Doctors will earn a high income from service! New measures to reform the way health care is paid

On | 20 November, the Office of the State Health Insurance Administration issued a notice of the National Medical Security Paid by Disease Value (DIP) Technical Specification and DIP Disease Directory Library (version 1.0) (Medical Insurance Office issued No. 50 (2020), referred to as "Notice"), marking the rapid and orderly progress of the pilot work of paying for diseases by value.
Although currently only piloted in 71 cities, according to the pilot program, the future to the whole country has been a matter of urgency, so non-pilot areas of medical institutions should also pay attention to and be ready for reform as soon as possible.
doctor said that compared to DRGS, the consumption of resources more clearly classified, more conducive to reflect the true weight of medical services.
health care workers rely on the provision of medical services to obtain value, the future will be a major trend.
will such a heavy-weight reform be carried out? What will be the impact on hospital doctors? The author tries to make an interpretation of the New Deal for readers, it can be said that the reform of medical insurance payment methods is playing an increasingly important role in China's medical pattern, hospital management concept, should be worthy of every medical worker, hospital management focus on.
1. In 2017, the General Office of the State Council issued the Guidance on Further Deepening the Reform of Basic Medical Insurance Payment Methods, calling for the full implementation of multi-composite medical insurance payment methods based on disease-based payment.
2020, the Central Committee of the Communist Party of China and the State Council issued the Opinions on Deepening the Reform of the Medical Security System, calling for the establishment of a well-working and efficient payment mechanism for medical insurance.
in the spirit of the document, the National Health Insurance Administration issued a report in December 2018 for the diagnosis-related cluster (Diagnosis Related Groups, DRG) pilot cities, and in May 2019 identified 30 integrated areas for drEG pilot.
requires the pilot cities and provinces to be under the unified leadership of the national DRG payment pilot working group, in accordance with the "top-level design, simulation testing, actual payment" three-step thinking, through the DRGs paid pilot city in-depth participation, jointly determine the pilot program, explore the way forward, develop and improve the national basic unified DRGs payment policy, process and technical standards, forming a reference, replicable, replicable pilot results.
specific requirements to ensure that the 2020 simulation runs and that the actual payment is initiated in 2021.
Because DRG to disease diagnosis as the core, similar cases into a group management, each group has dozens of similar diseases and similar operations, in principle, the group does not exceed 1000 groups, the advantage is easy to compare management, the disadvantage is strong professional, difficult to operate.
has been in place for more than a year and has not seen any reports of experience in a particular city.
October 19, 2020, the National Health Insurance Administration issued a total budget for the regional points method and a pilot work programme for paying by disease (Diagnosis-Intervention Packet, DIP) (Health Insurance Office No. 45) (Health Insurance Office No. 45), requiring all localities to complete the pilot city declaration by October 20.
November 4th, the National Health Insurance Administration decided to carry out a pilot project on the total budget of the regional points method and the payment by disease score in 71 integrated areas.
DIP emphasizes one-to-one matching of primary diagnostic and primary diagnostic methods, the number of diseases can reach tens of thousands to hundreds of thousands, although DIP is mainly based on data matching, lack of clinical judgment on the rationality of the main diagnostic choices and the matching of diagnosis and treatment methods, Code high sets, misfilling, leakage and other acts of supervision is more difficult, obvious shortcomings, but because the operation is easier, and the actual level of Chinese hospitals is relatively close, so easy to promote, and also to ensure that the fund is not overdrafted, so many experts believe that is with Chinese characteristics of health insurance payment methods.
DIP technical specification also pointed out that in the concept and operation methods, DIP conforms to the national conditions, objectively reflects the clinical reality, applicable to health care governance, health reform, public hospital management and many other fields, with open and transparent modern management characteristics.
THEDIP pilot program proposed the pilot goal is to use 1-2 years time, the overall regional health insurance budget and the point method combined to achieve hospitalization to pay according to the disease value-based multi-composite payment method.
can be used for reference, replicable and replicable experience, so as to set the foundation for the next step in a wider range of promotion.
implementation steps identified include the registration, preparation and payment phases, requiring pilot cities to pre-group and prepare for paid technology by December 2020 using real-time data and localized clustering programmes.
from March 2021, according to the technical preparation and supporting policy formulation of the pilot areas, the eligible regions can start the actual payment before filing, and by the end of 2021, all the pilot areas will have entered the actual payment phase.
, the technical specifications and disease catalogue library introduced this time provide the basis for the pilot cities to develop localized grouping schemes for the implementation of pre-grouping.
are the areas of interest in the 2.DIP technical specifications and disease catalog library? DIP technical specifications and DIP disease catalogue library (version 1.0) are issued as technical guidance for the pilot work, the Notice requires the pilot cities to strengthen the "technical specification" and "disease library" related business training, to ensure that the pilot city medical insurance agencies, medical institutions and relevant experts fully understand and master, and practical application to the pilot work.
and demand to improve to ensure quality, control costs, standardize diagnosis and treatment, improve the enthusiasm of medical personnel as the core of the pay-per-disease and performance management system.
, it is crucial to understand the core meaning of DIP and adopt a positive and correct attitude to meet the tide of hugging the reform of the payment system.
According to the technical specifications, DIP is a complete management system established by using the advantages of big data, exploring the common characteristics of "disease diagnosis and treatment methods" to classify the disease case data objectively, forming the standard positioning of each disease and treatment method combination in a certain area of the whole sample case data, objectively reflecting the severity of the disease, the complex state of treatment, the level of resource consumption and clinical behavior norms, which can be applied to medical insurance payment, fund supervision, hospital management and other fields.
under the total budget mechanism, the score points are calculated according to the total annual medical insurance payment, the proportion of medical insurance payments and the total score of cases in each medical institution.
medical insurance departments form payment standards based on disease score and score point value, and make standardized payments for each case in medical institutions, and no longer pay for medical service items.
DIP is mainly applicable to inpatient medical expenses settlement (including day surgery, medical insurance outpatient slow special disease medical expenses settlement), mental, rehabilitation and nursing cases with longer hospital stay should not be included in the DIP scope.
adaptability and scalability of DIP can be explored and applied to the establishment of general emergency payment standards, but also to the reform of medical institutions' fee standards.
the first page of the case is the basis for DIP.
because DIP groups diagnostic and surgical operation codes in a fully combined grouping manner, minor changes in diagnostic and surgical operation codes can eventually lead to the eventual division of different disease groups.
the expected benefits of high behavior of medical institutions coding sets are greater, and the probability of occurrence is high.
quality control on the home page of the case is mainly based on the medical case specification and clinical knowledge base, so the quality evaluation system of the case based on the above two contents can really reflect the high behavior of the hospital.
case quality index consists of three parts: (1) compliance index.
Compliance problems mainly refer to the diagnosis of surgery and basic information (such as age, gender, birth weight) occurred in the case of the disease does not match, diagnosis conflict, surgical conflict, diagnosis and surgery inconsistent, etc. , reflecting the medical institutions on the basic norms of the medical record, is a reflection of the quality of the case.
(2) coding set high index.
coding set high problem refers to the medical institutions through the adjustment of the main diagnosis, false diagnosis, false increase surgery and other ways to make cases into higher-cost grouping behavior, is the use of DIP case fraud insurance is a common way.
(3) code set low index.
low coding sleeve refers to the medical institutions due to diagnosis of missing filling, main diagnostic selection errors, surgical omission, main surgical selection errors and other problems leading to the case into the lower cost of disease.
low coding sets are generally caused by medical institutions' insoprehensible understanding of medical record science, negligence and other reasons.
to determine the labor value and efficiency of a medical institution is the total amount of services and disease score.
total number of services is the number of patients, in general, strong service capacity, good attitude, the more high-value medical care, the greater the amount of services.
should we emphasize "value medicine" here? It's not that the more patients you have, the more efficient you become, but that patients think you're providing the care they think is valuable or that they think is the most cost-effective.
and disease score is based on the degree of resource consumption of each disease combination, reflecting the severity of the disease, the complexity of treatment and the degree of difficulty.
of the disease is the standardized unit of different discharge cases, which can be used to evaluate and compare the output of hospital medical services and form the basis of payment.
of the disease score is: (1) calculate the average cost of each disease combination.
Generally speaking, the more serious the disease and the more advanced the technology used, the higher the average medical cost;
Because the data used in the disease score is the "average cost" of a co-ordination area, if your actual cost is lower than the average cost, you will get a positive number of benefits, put in a negative number, which requires a medical institution to achieve good benefits, not only to improve service capacity, treatment of major diseases, but also as far as possible to save money, to achieve reasonable diagnosis and treatment, rational use of drugs and supplies, this benefit is compared with a co-ordination area of the same level of medical institutions.
3. What are some of the things you need to plan ahead to meet DIP? Since the implementation of DIP is a general trend, although most regions, with the exception of the current 71 pilot cities, have not yet carried out pilot, but these areas have not yet started the pilot medical institutions must be prepared early, in accordance with the requirements of the DIP, medical institutions must focus on four aspects of preparation.
is information technology.
Is mainly to establish a relatively advanced to meet the hospital management, especially performance management, data analysis of the information system, because DIP is the use of big data advantages to establish a complete management system, the most important thing is to strengthen the management of medical cases, so that it can truly reflect the state of medical services.
is to speed up the establishment of a close community of medical services with the integrated area of health insurance as the unit.
because if there is no close community of health care services in the health care co-ordination area, DIP will also have a hard time playing its due role, and may end up in a pot of porridge.
is to further standardize the behavior of diagnosis and treatment.
The current implementation of DIP, the biggest difficulty is the hierarchical system of China's medical service system, due to the long-term implementation of the classification management of medical institutions, medical institutions evaluation also implemented grade assessment, directly resulting in a large gap in the ability of medical institutions at all levels, the degree of standardization of services gap, the lower the level of low-level medical institutions more irregular, which actually caused the DIP natural difficulty.
here is a special reminder to medical institutions that DIP is based on the disease score and score point value to form a payment standard, for each case of medical institutions to achieve standardized payment, no longer to pay for medical services project fees.
Therefore, medical institutions and medical personnel must fully realize that more examination, multi-medication, the use of better medical supplies are spent on hospital money, medical insurance does not support, so standardized diagnosis and treatment must be the conscious behavior of doctors.
fourth is to improve the level of management.
, while DIP may seem like a change in the way health care is paid, it will actually reverse the medical behavior and management of medical institutions and medical personnel.
management level of change, promotion, medical institutions may go into trouble.
Therefore, managers of medical institutions at all levels should deeply understand this requirement in the Notice: improve to ensure quality, control costs, standardize diagnosis and treatment, improve the enthusiasm of medical personnel as the core of the pay-per-view and performance management system, and embed it in hospital management.
enable managers to work with medical staff to achieve conceptual change.