┃Source: China Medical Insurance
The reform of the payment method of medical insurance is the top priority of the reform of the medical security system. Under the ideal payment method, the use of medical insurance funds is efficient, the burden of medical expenses of insured persons is small, the code of conduct of medical services is standardized, and medical institutions and doctors have benefits.
However, the reform of payment methods involves many stakeholders, and the tripartite relationship between doctors and patients is intricate and complex, which is the "hard bone" and "deep water area" of the reform of the medical security system.
After the establishment of the National Medical Insurance Bureau, it conscientiously implemented the deployment of the Party Central Committee and the State Council, and continued to deepen the reform of medical insurance payment methods.
Actively promote drg payment pilots
DRG payment is based on the patient's type of illness, severity of the disease, treatment methods and other factors, the patient is placed in a diagnostic-related group with similar clinical conditions and resource consumption. After the implementation of DRG, medical institutions pay more attention to the cost of drugs, consumables, etc., balance retention, reasonable overrun sharing, so hospitals should consider cost control, compress the water in treatment, and implement a more efficient management model. In this process, patients can also avoid unnecessary medical expenses.
In 2019, the National Medical Insurance Bureau launched the dreg payment national pilot work. In accordance with the three-step promotion strategy of "top-level design, simulated operation, and actual payment", the national pilot work of DRG payment will be carried out in 30 cities in about 3 years.
At present, the work is generally progressing smoothly, and a series of documents and technical standards including drg paid national pilot program, CHS-DRG technical specifications and grouping schemes have been formulated and issued at the national level, and the CHS-DRG subdivision group scheme (version 1.0) has been issued, and 376 ADRG groups and 618 DRG subdivisions have been identified.
DIP payments are steadily launched
In order to promote the application of big data in the field of medical insurance, the National Medical Insurance Bureau has accelerated the study of the application of big data-based payment by disease species (DIP), and upgraded the local traditional payment by disease to DIP payment. DIP payment is unique to China, combining the point method, total budget, payment according to the score of the disease and other methods, which can significantly expand the scope of diseases covered, improve the level of management refinement, and effectively control the risk of the fund, with distinct Chinese characteristics.
At present, the "Pilot Work Plan for the Total Budget of the Regional Point Method and Payment by Disease Value" and the "List of Pilot Cities for the Total Budget of the Regional Point Method and Payment by Disease Score" have been issued, and pilot work has been carried out in 71 cities; the "Notice on the Establishment of the Regional Point Method Total Budget and payment by Disease Score (DIP) Expert Database" has been issued, the "Notice on the Establishment of the Regional Point Method Total Budget and the Payment by Disease Score (DIP) Expert Database", the "Notice of the National Medical Security Administration on Payment by Disease Score (DIP) Technical Specifications and the DIP Disease Catalogue Database (Version 1.0)". Finally, 11,553 core disease groups and 2,499 comprehensive disease groups were formed, and the implementation conditions, data preparation, data variables and audit governance of paying by disease were uniformly standardized.
DRG/DIP payment method reform "full coverage"
Up to now, 30 DRG paid pilot cities and 71 DIP paid pilot cities have all completed cross-evaluation and entered the actual payment stage. On this basis, the National Medical Insurance Bureau recently issued the "Notice on Printing and Distributing the Three-Year Action Plan for the Reform of DRG/DIP Payment Methods" (hereinafter referred to as the "Notice").
The Notice gives the drg/DIP payment reform timetable, focuses on the four aspects of expanding the area, building a mechanism, laying the foundation, and promoting collaboration, and clarifies the task of completing the DRG/DIP payment reform in stages and batches from 2022 to 2024:
By the end of 2024, all co-ordinated areas in the country will carry out the reform of DRG/DIP payment methods, and start pilot areas in the early stage to continuously consolidate the results of reform;
By the end of 2025, the DRG/DIP payment method will cover all eligible medical institutions that carry out inpatient services, and basically achieve full coverage of disease types and medical insurance funds.
For "full coverage", there are 4 requirements:
1. Grasp the overall coverage of the overall area. On the basis of the pilot in 2019-2021, it will be arranged according to the three-year schedule of 2022, 2023 and 2024. With provinces (autonomous regions and municipalities directly under the Central Government) as the unit, no less than 40%, 30%, and 30% of the coordinated areas respectively will be launched to carry out the reform of DRG/DIP payment methods and actually pay. Encourage provinces (autonomous regions and municipalities directly under the Central Government) to complete the task of coordinating regional coverage in advance.
2. Grasp the comprehensive coverage of medical institutions. After the overall planning region starts the DRG/DIP payment reform work, the comprehensive coverage of medical institutions that meet the conditions for inpatient services should be fully covered according to the three-year arrangement, and the annual progress should be no less than 40%, 30% and 30% respectively, and the start-up areas in 2024 must be completed within two years.
3. Comprehensive coverage of diseases (in principle, 90%). After the overall planning region starts the DRG/DIP payment reform work, the full coverage of DRG/DIP paid medical institutions will be fully covered according to the three-year arrangement, and the annual progress should be no less than 70%, 80% and 90% respectively, and the start-up areas in 2024 must be completed within two years. Encourage enrollment to reach more than 90%.
4. Grasp the comprehensive coverage of the medical insurance fund (in principle, 70%). After the reform of DRG/DIP payment is launched in the co-ordination area, the DRG/DIP paid medical insurance fund expenditure will account for 70% of the inpatient medical insurance fund expenditure in the co-ordination area according to the three-year arrangement, and the annual progress should be no less than 30%, 50% and 70% respectively, and the start-up area in 2024 must be completed within two years. Encourage more than 70 per cent of the total budget coverage of the Fund.
The 1st China CHS-DRG/DIP Payment Method Reform Conference will be held on December 18-19! 1 conference/opening ceremony, 15 sub-forums, nearly 100 expert wisdom condensation, national medical insurance people, medical workers, and people of insight who pay attention to medical reform, do not miss this feast! Click to watch the live broadcast, online participation can be——
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