Recently, the National Health Insurance Administration has published the three major misunderstandings of DRG/DIP on the official WeChat, as well as an article entitled "DRG Leads to a Decrease in Medical Income, Leads to Hospital Losses, and This Pot DRG Can't Be Moved!", which has stirred up a thousand waves with one stone and caused heated discussions in the industry.
For the three major misunderstandings, the author basically agrees. Since 2015, when the DRG point method was explored in Jinhua and other places, to the release of the technical plan by the National Health Insurance Bureau, these three major issues have been the focus of discussion in the reform.
First, clinicians and hospital administrators generally believe that DRG/DIP is a means of cost control for the medical insurance department. In the previous project implementation, I will also come up with data from various angles to refute this problem, because in fact, there is indeed a squeezable "moisture" in the historical data of pay-per-project, and DRG does have a positive impact in this regard, and there are examples and data about this in various places, so I will not repeat it here. But a few years later, when I saw this topic again, I wanted to explore why the medical workers on the front lines of this reform had such misunderstandings.
(1) For many regions, it is true that the total budget of the fund cannot keep up with the sharp increase in medical expenses, which is related to the increase in the number of people who pay more attention to health, and some are also related to the change in the structure of diseases and the increase in average medical expenses, especially in 2023 compared with 2022 (the well-known reasons will not be discussed). Under this premise, as long as the total amount is controlled, regardless of the payment by project, by disease, or by DRG/DIP, there will be an illusion of cost control. The so-called smart woman is difficult to cook without rice, which is consistent with the perception of the general environment, and most industries have felt the pressure of revenue and cost management, which is actually equivalent to the feeling of "cost control". When everyone expects the fiscal back, the fiscal is like a powerless business manager, because it is not omnipotent, it has its own limitations, and it is powerless. From this point of view, DRG payment has indeed broken the original distribution pattern, and compared with the traditional model of project-based payment plus quota, it is largely more sensitive to changes in patient flow, changes in hospital disease structure, and technology improvement. For large hospitals, you have regressed, and the number of patients with high-weight diseases has decreased, and it is difficult to take advantage of the "cheap" according to the fixed reference of the average fee of the previous year, which does not consider the type of disease; for small and medium-sized hospitals, you have improved, and the high-weight diseases have attracted more patients, and you can see the benefits immediately. Many hospitals do not realize that it is related to their own management ideas and refinement, as well as the implementation of hospital management.
(2) The hospital does not know how to do fine management. At present, most of the DRG refined management is based on the rough line management of payment standards, and the standards and indicators transmitted to clinical practice are relatively single (except for a very small number of discipline development and health ranking targets that are higher than medical insurance income targets), except for the medical record coding is based on the payment standard. Because DRG follows the premise of the big number theorem, the dynamic adjustment progress of different disciplines in the reform is different, it can be seen that some departments are very successful, some are not satisfactory, and the idea that managers hope to replicate successful experience by creating benchmarks is correct, but there are not many good ones that can actually be copied and copied. Excluding the personal characteristics of discipline leaders, another key factor is discipline differences, and it is gratifying to see that in 2023, some hospitals have achieved very fine differentiated management of different disciplines in terms of performance orientation, but most of them still have no way to start. In addition to the hospital's own learning experience, the assessment policies and the principle of large-scale screening can also give hospitals more effective guidance. From the perspective of policy integration and continuity, the extension of the requirements of the G-side to the B-side management is the solution to the problem of the community of interests, otherwise there is always a preset of an opposing position, in addition to each proving itself and refuting each other, it is difficult to move towards deep thinking. It's just that this extended risk management needs to set some thresholds and regulatory mechanisms.
Second, concerns about case revenues beyond payment standards based on clinical complexity have also never stopped. Although there are special disease single negotiation and high compensation mechanisms in various places, and DRG/DIP is expected to look at the overall profit and loss, most hospitals must be re-developed, which determines that they should give priority to the short-term income and ignore the long-term impact of dynamic adjustment. This question has also plagued me for many years, and it has always been difficult to do both. From a practical point of view, the current part of the refinement pressure is in the hospital, and as the three-year action plan is nearing the end, the local medical insurance is also more refined in the supervision of big data, and the regulatory constraints and guidance may be able to play a certain role. For example, the detailed analysis of the magnification interval of the key disease groups in each hospital is not only the high and low magnification and normal cases, but also the proportion of cases with normal case overruns and surpluses.
Third, there are also many experts who believe that self-payment should not be included in the general contracting management. For a long time, I was a proponent of this idea, because the actual consumption of drugs at different prices does have different effects on different individuals, and I want to have more choices if I have the ability. However, it has to be said that from the experience of many leading countries (don't directly compare specific data, compare internal logic), the medical expenses of patients with strong payers are indeed higher than those without (the self-paying groups with free wealth also belong to the former), and the cost of the same disease of the employee insured is higher than that of the resident insured, and there are similar factors. In fact, there is no need to worry about whether to include at your own expense, the exclusion policy in many regions can partially solve this problem, but the steps of exclusion are not big at present, mainly for innovative drugs and new technologies, and individuals are very much looking forward to the participation of commercial insurance in addition to self-paid sharing, it is undeniable that this goal requires very fine insurance actuarial calculations, and on the premise of data quality, there is still a way to go.
Overall, the essence of the pot on the back of DRG/DIP is not caused by it, but it is reflected through it, and it has to be favored by the spearhead. However, it is undeniable that the DRG/DIP has made an upgraded version of the in-depth close connectivity and collaboration of the three doctors at an unprecedented speed. It can be seen that the overall idea of the National Health Insurance Bureau is to consider comprehensively, and centralized procurement has actually allowed many hospitals to enjoy policy dividends, and the price reform of medical services and the in-depth expansion of unannounced inspections are important guarantees for the orderly and healthy development of the industry. The industry reshuffle is cruel, a reality that has to be faced, and it is also the only way to the broad road.
Source | Medical insights
Edit | Fu Meiru Zhang Wenqing
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