How can DRGs point pay-as-you-go Zhejiang pharmaceutical companies adapt to the new situation of medical insurance control fees?

Since the National Health Care Administration decided in May last year to carry out pilot work in 30 cities across the country on the pilot work of DRGs paying for disease diagnosis-related sub-groups, the relevant news reports have been rare, so the results of the pilot so far are not knownIn this regard, Xu Weicai, deputy director of the Health and Health Bureau of Shanyang County, Shaanxi Province, said that first of all, it must be recognized that the implementation of disease diagnosis-related sub-group DRGs pay national pilot is very critical, very necessary, but also a key step in the reform of the health insurance payment system, although difficult, imperativeAs for the DRGs payment piloted in 30 cities across the country last May, it looks small and small, with little real progress, mainly because it doesn't do muchHere said "will not do", for two reasons: first, the local health insurance bureau to take over, the fight against fraud insurance is busy enough, estimated to DRGs have not yet started; In this sense, the Zhejiang Provincial Health Insurance Bureau issued the "Rules", on the one hand, can wake up the local health insurance departments, "catch up with learning", speed up the promotion of this work, on the other hand, can provide experience and demonstration for other places, to promote other pilot cities to acceleratethe Rules, drDRGs pays a total budget system and negotiates the growth rate of inpatient health insurance fund expenditure for the yearThe medical insurance operating institution approves the total budget of the hospital medical insurance fund for the year according to the established growth rate and the total final accountofed portion of the hospital medical insurance fund for the previous year (including the reserved portion, excluding the portion of the budget, excluding the overexpenditure and temporary supplementary budget due to the outbreak of diseaseTotal annual budget of inpatient medical insurance fundthe total final accountofed sum of the hospital medical insurance fund for the previous year in the co-ordination area x (1 plus the growth rate of the inpatient medical insurance fund expenditure)This budget includes the amount of medical insurance fund expenditure of the insured persons in the co-ordination area who are hospitalized locally and off-site, and the inpatient medical insurance fund for employees and urban and rural residents shall be included in the total budget and consolidated accountingvery much agree with the negotiation of the growth rate of inpatient health insurance fund expenditureHe explained that the quality of service, management capacity and development rate of each medical institution (including close-knit or medical associations) will be different, and each year will also be different, through negotiations to determine the new year's inpatient health insurance fund expenditure growth rate, is conducive to scientific evaluation of a hospital's health care management performance, so that good better, stronger and strongerHowever, even if negotiated, there should be some "standards"Therefore, Xu Suggested that a scientific and reasonable quantifiable evaluation system should be established, which includes the annual evaluation score of medical insurance management, the next year hospital development momentum evaluation and other indicators system, quantify a sub-sub-division, and then determine the growth rate of medical insurance fund expenditure in a hospitalthe Rules also explicitly establish a mechanism for sharing responsibility for "retention of balances and overexpenditures"If there is a balance or overspend in the annual accounts of the inpatient medical insurance fund in the co-ordination area (compared with the total annual budget of the inpatient medical insurance fund in the co-ordination area and the expenditure of the medical insurance fund required for the settlement of the insured person's inpatient medical insurance fund according to the project), the fixed-point medical institution and the medical insurance fund shall be retained or shared according to a certain proportion on the basis of the analysis of the reasons and the clarification of responsibilityThe proportion of the appropriate share (retention) of the inpatient medical insurance fund is adjusted dynamically according to the performance of the medical insurance fund management and so onEighty-five per cent of the balance of the annual accounts of the 2020 annual health insurance fund is retained by the designated medical institutions, and 85 per cent of the overspend is shared by the designated medical institutionsin Xu's view, the establishment of "balance retention, overspending sharing" of the responsibility sharing mechanism, no doubt can more effectively mobilize the main role of medical insurance management of medical institutions and control of costs, this mechanism is also the most active and effective mechanism"The balance is retained 85 per cent, the overspend is 85 per cent" seems to be relatively high, but that is why it is strongAs to whether it is reasonable, it is mainly determined by the level of medical insurance management and the level of hospital managementIf hospitals have the capacity to shoulder such a large responsibility, of course it is reasonable, and if they cannot afford it, then there may be problemsin the area of supervision and management, the Rules require that designated medical institutions shall adhere to the principle of treatment for patients who have been admitted to hospital, and shall not reduce the quality of medical care by reasonable examination, reasonable treatment, reasonable use of drugs and reasonable chargesDetails of medical expenses incurred during the patient's hospitalization (including self-funded, outsourced medical supplies and medicines) must be uploaded to the medical insurance operators in a timely manner in accordance with the provisionsThe designated medical institution shall reasonably control the cost of drugs, materials and medical treatment items at the out-of-patient expenses of the inpatient, and the proportion of expenses outside the scope of the individual policy shall be controlled within 15% in principlein fact, before some local health poverty alleviation, the proportion will be controlled at 5%-8%, and Fujian Sanming implementation of the whole disease to pay for the scope of the patient's non-cost requirements to control within 10%, although The proportion of Zhejiang is more stringent, but in addition to individual diseases or individual department diseases have difficulty, most of the efforts can be completedBased on this, Xu believes that Zhejiang's control of this indicator to 15% of the ratio is basically reasonable"Of course, in the case of strict cost control of both medicated drugs and self-funded drugs, how to ensure the quality of patients' medication and service quality, I think hospitals and doctors have more methods than we do, as long as the real full mobilization of their enthusiasm, nothing is the case." Of course, for individual special patients, special diseases can also establish a policy subsidy mechanism, such as over-reporting review and approval mechanismXu said there was no need to worry about medication and the quality of serviceArticle 17 of theRules clearly states that, in accordance with the characteristics of Chinese medicine services, the principle of the same efficiency and efficacy of the same disease, the selection of suitable diseases to carry out the DRGs point payment pilotXu Yucai pointed out that at present, DRGs for health care management departments and many hospitals, are still very strange, and Chinese medicine to carry out DRGs point payment pilot is more unfamiliar, there are two major difficulties: First, no experience, no experience abroad, domestic is not much; However, since Chinese medicine has always stressed the importance of simple and incorruptible examination, so "according to the characteristics of Chinese medicine services, with the same efficiency and price of the same principle, choose the appropriate disease to carry out THE DRGs point fee pilot", i personally feel very meaningfulSo which "suitable diseases" to choose? Xu Yucai believes that it is supposed to be a special disease of Chinese medicine treatment, that is, there are clear diagnostic standards, clear treatment path, clinical efficacy and other common characteristics of the disease by the "rules" can be seen, Zhejiang Province's medical insurance fees not only control the medical insurance catalog of drugs, but also the cost of out-of-pocket drugs also have restrictions This means that in the future, whether it is medicated or out-of-pocket medicine, it will require rational use Xu said that the control of self-funded drug use, and give a clear and specific and reasonable proportion, will certainly have a huge impact on the hospital's drug habits In the past, since Medicare only managed the cost of health care and controlled the total cost, it was necessary to control the use of out-of-pocket drugs because patients were not paying for their own drugs because they were not paid for by the Health Insurance Fund, but this actually led to a rapid increase in state inputand and the burden of patient costs remained heavy This will also have a huge impact on the hospital, doctors clinical drug use, the rapid formation of "only right, not expensive" drug habits under the general trend of medical insurance control fees, for pharmaceutical enterprises how to do a good job in the hospital marketing work, Xu Yucai, pharmaceutical enterprises must face up to this reality, which is also the future hospital drug application trend Enterprises have this understanding, in the hospital marketing will make a big change, one should not invest too much human and material resources; Xu Weicai also said that as to whether the "rules" of Zhejiang Province can achieve the "control fund" and "quality" double goals, but also need to see concrete implementation, especially the local health care sector and medical institutions understanding and implementation, from the policy design situation, or better, there is a great hope to achieve the goal In addition, the "rules" to other provinces and cities landing DRGs certainly have reference significance, if can be better implementation, spread in the country is not impossible.