Expert interpretation: National health insurance CHS-DRG sub-group program finally announced how to land?

in order to solve the problem of many versions of DRG and the difference of technical standards in various parts of the country, guide and standardize the work of DRG grouping strain in various places, the National Health Insurance Administration has formulated the deployment of the "three-step" (top-level design, simulation test, actual payment) of the DRG paid pilot workIn October 2019, the National Health Insurance Administration officially issued the National Medical Security DRG Sub-group and Paid Technical Specification and the National Medical Security DRG Subgroup Program (Core Group ADRG), marking the official entry of China's health insurance CHS-DRG payment pilot into the implementation phaseOn June 18 this year, the National Health Care Administration also released the "Health Care Disease Diagnosis Related Sub-Group (CHS-DRG) Sub-group Program (VERSION 1.0) " (hereinafter referred to as the "CHS-DRG Sub-group"), the National Health Insurance CHS-DRG before the landing of the sub-group plan is ready to be announced, and to the "three-step" work goal has taken a solid stepDisease Diagnosis-Related Group (DrG) is a combination of similar clinical processes such as disease diagnosis or surgical operations, with similar resource consumptionDRG grouping follows the principle of layer-by-layer refinement and generalization of large categoriesPatients with different types of disease, through the diagnosis of separation, similar cases but treatment methods are different, through operation of separation, these two factors constitute the first level of the DRG grouping, that is, the core group ADRG; Figure 1 showsIt can be seen that the core group ADRG is only the intermediate stage of the DRG grouping, which embodies the principle of similar disease diagnosis and clinical process in the DRG grouping, and is based on clinical experience as the main consideration, supplemented by a small amount of data statistics to determine the groupingThe first consideration of ADRG grouping is similar clinical processes, not excessive consideration of resource consumptionThis means that in patients in the same ADRG group, there may be significant differences in actual resource consumption, as shown clinically in the same ADRG group patients with significant differences in hospital time and medical expensesOn the basis of the core group ADRG, the DRG subdivision group is to use regression analysis, cluster analysis, factor analysis, decision analysis and other statistical methods to find key grouping factors and grouping nodes, such as complications or complications, age, etc., to further subdivide ADRG, and eventually form a similar clinical process, resource consumption similar TO the DRG sub-groupStatistically, after the completion of the sub-group, the difference in resource consumption among inpatients was more expressed as the difference between the DRG groups, and the difference in the group was smaller, that is, the proportion of the difference in the total difference in the DRG group was smallerAfter the sub-group, the medical expenses of patients in the same DRG sub-group were basically similar, and the basis for medical insurance payment signed with the unified payment standardthe National Health Care DRG Sub-Group Program (Core Group ADRG) published in October 2019, divided all hospitalizations into 376 core disease diagnosis-related groups (ADRG), including 167 surgical operation groups, 22 non-operating room operation groups and 187 internal medicine diagnostic groupsBased on this ADRG programme, the CHS-DRG subdivision scheme is based on a statistical analysis of the historical data of 30 pilot cities for 2016-2018, resulting in a MCC/CC list, a list of complications or complications exclusions, and the final breakdown group directoryThe main content of theCHS-DRG subdivision scheme is shown in Figure 2:In the CHS-DRG sub-group scenario, the Disease Diagnostic Synod (MDC) and the Core Disease Diagnosis Related Group (ADRG) are basically in line with the National Health Care DRG Subgroup (Core Group ADRG) published in October 2019 The MCC/CC table identifies complications or complications that have a significant or general impact on medical expenses after statistical analysis, and because some of the patient's other diagnoses are closely related to the main diagnosis, these other diagnoses should not be excluded as MCC/CC Each MCC or CC in the subdivision scenario corresponds to the table number of an exclusion table, each containing several disease diagnoses, indicating that when these disease diagnoses occur as the primary diagnosis, the corresponding MCC or CC should be excluded and should not be considered MCC or CC When a patient's settlement list or case enters the grouping process, first determine whether it is a special group, such as organ transplantation, ventilator use for more than 96 hours or the use of ECM in the early group cases (divided into MDCA), newborns younger than 29 days (divided into MDCP), HIV infection cases (divided into MDCY), multiple severe trauma cases (divided into MDCZ); Diagnosis must take into account gender, males are classified as MDCM, women are classified as MDCN, and according to the main surgery and operation and main diagnosis of the case, according to the surgical operation ADRG, non-surgical operation ADRG, internal medicine diagnosis ADRG sequence, the case is divided into each ADRG; The other diagnosis is not considered MCC or CC and remains, if there is MCC, then is divided into the group with severe comorbidities or complications, and if only CC, into the companion comorbidities or complications group If neither is available, the group is divided into non-complications or complications Figure 3 shows The CHS-DRG sub-group is a further refinement of the 376 core group ADRG of the National Health Care DRG (CHS-DRG) Subgroup Scheme, and is the basic unit of medics DRG payment Each pilot city should do a good job in the implementation of the CHS-DRG sub-group program in light of the actual situation Mainly includes the following aspects: due to the large differences in the situation of the pilot cities, the national version of the sub-group program mainly adopted the complications of comorbidities / severe comorbidities table (CC -MCC table) to subdivide the ADRG group, forming 618 DRG sub-groups After receiving the national sub-group scheme, each local government should use local historical data to simulate the national segmentation scheme to see if it can meet the needs of local health insurance grouping and settlement If 618 DRGs have been able to better meet local needs or local conditions do not have DRG sub-groups, the national version of the CHS-DRG sub-group program can be directly adopted for late pilot simulation and operation if the pilot cities have the need to further localize the DRG sub-group, first of all, in accordance with the National Health Insurance Administration"on the issuance of disease diagnosis-related sub-groups (DRG) paid national pilot technical specifications and sub-programme requirements (Medicare Office issued (2019) No 36) ) to ensure that 26 MDCs and 376 ADRGs are consistent with national standards, not changeats at will In addition, in violation of the Uniform Grouping Principles and Systems stipulated in the Technical Specifications, reference to the national CHS-DRG sub-group group group inggroup rules, grouping methods, naming formats, grouping results, including CC/MCC tables, exclusion tables, sub-groups, etc., to develop localized DRG sub-group programs, and submitted to the expert group for demonstration, through the demonstration can be used for local pilot simulation operation with the announcement of the national version of the CHS-DRG sub-group program, the national health insurance DRG payment pilot has entered an accelerated stage A very important prerequisite for the proper grouping and efficient operation of DRG is to provide high-quality, standardized health insurance billing lists or case home page data for use in DRG grouping services Therefore, the medical institutions participating in the DRG pilot in the pilot cities should actively coordinate the departments of disease cases, information, finance and so on, do a good job in the quality control of the relevant data sources of the DRG group, especially the control of the quality of the disease cases, to ensure that the medical security fund settlement list of indicators items are true, accurate and traceable At the same time, the medical insurance management departments of the pilot cities should also strengthen the sampling and audit of the quality of the pilot hospital settlement list data, ensure the integrity and accuracy of patient information, and further reform the relevant information system, improve the reporting, auditing and feedback mechanisms of DRG-related data in order to steadily advance the PILOT work of the DRG-paying country, the National Health Insurance Administration has formulated a "three-step" master plan for the pilot work All localities should do a good job in the pilot work of DRG payment, in addition to formulating the DRG sub-group program, but also to formulate and improve the relevant weight adjustment, total budget management, settlement and settlement, supervision and assessment policies, strengthen the DRG payment and project-based payment methods in the fund expenditure, patient burden, medical institutions income and efficiency, medical behavior and other changes in monitoring, the possible reduction of services, high-set grouping, decomposition of hospitalization, push patients and other acts to develop targeted management measures At the same time, we should also promote the pilot medical institutions to carry out the reform of internal management mechanisms such as disease quality, clinical path, cost accounting and performance management Only in this way can we maximize the comprehensive effectiveness of the health insurance DRG payment reform The preparation and perfection of the DRG subgroup is a long - term work The current release of CHS-DRG Subdivision Group 1.0 is based on the historical data of 30 cities, there are some limitations, which need to be revised and perfected through practice in various places in the future I personally think that the next step can be improved from the following aspects: 1, the establishment of DRG technical experts, clinical experts, statistical experts, health care management, hospital management and other multi-participation CHS-DRG technical team, the development of a normal DRG packet program maintenance and revision mechanism, the regular introduction of major version sized CHS-DRG updates, and the introduction of program strucizing "patches" from time to time 2, the formation of CHS-DRG clinical committee, regular or irregular meeting of CHS-DRG clinical application seminars, actively listen to and absorb the views and suggestions of various clinical disciplines on CHS-DRG grouping and application, and the relevant recommendations analysis and demonstration, the rationalization recommendations will be absorbed into the normal update of the CHS-DRG sub-grouping program 3, actively absorb the latest achievements of international DRG research and practice, combined with the actual situation in China, carry out DRG packet technology and efficiency research, make full use of and expand the existing big data, explore and develop a more scientific and reasonable packet technology model, form a CHS-DRG packet program with Chinese characteristics 4, in practice, constantly improve the CHS-DRG program Make full use of the national and local expert teams, the process and effectiveness of THE DRG payment pilot in real-time tracking and monitoring, timely discovery and summary of the pilot of THE DRG grouping and payment problems, and accordingly, the CHS-DRG technical specifications and sub-grouping programs to be revised and improved 5, the pilot cities should continuously improve the quality of settlement list data, and in accordance with the requirements of the continuous submission to the country in line with technical specifications of the settlement list or disease data, in order to accumulate case data, the formation of CHS-DRG packet program update of the big data basis, to facilitate the future continuous optimization of the update program.