Five highlights of National Health Insurance Bureau

Source: National Health Insurance Bureau ▍ finishing: Cypress blue - looking forward From DRG to chs-drg, according to the grouping scheme and technical specifications of disease group payment, the reform of medical insurance payment mode will be accelerated, and the large prescription and large examination will be effectively reduced Recently, the National Medical Insurance Bureau officially released the technical specifications for DRG grouping and payment of national medical insurance and the scheme for DRG grouping of national medical insurance The implementation of DRG has specific specifications and methods After reading the two documents, cypress blue specially combed out several issues worthy of high attention: In 2017, the guiding opinions of the general office of the State Council on further deepening the reform of payment methods of basic medical insurance (GBF [2017] No 55) formally and explicitly proposed that pilot payment by disease diagnosis related group (DRG) should be carried out nationwide In June this year, the state health insurance bureau and other four departments identified 30 cities as pilot cities for DRG payment: Beijing, Tianjin, Handan, Linfen, Wuhai, Shenyang, Jilin, Harbin, Shanghai, Wuxi, Jinhua, Hefei, Nanping, Shangrao, Qingdao, Anyang, Wuhan, Xiangtan, Foshan City, Wuzhou City, Danzhou City, Chongqing City, Panzhihua City, Liupanshui City, Kunming City, Xi'an City, Qingyang City, Xining City, Urumqi City, Urumqi City (directly under the Corps, 11th division, 12th Division) For the time being, DRG settlement rules are only applicable to all medical institutions (mainly those above level 2) that carry out DRG payment pilot Medical institutions that do not carry out DRG pilot will continue to use the original settlement methods and policies Chs-drg is developed on the basis of ICD-10 code (including 2048 categories of disease diagnosis, 10172 sub categories, 33392 items) and icd-9-cm3 code (including 890 sub categories of operation and operation, 3666 sub categories, 13002 items) of the national medical insurance version, which can cover all critical and short-term (within 60 days) inpatients DRG payment is more suitable for acute inpatients Chs-drg is initially divided into 376 core disease diagnosis related groups (ADRG), including 167 surgical groups, 22 non-surgical groups and 187 internal medicine groups DRG aims to divide the output of medical services, which is essentially a set of "management tools" Only those cases whose diagnosis and treatment methods have significant impact on resource consumption and treatment results are suitable for DRG as a risk adjustment tool, which is more suitable for acute inpatients It is not suitable for the diseases with long hospitalization time, or the consumption of hospitalization resources is not closely related to the medical effect, or there is a special settlement policy For example, psychiatric patients, long-term inpatients who have been in hospital for more than 60 days, in-hospital delivery patients with quota subsidy, daytime surgery, etc., generally do not use DRG settlement method, but use bed day or single disease payment In addition, DRG settlement is clearly not applicable in the following situations: 1 outpatients; 2 rehabilitation cases; 3 cases requiring long-term hospitalization; 4 some cases with the same diagnosis and treatment, but the resource consumption and treatment results vary greatly (such as mental diseases) According to the payment of medical insurance according to disease diagnosis related groups, many insiders believe that even for the same disease, due to different patients, individual differences are large, rashly grouping, may lead to the situation of cutting treatment and shirking the responsibility of patients in the hospital However, according to the grouping scheme released by the state health insurance bureau, in the process of forming DRG group, various situations have been fully considered, and the practicality is far higher than the previous doubts in the industry DRG is essentially a case mix classification scheme, that is, according to age, disease diagnosis, comorbidities, complications, treatment methods, disease severity, outcome and resource consumption and other factors, patients are divided into several diagnosis groups for management system DRG group adopts the idea of case mix Different types of diseases should be distinguished by diagnosis; the same kind of cases should also be distinguished by operation if they are treated differently; the same kind of cases should be treated differently if they are treated in the same way, but their individual characteristics are different, and they should also be distinguished by age, complications, complications, complications, birth weight and other factors to finally form DRG group Moreover, DRG focuses on the two dimensions of "clinical process" and "resource consumption" The grouping results should ensure that the clinical process and resource consumption of cases in the same DRG are similar In order to realize the above grouping concept, disease types are distinguished by disease "diagnosis"; treatment methods are distinguished by "operation or operation"; individual characteristics of cases are reflected by variables such as age, gender, birth weight (newborn case), other diagnosis, especially complications, etc According to cypress blue, because DRG is paid in advance by disease group, inspection fee, medicine fee and medical service fee need to be packed together, and the payment standard should be formulated in advance, then it will inevitably involve what price is collected as the payment standard If the collected price is not scientific, it may lead to high or low medical insurance payment On this issue, the document issued by the state health insurance bureau also answers Although most DRG schemes currently use the historical data method of medical expenses to calculate the basic weight, due to the serious distortion of the current medical service price, the medical service charge price can not reflect the technical service value of the medical staff well, and the current structure of the actual hospitalization cost is not real It reflects the cost structure of medical services Therefore, the activity-based cost method is used in this collection and payment standard According to the process of medical service, the activity-based costing divides the inpatient expenses into five categories according to "medical treatment", "nursing", "medical technology", "drug consumption (drug consumables)" and "management" According to the cost structure of different parts of international inpatient expenses, the proportion of each part of DRG is determined by referring to the clinical pathway or expert opinion, and the internal structure is adjusted to improve the DRG weight to reflect the labor price of medical staff Then the DRG weight value is calculated by using the adjusted average cost, which can better reflect the real cost structure of medical services than the historical data method ▍ DRG supervision and assessment system will be established In the process of implementing DRG payment, in order to ensure the sustainable operation of DRG payment, avoid and curb the possible phenomenon that medical institutions choose to neglect patients' hospitalization, shirk the responsibility and pay more attention to patients, upgrade diagnosis and insufficient service, and ensure the benefit level of insured residents, medical insurance agencies should establish corresponding DRG payment supervision and assessment system DRG regulatory assessment focuses not only on results, but also on processes, including real-time and post regulatory With the improvement of agency capacity and information technology, real-time supervision and intelligent supervision become necessary and trend The main contents of DRG assessment and supervision indicators include organization management and system construction, medical record quality, medical service ability, medical behavior, medical quality, resource efficiency, cost control and patient satisfaction For example, cost control needs to examine whether medical institutions take the initiative to control costs, reduce unreasonable drug use and inspection, curb unreasonable rise of medical costs and improve the benefit level of participating farmers after DRG payment is implemented from the aspects of drug proportion, average hospitalization cost per time, actual compensation ratio and cost proportion of self funded projects The full score of the above assessment is 100 points If the assessment is full score or qualified, all the quality deposit will be allocated If the assessment is unqualified, the quality deposit to be allocated will be deducted according to a certain proportion If 1 point is deducted, the corresponding proportion (such as about 1%) shall be deducted With this mechanism, the cost of drugs and other expenses will be really transformed into the cost of the hospital For the medical insurance payment, the surplus of the hospital will be retained and overspending will be shared ▍ DRG payment standard will be adjusted dynamically DRG-PPS is a payment method to make payment standard and prepay medical expenses for each disease diagnosis related group.