"After a month of hard work, the department deducted money after accounting", "The patient's complaint is just an ordinary disease, and it is found that there are multiple comorbidities after checking, which is embarrassing!" "There are many operational steps that need to be handled for complex patients, and the cost is significantly higher than the standard after benchmarking against DRG. According to the existing medical insurance regulations, doctors often have to do hard work when it comes to reality. Industry insiders confided their hearts.
As an important part of the reform of medical insurance payment in mainland China, how can DRG pay to control the excessive growth of medical expenses, better meet the clinical needs of patients, and provide better services? In the face of this global problem, the reporter of Jiefang Daily and Shangguan News recently conducted an in-depth interview to solve it.
Payment methods are designed to reduce fees
To understand DRG payment, we must first start with the payment method of medical insurance. Professor Gao Jiechun, director of the Hospital Management Institute of Fudan University, made an analogy for reporters: the medical insurance payment is diverse, just like a "restaurant", the medical insurance postpayment system is "I invite guests, the customer pays", the total prepayment system is "buffet", and DRG payment is more like "a variety of packages at a variety of prices".
DRG originated at Yale University in 1967 as a 40-year-old Medicare payment method in the U.S., with the original intention of innovating to apply cost and quality control methods used in industrial production to hospital settings. In 1983, Medicare introduced DRG payments, and today this payment method has spread all over the world. In Germany and other places, DRG payment has become the most important means of medical insurance payment.
The biggest change brought about by DRG payment is that medical costs are significantly reduced, the length of hospital stay is significantly shortened, and because the diagnosis and surgical operation coding is the basis of DRG grouping, the medical record is the source of the code, which can guide the administrator to pay attention to the medical record.
With the wide application of big data in the world, DRG combines big data to derive DIP (according to the value of big data disease components) payment, in order to achieve scientific grouping through more accurate data models. In 2021, the National Healthcare Security Administration issued the Three-Year Action Plan for the Reform of DRG/DIP Payment Methods, which clarified that the DRG/DIP payment reform will be completed in phases and batches from 2022 to 2024. The reporter learned that before the general implementation of the reform by the state, Beijing has started the implementation of DRG payment since 2011, and the pilot selection of Beijing Third Hospital, People's Hospital, Friendship Hospital and other six tertiary general hospitals to carry out.
Zhang Luying, associate professor of the School of Public Health of Fudan University, has conducted research on this and introduced: taking coronary artery bypass grafting as an example, the weight rate of the Beijing version of DRG is 6.2, the unit payment price is 14,300 yuan, and the payment standard is 88,660 yuan. After one year of such a pilot, the out-of-pocket expenses of patients have been reduced, the number of inpatient bed days has been reduced, and the efficiency of medical institutions has indeed improved. In the mid-term evaluation of the five-year pilot, the effect was re-demonstrated using the multiplier method.
Doctors "have to be accountants in addition to seeing patients"?
At the time of the reduction of fees, the disadvantages of DRG payment gradually emerged in the broader reform. "After some medical institutions adapt to the DRG payment rules, in order to obtain more medical compensation, new medical violations that are different from the traditional project-based payment are derived. An industry expert revealed, "The traditional project-based payment method may include fake medical services, fake hospitalizations, and collusion projects." In the context of DRG payment, there are higher requirements for data quality and coding such as diagnosis and surgical operation. Breaking down hospitalizations, high set points, passing on costs, insufficient diagnosis and treatment, and passing the buck to patients have become new problems. ”
Passing the buck to complex patients is one of them. A doctor in a hospital told reporters: In addition to seeing patients, he also has to work as an accountant. For example, he said that imaging showed that patients had "community-acquired pneumonia", and it did not matter much whether to diagnose severe pneumonia in the past, as long as doctors identified it early in clinical practice and put measures in place. However, the payment situation for the pilot DRG is significantly different. In the DRG payment catalog, there is a significant difference in the amount of medical insurance payment corresponding to common pneumonia and severe pneumonia, if the corresponding DRG payment exceeds the standard after treatment, the amount of medical insurance payment exceeds that borne by some hospitals, and some hospitals will "pass on" this to departments or individual doctors.
The doctor further explained that ordinary pneumonia is set into "severe pneumonia", and the surplus of this DRG "low code and high number" treatment cost may bring more benefits to the hospital, and the treatment of real severe pneumonia patients, once ECMO and other instruments are used, the treatment cost is often uncontrolled, and the existing DRG payment is likely to exceed the standard. Under this guidance, medical institutions may be reluctant to admit truly complex cases, and departments with concentrated incurable diseases such as intensive care will also be greatly affected.
The staff of the big data center of Shanghai Tenth People's Hospital also said, "If the clinical path is not prescribed, doctors will complicate simple problems." For example, uterine fibroids should be ruled out as cervical and uterine muscle cancer, but the doctor may prescribe a full set of tumor markers and hysteroscopy examinations to the patient, and some diseases that can be solved by conservative treatment and conventional chemotherapy may also be prescribed by the doctor for MRI examinations. ”
This was confirmed by previous foreign data. In the United States, the proportion of "low-code, high-number" in public hospitals increased from 4.3% to 4.9% between 2000 and 2007 after the implementation of DRG payments for heart failure diseases alone, and after the implementation of DRG payments in Lombardy, Italy, the proportion of "low-code, high-number" in public hospitals increased from 4.3% to 4.9% between 2000 and 2007. Therefore, how to make good use of DRG tools has become the core issue.
How to read the "foreign scriptures" of DRG payment
There is no perfect way to pay for health insurance, and there are pros and cons to each. Gao Jiechun said bluntly: the post-payment system will induce the demand side to consume and bring pressure to the payer; the total budget will lead to quality problems, personal satisfaction will be affected, and the hospital may also select patients; DRG payment must take into account the fairness of patients and the guidance of the supply side.
How can we maximize the advantages of DRG payment and avoid the drawbacks? In the opinion of experts, perfect coding regulations are the foundation. The implementation of DRG payment in Germany is efficient and fast, based on perfect coding and regulations. It is reported that stroke patients under the German DRG model are divided into 10 groups, and factors such as stroke care level, systemic thrombolysis, intracranial hemorrhage and death are all taken into account. The relevant German coding regulations instruct doctors on how to fill in the information in principle, and at the same time cite a number of typical cases under each principle, especially the dispute cases arbitrated by the arbitration committee. These regulations help auditors to ensure that clinicians and coders can quickly determine the accuracy of the medical information they fill in.
Jin Chunlin, director of the Shanghai Health and Health Development Research Center, said that in May 2021, the National Health Insurance Administration announced the DRG group, which was first divided into 26 main diagnostic categories, then divided into 376 core groups, and finally subdivided into 628 charging groups based on other individual characteristics, comorbidities and complications of cases. Depending on the actual situation of the local hospital and the cost structure of the patients, the local government will increase or decrease the number of payment groups on the basis of 628 payment groups. At the same time, he revealed that this year, the country will introduce version 2.0 of the DRG (according to disease diagnosis-related grouping)/DIP (according to the score of big data disease group) classification, and the number of new groups will be increased to about 7800 groups and more than 9,000 groups respectively.
It is also worth paying attention to whether doctors should be excluded from DRG payments to protect the value of doctors' labor. Jin Chunlin believes that DRG as a combination of cases does have the effect of cost control, but in view of the particularity of medical treatment, more attention should be paid to the quality of medical care to achieve "the same disease, the same treatment, the same price, and the same quality". In the United States, before the application of DRG payment, the "Tax Fairness and Financial Responsibility Act" was passed to separate doctors' professional services from hospital services and exclude them from DRG payment, so as to ensure that doctors' income is not affected, and doctors have no incentive to control costs in disguised form by reducing the quality and quantity of medical services, and there is no phenomenon of screening patients and being unwilling to accept complex patients. At the same time, the experts emphasized that DRG pays attention to the labor value of medical staff, establishes trust between doctors and patients, and ultimately achieves a win-win situation for both parties.