On October 26, under the guidance of the National Medical Insurance Bureau, the Shandong Provincial Medical Insurance Bureau, together with 12 municipal governments such as Jinan, Qingdao, Zibo and Dongying, held the official payment kick-off meeting of the reform of Shandong Province's payment by disease diagnosis related grouping (DRG) and payment by disease type (DIP) in Dongying City. These two medical insurance payment methods, which are characterized by "package payment", have been officially implemented in our province.
What are DRG, DIP?
What are DRG, DIP? This needs to be compared to the mainstream pay-per-project model of the past.
Pay by project, popular interpretation, that is, according to all the drugs, service items, consumables used in the diagnosis and treatment process, how much is used to settle, and medical insurance is reimbursed proportionally according to the cost. This model can easily lead to excessive medical treatment, which not only causes the waste of medical resources, but also allows the insured to spend more money and the medical insurance fund to spend more.
In contrast, DRG payment is to divide the disease into different groups according to the severity, the complexity of the treatment method and the different costs of treatment, and the group is priced separately to package the payment, in general, the more serious the disease, the more complex the treatment method, the more the cost paid by medical insurance; DIP payment is the use of big data, the disease according to the "diagnosis + treatment mode" combination as the payment unit, the medical insurance department according to the total amount of medical insurance funds that should be paid each year, determine the payment standard of each disease, and pay the hospital according to this standard.
The reform of medical insurance payment methods, as an important part of the reform of the medical security system, is also a key part of the reform of the "three medical linkages". In accordance with the national deployment, our province will promote DRG and DIP payment as an important part of the reform of multiple composite medical insurance payment methods.
Since the launch of drrg and DIP payment reform in our province in 2019, Qingdao has been selected as a national pilot for DRG payment reform, and 8 cities such as Jinan, Zaozhuang and Yantai have simultaneously carried out provincial pilots for DRG payment reform; 7 cities such as Dongying and Zibo have been selected as national pilots for DIP payment reform, ranking first in the country. Shandong has become the only province in the country to achieve full coverage of the reform of drg payment and DIP payment.
"Promoting the reform of DRG and DIP payment is no longer a simple 'pay as order', but to deepen the whole process of medical clinical path, inspection and inspection, the use of pharmaceutical consumables and medical services, promote the improvement of medical service level, make the clinical path more scientific, the use of pharmaceutical consumables more reasonable, let the limited medical insurance fund buy more scientific, more optimized and more effective medical services, reduce the burden of medical treatment for the masses, and achieve a win-win situation for the three parties." Zhang Ningbo, director of the provincial medical insurance bureau, said.
Instead motivate the hospital
Proactively regulate medical care and reduce waste
This example can reflect the basic logic of dreg payment reform: suppose a patient diagnosed with acute appendicitis needs to be hospitalized for surgery, and after the doctor's evaluation, the DRG group assigned to the patient is estimated to have an estimated medical cost of 5,000 yuan. After the diagnosis, the medical insurance department will pay the hospital 5,000 yuan in advance for the treatment cost. If the hospital has good medical conditions and a high level of medical conditions, and cures the patient with a medical cost of less than 5,000 yuan, the hospital will generate a cost balance. On the contrary, if the hospital spends more money to cure patients due to overtreatment and other reasons, the part exceeding 5,000 yuan will be borne by the hospital.
Judging from the previous pilot situation, an important change in the REFORM OF DRG and DIP payment is to change the previous inspection and examination, drugs, consumables, etc. from "medical revenue" to "medical cost", forcing hospitals and doctors to take the initiative to regulate medical services, control costs, and reduce waste.
Wu Jitao, director of the Department of Urology of Yantai Yuhuangding Hospital, believes that DRG is essentially a classified payment method for patients, and at present, it can effectively reduce the unreasonable growth of medical costs.
Wang Tao, director of the Department of Spine Surgery of Dongying People's Hospital, feels that DIP uses the advantages of big data to objectively group the diagnosis and treatment data according to the common characteristics of the "diagnosis + treatment mode" of the disease, which can basically reflect the actual consumption of medical resources in the process of diagnosis and treatment.
"This reform frees physicians from the heavy 'accounting' work, no longer have to struggle with various proportions, give full play to the autonomy of diagnosis and treatment behavior, and formulate a more reasonable, accurate and effective clinical diagnosis and treatment plan." Song Xu, director of the Department of Infection of Rizhao People's Hospital, said.
Promote the reform of "three medical linkage"
The results are beginning to show
"My mother is an old patient, often hospitalized, compared with before, I feel that now the cost is reduced, the hospital stay is also shorter, some high-priced drugs and non-reimbursable items are reduced, and the number of reimbursements that can be reimbursed has increased." At Rizhao People's Hospital, a patient's family member expressed his feelings about the hospital's trial of DRG reform.
Zhang Ningbo introduced that from the actual operation of Dongying, Yantai, Rizhao and other cities, the results of drg and DIP payment reform in our province in promoting the reform of "three medical linkages", improving the level of medical services, improving the efficiency of the use of medical insurance funds, and reducing the burden of medical treatment on the masses have initially emerged.
From the perspective of medical services, a total of 19 DRG-paid pilot hospitals in Yantai and Rizhao cities, the 14-day re-hospitalization rate reflecting the quality of medical services decreased by 10.5% and 27.93% respectively; the average hospitalization days, time consumption index and cost consumption index reflecting the efficiency of medical resource use decreased by 3.3%, 4.2%, 16.5%, 3.3%, 0.51% and 1.06% respectively.
From the perspective of medical insurance governance, the income structure of pilot hospitals in Yantai and Rizhao continued to be optimized, and the medical service income that reflected the value of medical personnel's technical labor services rose by 8% and 10.39% year-on-year, respectively, and the proportion of drug revenue fell by 15.3% and 4.88% respectively year-on-year. The fund audit is more efficient, and the two cities have retrieved and rejected more than 15.27 million yuan of medical insurance funds according to the agreement through big data retrieval and analysis screening and audit cases.
From the perspective of medical burden, 16 of the 19 pilot hospitals in Yantai and Rizhao have experienced negative growth in average hospitalization costs, of which the largest reduction in average secondary costs has reached 25.32%.
It is understood that on the basis of summarizing experience, the Provincial Medical Insurance Bureau will accelerate the expansion of coverage, and all 16 pilot medical institutions in 16 cities will officially pay for DRG and DIP payment reform by the end of this year, and achieve full coverage of qualified designated medical institutions by the end of 2022.
Source: Dazhong Daily