After Hefei was identified as a national pilot city for disease diagnosis related grouping (DRG) payment, the municipal party committee and the municipal government attached great importance to it, and established the Hefei Disease Diagnosis Related Group (DRG) Paid National Pilot Leading Group headed by the municipal government in charge of the mayor, and the Hefei Municipal Government Office issued the "Hefei Disease Diagnosis Related Group (DRG) Paid National Pilot Work Implementation Plan", focusing on the "Five Ones" goal, adhering to the goal orientation, and following the work idea of "easy first and then difficult, step-by-step implementation". Clarify the key tasks and timetables of the pilot work, and actively and orderly promote the pilot work.
In January 2021, Hefei officially launched the first batch of 17 pilot medical institutions to pay for the actual DRG, and the medical insurance fund expenditure, secondary average hospitalization cost, and personal burden all showed a downward trend month by month. From January to August, the total payment of employees and resident medical insurance funds (including basic medical insurance and major illness insurance) decreased by 3.12% and 5.48% respectively compared with 2019 and 2020, respectively, and the proportion of individual out-of-pocket payment decreased by 0.17% and 0.22% respectively compared with the same period in 2019 and 2020. At the same time, through the implementation of the DRG payment reform, the quality of medical insurance data has been greatly improved, and Hefei, on behalf of Anhui Province, has taken the lead in passing the acceptance of the National Medical Insurance Bureau's standard implementation work.
On paper, it is finally shallow, and only practice produces true knowledge. Hefei continues to pay attention to the operation, pay attention to collecting and sorting out the problems existing in the operation, and accumulate some typical practices and experiences that can be promoted and copied.
The first is to lay a solid foundation and advance in an orderly manner. In order to ensure the effectiveness of the reform work, the Hefei Municipal Medical Insurance Bureau has successively issued the "Notice of the Trial Measures for the Payment of Hospitalization Expenses of Hefei Medical Insurance by Disease Diagnosis Group (DRG)", "The Management Regulations for The Handling of Medical Security by Disease Diagnosis Related Groups (DRG) in Hefei (Trial)", the "Notice on Supporting Documents Related to the Pilot Work of Paying by Disease Diagnosis Related Grouping (DRG)" in Hefei City, the Notice on Standardizing the Upload of Disease Diagnosis and Classification Codes, the "Notice on Activation", "Notice on Activation", "Notice on Activation", "Notice on The Implementation of Disease Diagnosis Related Groups", "Notice on The Implementation of Disease Diagnosis Related Groups (DRG)", "Notice on The Implementation of The Notice on the Implementation of The Notice on the Implementation of the Disease Diagnosis Related Grouping (DRG)" Supporting documents such as the Notice on Promoting the National Pilot of DRG Payment in Hefei and implementing the Medical Insurance Settlement List have established supporting measures such as DRG audit, data analysis, clinical discipline negotiation, and exit mechanism, and strive to reform the pilot to be stable and far-reaching, and then make progress. In order to improve the comprehensive efficiency of medical insurance governance, Hefei Innovation packaged the DRG payment system and the medical insurance intelligent monitoring system, and introduced Guoxin Health as a third-party service provider to jointly complete the system construction. In order to steadily promote the national pilot of DRG payment, after full research, 17 medical institutions with better basic conditions were selected as the first batch of DRG payment pilots. On this basis, the coverage will be further expanded, and all 92 qualified medical institutions at the second level or above in the co-ordination area will be included in the DRG payment management. At present, a total of 2026562 data extraction work of each medical institution has been completed in 33 months through the DRG payment system interface, and the actual payment is planned to be realized in January next year.
The second is to face up to the problem and strengthen communication. Due to the lack of awareness and attention paid by most medical institutions to carry out DRG payment, the performance management of medical institutions cannot keep up with the pace of drg payment reform, and there are many opinions. In order to ensure the smooth progress of the pilot work, Hefei has established a scheduling work system, a pilot notification system, and a clinical discipline communication mechanism. In particular, strengthen coordination and communication with provincial-level medical institutions and establish a provincial-municipal linkage mechanism. The Anhui Provincial Medical Insurance Bureau commanded and guided in a timely manner, and the leaders in charge of the bureau listened to special reports many times, carried out field research, and led the convening of medical institution coordination meetings to give specific guidance on key issues such as fund budgets, allocation methods, disease group adjustment coefficients, and special disease single discussions. In order to solve the contradictions and problems in the promotion of the pilot in a timely manner, on August 4, 2021, the main responsible comrades of the Hefei Medical Insurance Bureau held several DRG payment pilot work promotion meetings and symposiums to analyze the existing problems and negotiate and study solutions.
The third is to strengthen auditing and strengthen supervision. In order to strengthen the supervision of the use of medical insurance funds, avoid the occurrence of prevarication, insufficient medical treatment, decomposition of expenses, transfer of burdens and other violations in the draught payment process, standardize clinical diagnosis and treatment behavior, and protect the legitimate rights and interests of insured persons, Hefei has established a set of scientific and efficient review rules for decomposing hospitalization, reducing admission standards, and coding low and high sets in the process of DRG payment. At the same time, the use of results is strengthened, not only linking the audit results and the adjustment of the comprehensive coefficient of medical institutions with the year-end liquidation, but also transferring some violations of the regulations of the medical insurance fund to the medical insurance regulatory authorities for further processing.
The fourth is to optimize adjustment and improve the mechanism. In order to promote the scientific, democratization and standardization of DRG payment decision-making, Hefei has established a DRG paid public review system and a sampling system for hospitalized cases, which includes the annual regional budget, subdivision group plan, disease group point calculation, special disease single discussion, coefficient adjustment, annual liquidation and other matters into the scope of public review, sampling samples are collected in accordance with stratified and isometric sampling rules, and the sampling ratio of tertiary medical institutions is not higher than 5% in principle, and other levels can be appropriately increased according to the scale of admission and treatment. At the same time, the core content of DRG payment is respected for reality, appropriately adjusted, scientific and reasonable. In terms of budget adjustment, in 2021, the 17 medical institutions included in the DRG payment management will implement a packaged budget for the inpatient medical insurance fund and reserve a certain proportion of the transfer fee. In terms of coefficient adjustment, in view of the fact that DRG payment in Hefei is in its infancy, the weight calculation of each disease group is based on historical data, in order to make the DRG payment system land smoothly, a comprehensive adjustment coefficient is set up when measuring the weight and points, and the adjustment coefficient of the number of points of the disease group is corrected according to the relevant indicators of the medical institution during the annual liquidation.
In recent years, Hefei has further promoted the high-quality development of medical insurance management through drg payment pilot work. Through the pricing function of DRG, the refined management of resource consumption is realized; through the assessment of the liquidation coefficient, the unreasonable growth of personal burden is controlled; through DRG payment, the standardized management of the clinical path of disease treatment is realized, and the same price for suitable diseases is realized, which promotes the rational allocation of medical resources.
In the next step, the Hefei medical insurance department will continue to follow the requirements of the national payment method reform, strengthen the determination of reform, adhere to the problem-oriented, strengthen communication and cooperation with the health department and medical institutions, adhere to the innovative and integrated development, further improve the payment negotiation, the pricing demonstration of the disease group, the performance appraisal of medical institutions and the treatment and resource consumption, etc., and strive to try out "new ideas and new models" with the help of third-party professional forces such as Guoxin Health, and promote the in-depth development of the reform of medical insurance payment methods in Hefei. Contribute Hefei wisdom to the reform of national medical insurance payment methods.
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