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    Home > Active Ingredient News > Drugs Articles > Case Interpretation DIP/DRG Dual Pilot Improves the Use Efficiency of Medical Insurance Funds

    Case Interpretation DIP/DRG Dual Pilot Improves the Use Efficiency of Medical Insurance Funds

    • Last Update: 2022-03-06
    • Source: Internet
    • Author: User
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    In July 2019, a tertiary hospital in Shanghai became a pilot hospital for payment by disease points (DIP), and in 2020, it became a pilot hospital for payment by disease diagnosis-related groups (DRG), becoming the only DIP/DRG dual hospital in Shanghai.
    One of the pilot hospitals
    .


    Through the use of DIP/DRG management tools, the hospital provides a starting point for clinical departments to improve the level of discipline construction, realizes the decline of simple diseases and the improvement of diagnosis and treatment of difficult and difficult diseases, and promotes the transformation and upgrading of medical institutions from the development of extension scale to the development of connotation quality.


    Case description

    Case description

    (1) Setting up a working group

    (1) Setting up a working group

    In July 2019, the DIP promotion leading group and working group were formed by the hospital leaders and relevant functional departments, and on this basis, the DRG+DIP promotion leading group and working group were established in July 2020 to be fully responsible for the hospital's DRG/DIP payment.
    Advancement of work
    .

    (2) Carry out training and publicity

    (2) Carry out training and publicity

    Through on-site publicity in clinical departments, regular meetings of clinical leading doctors, etc.
    , actively do a good job in promoting the transformation of DIP/DRG disease structure, and mobilize the enthusiasm and initiative of all staff to support and cooperate with the reform
    .


    All relevant functional departments summarize the progress and management experience in a timely manner, and promote good experience and good practices by organizing experience exchange meetings, on-site meetings, special training courses,


    (3) Responsibilities of each department

    (3) Responsibilities of each department

    1.
    Financial Operations Department

    Financial Operations Department

    Finance is responsible for historical data measurement and cost monitoring, and uses DIP/DRG as a management tool to guide hospitals in cost control, correct extensive income increase behavior, standardize medical behavior with high-quality clinical pathways, and refine cost control to disease types.
    The positioning of the hospital (tertiary public hospital) is clarified from the two dimensions of disease cost control ability and diagnosis and treatment ability, and a department cost control model with DIP/DRG core indicators as variables is constructed to optimize the department's economic structure and reasonably control costs
    .

    2.
    Information management department

    Information Management Department

    The information department is responsible for ensuring the safety and stability of the hardware platform and network services, interconnecting the hospital's internal HIS system, medical record system, charging system and medical insurance settlement system, and completing interface transformation and data according to the data interface specifications on the front page of medical records and the requirements for data quality control on the front page.
    Reporting, effectively ensure the connection of data reporting interfaces, the accuracy and timeliness of data format conversion, improve data quality, and provide timely and professional technical support for the information needs of various departments
    .

    3.
    Medical record management department

    Medical record management department

    The medical record room accurately writes disease classification and surgical operation codes in accordance with the requirements of the homepage filling standard, and builds a three-level quality control system for coding to ensure the quality of the medical record homepage
    .


    In the case that the clinician has made a definite diagnosis, but the writing format does not conform to the disease classification rules, the coders should implement the coding according to the classification rules


    4.
    Medical insurance management department

    Medical insurance management department

    The Medical Insurance Office handles the linkage supervision relationship among various departments.
    While emphasizing the internal linkage of medical care, medical insurance, and pharmacy, the equipment, finance, and information departments are included in the linkage work mode.
    Multiple departments realize normal communication and connection, and treat diagnosis and treatment from their own perspectives.
    Behavior evaluation and timely feedback
    .


    Regularly check the feedback results, continuously summarize and revise, promote the optimization of the diagnosis and treatment process, form a virtuous circle, and promote the rational use of medical insurance funds


    5.
    Medical management department

    Medical management department

    The Medical Service is responsible for conducting regular inspections and medical quality evaluations to identify weak links and loopholes in management and reduce medical safety problems
    .


    Focus on selecting some quality indicators and incorporate them into the monthly department and individual quality evaluation system, establish an evaluation and scoring system, and use data to dynamically evaluate the service level of hospitals, specialties and physicians in multiple dimensions


    (4) Working mechanism

    (4) Working mechanism

    1.
    Establish a data-based decision-making management mechanism

    Establish a data-based decision-making management mechanism

    Perform online analysis, processing, data mining and data presentation on the operation of the hospital's DIP, deeply mine the value behind the data, help the hospital to dynamically monitor the medical quality and safety of each link in a vivid and accurate visualization, and provide continuous improvement for the hospital's management decision-making and quality Provide more scientific, standardized and accurate data support
    .


    The hospital automatically analyzes the operation of the hospital in terms of the average cost per patient, the proportion of drugs, the proportion of laboratory tests, the proportion of sanitary materials, the proportion of expenses outside the medical insurance catalog, the average length of stay and the proportion of antibiotics


    2.
    Establish a grid information feedback mechanism

    Establish a grid information feedback mechanism

    The hospital integrates the horizontal mesh management model on the basis of the existing vertical hierarchical management, integrates various information in an orderly manner, and reasonably improves the allocation of resources and the efficiency of decision-making
    .


    In terms of organizational structure, implement the department director's responsibility letter system, and rely on the leading doctors, medical insurance specialists, and medical record homepage specialists to realize the management method of functional departments to supervise the movement of clinical departments, establish fast feedback information communication channels, and reduce the interference of information transmission , to bring the management and decision-making layers closer to the front-line clinical departments and improve management efficiency


    3.
    Establish an incentive and restraint mechanism

    Establish an incentive and restraint mechanism

    The hospital strengthens the refined management of medical insurance funds, actively improves the identification of violations, and focuses on the implementation of management systems for standardized diagnosis and treatment, decomposition of hospitalization, and rational drug use
    .


    The first is to incorporate information on medical insurance violations into the system, form a negative list of personal violations by physicians, increase the cost of physician violations, and urge medical insurance physicians to conduct reasonable inspections, rational drug use, and reasonable treatment


    Case results

    Case results

    1.
    Optimize the allocation of medical resources and improve the utilization rate of medical insurance funds

    Optimize the allocation of medical resources and improve the utilization rate of medical insurance funds

    Compared with January-June 2019, the distribution of the RW interval of the hospitalization medical insurance amount from January to June 2021, the group with the largest decrease was RW<0.
    2 (-56.
    9%), and the three groups with the largest increase were 2.
    5 ≤RW<3 (72.
    82%), 3≤RW<3.
    5 (46.
    44%) and RW≥5 (45.
    15%), the overall trend of medical insurance funds in the low RW group was gradually distributed to the middle and high RW group
    .
    This shows that the hospital has initially formed a path for optimal allocation of resources in which high-quality medical resources are more concentrated on medium- and high-difficulty diseases, achieving a win-win situation between the use efficiency of medical insurance funds and the connotation of valuable medical care (see Table 1)
    .

    2.
    Establish a rapid new technology screening mechanism to accelerate the transformation and development of hospitals

    Establish a rapid new technology screening mechanism to accelerate the transformation and development of hospitals

    Rapid grouping and real-time feedback based on big data patient group value payment, combined with information systems, can quickly identify new clinical technologies and encourage clinical technological innovation
    .
    For example, in the data monitoring, it was found that the innovative surgical method "laparoscopy, electronic colonoscopy, and anoscopy combined with three-dimensional endoscopy" under the disease "laparoscopic radical resection of sigmoid colon cancer", and its operation path was compared with the traditional path "laparoscopic, The comparison and analysis of electronic colonoscopy and dual-scope combination” found that the innovative surgical method can not only effectively reduce auxiliary incisions and postoperative adhesions, reduce the inflammatory response in the abdominal cavity, and promote the recovery of intestinal function, and the “three-scope combination” is better than the traditional two-scope.
    The average length of hospital stay for surgery was shortened by 8 days, resulting in a 23.
    9% drop in the cost of diseases and a 31.
    24% increase in medical insurance balances
    .
    Through the study of the relationship between the clinical application of new technologies and new projects, diagnosis and treatment paths, and medical expenses, the hospital realizes the improvement effect of technological innovation on the treatment effect of patients and the economic structure of the disease, and accelerates the transformation and development of the hospital
    .

    3.
    Build a new performance incentive mechanism to realize the connotation of value medical care

    Build a new performance incentive mechanism to realize the connotation of value medical care

    Taking the reform of payment method as the starting point, the department CMI progress award was established to guide clinical departments to improve the ability and service level of treating difficult patients
    .
    Combining the six dimensions of CMI, total index, number of enrollments, proportion of "National Examination" four-level surgeries, proportion of difficult and critical cases, low-risk mortality, etc.
    Rewards are issued once
    .
    Guide doctors to choose more valuable medical technologies to provide services to patients through a new performance incentive mechanism
    .
    From January to June 2021, the hospital performed a total of 19,349 third- and fourth-level surgeries, an increase of 17% over the same period in 2019; the corresponding medical insurance cost was 454.
    64 million yuan, an increase of 33.
    15% over the same period in 2019
    .
    There were 7,079 cases of third- and fourth-level operations, an increase of 45.
    21% over the same period in 2019; the corresponding medical insurance cost was 189.
    6 million yuan, an increase of 66.
    75% over the same period in 2019
    .
    The volume of third- and fourth-level surgeries and operation services has increased, and the functional positioning of third-level hospitals for difficult, complex and severe diseases has been further reflected, effectively guiding the clinical trend towards value medical care, and promoting medical insurance funds to be more inclined to difficult operations and operations
    .

    Reviews

    Reviews

    Establishing an effective and efficient medical insurance payment mechanism is an important means to promote the high-quality development of medical insurance and medical care in the era of universal medical insurance
    .
    As the core management unit of the medical insurance payment mechanism, medical institutions are not only the implementation objects of the medical insurance payment mechanism, but also the forefront of implementing the reform of various payment methods.
    How to adjust the internal management system and performance system of the hospital in order to accurately control the cost The transmission of the incentive mechanism for increasing efficiency to medical service behavior is an important part of determining the effectiveness of the reform of payment methods
    .
    As a DIP/DRG dual pilot hospital, the case hospital has accurately understood the spirit of reform.
    In the process of reforming the payment method, it has realized the double improvement of medical insurance fund expenditure and efficiency by integrating and optimizing the internal management process and organizational mechanism.
    There are two outstanding highlights
    .

    First, the management of medical insurance cost control and the improvement of medical quality go hand in hand, reflecting the core essence of the reform of payment methods
    .
    Regardless of DRG or DIP, the essential goal is to guide the "self-awakening" of medical behavior awareness through the incentive mechanism of payment means, to achieve reasonable diagnosis and treatment, and to play the strategic purchasing role of medical insurance funds
    .
    In the process of implementing the payment method reform, the case hospital has carried out this concept throughout, and has always adhered to the two dimensions of disease cost control and diagnosis and treatment capacity, and carried out cost calculation, operation supervision, assessment and evaluation, performance distribution and other work to promote clinical practice.
    Experts actively explore more cost-effective treatment methods, so that more "high-quality and low-cost" medical services can quickly be paid attention to and benefit the masses
    .
    At the same time, it guides medical institutions to optimize resource allocation, and focuses on medium and high difficulty diseases around their own functional positioning, achieving multiple effects of improving quality, increasing efficiency, controlling costs, and benefiting the people
    .

    First, the management of medical insurance cost control and the improvement of medical quality go hand in hand, reflecting the core essence of the reform of payment methods
    .

    Second, through process reorganization and departmental coordination, a whole-process management system for medical insurance payment of “horizontal to edge and vertical to the end” has been established to ensure that reform measures go directly to the core links of medical services
    .
    The reform of medical insurance payment method not only involves the transformation of financial accounting methods of medical institutions, but also a comprehensive upgrade of development concepts, management models and operating mechanisms.
    Layer by layer implementation
    .
    The case hospital pays attention to the full combination of cross-departmental collaboration and grid management in the implementation process.
    The operation system ensures that the policy is implemented in place, thus forming a "horizontal to edge, vertical to the end" medical insurance payment whole-process management system to achieve effective linkage from top to bottom
    .

    Second, through process reorganization and departmental coordination, a whole-process management system for medical insurance payment of “horizontal to edge and vertical to the end” has been established to ensure that reform measures go directly to the core links of medical services
    .

    The "Notice of the National Medical Security Administration on Printing and Distributing the Three-Year Action Plan for the Reform of DRG/DIP Payment Methods" (Medical Insurance [2021] No.
    48) pointed out that by the end of 2025, DRG/DIP payment methods will cover all eligible medical services that carry out inpatient services.
    Institutions have basically achieved full coverage of disease types and medical insurance funds
    .
    As an important reform measure that "affects the whole body", the payment method is becoming more and more important in the context of the deepening of the "three medical linkage" reform, and has become a check and balance point for connecting doctors, patients, and protecting the interests and efficiency of multiple parties
    .
    As the DRG/DIP pilot fully starts actual payment at the end of 2021, its reform effects will be further projected to multiple dimensions such as medical quality, operational efficiency, standardization of information standards, and patient benefit
    .
    At the same time, the two payment methods are based on the common reform purpose, and on the basis of basically the same technical principles, they will further learn from each other and continue to integrate in the practice process, so as to promote the continuous optimization of clinical pathways, and give the patient groups/diseases to standardize More connotations such as diagnosis and treatment, improving efficiency and reducing costs
    .

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