Policies | Shandong Unified DRG Payment Regulations, implement "the same price of the same city and the same disease"

Since Shandong Province launched a pilot work in accordance with the disease -related group (DRG) in 2019, the cities have actively explored and practiced, forming an effective practice of local behaviors, and achieved preliminary results. In order to further promote the reform of the DRG payment method of our province, recently, the Provincial Medical Insurance Bureau issued the "Notice on Printing and Distributing the Management Regulations (Trial of DRG) Pay Medical Insurance (Trial)> (hereinafter referred to as the regulations) of the" Shandong Province). Formulate the province's unified processing procedures, guide the cities to implement the national and provincial DRG paid technical standards and the process of running, and follow the state and provincial clear reform direction, steps and paths, and do a good job of DRG paid reform.

Combined with the actual situation of DRG paid reform in our province, the "Regulations" further refined and improved on the basis of the national DRG running regulations, and the applicability and guidance are stronger. Compared with the national DRG regulations, it mainly adjusts and adds 12 related content:

Clarify the total regional budget management. In accordance with the requirements of national technical specifications and three -year action plans, the total regional budget of DRG paid is clearly expressed in the rules and regulations. Reasonable allocation of medical resources.

Strengthen fund budget management. DRG paid shall be managed by separate budgets as a whole. Strengthen the management of the process, discover and respond correctly in time for the abnormal implementation of the possible budget progress and the large number of people's heads. Stable medical institutions expect to enhance the enthusiasm of medical institutions to participate in DRG paid reform.

Do a good job of work together. Make DRG paid reforms with other payment methods such as head, bed and day, etc., negotiating drugs "dual channels", centralized pharmaceutical consumables procurement, outpatient protection guarantee, long -term care insurance and other tasks to form a positive stacking effect The implementation of the implementation of DRG paid reform.

Data quality evaluation mechanism. The data quality of the medical insurance fund settlement list is the basis and premise of paid. Through the data quality evaluation and reporting mechanism to guide medical institutions to continue to improve the integrity and standardization of data.

Improve medical institution coefficient management. In accordance with the requirements of the three -year action plan, the core element of the "medical institution coefficient" is increased, and the ductility of DRG paid reform is broaden. Fully consider differentiated factors such as medical institution level, functional positioning, and technical capabilities, and continue to refine and improve the coefficients of medical institutions; build a foundation for negotiating negotiations with medical institutions, participating in paid reforms in traditional Chinese medicine medical institutions, and implementing the same price of the same city.

Promote the same price of the same city. Choose a DRG disease group with basic clinical paths, clear admission standards, and low treatment difficulty, set up the same medical institution coefficient, implement the "same city and the same price", and gradually expand Classified diagnosis and treatment to improve the performance of the medical insurance fund.

Improve the payment settlement system. The monthly pre -settlement and year -end liquidation of the DRG paid cases of fixed -point medical institutions are implemented. It is also required to formulate a monthly payment settlement process to upload the settlement list of medical insurance funds, data quality control, case enrollment, communication feedback, results of results, and expense settlement in the discharged cases of discharged cases.

Review and audit. Emphasize the key review of high -sets, resolving hospitalization, transfer of hospitalization costs, insufficient service, pushing heavy sufferings, etc., and improve and improve the cost review system that is adapted to DRG.

Carry out special assessment and evaluation of DRG paid. Indexs related to DRG will be incorporated into DRG special assessment, such as organizational management, institutional construction, service quality, data quality, cost control, and insured satisfaction, and simultaneously include the overall performance assessment and evaluation system.

Regular DRG operation monitoring. Regularly carry out DRG operation monitoring, and analyze the medical insurance fund, medical institutions, medical institutions, medical institutions, medical institutions, medical institutions, medical institutions, medical institutions, and personal burdens of medical services, medical service capabilities, medical service efficiency, disease structure, disease structure, and personal burden. The influence of participants will continue to improve and improve the management support measures and assessment mechanisms. Evaluation should be performed every quarter, and annual evaluation is performed after the annual liquidation is completed.

Public related indicators. It is clear that the medical insurance department must disclose the core factors such as the medical institutions, weights, and coefficients, and operate parameters such as rates, average hospitalization days, average of examples, etc., and give full play to the role of medical institutions' active control of medical costs. Promote fairness and fairness in public and transparency, and guide medical institutions fair and orderly competition.

Dispute processing mechanism. In terms of DRG paid workflow and paid standards, we will strengthen negotiation with medical institutions and properly handle disputes. If there is a large difference in the fees of the disease group (species) due to the treatment of critical illness, emergency rescue, and reasonable use of new drugs and new technologies, etc., it is necessary to reasonably compensate for reasonable diseases and except for payment. The enthusiasm of medical institutions.

(Source: Volkswagen Daily)

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