National medical insurance DRG (chs-drg): consider its benefits and "risks"

Author: Qiu Yulin School of labor and personnel, Renmin University of China On October 16, 2019, the National Medical Security Bureau issued the notice on printing and distributing the technical specifications and grouping schemes of DRG paid country pilot (Medical Insurance Office [2019] No 36), officially published the two technical standards of DRG grouping and paying technical specifications and chs-drg grouping scheme of national medical security, which are national medical insurance The DRG payment work of the medical support department provides a unified standard The introduction of a new policy and new scheme is of great significance, but it will inevitably bring some maladjustment and possible risks, which need to be paid attention to in practice Chs-drg has a lot of significance in deepening the reform of medical insurance, improving medical management, improving patients' medical experience and developing great health This paper mainly analyzes the possible development of chs-drg in medical insurance, medical treatment, patients and great health undertakings from the aspects of deepening the reform of payment method, promoting the standardization of diagnosis and treatment behavior, improving patients' satisfaction and the construction and application of big data of health care Several aspects of the impact We will deepen reform of payment methods 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) put forward that "by 2020, the reform of payment methods of medical insurance will cover all medical institutions and medical services, and multiple composite payment methods of medical insurance suitable for different diseases and different service characteristics will be widely implemented nationwide, and the proportion of payment by project is Than a significant decline "in the goal of payment reform The reform of payment method needs not only perfect technical support, but also the initiative promotion of practical staff in hospital and medical insurance management department "Standardized and scientific grouping is an important prerequisite for DRG implementation, and accurate payment is DRG Important guarantee for implementation ", the release of chs-drg technical specifications and grouping scheme, on the one hand, provides a unified path from the national level, alleviating the technical problems of DRG pilot and payment method reform in practice to a certain extent; on the other hand, the release of unified document is also a" backwardness "to management behavior, which will delay payment due to the lack of motivation for initiative promotion The process of mode reform has been transformed into "passive" promotion, that is, to further implement DRG pilot and deepen payment mode reform in technology and management practice Promote the standardization of diagnosis and treatment process and behavior The technical specifications of chs-drg standardize the data such as patient's medical record information, medical insurance settlement information, the naming and coding rules of disease groups such as Chinese name and code of disease groups, the specific grouping ideas, grouping strategies and other grouping concepts The implementation of these standardized designs not only establishes the information basis for the implementation of DRG payment method, but also brings the standardization of clinical diagnosis and treatment path and disease The standardization of case preparation management promotes the standardization of daily diagnosis and treatment process, behavior and management Reduce the burden of patients' medical expenses and improve patients' satisfaction With the practice of chs-drg to deepen the reform of payment mode and standardize the behavior of diagnosis and treatment, it is necessary to reduce the burden of patients' medical expenses and improve the satisfaction of medical treatment On the one hand, the change from the post payment system to the pre payment system helps to improve the efficiency of the use of medical insurance funds In the long run, the refinement of cost management can reduce the overall medical burden of patients; on the other hand, the standardization of clinical pathway through chs-drg can make the diagnosis and treatment behavior transparent, reduce the information asymmetry between the supply and demand sides to a certain extent, and thus improve the medical treatment of patients Satisfaction Provide basic information and data system support for health big data construction The outline of "healthy China 2030" plan proposes to "promote the application of big data in health care" Just as this grouping scheme is supported by more than 62 million cases in 30 pilot cities, the introduction of chs-drg depends on the integration of medical data, while the implementation of chs-drg practice, the combination of clinical experience and data verification (that is, one of the grouping principles of chs-drg), can form More systematic new data collection, so as to provide basic data sources for the construction of health big data, and promote the construction and application of health care big data.