By using DRG/DIP payment management tools, hospitals can standardize medical record management, rationalize hospital cost accounting behavior, reduce patient costs, realize process reengineering and technological innovation, and improve patient efficacy and medical experience through the transformation of management, treatment, service and operation models. Therefore, studying the impact of the reform of medical insurance payment methods on hospital financial management is helpful to further optimize the internal management and external services of hospitals, and promote the transformation and upgrading of medical institutions.
The need for reform of health insurance payment methods
1. Limitations of traditional medical insurance payment methods
The traditional medical insurance payment method has gone through different periods, and the hospital initially explored the medical insurance settlement mode of the hospital according to the "Hospital Financial System", and the medical insurance payment method was paid according to the project, and the drug consumables and other items could be used to obtain benefits, and the hospital medical insurance payment was in a state of extensive management.
With the promulgation of the "Guiding Opinions on Strengthening the Financial and Budget Management of Public Hospitals" in 2015, it is required that the medical insurance payment method be reformed in combination with clinical practice, and the accounting cost should be calculated according to the project and the classification of diseases. In the process of deepening medical reform, the markup of drugs and consumables has been cancelled, but the payment method of medical insurance has not changed substantially, and the old model of project billing is still continued, and there is still the phenomenon of overtreatment.
2. Requirements for comprehensively deepening the reform of the medical and health system
In 2019, the National Health Insurance Administration (NHSA) issued the Notice on Printing and Distributing the List of National Pilot Cities for Payment by Disease Diagnosis-related Grouping and in 2020, the Notice on Printing and Distributing the Pilot Work Plan for the Total Budget of the Regional Point Method and the Payment by Disease Score. Therefore, it is necessary for medical institutions to re-examine their own operation and operation, start training on medical record management, pay attention to cost accounting management, etc., and continuously promote the reform of the medical and health system.
The impact of the reform of medical insurance payment methods on the financial management of hospitals
The implementation of DRG/DIP payment method reform has put forward higher requirements for the financial management of medical institutions, which is manifested in the following ways:
1. Impact on the perception of financial management
DRG/DIP payment methods put forward higher requirements for financial management. Hospitals must control operating costs and improve financial management to effectively manage the DRG payment process and ensure that DRG payment reforms are effective in certain relationships between hospitals. The reform of the DRG payment system is an important part of the financial management of hospitals, the trend of medical insurance payment in the future, and the only way to go for the reform of the medical and health system. The change of DRG/DIP payment method makes it more difficult to change the financial management method of the hospital, and also increases the risk of the hospital's financial management.
2. The impact on the hospital medical record management system
At present, in the process of implementation in the whole hospital, it has a great impact on the management of hospital medical records. Compared to clinicians, the professionalism of case reviewers is more likely to occur with DRG coding errors because they are not working on the front line. Due to the lack of budget for the hospital to hire professionals, the quality of the personnel who review the medical records is low, and there are coding errors at present. Hospitals still need to further improve the practice standards of DRG coding. As an important part of hospital management, the supervision and review of medical records by hospitals on DRG payment methods requires a lot of manpower in a short period of time, even if the cost of consuming enough human resources is not equal to the amount of medical insurance fund loss caused by the implementation of DRG payment. The implementation of DRG/DIP payment method requires the implementation of an internal control management system for the hospital case management system, and the computer technology related to the medical record management procedure often lags behind, and some cannot keep up with the development speed of the DRG group, and the review of the medical record management is delayed.
3. Impact on hospital revenue recognition
Medical institutions provide medical services to patients, and their income mainly comes from financial subsidies and medical service activities. At present, due to the continuous impact of the epidemic, the state has invested a lot of financial, material and human resources to stabilize the epidemic, which will have a certain impact on the overall economic development of the country, and the scale and growth rate of financial compensation received by medical institutions will continue to slow down. Under heavy pressure, public hospitals should face up to the income of their own hospitals, pay attention to the quantity and quality of hospital business, and pay attention to the added value of hospital income. Changes in DRG/DIP payment methods will affect the hospital's revenue method, cash details and earnings, and will also affect the way the hospital's revenue is recognized.
4. The impact on the refinement of hospital cost accounting
The reform of medical insurance payment methods has brought about the hospital payment standard, under this standard, if the hospital is not operating well, the loss will become increasingly serious, and gradually withdraw from the market environment, so the hospital should pay attention to cost accounting, control the cost to increase the income of the hospital. Prior to the pandemic, total healthcare expenditure remained stable, with major factors such as regional morbidity, regional population, and healthcare costs remaining stable.
The content of the DRG/DIP medical insurance payment method refers to the treatment of patients after admission, and there is a fixed medical insurance income for specific diseases. With the widespread promotion of DRG payment across the country, the revenue calculation model of most hospitals so far has been converted to the DRG payment model with the assistance of the information department. The cost calculation caliber should be unified throughout the hospital, and the cost management and control requirements for clinicians, departments and projects are high. First of all, it requires a lot of clinical experience to divide disease groups, and there is a lack of scientificity in calculating and pricing the costs within the group, and the differences in charges and operating costs of different hospitals are not fully considered when formulating medical insurance reimbursement standards. Second, the operation of medical business activities in hospitals is low, which is higher than the standard level of medical insurance reimbursement due to non-standard operation, and there is also a waste of medical resources, which is not conducive to cost management.
5. New requirements for the hospital's information system
The implementation of the DRG/DIP payment method is, to some extent, to simplify the payment method and reduce the additional burden on patients. The traditional payment method for hospital services has been changed, and the unified payment for hospital health services has been eliminated, and the reform has been carried out simultaneously with the reform of the health system. In practice, it is essential to properly implement payment reforms from the perspective of effective hospital management, which is a serious challenge to the hospital's information system.
Effective information systems control the content and characteristics of DRG payment procedures and must be compatible with accounting procedures to ensure that they do not materially interfere with existing accounting systems, accounting policies and procedures. The reform of the DRG payment system will require hospital information management personnel and hospital accounting personnel to effectively transform and utilize the accounting system to adapt to the changes in the DRG payment system. DRG payment method reform requires a strong financial management information system that rationalizes the hospital's financial accounting work and makes effective use of designated accounts.
6. The impact on the quality of hospital financial personnel
The reform of medical insurance payment methods has put forward higher requirements for the quality of hospital financial personnel. Hospital financial personnel need to understand the medical insurance business, but the medical insurance business requires professional knowledge in economics, treatment, drugs, supplies and information, etc., and it is more difficult for hospital financial personnel to carry out reform work. In addition, financial personnel should also be familiar with information management, the current financial personnel have less knowledge of information technology, are not very proficient in the relevant operations of computer software, lack of experience in financial information management, and reduce the efficiency of financial management to a certain extent. In the process of financial management of hospitals, there is not only a lack of professional and technical personnel related to information management, but also the management ideas of some financial management personnel are still at the level of traditional management concepts, which is difficult to update in real time and cannot flexibly use information management, which has an adverse impact on the promotion of payment method reform. Medical institutions have a large number of medical insurance professional and technical personnel and information technology personnel, but the lack of medical insurance professional knowledge and information technology knowledge of hospital financial personnel has certain restrictions on the implementation of DRG/DIP payment methods.
Countermeasures to be taken by the hospital's financial management department
1. Improve the hospital budget management system
Public hospitals need to continue to improve budget management, establish a budget management structure that adapts to DRG payments, and promote the transformation of hospital budget management from departments to DRG wards. The implementation of the medical insurance plan with the DRG payment model, the establishment of an incentive mechanism to ensure income and expenditure, overspending and responsibility, from the traditional payment according to the amount to the quality of the payment, can mobilize the vitality and vitality of budget management, the formation of an all-round, full-process, full-range budget management model. Therefore, the hospital should actively carry out the budget work, and make annual revenue forecasts and expenditure plans according to the hospital's own development goals and strategies. To do a good job in budget management, the hospital needs to comprehensively consider all the medical business of the hospital and formulate a detailed business cost management plan, and actively implement the budget management work to improve the effectiveness of budget management by improving the budget management system. Budget management involves a comprehensive content to control the hospital's income and related expenditures.
In order to ensure the smooth and effective implementation of the budget management system, it is necessary to clarify the budget management objectives, control and continuously optimize the budget process, and build a sound and efficient budget management and operation mechanism. Formulate relevant systems and regulations for the budget management of the hospital, ensure that the budget preparation is based on rules and evidence, and ensure that the budget management work is completed scientifically and efficiently. Improve the budget management and supervision system, strengthen the supervision of the process, and escort the smooth implementation of budget measures. Improve the evaluation mechanism of budget management, evaluate various evaluation indicators, optimize the evaluation indicators, and carry out the process in an orderly manner in accordance with regulations, so as to obtain fair and just evaluation results. Communicate with the information technology department of the hospital, and be good at using information technology tools to ensure the stable implementation of budget management in an all-round way.
2. Improve the financial analysis mechanism
The implementation of DRG/DIP payment method has increased the difficulty of financial management, and it is necessary to improve the financial analysis mechanism. In terms of performance appraisal, hospitals should make overall planning, and on the basis of the original performance appraisal plan, they can reform the performance appraisal of medical staff according to the characteristics of DRG payment, encourage departments to admit difficult cases and carry out difficult surgeries, and incorporate DRG-related indicators into the performance appraisal of departments, so as to further increase the proportion of difficult diseases and promote the improvement of medical quality.
3. Implement refined management of medical costs
The full implementation of the DRG payment model in hospitals will affect the profitability of hospitals to a certain extent, and it is necessary to pay attention to refined management in financial management.
The first is to formulate standardized settlement standards, which not only promotes the promotion and implementation of the new medical insurance payment model, but also helps to promote the integration of overall settlement income. In order to ensure the standardized formulation of settlement standards, the hospital should formulate a hospital-wide adjustment plan according to the profitability plan of the department reported by each department. Formulate standardized settlement standards, first carry out cost management training, so that the personnel engaged in settlement work can understand cost management, understand the significance of settlement standards, and be able to better implement settlement standards.
The second is to eliminate the waste of resources, do a good job in the promotion of resource conservation, and guide the staff of the hospital to reduce the waste of resources. The management cost approach tends to be fixed cost.
The third is to improve the cost management mechanism. In the process of implementing DRG/DIP payment method, the hospital has an unprecedented impact on income, and the hospital should control the medical cost, make the cost accounting work more refined, calculate the cost of specific diseases separately, adjust the income structure on the basis of cost control, and reduce the impact of the payment method reform on the hospital income. Develop a hospital business plan. Each department submits a long-term business plan according to its own actual situation, and the hospital adjusts the strategic development layout of the hospital after summarizing and sorting it out to improve the overall operation of the hospital. According to the summary data of drug consumption over the years, the hospital calculates the rational drug consumption, draws the red line of consumption, controls the proportion of drug consumption, improves the cost management mechanism of the hospital, and ensures the rational and efficient use of medical resources.
4. Strengthen the construction of the medical record management system
The competent department of the hospital took the lead in setting up a special supervision group, and the medical record management involved many fields, and the professional and technical personnel of the department should master the clinical knowledge, and the group should also invite clinical medical experts, medical insurance fund scholars and experts in the field of case coding to provide technical support for the supervision team. The advantage of the highly professional supervision group is that the personnel in the group have the absolute right to speak on the issues of medical insurance payment and medical case management, so as to ensure that the supervision process is efficient, professional and scientific. The supervision team regularly reviews the DRG cases in our hospital, finds problems such as improper use of codes, verifies the causes of errors, puts forward suggestions for improvement, and reviews the improvement results in the later stage. After the relevant processing is completed, the process of dealing with the relevant problems should also be sorted out into learning cases for each medical institution to learn.
5. Improve the management of information construction
The informatization construction work should focus on intelligent information technologies such as DRG-based payment methods, manual audits, and computer technology and comprehensive audit software. The informatization upgrade and maintenance work must be carried out regularly to ensure the long-term high-quality and stable operation of the DRG payment system. In the process of informatization upgrading, we should pay attention to supervision, learn from foreign experience and technology, such as the United States, Australia and the Netherlands, all attach great importance to internal audit, for DRG/DIP payment methods used in DRG coding, technical specifications including the use of comprehensive verification software systems and medical standard codes, all need to be regularly audited. It's important to ensure that the likelihood of errors in coding cases is reduced. At the same time, we pay attention to external review, learn from the experience of Germany and Poland, mainly through the regular review organized by relevant scholars and experts to verify the problems in the case coding, and then solve the problems in a timely and accurate manner.
In addition, according to the national diagnostic catalogue and operational classification coding, the coding rules are improved to help the medical record reviewers improve the quality of case descriptions. Using information technology or procedures, identify and extract common diseases or disease groups with a high frequency of DRG coding errors, and discuss and analyze them in the hospital expert group. Connect with the national big data platform to smooth the communication channels for case management. Strengthen the management of information construction, apply computer technology and artificial intelligence technology, and improve the accuracy of DRG coding and the quality of medical records.
6. Improve the quality of financial personnel
Finance personnel play an extremely important role in the implementation of the DRG/DIP payment method reform. Hospitals should regularly organize financial knowledge learning, always remind financial personnel to pay attention to the prevention of financial risks, strengthen the management of monetary funds, and enhance the awareness of prevention. The reform of payment methods affects the profitability of hospitals, and financial personnel should properly manage monetary funds to prevent bad debts in the financial department. Considering the use of cash flow in the operation of the hospital, combined with the payment time of the medical insurance fund, and the dislocation of the receivables and payables, the funds are flexibly used to improve the efficiency of fund use. According to the hospital budget management plan, the budget expenditure is strictly controlled. Combined with financial analysis, the financial problems found in the work are solved and reported to the leadership in a timely manner, and the reform process of payment methods is solidly promoted.
In short, the reform of medical insurance payment method is the only way for the long-term development of hospitals, which directly affects the overall operation of hospitals and the implementation of refined management. The implementation of DRG/DIP payment is both an opportunity and a challenge for hospitals. Hospitals should strictly control medical expenses, standardize medical methods, combine clinical management, improve the accounting mechanism, optimize the cost accounting process, achieve effective cost management, and ensure the smooth progress of hospital management reform.
Original title: Research on the impact and coping strategies of hospital financial management based on DRG/DIP payment method reform
Source | Three wisdom medical management
Edit | Yang Zixuan, Liu Xinyu
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