The purpose of the health insurance regulatory system is to improve the quality of medical services, not to blindly reduce prices.
In recent years, the growth of medical expenses has been significantly controlled after the reform of many provinces and cities to pay according to disease diagnosis-related groups (DRGs). However, in the face of such a complex medical problem, there is no perfect regulatory method in the world, and with the deepening of reform, a new problem has emerged, that is, some medical institutions are unwilling to accept patients with complex conditions.
This is because the patient's initial complaint is only a common disease, and after the standard is determined, it is found that there are multiple comorbidities, which will lead to a significant excess of the cost after the DRG is benchmarked. After the cost is exceeded, the excess amount of medical insurance payment will be borne by the hospital itself, and some hospitals will require the department or doctor to bear it personally. The responsibility was pressed step by step, and as a result, the doctor worked hard for a month, and as a result, he had to be deducted money after accounting.
DRG originated at Yale University in 1967, and its inventors applied the methods used for cost and quality control in industrial production to service performance evaluation and health insurance payment management. In 1983, Medicare launched the DRG payment system. Subsequently, the DRG payment system was widely used in many countries around the world, such as Germany and France.
To put it simply, DRG/DIP is to determine what the disease is, and then the medical insurance pays according to the type of disease. Of course, this is just the most simplified statement, in fact, it is also necessary to consider the total cost of the region, the total amount of medical services in the region, etc. The DRG point method is similar to DIP in terms of methodology, and in areas where the DRG/DIP payment method reform is implemented, hospitals obtain points/points through medical services, and then the medical insurance bureau settles the corresponding medical insurance funds to the hospital according to the total points/points and point values of the hospital in the current year, similar to a "work division system". That is, the point value of the disease (unit price) is the cost paid by the medical insurance fund for DRG/DIP (total cost) / the total score (service volume) of all hospitals in the region.
When the doctor needs to bear the excess, in order to avoid the loss of his own interests, the doctor has to control the cost. There are many ways for doctors to do so. For example, avoid those complicated diseases, which is the phenomenon at the beginning of the article.
The solution to these problems is to codify regulations more. To put it simply, it is to classify the diseases more carefully, and list as many diseases and complex diseases as possible. For example, stroke patients were divided into 10 groups under the German DRG model, and factors such as stroke care level, systemic thrombolysis, intracranial hemorrhage, and death were all taken into account. This allows doctors to face complex conditions, and can also find the corresponding code, so that they no longer have to pass the buck to complex conditions.
In fact, DRG also creates another problem, that is, doctors will try to rely on diseases with higher scores. For example, for community-acquired pneumonia and severe pneumonia, doctors will try to rely on severe pneumonia as much as possible, so as to get more medical insurance funds, and the balance is the profit of the hospital. However, this would push up the overall score of the region's medical services, putting the entire region in another predicament.
If the regional medical insurance fund declines, the total score of the regional medical service increases, that is, the denominator becomes larger, and the disease point value will decrease. This leads to the so-called depreciation of the value of the DRG/DIP point method. Zhong Chonghai, a well-known medical management expert, cited the case of a township health center in his article: "Last year, the DIP point was worth 9 yuan, but this year it has become 6 yuan. "This has created a cycle in which the hospital is constantly controlling costs and has a larger workload, but its income is decreasing.
In a way, DRG is the algorithm. Speaking of algorithms, since that article "Trapped in the System", society seems to have an inexplicable antipathy towards algorithms. The algorithm drives the rider to be faster, and the system discovers that the rider can be faster, and raises the bar. To some extent, doctors face a similar dilemma. A doctor on Zhihu complained: The most suffocating point of DRG is that after the reimbursement cost of this year's disease is obtained according to the weighted average of the treatment cost of a certain disease in the local area in previous years, when the hospitals want to reduce the cost by reasonable or unreasonable means to ensure the survival of profits, the reimbursement ratio of the disease will be reduced next year.
Essentially, these behaviors, phenomena are interactions between people and management methods. DRG is dealing with a very complex system. Human diseases themselves are extremely complex, and then, on top of complex diseases, patient demands and doctors' behaviors will add more complex human nature. This often defeats the original intent of the DRG system.
DRG was invented in the 70s of the 20th century, when computers had just appeared, and human beings had not yet made a qualitative leap in their ability to grasp data, so to a certain extent, the methodological essence of DRG was still simplified. Although DRGs now make extensive use of computers, in essence, they are still adding new technologies to the methodology of "simplification" in the past.
At present, with the emergence of computers, big data, and artificial intelligence, human beings have made a qualitative leap in their ability to find clues from vast data. For the behavior of doctors and medical institutions, it is also possible to directly grasp the massive data without simplifying. More directly, with the intervention of artificial intelligence and big data, even if there is no model to simplify or reduce it to points, it is basically possible to judge whether doctors are abusing medical insurance from every medical behavior of doctors. Therefore, it is now possible to carry out fundamental innovation in methodology on the basis of DRG, so that the model and points disappear invisible, so that doctors no longer have to calculate various points, but only need to be good to patients wholeheartedly, and the system can naturally get the correct conclusion. On this basis, it is possible to decouple doctors' medical labor from medical expenses, and doctors will no longer be allowed to unfairly bear the extra costs.
On a larger level, the purpose of the health insurance regulatory system is to improve the quality of medical services, not to blindly reduce prices. Any transaction and payment behavior cannot be exhausted, and once the price approaches the edge of cost, it will inevitably be accompanied by a decline in quality. This point must not be ignored by both the DRG and the centralized procurement system.
Written by丨Liu Yuanju
Source丨Yangcheng Evening News