How to build a "reform model" of the payment system in the country's first DRG payment province

medical insurance payment is the key mechanism to ensure the people's access to high-quality medical services and improve the efficiency of fund useAfter the establishment of the Zhejiang Medical Insurance Bureau, the in-depth implementation of the General Secretary to Zhejiang "do in the real never-ending, walk in the forefront to seek a new article, yongli tide head to play a new role" new requirements, around the provincial government "two high-level" construction and "three places" political mission to assume, based on the "three medical linkage" "six medical Co-ordinate", sum up the advantages and disadvantages of the existing medical insurance payment method, comprehensively clarify the "medical, insurance, suffering" three interest unit boundaries and mutual relations in the reform of the payment method, based on the actual situation of the province, scientific research and evaluation of the direction of reform, put forward Zhejiang first, the first in the province to implement the hospital DRGs point method payment reformStrive to build a health insurance payment system with more reasonable budget, more scientific classification method, more powerful coordination guarantee and more effective resource allocation by 2022, so as to achieve the dual goals of "promoting performance" and "excellent service"With the development of medical undertakings and the continuous improvement of the level of medical security, especially in Zhejiang Province, the construction of the whole province medical community has been accelerated, and the medical needs of the insured people have been rapidly releasedIn 2019, the province's medical insurance settlement of about 5.5 billion times, the average annual settlement of each insured personnel 10 times, the staff health insurance fund expenditure increased by 12.3% YoY, the residents' health insurance fund expenditure increased by 10.3% YoY, the growth rate of health insurance fund expenditure remained high, and in the context of the new economic normal, health insurance Fund income growth slowed, employee health insurance fund income increased by 4.2% YoY, residents' health insurance fund income increased by 4.6% YoY, employee health insurance fund income and expenditure growth ratio was 1:3, residents' health insurance is 1:2, income and expenditure growth showed a clear "scissors difference", the fund balance of payments has appeared inflection pointthe aging process into the fast lane, in the past three years, the average annual reduction of the labor force in Zhejiang Province is 260,000, the number of job retirements than in 2018 is 1:4.1, in 2019 about 1:4.08, is forecast to reach 1:1 by 2050, aging will bring further reduction in fund income (retirees do not charge), fund expenditure will be further accelerated2019, zhejiang's 71 workers' health insurance fund co-ordination area, the current deficit of 15; The combination of the above factors will affect the long-term balance of the medical insurance fund, and it is urgent to improve the performance of the medical insurance fund through the reform of payment method, and realize the smooth and sustainable development of the medical insurance fundthe results of the special action to combat fraud and insurance fraud shows that there are two obvious characteristics of the current violations in the field of medical insurance: the characteristics of the violation of private medical institutions are mainly fraud and insurance fraud, the characteristics of public medical institutions are mainly excessive medical treatmentPast payment methods or lack of interest control mechanism for medical behavior, the lack of effective control means (such as pay-per-project payments), or methods too simple and crude (e.gtotal control payment, etc.), in ensuring the quality of service and play the professional level of health care workers has been criticized, easy to form a "health care, medical" opposition, resulting in the health insurance fund margin decline, weaken the efficiency of the institutional mechanismThere is an urgent need to further standardize the behavior of medical services through the reform of payment methods, stimulate the endogenous motivation of hospitals and doctors to participate in medical insurance control fees, and realize "to give hospitals the incentive to use drugs and control costs" (The General Secretary's speech at the National Health and Health Congress)Zhejiang is the first place for reform and opening up, the reform atmosphere is strong, in the reform of medical insurance payment methods, the enthusiasm for reform in various cities is very high, which is representative of Hangzhou City in 2009 to implement the total prepaid system, Jinhua City in 2016 began to implement the disease group point payment systemIn 2017, after the release of The General Office of the State Council No55, the city of the application of DRG tools pay awareness of a high degree of unity, following Jinhua City, Zhangzhou City, Taizhou City launched the implementation of DRGs payment reform, other regions are also actively planning to promoteWhile affirming the local exploration enthusiasm, we also recognize that this bottom-up reform path will bring about new "fragmentation" ills such as inconsistent standards, inconsistent rules, system disunity and regional imbalancesAfter the establishment of the provincial medical insurance bureau, keenly grasp the province's overall promotion of payment method reform window period, clearly put forward the province to implement the DRGs point payment work ideas, the introduction of the provincial committee "the province a game of chess, city-level grasp inganco-ordination, county-level responsibility, grass-roots strong implementation" of the provincial social governance work mechanism, the formation of "provincial focus on top-level design, local strengthening of the main responsibility, medical institutions actively control fees" governance mechanism, to achieve "the masses to benefit from the benefits, hospitals can be encouraged to achieve the goal of health care."the reform of medical insurance payment mode is the basic reform of medical insurance, in order to play a lever-traction role in the "three medical linkage", it must involve medical insurance, medical institutions, doctors, pharmaceutical enterprises, patients and other multi-stakeholder subjects, involving medical insurance, finance, health and health management departments, very much in line with the emphasis on multi-directional consultation and cooperation between the various subjects of governance In the province's DRGs point payment system design, always adhere to the governance thinking, highlighting the system, mechanism and model innovation, emphasizing multi-party participation, emphasizing consultation and cooperation, emphasizing fair ness and openness, emphasizing multi-win situation, fully mobilize the enthusiasm of all parties, to avoid the past health insurance payment system is biased towards one-way constraints on health insurance, single-handedly, so as to achieve better reform results in the process of advancing the reform process, we work diligently to plan, cleverly borrow, firmly grasp the provincial government to promote the county medical community construction opportunity, the medical insurance payment method reform actively integrated into the construction of the medical community, as its main supporting policy has been highly valued by the provincial government In June 2019, the provincial reform committee deliberated and adopted the reform plan of payment mode in Zhejiang Province, issued the Opinions on Promoting the Reform of the Payment Method of the County Medical Community Basic Medical Insurance in the province, and the Provincial Committee reform committee is the highest decision-making body at the provincial level to lead the reform work After the issuance of the Opinions, the Party committeegovernments around the country attach great importance to this reform, the formation of the main leaders of the Party and government personally asked questions, the leadership of the general, the health care department led the implementation, the relevant departments to cooperate with the good situation, give full play to the institutional advantages of concentrating efforts to do great things, for the smooth promotion of the province's health insurance payment reform to provide a strong institutional support to determine the total medical insurance budget in consultation, through negotiation, medical insurance, finance, health care, medical institutions jointly negotiate to determine the total annual medical insurance budget; clear division of responsibilities in the departments of health insurance, finance, health and other departments to ensure the smooth operation of the payment system through the real-time monitoring system of medical insurance, real-time reminder interviews on abnormal costs in the operation of medical institutions, to ensure the balanced annual distribution of the fund, while avoiding the imperfection of medical institutions to cause major losses emphasizes that fixed-point medical institutions should standardize clinical diagnosis and treatment behavior, treat patients, use reasonable drugs, not increase the personal burden of insured personnel, stipulate that the proportion of expenses outside the scope of individual policies should be controlled in principle within 15%, avoid medical institutions to pass on the risk of reform to patients, ensure that patients' interests are not damaged, and effectively safeguard the social stability of the reform process the hospital fund to implement the regional total management, no longer subdivided into each medical institution, the region's medical institutions form a game relationship, encourage medical institutions to provide more reasonable medical services to obtain more share of the medical insurance fund, promote medical institutions to improve the efficiency of factor use, avoid medical institutions to the end of the year due to insufficient total amount of patients, while effectively reducing the total allocation of the medical insurance department when the risk of integrity points as the only measure of the resource consumption of all hospitalizations, all in-group cases into THE DRGs point management, by bed day payment and special disease single negotiation cases through folding algorithm into the point management, case value by point value multiplication to determine, points and point value is not determined by health insurance, but calculated according to actual data "Hospital scoring, medical insurance calculation" settlement model to ensure that the medical insurance settlement is true and reversible, while the autonomy of medical care returned to the doctor, doctors see the doctor without direct profit restrictions, can actively choose "high quality and low price" medical resources for the vast number of patients, encourage hospitals and doctors to calculate large accounts, actively control costs, more doctors, optimistic about the disease provincial standards, municipal points, county-level counting values, clear provincial, municipal and county responsibilities Provincial standards to ensure the provincial top-level design unity and rigidity, municipal count points in line with the requirements of real city-level co-ordination, in line with the law of large numbers of insurance, conducive to the fairness of the system at the municipal level, county-level counting value in line with the actual management of the fund county-level, clear county-level control fund main responsibility, effectively play the county-level management enthusiasm the settlement method of shall incorporate all hospitalization expenses incurred by fixed-point medical institutions into the management of DRGs points, including expenses outside the scope of the policy, cash settlement expenses, hospitalization expenses of patients in different places, etc The inclusion of extra-scope costs in the management of policies can avoid the transfer of hospital costs to patients, increase the burden of patients, cash settlement costs into the management can plug the medical institutions intentionally increase non-credit card settlement costs, the use of "in vitro cycle" to avoid regulatory loopholes, off-site patient costs into the management is conducive to ensuring that patients in different places enjoy fair medical treatment, while avoiding hospital selection and treatment of foreign patients, harming the fair interests of local patients DRGs is just a payment tool, a means, it is impossible to solve all the problems in the field of payment, the need for a combination of fixed-point agreements, health care physicians, intelligent supervision, budget implementation constraint incentives and daily assessment awards and penalties and other means to fill loopholes, fill short board, in order to ensure the efficient operation of the payment method In 2019, Zhejiang Province has issued "on the promotion of the province's county medical community basic medical insurance payment method reform" and "Zhejiang Province basic medical insurance hospitalization costs DRGs points payment provisional measures" two platform documents, each district and city all issued the corresponding implementation rules, the work in an orderly progress, but the payment method reform more serious process management, reform is just beginning, is still far from entering the full implementation and the difficulties in the progress The reform of DRGs point payment is a profound revolution for the pharmaceutical industry, which will completely transform the production practices of medical institutions, doctors and patients' medical practices, which are currently poorly understood by both the health care and medical sectors Last year, during the system design period, we arranged more than 20 various types of medical institutions to visit the research, the overall feeling is not enough research, inadequate preparation Although the Zhejiang Health Department has been piloting DRGs management since 2016, this is only a quality management tool and a paid tool for DRGs DRGs payment method is the specific practice of value law in the field of health care, its essence is to standardize as a carrier, with the average cost of the same level of medical institutions in the co-ordination area to determine the payment standard, when a hospital expenditure is higher than the average cost will be a loss, when the expenditure is lower than the average cost can get the benefit, but specific to the disease group because of the disease is changing, defining the group, forming the standard will be very complex and difficult, once the payment method will be formed as a strong ecological constraint the reform of payment methods is not only a matter of concept, but also a high degree of specialization of technical activities, involving medical insurance management, information technology, statistical analysis, case management, clinical medicine and other aspects of technical support In particular, the DRGs point payment reform, the National Health Care Administration, the national effort, took more than a year to launch the "DrG) paid national pilot technical specifications and sub-groups program", but also only set up a basic framework, including 26 major diagnostic classification and 376 core DRG subgroups, to land There is still a lot of localization work to be done, in addition to the introduction of medical insurance disease diagnosis and operation, medical services, medicines, medical supplies and other 16 business standards, need to be implemented synchronously, and the existing city (county, district) policy system fragmentation, information system slack, relative lack of professional team, which poses a great challenge to us this reform, in addition to the direct impact on medical institutions, medical personnel themselves, but also will gradually pass the effect of reform to patients through medical personnel, micro-conduction path is ever-changing Although we have considered in the system design, but if the process supervision is not good, transmission once the change, the patient's feelings may be with the deepening of reform profound changes, and even to the reverse of the system design, we need to promote reform in the future to attach great importance to the solution Zhejiang took the lead in promoting the reform of DRGs point payment in the province, no more experience to learn from, encountered difficulties and problems will even exceed our pre-judgment, reform is always on the road But this reform of the country has the requirements, the province has the deployment, is a consensus-building, trend-oriented reform initiatives, we firmly believe that the reform is on the right path 2020 is the beginning of this reform, but also the decisive year, we ask the province's health care cadres dare to face up to difficulties, have the courage to take on the head of the tide, bite the qingshan do not relax, clear work tasks, improve the working mechanism, strengthen the work of supervision, strengthen public opinion guidance, grasp the implementation of the specific work, for the province to carry out this reform start, start a good step, to build the province to implement THE DRGs reform "Zhejiang model", to provide the national DRGs payment experience .