Since the reform of disease diagnosis-related grouping (DRG) combined with point method payment (hereinafter referred to as DRG payment) under the control of the total budget of the medical insurance fund was launched in March 2018, Panzhihua City, under the guidance of the National Medical Insurance Bureau and the Provincial Medical Insurance Bureau, has been promoted horizontally and vertically, and has been selected into the list of provincial pilot cities and national pilot cities, and in December 2021, it has become one of the 18 national DRG demonstration point cities. The reform of payment methods has been carried out in an efficient and orderly manner.
Panzhihua City is located in the southwest of Sichuan Province, northwest Yunnan, the jurisdiction of "three districts and two counties", known as "immigrant city", the characteristics of the aging society is particularly obvious. Before 2017, the annual increase in the expenditure of the medical insurance pooling fund was about 18%, and the employee medical insurance pooling fund has been unable to offset the current income and expenditure for 4 consecutive years, and the situation of fee control is very severe, and it is imperative and urgent to deepen the reform of medical insurance payment methods. Therefore, at the beginning of 2018, Panzhihua City implemented the spirit of the relevant documents of the State Council and the provincial government on the reform of medical insurance payment methods, issued the Implementation Plan for Further Deepening the Reform of Basic Medical Insurance Payment Methods (Panbanfa [2018] No. 23), and decided to fully implement the reform of multiple composite medical insurance payment methods based on the total budget of medical insurance funds and based on DRG payment.
After nearly 4 years of operation, Panzhihua City has initially built a DRG payment management system with "strong guarantee, solid foundation, sound mechanism, comprehensive coverage and strong supervision", realized the transformation of the current balance of the city's hospitalization fund from "negative" to "positive", and guarded the "people's life-saving money" from the source. At the macro level, a long-term mechanism for the balance of the budget and revenue and expenditure of the regional medical insurance fund and a regulatory mechanism for the reasonable growth of the fund have been established, and a guiding mechanism for medical institutions to control costs, improve quality and healthy competition has been established at the micro level. Achieve "three coverages" and "one decline" in the region. That is, the full coverage of urban and rural workers' medical insurance and urban and rural residents' medical insurance in the overall planning area, the full coverage of diseases except for serious mental disorders, the full coverage of medical institutions with hospitalization conditions, and the proportion of project payment funds have decreased significantly. Panzhihua took the lead in the southwest area to realize the inclusion of all primary medical institutions in DRG payment. After the pilot reform, the proportion of employee medical insurance and resident medical insurance paid by project has decreased from 97.14% and 98.52% before the reform to 36.86% and 20.35% respectively, and the payment by project is mainly for off-site medical treatment, outpatient special diseases and other expenses. Improve the purchasing power and efficiency of the fund. Panzhihua City's 2020 employee medical insurance fund expenditure decreased by 13% compared with 2017; in 2020, the resident medical insurance fund expenditure increased by only 1% compared with 2018, and the two insurances reduced the medical insurance fund expenditure by 195 million yuan in three years, and the current balance of the fund changed from "negative" to "positive", changing the past high growth trend. At the same time, after the pilot reform, the types of treatment accepted by medical institutions are more in line with functional positioning, the difficulty of admitting and treating cases has been significantly improved, and the CMI of tertiary, secondary and first-level medical institutions has been improved. Promote the high-quality development of medical insurance and medical institutions. The management team of Panzhihua City to adapt to the DRG payment reform has been initially established, the multi-departmental joint payment guarantee mechanism has been basically established, and the diversified composite medical insurance payment system based on DRG payment has become increasingly perfect. At the same time, all medical institutions have started from the reform, strengthened medical quality management, standardized medical service behavior, strengthened cost accounting, and established a performance management model that is compatible with DRG payment, from the extensive development of scale expansion to the intensive development of quality and efficiency improvement. Form replicable and generalizable panzhihua experiences. Combined with the pilot practice of Panzhihua City, the Provincial Medical Insurance Bureau, the Provincial Department of Finance, and the Provincial Health commission jointly issued the Implementation Opinions on Promoting Payment by Disease Diagnosis-Related Grouping (DRG) combined with the Point Method (Sichuan Medical Insurance Regulation [2021] No. 12), requiring all co-ordination districts in the province (except for the co-ordination areas that implement the payment by disease type or disease component value) to start the implementation of the DRG payment method reform based on Panzhihua's experience.
Overall, in the past four years since the implementation of the DRG reform in Panzhihua City, the goals of affordable medical insurance funds, sustainable development of medical institutions, and overall non-increase in the burden of the insured masses have been basically achieved. Summarizing the main practices and experiences of Panzhihua City, there are the following aspects:
The first is to strengthen the "three guarantees" and accurately implement policies to lay the foundation. To strengthen organizational guarantees, the Panzhihua Municipal Party Committee listed the DRG payment reform as the key work of "deep reform", and established a national pilot work leading group with the mayor in charge as the leader and the leaders in charge of relevant departments as members. Strengthen institutional guarantees, build a "1 + N" DRG payment system, covering budget management, handling procedures, medical institution assessment, special disease single discussion, agreement management and other aspects. Strengthen technical support, public bidding to determine Guoxin Health as the builder of DRG paid application software system.
The second is to establish "three mechanisms" and cooperate carefully to promote optimization. Establish a mechanism of equal emphasis on incentives and constraints, strengthen the management of the revenue and expenditure budget of the medical insurance fund, and achieve "five" inclined support through the adjustment coefficient, that is, to promote hierarchical diagnosis and treatment to support grass-roots medical institutions, encourage discipline construction to support key departments (key specialties), promote the development of traditional Chinese medicine to support the dominant diseases of traditional Chinese medicine, rationalize functional positioning to support the admission and treatment of critical and severe diseases, and encourage and support the development of high-tech and cutting-edge technologies. Establish a consultation and evaluation mechanism, set up a group standard committee with the participation of hospital experts, and jointly negotiate to determine the group standard, the basic number of points of the disease group, and the adjustment coefficient. Carry out DRG paid dispute handling, review and evaluation work. Establish a normalized publicity and training mechanism, centralized training at different levels, centralized training by county (district), and key one-on-one training, door-to-door explanation of group measurement results, and business operation guidance in lower counties (districts).
The third is to highlight the "three unifications" and strengthen the quality and efficiency of fine management. Unified data standards, 15 medical security information business coding standards have been successfully implemented. Unified group settlement, Guoxin Health accurately docked with national standards, helping Panzhihua City form a local subdivision group scheme with a total of 376 ADRG and 730 DRG disease groups. Unified audit and supervision, on the basis of 26 conventional intelligent audit rules, 6 intelligent audit rules that are closely compatible with DRG are explored and implemented, focusing on exploring and studying the regulatory verification mechanism for new illegal medical behaviors under the DRG payment model.
The fourth is to focus on the "three focuses" and accurately manage and prevent risks. Gather the management links of the agreement, increase the special content of DRG settlement, and incorporate quality service management indicators, medical service supervision and assessment, medical expense allocation and liquidation into the agreement. Focus on the intelligent supervision link, start to build an "integrated" intelligent supervision system based on the DRG payment system, and gradually establish and improve the medical insurance supervision system suitable for DRG. Focus on the performance evaluation link, establish a "reward for the good and punish the inferior" point adjustment mechanism, and discuss the introduction of the "Interim Measures for THE PERFORMANCE EVALUATION OF DRG Point Payment under the Regional Total Budget Management of Basic Medical Insurance in Panzhihua City".
Fifth, make up for the "three short boards" and strive for innovation through reform. Make up for the shortcomings of TCM grouping, select the dominant diseases of TCM, and take the lead in exploring and carrying out DRG payment according to the efficacy value of TCM in the province. Make up for the shortcomings of "avoiding the heavy and light", increase policy support for the treatment of critical and severe diseases and difficult and complicated diseases in medical institutions, appropriately increase the adjustment coefficient of critical and severe disease-related disease groups, and give a moderate tilt policy for carrying out high-tech technologies. Explore supplementary payment methods, and include bed-by-day payment for serious mental disorders, long-term rehabilitation, hospice services, etc. into the DRG point method payment management. It is the first in the province to include day surgery in DRG payment management.
The sixth is to promote the "three medical linkage" and achieve results in sincere co-treatment. Promote the benign interaction between medical insurance and medical institutions, establish a group group standard committee, and negotiate and jointly complete the work of disease group group and payment standard calculation. Promote the fine management of medical institutions, in 2020, the total cost of hospitalization, the average cost of hospitalization, and the average hospitalization day of medical institutions in the city are within a reasonable growth range, and the proportion of drugs and examinations in most medical institutions is also declining. Lead medical insurance to promote the role of medical improvement, do not reduce the total amount control index of medical institutions due to the decline in collection and use costs, and leave all the profit margins freed up after the collection of pharmaceutical equipment to medical institutions.
In the next step, Panzhihua City will continue to show its leading role and promote the reform of medical insurance. At the same time, give full play to the power of medical insurance, promote the construction of regional medical highlands, promote hierarchical diagnosis and treatment, improve the policy of supporting grass-roots medical institutions, improve the regulatory system, ensure the continuous deepening of medical insurance payments, and further promote the modernization of the medical insurance governance system and governance capabilities through the in-depth promotion of DRG payment, and help the high-quality development of medical security and medical institutions.
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