echemi logo
  • Product
  • Supplier
  • Inquiry
    Home > Medical News > Latest Medical News > DRGs new deal of medical insurance bureau, senior experts explain how the ecology will change

    DRGs new deal of medical insurance bureau, senior experts explain how the ecology will change

    • Last Update: 2018-12-24
    • Source: Internet
    • Author: User
    Search more information of high quality chemicals, good prices and reliable suppliers, visit
    On December 20, 2018, the State Health Insurance Bureau officially issued the notice on applying for the pilot countries to pay by disease diagnosis (hereinafter referred to as the notice)

    According to the notice: in order to implement the task requirements of "the state selects some regions to carry out DRGs based payment pilot and explore the establishment of DRGs based payment system" put forward in document 55, the national health insurance bureau is studying and developing DRGs standards suitable for China's medical service system and medical insurance management capacity, and launching DRGs based payment pilot in some cities

    Medical insurance management departments at all levels should attach great importance to, actively participate in the pilot work of DRGs payment, accelerate the improvement of medical insurance fine management level, and gradually use DRGs for actual payment and expand the scope of application

    Based on this background, the arterial network has organized a long-term column for in-depth reporting on DRGs payment system

    As the first issue, we invited senior experts in the field of DRGs in China, national health and Health Commission statistical information center workstation, Fudan University public management mobile station to jointly cultivate postdoctoral Ms

    Liu Zhichen, to conduct in-depth interpretation of the notice of the National Health Insurance Bureau

    In this paper, you will learn the following core contents: 1

    DRGs payment pilot is not enough to form three major factors for large-scale promotion in China; 2

    The relationship between medical insurance bureau and DRGs of Health Care Commission; 3

    The relationship between DRGs and "4 + 7" volume procurement; 4

    The impact of DRGs on medical institutions, pharmaceutical enterprises, consumables manufacturers and medical equipment manufacturers


    Liu Zhichen arterial network: there have been pilot DRGs in China before, but why hasn't it been widely promoted? Liu Zhichen: DRGs is essentially a fixed payment method packed by disease groups

    Relying on DRGs' payment system, it is helpful to build a positive incentive mechanism to change the behavior of medical service providers, realize the fine management of medical insurance funds and the control of total expenses, guide and motivate medical institutions to establish the awareness of cost control, change the income strategy of hospitals, and through the competition mode and The design of quality monitoring mechanism strengthens the supervision of medical service quality

    In this system design, medical insurance institutions become the overall controller of medical expenses and the agent of patients, to a certain extent, inhibit the induction demand, and promote the hospital to shorten the inpatient period as much as possible

    Therefore, its implementation will inevitably bring changes in the new game rules of the medical ecosystem

    This is a reconstruction of the interest relationship, which involves a wide range of aspects and requires a lot of preparatory work in advance

    Therefore, from the preparation, pilot to large-scale promotion needs a process, not overnight

    From the perspective of international experience, taking Germany as an example, it took more than 10 years from preparation to full implementation

    China has introduced DRGs theory research since 1980s, and started the application of hospital performance evaluation in the 21st century

    But in the field of DRGs payment pilot, so far, the main pilot cities are still relatively limited, not enough to form the trend of large-scale promotion, the main reasons are as follows: first, the unification of technical standards

    It is mainly reflected in the unified specification of DRGs packet and coding, and the application of DRGs payment system, which is the unified specification of three levels

    From the international experience, DRGs payment is based on the payment pricing of each group determined according to DRGs packet as a package paid product

    However, the basis of grouping is disease classification and operation classification code

    At present, the unified standard version of DRGs grouping device has not been clearly defined in China

    Although there is a unified national standard version in the coding system countries, the current coding system is inconsistent with the DRGs blocker and the DRGs payment system in terms of applicability because the DRGs payment is not taken into account because the coding system comes first

    In addition, scholars and manufacturers of different schools in China have developed different versions of DRGs based on foreign experience and constraints of technology and data availability

    At the same time, in order to meet the requirements of different DRGs, we developed our own coding system, which led to the disunity of standards, unable to carry out data standardization and effective comparative analysis

    Therefore, the unification of technical standards is the primary reason to restrict the large-scale promotion of domestic DRGs payment pilot

    The National Health Insurance Bureau launched the collection of DRGs payment pilot cities, in order to summarize the pilot experience and better support the construction of DRGs standard system

    Second, the accuracy, availability and availability of data

    It is mainly reflected in the data quality of the front page of medical records and the accuracy, availability and availability of cost data

    From a global perspective, the research and development, correct grouping and weight determination of DRGs system need two kinds of data information as the basis: one is the medical information contained in the front page of medical record, including diagnostic code and operation code; the other is the cost information based on medical record

    According to the medical information, determine which DRGs group each case belongs to, and according to the DRGs cost information, get whether the homogeneity of different DRGs groups is high, if not, whether it should be divided into different groups

    Therefore, the collection and analysis of medical record home page data and cost data is very important for the correct grouping and weight determination of DRGs

    Data quality problem of front page of medical record: because the data of front page of medical record of hospital has not been linked with payment before, there has been a problem of poor data quality of front page of medical record for a long time

    In addition, the overall quality and level of the hospital's medical record room staff and coder are low, which is also an important factor restricting the data quality of the front page of the medical record

    Accuracy, availability and availability of cost data: foreign DRGs generally use cost data as weight and rate calculation, as well as grouping basis for evaluation of medical resource consumption

    But for a long time in China, because of the implementation of the hospital compensation mechanism of drug-based medicine, there is a big deviation between the cost and the cost

    The cost data of the hospital can not truly reflect the normal or reasonable resource consumption of the hospital

    The cost of drugs and consumables can not be kept high, which can not reflect the labor value of medical personnel

    In addition, many hospitals do not pay enough attention to cost accounting, do not have a cost accounting system, or the authenticity and reliability of the data itself are low, which have become an important factor affecting DRGs payment weight calculation and pricing

    Third, data standardization and data interconnection

    At present, the degree of data standardization among various information systems in China is relatively low, the phenomenon of information island still exists universally, and the data interaction among medical insurance, hospital and government has not been completely solved

    For example, the current situation of standardized coding of consumables is that there is no unified standard within each medical institution, which brings challenges to DRGs grouping and unified pricing payment

    According to foreign experience, many countries will establish a unified data collection and analysis department to collect and group data and supervise and analyze data quality when implementing DRGs payment

    At present, there is no unified Department of DRGs data collection and data quality supervision and analysis in China, which is one of the reasons for the failure of large-scale DRGs promotion

    Arterial network: will the National Health Insurance Bureau study its own DRGs standard conflict with the DRGs standard of the health care commission? Liu Zhichen: from the experience of introducing and promoting DRGs payment system in Germany, Australia and other countries, the national level will have a master plan or idea from the perspective of top-level design

    Although in 2017, China issued a series of policy documents intensively, such as the 13th five year plan for deepening the reform of the medical and health system, the notice on printing and distributing the 13th five year plan for deepening the reform of the medical and health system, and the guidance of the general office of the State Council on further deepening the reform of the payment method of basic medical insurance The procedure and other aspects are clearly defined

    However, there are a series of rules, methods and standards that need to be defined in advance, such as the national standard version of DRGs, the coding rules and standard coding system that are suitable for DRGs, the calculation rules of whether the weight depends on the cost or the expense, the method selection of cost accounting, the maintenance mechanism of DRGs, the calculation of the rate, the weight, the rules of medical insurance negotiation and the rules of data interaction There is no unified top-level design scheme, which leads to the inability of each pilot area when promoting DRGs payment pilot

    Each research institution and the R & D team of the packet device invest resources and research forces respectively, which also causes the difficulty of unified standards and the waste of repeated investment of resources

    At the same time, in terms of organizational guarantee, Germany, Australia and other countries have set up special agencies to take the lead in the overall top-level design and implementation of DRGs, such as InEK in Germany and IHPA in Australia

    Before the establishment of the medical insurance bureau in China, the human resources and social security, health, development and reform, civil affairs and other departments have some responsibilities of payment or pricing of medical services

    After the establishment of the medical insurance bureau, the new rural cooperative medical insurance of the former health and Family Planning Commission, the basic medical insurance for urban employees and urban residents of the Ministry of human resources and social security, the birth insurance, the price management of drugs and medical services of the national development and Reform Commission, and the medical assistance of the Ministry of civil affairs will be included in the scope of responsibilities of the medical insurance bureau

    The medical insurance bureau is positioned as the main purchaser of medical services, so as to better play its decisive role in the development of medical service system and the allocation of health resources

    Therefore, what the medical insurance bureau should study and formulate is not its own department level DRGs standard, but a unified top-level design scheme at the national level

    It is not in conflict or contradiction with the DRGs related achievements and pilot research led by the health care Commission before the establishment of the medical insurance bureau

    Because the avant-garde Health Committee will take the lead in the relevant research results and pilot of DRGs, which will have a very valuable reference for the construction of this standard system and the exploration of the payment system of the medical insurance bureau

    Arterial network: if DRGs of the medical insurance bureau are implemented, how is it mandatory for hospitals? Liu Zhichen: as the purchaser of medical services, the medical insurance bureau implements DRGs payment, which is a payment and pricing method for medical service purchase

    Most of them are enforced through special legislative guarantee in foreign countries

    Of course, it is mandatory for hospitals

    This will inevitably bring about profound changes in hospital management mode

    With the gradual promotion of the pilot mode and the introduction of the top-level design at the national level, it is believed that in the future large-scale promotion, the state will issue corresponding laws and regulations or policies and systems to enforce them, and it is recommended that medical institutions prepare in advance

    If the hospital can not adapt to the system actively, it will face the risk of withdrawal

    It should be noted that during the DRGs payment system reform in 1987-1994 in the United States, 454 hospitals were closed, and 22000 acute beds were closed

    As the risk of financial responsibility of hospitals increases, the corresponding medical behaviors of doctors and hospital management mode must be changed accordingly

    Arterial network: can DRGs carried out by medical insurance bureau be regarded as a supplement after 4 + 7 volume purchase? Liu Zhichen: I don't think it can be described as "supplement"

    The establishment of the national health insurance bureau is to fulfill the role of purchaser of medical services, and the purchase right, pricing right and payment right are highly unified

    DRGs payment is to solve the problem of pricing and payment, while volume purchase is to solve the problem of procurement

    The two are complementary

    From the introduction of DRGs payment, DRGs changed the payment method of medical service institutions from project based payment to group based payment through package payment
    This article is an English version of an article which is originally in the Chinese language on and is provided for information purposes only. This website makes no representation or warranty of any kind, either expressed or implied, as to the accuracy, completeness ownership or reliability of the article or any translations thereof. If you have any concerns or complaints relating to the article, please send an email, providing a detailed description of the concern or complaint, to A staff member will contact you within 5 working days. Once verified, infringing content will be removed immediately.

    Related Articles

    Contact Us

    The source of this page with content of products and services is from Internet, which doesn't represent ECHEMI's opinion. If you have any queries, please write to It will be replied within 5 days.

    Moreover, if you find any instances of plagiarism from the page, please send email to with relevant evidence.