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People's Daily Health Client Xie Chen

On December 18, the First China CHF-DRG/DIP Payment Method Reform Conference released the results of the CHS-DRG (payment by disease diagnosis-related grouping)/DIP (payment by disease score) national pilot, and launched a three-year action plan for payment method reform.

As early as October 2016, the "Healthy China 2030" Planning Outline issued by the State Council clearly put forward: "Actively promote payment by disease type and head, actively explore payment by disease diagnosis-related group payment (DRGs) and payment by service performance, and form a compound payment method under the management of the total budget." In June 2019, the National Medical Insurance Bureau officially announced the list of pilot cities for DRG payment, and in November 2020, it issued a specification and disease catalog database for DIP payment.

Traditional Medicare payment method: Pay per project

China's traditional medical insurance payment method is to pay by project, that is, according to all the drugs, medical service items, medical consumables, etc. used in the diagnosis and treatment process, how much the hospital uses in the diagnosis and treatment process, and how much medical insurance and patients pay according to the proportion.

Why Health Insurance Payment Reform?

The payment method under the traditional model may produce excessive medical behaviors such as "big prescriptions" and "big examinations", which not only causes a waste of medical resources, but also makes the insured spend more money and the medical insurance fund spend more. The two new payment models of DRG and DIP can overcome the shortcomings of the current payment model.

Payment by disease diagnosis-related group (DRG) is based on the patient's type of disease, severity of the disease, treatment methods and other factors, the patient is divided into a diagnosis-related group with similar clinical conditions and resource consumption, and the medical insurance payment standard is determined in groups.

Payment by Disease Score (DIP) is the use of big data to use the disease according to the "disease diagnosis + treatment mode" combination as a payment unit, the medical insurance department according to the total amount of medical insurance funds payable each year to determine the payment standard for each disease.

Both of these reforms are to promote the transformation of the operating mechanism of medical institutions through package pricing, and to promote medical service providers to actively control costs and provide the most appropriate services for the insured people to meet their health needs.

What is the role of Medicare payment method reform?

The reform of medical insurance payment method determines a payment standard for disease treatment packaging, the balance cost becomes the hospital income, the excess cost of the hospital is at its own expense, which can promote the clinical path to be more scientific, the use of drug consumables is more reasonable, and through the balance retention, etc., so that patients, medical insurance and medical institutions can go in the same direction in reducing the cost and improving the quality.

Under the new payment model, medical institutions in the pilot areas can actively control costs, reduce unnecessary diagnosis and treatment, medicine and consumables projects, and improve the degree of refined management. Many performance indicators such as the efficiency and resource allocation of hospitals have been significantly improved, such as the average cost of cases, the cost of medical consumables, the length of hospitalization and other indicators have decreased year by year, which has reduced the burden on the people to see a doctor.

How effective is the health insurance payment reform so far?

Li Tao, deputy director of the National Medical Security Bureau and member of the party group, said that in the past three years, the pilot cities have all entered the actual payment, basically achieved the expected effect, and promoted the profound transformation of the medical insurance management mechanism, and the medical insurance payment has changed from project-by-project payment to value payment, from passive payment to active action, from simple manual audit to big data application, from extensive supply-side management to refined supply-side management.

When will the reform of medical insurance payment methods be implemented?

The reform of payment methods plays a basic and guiding role in the process of medical reform. In November, the National Health Insurance Bureau issued the Three-Year Action Plan for the Reform of Medical Insurance Payment Methods, which requires that it be promoted from the current 101 pilot cities to the whole country within three years. By the end of 2024, all co-ordinated areas in the country will carry out payment method reform, and by the end of 2025, all eligible medical institutions that carry out inpatient services will be covered.