After the DRG is actually running, how is the operation status of your department? What about your income?
In the face of DRG, a new way to pay for medicare, the above problems may be the main problems that doctors discuss privately.
"In the early days of the DRG reform, some hospitals were in a state of loss due to the difficulty of balancing drg payment standards and treatment costs." In January 2022, researchers at Xuzhou Medical University published a paper in China Hospital Management.
After the implementation of DRG, Wang Yan, a cardiologist at a third-class hospital in Wuhan, told the health community that his personal income decreased by 15 percent; Chen Ming, a heart surgeon at another top-three hospital in Hubei, said that his department lost 5 million yuan a year.
On June 7, 2021, at the State Council's regular policy briefing held by the State Council's new office, Huang Huabo, director of the Department of Pharmaceutical Service Management of the National Medical Insurance Bureau, said that in 2021, all 30 pilot cities will carry out actual payments.
In March 2022, a pilot hospital in the southwest region is still in the simulated operation stage.
"Mainly because there are some disputes between doctors and the price of the disease group." Li Ping, director of the obstetrics and gynecology department of the hospital, told the health community that according to the current price given by medical insurance, they will "make a case of loss" for patients with difficult and critical illnesses.
Under the DRG payment model, various diseases are divided into different groups according to resource consumption, economic costs, etc., and according to the cost of the first three years, the price of the disease group is determined in advance, and a certain medical insurance fee is prepaid to the hospital - if the cost generated in the hospital diagnosis and treatment process is lower than the amount, the extra medical insurance cost is a profit or surplus; if it is higher than the amount, the higher part is a loss, which needs to be borne by the hospital itself.
In this process, as a front-line executor, clinicians can be described as the most core and critical element of regulating the payment cost - what kind of patients are admitted (that is, the main diagnosis), which directly determines which patient is in which group and which price is reimbursed, and the subsequent treatment behavior of patients determines the specific cost of the hospital.
Industry experts have pointed out that the purpose of DRG payment is to change the project-based payment model, turn drugs, consumables, examinations, etc. into costs, and urge doctors to change the unreasonable behavior of excessive diagnosis and treatment of patients such as prescribing large prescriptions to patients and using expensive drugs, consumables and large examination equipment.
However, after drging incentives for excessive medical treatment is limited, there may be concerns about hospitals leading to under-treatment in order to control costs.
What choices do doctors at the center of this storm of reform face?
Increased workload: Will doctors still be able to settle accounts?
After the implementation of drging, standardizing the filling in of the first page of the case has become one of the most important things for hospitals and doctors.
DrG is known to influence doctors' medical behavior in various forms, the most important of which is to fill in the first page of the case.
Chen Zihua, vice president of Xiangya Hospital of Central South University, once compared DRG to "stir-frying", of which "ingredients" are the first page data of the case, "pot" is the grouper, and the fried dishes are indicators such as disease group and CMI.
The doctor standardizes the writing of medical records and fills in the home page of the case, which has become the basis and key link of DRG.
Among them, the "main diagnosis" on the homepage is the important information required by DRG, which almost directly determines which disease group the patient is assigned to and which price is paid.
Before the implementation of DRG, the main diagnosis is generally written as the reason for the patient's hospitalization, and only needs to consider the patient's condition; after DRG, in addition to the patient's condition, it is also necessary to consider the consumption and cost of medical resources to ensure that the patient enters the appropriate disease group and receives the appropriate payment.
"If the code is too low, it will make it impossible to fully compensate for medical expenses; if it is low and high, it will be suspected of insurance fraud and will face severe penalties." The president of a second-class hospital once told the media that once there is an error in the diagnosis of the disease and the main treatment methods, it will bring great risks.
Faced with heavy clinical work and years of habits, clinicians are under a sharp pressure to fill in the information on the first page of the case, and need continuous learning and training to change old thinking and habits.
"Doctors under DRG should not only be 'technologists' who treat diseases and save people, but also 'accountants' who can calculate accounts and have economic thinking." Wang Yan told the health community that these are all extra workloads for him and require a lot of time and effort.
According to a survey released by the Union Hospital Affiliated to Fujian Medical University in June 2021, after the implementation of drRG formal payment, more than 95% of doctors believe that the workload has increased, including the study of filling rules on the first page of the case and the increase in the content of filling.
Doctors are more cautious, and the medical burden has indeed dropped
After knowing the paid price of a certain disease in advance, what the hospital and doctor need to do is to control the cost of medical behavior under the premise of ensuring the quality of medical treatment, and do not exceed the amount, otherwise it will produce losses.
In the treatment process, cost savings and no overruns have become one of the main considerations of hospitals and doctors implementing DRG.
To control the cost of DRG diseases and avoid losses, hospitals can do a lot, the first of which is to standardize medical behavior, rational use of drugs, reasonable examination, eliminate inducement demand, and excessive medical treatment.
"Before the implementation of DRG, surgical suture wounds, the use of a large number of high-grade hemostatic materials, staplers, click a few thousand dollars is gone; after the implementation of DRG, we must try to save consumables, and encourage young doctors to suture one stitch after another." 」 A hospital administrator once told the media that the DRG reform has led hospitals to reduce the use of consumables to reduce medical costs and improve efficiency.
Shi Ju, an associate professor at the School of Economics of Peking University, found that in order to reduce costs, the amount of medication and the amount of medication in the pilot hospitals have declined, especially for the use of Class B drugs, which has been significantly reduced.
It can be seen that DRG can indeed prompt doctors to avoid the use of high-value consumables, high-priced drugs, especially auxiliary drugs, reduce excessive medical treatment, let patients spend every penny on the cutting edge, reduce the total medical cost, and further reduce economic pressure.
A study released in April 2020 by the School of Public Health of Capital Medical University also confirmed that DRG makes doctors' medical behavior more standardized than paying for projects, and that the amount of medical services provided by doctors is closer to the optimal amount of services under its incentives.
The bigger the hospital, the worse the loss?
However, due to the complexity of diagnosis and treatment behavior and the imbalance of China's medical resources, in the early stage of DRG reform, it was difficult to grasp the balance between DRG payment standards and diagnosis and treatment costs, and many pilot hospitals were still in a state of loss.
The above-mentioned study of Xuzhou Medical University took a large public hospital in Jiangsu Province as a sample and found that after the implementation of DRG, there were losses in gastrointestinal and urinary departments.
The actual medical expenses of the departments in the first and second quadrants exceed the medical insurance costs.
Photo excerpt from "Problems and Countermeasures of Public Hospital Operation and Management under the Background of DRG Payment"
Top 10 Diseases with Losses Photo excerpt from "Problems and Countermeasures of Public Hospital Operation and Management under the Background of DRG Payment"
The direct consequence of the loss is that there are no bonuses available for the department and the salaries of medical staff are reduced. "After the implementation of drg, my personal income decreased by about 15%." Wang Yan told the health community that as far as he knew, many of his colleagues had their wages affected.
"In the first year of drrg actual payment, our department lost 5 million." Chen Ming, who also works in cardiac surgery, told the health community that at that time, because it was the first year, this part of the loss hospital helped them bear it, but this year there was another loss, "it will be deducted from the income of our medical staff."
"If they follow the payment standards set by Medicare, they will be treated with difficult and critically ill diseases." Li Ping, director of the gynecology department of a large third-class hospital in southwest China, told the health community.
According to Li Ping, in order to comply with the national three-level diagnosis and treatment policy, they adjusted the structure of diseases, received most of the difficult and serious diseases in the southwest region, and most of them were older patients with more comorbidities of malignant tumors, and the treatment effect was also recognized by peers and patients in the region.
"Many of them are patients who cannot be treated by other tertiary hospitals and are transferred to us for treatment." Li Ping said that if they paid according to the average price given by the patient group, many of the difficult and critical illnesses they treated would be "unable to make ends meet".
DrG originated in the West, and china's medical reality is more complex and the level of diagnosis is uneven compared to them.
"Even if they are tertiary hospitals, there are large gaps between medical technology and capabilities, and the treatment methods are very different, and the means of disease groups obtained in this case are actually controversial." Huang Wei, director of the Department of Orthopedics, another top three hospital in the southwest region, told the health community that in those areas with more equal medical resources, it may be easier to implement DRG, while in areas with large gaps, the problem will be more obvious, and the implementation resistance may be greater.
Prevaricating seriously ill patients and hindering the application of new technologies?
If hospitals and departments continue to lose money, can the quality of medical care be guaranteed?
Chen Ming told the health community that in the end, if the loss is on the head of an individual, then the doctors will definitely find ways to save costs, "at least Mr. Save".
In this process, it is very likely that there will be prevarication of critically ill patients with large resource consumption, transfer some patients or projects to outpatient clinics, or shorten the length of hospitalization of patients, and let them go home to recuperate if they have not yet recovered, affecting the effectiveness of treatment.
"The resource consumption of difficult and critically ill patients also requires doctors to have a higher level of diagnosis and treatment and operation, and invest more time and energy. If the payment standard of medical insurance cannot reflect these, it will definitely affect the admission and treatment of difficult and critical diseases in the long run." Li Ping said.
"After all, DRG is a group of patients, there are a series of similar diseases in the group, and under the same fee, people are definitely more willing to choose mild patients, because they consume less cost." 」 Huang Wei.
Getting patients discharged early is also one of the ways doctors may take to control a single cost.
"There's no way around it." Zhang Ping said that after the implementation of DRG, due to payment restrictions, one of their patients who needed to be transferred could not be transferred, and he could only be discharged from the hospital first and then re-admitted, "which is very delaying the treatment of patients."
According to a paper published in Health Economic Research in July 2020 by Wang Hui of Hezhou Traditional Chinese Medicine Hospital in Guangxi Zhuang Autonomous Region, hospital readmission rates increased after the implementation of DRG payments, of which 9%-48% of patients could have prevented readmission by adequate treatment and reasonable scheduling of discharge time.
The above-mentioned study from the School of Public Health of Capital Medical University also confirms that under the DRG model, doctors do tend to provide inadequate medical services, and the degree of this inadequacy will increase with the severity of the disease and the increase in resource consumption.
In addition, due to cost considerations, doctors may also prefer to use traditional, lower-cost technical methods, abandoning the use of new technologies, new methods, and new drugs with good efficacy, which eventually leads to insufficient initiative in innovation such as doctors and innovative pharmaceutical companies.
"The application of new technologies and new equipment are additional inputs and costs, such as a surgical robot that costs more than 10 million yuan, which requires the department to take money to buy." Huang Wei believes that in the case of payment restrictions, everyone has no more willingness and ability to learn, purchase, and use new technologies and new equipment, and in the long run, the overall level of diagnosis and treatment may be affected.
How do you balance cost with results?
Under the premise of determining the "ceiling" of payment, how to ensure that the quality of medical services is not affected may be a problem that needs to be paid attention to after the FULL rollout of DRG.
Dr. Liao Zangyi, associate professor at China University of Political Science and Law, has pointed out that the establishment of "special diseases" and "exclusionary payment mechanisms" may be a solution.
The special disease single discussion is mainly for cases with abnormal costs or complex diagnosis and treatment, allowing medical institutions to submit applications, and the medical insurance department regularly organizes expert review and reasonable cost compensation according to the rules.
In addition, the cost of payment is compensated according to the project fee for cases that significantly exceed the benchmark price of the disease group due to technological innovation of medical institutions and critical and critical care.
At present, the National Medical Insurance Bureau has issued DRG handling procedures, which have put forward relevant requirements for the "special disease bill discussion".
"The local health insurance bureau has proposed that we try to list the special situations as much as possible, and then see if we can review and solve them together." Li Ping said.
Wang Yan said that they are currently reviewing the high-rate cases in the first three months to see if they meet the policy of "special disease single discussion", but from the application to the final result, it is a long process.
With the development of the economy and society, the rising cost of medical care is a major challenge for any country. Improving the efficiency of the use of medical insurance funds is an inevitable direction, DRG is the general trend, which is the consensus of medical institutions, medical personnel and relevant experts.
"With DRG as the main line, for different situations, it is necessary to formulate corresponding supplementary regulations to solve some of the 'side effects' that DRG may bring, and I believe that with the advancement of reform, the relevant policies will be more perfect." Wang Yan remains optimistic about the future development of DRG.
Huang Wei believes that the more critical thing behind the problem is that it needs to be clear that the national medical insurance funds are used to insure the basic, if you choose a high reimbursement ratio, you can only enjoy relatively cheap treatment methods and drugs, if you want to use new technologies, new drugs and better quality diagnosis and treatment services, you need to pay yourself.
"This part of the out-of-pocket money can be taken by the patients themselves, or it can be paid for by commercial insurance, rather than all hoping for the state." Huang Yong said.
(At the request of the interviewee, Li Yan, Chen Ming, Li Ping, and Huang Wei are pseudonyms)
Sources | the health community
Written by | Valley Will