Core content and operating norms issued, DIP pay by disease is about to start, health insurance payment method reform of the actual payment stage is not far away.
1, the core content issued yesterday, the State Health Insurance Administration issued "on the issuance of national medical security according to the disease value-added (DIP) technical specifications and DIP disease catalogue (version 1.0) notice", related to the DIP pilot and promotion of further. The
document emphasizes that the pilot cities and the provincial health insurance departments should, in accordance with the requirements of the "Total Budget of the Regional Points Law and the Pilot Work Programme for Paying by Disease Value", set up pilot leading institutions, appoint a person in charge, organize a team of technical experts, and fully implement the pilot tasks.
to strengthen the "Technical Specifications" and "Disease Library" related business training, to ensure that the pilot city medical insurance agencies, medical institutions and relevant experts fully understand and master, and practical application to the pilot work.
provinces should combine the actual situation, the development of local disease catalogue.
"SickNess Library" will be divided into the main directory of nearly 11553 groups of core diseases, comprehensive diseases 2499 groups, the pilot cities of the disease catalog of the grouping rules and the "disease library" consistent.
the National Health Insurance Administration of China used historical data available from the pilot cities to form a catalogue of diseases in the pilot cities.
pilot cities in the pilot process in accordance with the unified grouping rules and constantly improve the local disease catalog.
addition, the pilot cities should develop local total budget management measures around the Technical Specification, determine the number of points for core diseases and other points conversion methods for hospitalization cases.
, according to the characteristics of paying according to the disease score, improve the corresponding medical insurance procedures and protocol management process.
Strengthen the research on the regulatory system adapted to the characteristics of the disease score payment, give full play to the role of big data in view of the characteristics of the disease score payment medical service, formulate relevant regulatory indicators, implement big data-based supervision, and formulate targeted measures for possible high sets of groupings, punch points and other acts.
2, the control fee further information shows that DIP score payment technical specification is the DIP score implementation conditions, implementation steps, implementation programs and other aspects of the development of a set of guidelines and standards - technical specifications and disease catalogue publication, it means that DIP, China's 1.5 version of DRG, further. The formation of the
directory library, through the real large amount of disease data, found the inherent law and association between disease and treatment, extracted data characteristics to combine, and the region of each disease and treatment resource consumption of the average and the total sample resource consumption of the average, forming a DIP score, gathered into the DIP catalog library.
and DIP's directory library is a common feature of the method of condensing disease and diagnosis and treatment with big data, reflecting the general law of diagnosis and treatment, and is the basis of DIP - the main directory is divided into core and comprehensive diseases in the form of case critical values. The auxiliary directory is formed, which plays a corrective work, and complements the main directory with the specific characteristics of big data extraction diagnosis, treatment, behavior norms, etc., and corrects the resource consumption of clinical diseases, complications/mergers, and medical codes of conduct.
, the publication of technical specifications and catalog libraries means that the core content and specification process of DIP implementation has been issued, not far from the pilot and further implementation.
3, deep water area to a certain extent, the point method combined with the total regional budget means that health insurance control fees into the deep water area.
, according to the plan, from October to November, the pilot cities usually report historical data, and the National Health Insurance Administration will organize the pilot city data to form a localized group of diseases.
that by the end of 2021, all pilot areas will have entered the actual payment phase.
data show that DIP, also known as the disease score method, is a big data-based DRG payment method, and according to the disease score, refers to the medical system in accordance with the "disease grouping and treatment method" way, the patient's electronic medical records into a disease, with the average hospitalization cost of each disease to form a price score between diseases, and then consider age, complications and accompanying factors to correct the disease payment, so as to achieve fine, personalized payment.
Combined with the above work, the Medical Insurance Bureau shall budget the total medical insurance quota for all designated medical institutions in the area under its jurisdiction, calculate the amount of payment of the medical insurance fund eventually obtained by each medical institution according to the total score of each medical service provided by each hospital, and no longer limit the total amount index of the unit-price medical institution.
Cai Jiando writes about the logic behind it: If hospitals want to get more health care payments, they need more points, which require patients to "vote with their feet", which hospitals have a high number of votes and get more health care payments;
, hospitals need to attract patients by reducing medical costs and improving the quality and efficiency of their care in order to avoid a shrinking share of Medicare payments caused by the loss of patients.
There is a view in the industry that the future will be from the incremental game into the stock game, and hospitals will not be able to estimate the allocation of medical insurance funds, according to their first three years of case data to extract the disease catalogue, the formation of each city's own score directory, and included all hospitalization cases;
but it also raises a problem, with research groups saying that DRGs and DIP are moving forward in tandy, and that long-term convergence will boost health care costs.
Compared with DRGs, DIP is mainly based on the historical data of the average cost of diseases in the industry, which can reduce the dependence on medical professionals in the process of DRGs coding production, facilitate the promotion of low-grade hospitals, and enhance mutual supervision and competition among hospitals in the region, but DIP is difficult to identify the irrationality of historical data, and may lead to the screening effect of patients.
according to the DRG pay country pilot work "three steps" step arrangement: 2019 is the DRG top-level design phase, 2020 is the simulation operation stage, 2021 is the actual payment phase, 2020 is coming to an end, health insurance payment methods are about to enter the actual payment phase.