Payment by Disease Diagnosis-Related Group (DRG) is based on disease diagnosis and aims to achieve reasonable payment through scientific grouping. This model is not only conducive to curbing the unreasonable growth of medical expenses and ensuring the sustainable operation of the medical insurance fund, but also conducive to encouraging medical institutions to improve service efficiency and medical quality, and is becoming an important tool for medical insurance management.
In order to discuss how to better coordinate clinical practice and medical insurance management, and how to further improve and optimize relevant policies, Dong Siping, a researcher at the Hospital Management Institute of the National Health Commission, together with researchers from scientific research institutes and medical institutions such as Peking Union Medical College and Beijing Hospital of the Chinese Academy of Medical Sciences, and managers of medical institutions, jointly compiled the "Collection of Typical Cases of Medical Insurance Management of DRG Paid Cases" from the practical needs of medical insurance management of medical institutions.
From this issue onwards, Health News will continue to publish some representative medical insurance management cases of DRG payment cases, in order to discover the commonalities of the industry through case analysis, and then put forward suggestions on optimizing clinical practice models and medical insurance management policies.
Case 1
Pre-hospital definitive diagnosis is included in project management
A 23-year-old male patient with tuberculosis underwent sputum culture examination at Shanghai Pulmonary Hospital in January 2020, and the results showed "multidrug resistance". Chest CT is reviewed regularly. In November 2020, chest CT showed that "lung lesions have progressed compared to before". On January 27, 2021, the patient received bedaquiline (Bdq)-linezolid (Lzd)-clofazimine (Cfz)-cycloserine (Cs)-levofloxacin (Lfx) anti-tuberculosis therapy and liver protection supportive therapy.
In October 2021, the patient came to Wuhan Pulmonary Hospital with numbness in both feet, hoping to receive further diagnosis and treatment.
The hospitalization
On October 19, 2021, the patient was admitted to the hospital. The department has improved auxiliary examinations such as blood routine, blood biochemistry, CTB (tuberculosis culture), PCR (polymerase chain reaction), etc., and temporarily continued Bqd-Lzd-Cfz-Cs-Lfx anti-tuberculosis therapy and liver protection supportive therapy; Because the patient was enrolled in the bedaquiline fumarate short-course program, the need for adjustment of related medications was additionally evaluated.
On October 20, 2021, the department temporarily continued the original treatment plan and continued to improve the relevant examinations. The patient still feels numbness in both lower extremities.
On 24 October 2021, the patient complained of numbness in both lower limbs and requested to be discharged. For solid intrahepatic lesions, the department recommends that they go to the hepatology department if necessary; For chronic pharyngitis, tonsillar hypertrophy, etc., it is recommended to go to a specialist or general hospital for further diagnosis and treatment.
Clinical diagnosis
During the treatment period, the patient rests at home, has no fixed income, and is under great financial pressure. Multidrug-resistant tuberculosis (MDR-TB) has a long course of treatment, a large number of medications, and a high cost of treatment. Patients who have an adverse reaction to the drug, and numbness in the feet are thought to be peripheral neuropathy due to linezolid.
The main diagnosis of this admission was "secondary tuberculosis (naïve, multidrug-resistant)". Other diagnoses were "bronchiectasis with infection; community-acquired pneumonia, non-severe; peripheral neuropathy (peripheral neuritis); eosinophilia".
If the patient can complete the anti-tuberculosis treatment according to the rules, the tuberculosis can be cured.
Follow-up and outcomes
The patient was hospitalized for a total of 5 days, and the total hospitalization cost was 6212.54 yuan. The medical insurance DRG settlement group is "ES1A respiratory tuberculosis with serious or general complications and comorbidities", and the medical insurance payment standard is 8728.64 yuan, and the hospital has a surplus. The patient has been taking the medication regularly so far, and the compliance is good, and there are no adverse reactions or accidents.
discuss
Patients with MDR-TB were enrolled in the same condition as patients with susceptible TB. If the normal treatment pathway for the ES1A group is followed, the cost of treatment for the patient should be much higher than the standard for the treatment group.
The reason for the surplus in this case is that the patient is a previously confirmed case, and the examination cost is relatively low, and the hospitalization cost is relatively low; Second, due to the poor economic situation of patients, they were included in the relevant project management, and some drug fees were reduced or reduced.
Clinically, the diagnosis process of MDR-TB is complex, the cost of treatment drugs is high, and the economic burden of patients is heavy, which far exceeds the payment standard of the DRG group. In view of the complexity of the diagnostic process, the use of drugs, the number of adverse reactions, and the high cost, some patients are unable to adhere to regular anti-tuberculosis treatment due to excessive economic burden. Therefore, it is recommended that the medical insurance department appropriately increase the reimbursement ratio for MDR-TB and pay it separately from sensitive TB in the DRG group, so as to ensure that MDR-TB patients receive the necessary treatment in a timely manner and lay a good foundation for ending the TB epidemic.
Case 2
The diagnosis process is complex and the cost of examination is high
A 49-year-old male patient with a history of diabetes mellitus for 1 year came to Wuhan Pulmonary Hospital with cough and weight loss for 2 weeks, hoping to confirm the diagnosis of tuberculosis and receive treatment.
The hospitalization
On July 5, 2021, the patient was admitted to the hospital. The department dynamically monitors blood glucose, continues hypoglycemic therapy, and improves auxiliary examinations such as blood routine, blood biochemistry, CTB (tuberculosis culture), PCR (polymerase chain reaction) and so on.
On July 6, 2021, the department continued to improve the auxiliary examination; At the same time, considering that the patient has gout symptoms, isoniazid (H)-rifampicin (R)-ethambutol (E)-levofloxacin (Lfx) anti-tuberculosis treatment was given, and the drug toxicity and side effects were monitored.
On July 7, 2021, the results of Mycobacterium tuberculosis and rifampicin drug resistance test suggested that "Mycobacterium tuberculosis DNA detection (low) and rifampicin resistance gene mutation detection detection". The department considered rifampicin tuberculosis, suspended the current protocol, and improved other rapid drug resistance gene testing.
On July 10, 2021, other rapid drug resistance gene tests showed that "fluoroquinolone resistance gene gyrA mutation detection detection, isoniazid resistance gene inhA mutation detection detection, isoniazid resistance gene katG mutation detection not detected". The department is requested to consult the multidrug-resistant ward in the hospital.
On 12 July 2021, the patient was transferred to a multidrug-resistant ward for further treatment. Relevant examinations are carried out in the ward, and multidrug-resistant specialists are invited to discuss and formulate a treatment plan for anti-MDR-TB.
On July 13, 2021, linezolid (Lzd)-cycloserine (Cs)-clofazimine (Cfz)-delamanib (Dlm)-propylthionimidamide (Pto) anti-tuberculosis treatment was given in the ward, and liver protection therapy was given.
On July 19, 2021, the patient did not complain of discomfort after taking medication and requested to be discharged, which was handled by the hospital. The patient continued to receive anti-tuberculosis therapy after discharge.
Clinical diagnosis
Patients have limited annual income, poor economic conditions, and chronic diseases such as diabetes.
The main diagnosis of this admission was "secondary tuberculosis (naïve, multidrug-resistant)". Other diagnoses were "type 2 diabetes mellitus, gouty arthritis, pulmonary cavities".
The patient has pulmonary tuberculosis combined with diabetes mellitus, and rifampicin, if the course of treatment is completed smoothly, the prognosis is average; If the course of treatment is not completed smoothly, blood sugar control is not good, and the prognosis is poor.
Follow-up and outcomes
The patient was hospitalized for a total of 14 days, and the total hospitalization cost was 13,852.87 yuan. The medical insurance DRG settlement group was "ES1A respiratory tuberculosis with serious or general complications and comorbidities", and the medical insurance payment standard was 8728.64 yuan, and the hospital suffered a loss. Follow-up patients' medication compliance and tolerability were acceptable, and there were no adverse reactions or accidents.
discuss
Patients are admitted to the hospital because they are suspected of tuberculosis, and after admission, they undergo a large number of examinations to confirm the diagnosis of tuberculosis, resulting in a relatively high proportion of examination costs. After the diagnosis is confirmed, the patients need many types of drugs for treatment, the treatment time is long, the adverse reactions are large, and other adjuvant drugs are required during the treatment process, and the cost of combined drugs is high. The combination of the two causes the overall treatment cost of the patient to exceed the DRG payment standard.
Therefore, it is recommended to increase the DRG payment standard for MDR-TB and provide policy support for the examination and medication of MDR-TB patients.
Expert commentary
It is unreasonable to have the same payment standard for both types of tuberculosis
Researcher of the Hospital Management Institute of the National Health Commission
Dong Siping
This issue focuses on an ancient infectious disease, tuberculosis. Tuberculosis, also known as tuberculosis, is an infectious disease caused by infection with the bacterium Mycobacterium tuberculosis.
According to the 2023 Global Tuberculosis Report released by the World Health Organization, the number of new TB patients in mainland China in 2022 is about 748,000, and the burden of TB treatment is high. Improving the quality of medical services and the level of medical security for tuberculosis patients is of great significance for protecting people's health, ensuring public health safety, and maintaining economic and social stability, and is also an important proposition in deepening the DRG payment reform.
The consumption of medical resources for tuberculosis patients is mainly focused on the cost of examinations and medicines. With the support of relevant national policies, the cost of examination and medicine for ordinary tuberculosis patients is relatively low. However, the diagnostic process for patients with MDR-TB (resistant to at least isoniazid and rifampicin) is relatively complex, and bronchoscopy, sputum culture, molecular biology tests, and drug susceptibility tests are often required in addition to routine x-rays, CT scans, and sputum smears. As a result, the cost of testing for MDR-TB patients is high, which in turn leads to the inability of DRG payment standards to meet the payment needs of patients.
In Case 1, the medical institution achieved a settlement surplus because the patient was diagnosed outside the hospital due to the multi-drug resistance, and the hospitalization mainly consumed drug costs. In case 2, the patient was diagnosed with multi-drug resistance during hospitalization, and formulated, adjusted, and implemented a treatment plan during the hospitalization, and the hospitalization resource consumption included examination fees and drug fees, so the overall cost exceeded the DRG payment standard, which in turn led to the settlement loss of the medical institution.
The difference in the treatment cost of patients with common tuberculosis and multidrug-resistant tuberculosis shows that it is not reasonable to adopt the same payment standard in the payment process of DRG, and it does not conform to the grouping concept of "similar diagnosis and treatment process and similar resource consumption". In the practice of DRG payment, it is recommended to optimize the DRG grouping scheme, divide MDR-TB and common TB into different DRG disease groups for data measurement, and formulate different payment standards accordingly. In this way, there is enough space for medical institutions to admit MDR-TB patients, which is of great significance to ensure that patients receive high-quality and reasonable medical services.
Case review: Wuhan Pulmonary Hospital, Ren Nili, Chen Xianxiang
Editors: Zhang Mo, Ning Yanyang, Yang Zhenyu
Proofreader: Li Shiyao
Review: Qin Mingrui, Xu Bingnan
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