with positive balances has continued to increase. There are 52 DRG settlement medical institutions in Shanwei City, 32 in the third quarter of 2021, and 31 in the fourth quarter; 39 in the first quarter of 2022, and 42 in the second quarter, such as the sea, such as the sea, such as the sea, such as the sea Fengxian Pengyou Memorial Hospital cumulatively overdue 1429,674 yuan in the second half of 2021. In the first half of 2022, it had turned a profit to make a profit, and the cumulative balance reached 182,4450 yuan.

The second is to promote the improvement of medical services. The CMI index is usually used to measure the technical level and difficulty of a hospital for cure and critical illness. From July 2021 to June 2022, the CMI index of Shanwei City paid by DRG (except for the Shenshan Central Hospital) CMI index was on the rise, from 1.14 in July 2021 to 1.2 in June 2022, 2022 in 2022, 2022 The March CMI index reached a maximum of 1.28.

Third, the average cost of hospitalization for medical institutions continued to decline. In the first half of 2022, the average inpatient cost was 8917.13 yuan, a decrease of 227.83 yuan from the same period last year (9144.96 yuan), a decrease of 2.5%year -on -year; the average number of hospitalization days in the first half of 2022 was 6.13 days, a decrease of 1.43 days from the same period last year (7.56 days). A year -on -year decrease of 18.9%.

From the perspective of patients, Shanwei DRG paid reform has not increased the burden on patients. Instead, the patient's own expense growth rate has decreased at the same time. In January 2022, the average average cost of the personal affordable hospitalization was 3969.62 yuan. In June, the average cost of the personal affordable hospitalization was 3102.81 yuan. The expensive problem was relieved.

"21st Century": In the next step, what are the aspects of Shanwei City to deepen the reform of medical insurance payment?

Chen Liangchuan: First of all, we will further strengthen DRG operation monitoring, and conduct comprehensive monitoring from four aspects: fund operation, medical group analysis, performance indicators and personal burden.

Secondly, DRG paid is not a panacea, and all cases cannot be applied. The follow -up will provide a reasonable payment plan or policy tilt on the basis of scientific calculations, such as paid by bed and daily, daily surgical case treatment, Chinese medicine, maternal and child specialist policies, etc.

In addition, we will establish a DRG regulatory assessment mechanism.For the lack of medical services, low standards admission, high sets of high sets of high standards, high sets, surgery upgrades, pushing patients, and transfer of expenses after DRG paid.The whole process and the time supervision of the whole process, keep the "life -saving money" of the people, and prevent the safety risks of the medical insurance fund.In the end, the reform wants to succeed without the cooperation of medical institutions.We will continue to carry out "point -to -point guidance, face -to -face interpretation, and handle teaching" on designated medical institutions, improve medical institution's medical cases, settlement lists and coding quality, and guide hospitals to manage and clinically establish correct reform orientations.At the same time, continuously track the situation of hospitals with a large difference in payment, so that medical institutions can truly enjoy the dividends brought by DRG paid reform.

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