New developments in health care payment reform! The impact on the healthcare industry is enormous.

On October 19th, the Office of the State Health Insurance Administration issued a notice on the total budget of the regional points method and the pilot work programme for paying according to the value of the disease (medical insurance office issued No. 45 of 2020, referred to as the "Programme"), requiring the provinces to refer to the conditions of the pilot cities by mid-October and select the eligible cities to declare to the National Health Insurance Administration.
the end of October, the National Health Insurance Administration will assess and determine the list of pilot cities.
, the pilot cities will be pre-grouped and ready to pay for technology.
March 2021, eligible regions will be eligible to initiate actual payments first after filing, and by the end of 2021, all pilot areas will have entered the actual payment phase.
, the process is still very fast.
, how will this payment model affect the health care practices of medical institutions and medical personnel? Today, the author will talk to everyone.
what happens to the total budget for the regional points method and to pay by disease score? Point method is through a co-ordination area in previous years (generally 3 years) the actual diagnosis and treatment of disease consumption resources (including bed days, costs, effects, etc.) for comprehensive evaluation and analysis, reference to other regions to treat the disease's resource consumption, to determine the region's "disease score" (i.e. points), a medical institution to treat different diseases will get different values (points), the treatment of high value of major diseases, serious diseases, get more value.
So, the essence of the points method is to settle by disease (group) score, all called total control by disease (disease group) score settlement, is a fusion of macro-total budget management and pay by disease (group) payment system.
this method represents the difference in resource consumption at the time of treatment of different diseases by the score (group) of each disease (group) in the disease score table, but does not give the settlement price of each disease.
settlement price for each disease is determined by the unit price of the score (i.e., the cash value of the score) together with the score of the disease.
the unit price shall be determined by the total budget of the regional co-ordination fund together with the total amount of services provided by each medical institution.
medical institutions accumulate points according to the disease and treatment of the patients received.
To set the total budget on a co-ordinated area, all medical institutions share a total amount, the implementation of hard budget constraints, overspending does not make up, the excess service is the unit price of the decline, the hospital from the disease to obtain income decline, and ultimately lead to a decline in hospital profits.
so much, the point method is very similar to the "work- points system" in rural areas in the era of planned economy.
family earns different points for every day they do, the added work earned by a family a year is the basis for the year-end penny.
Simply put, the point method is a way for health insurance fund payments to be allocated according to the total number of points provided by medical institutions, instead of simple and crude total advances, nor sub-average fee control.
For example, if the total number of service points in a region is 1 billion and the total number of regional health insurance is 1 billion, then each point can be allocated 1 yuan, if the total number of service points in the region increases to 1.2 billion, while the total number of health insurance remains unchanged at 1 billion, with 0.833 yuan per person.
this means that intentionally high-set coding, punching points behavior can not be profitable.
Although intentionally high sets of coding, punch points behavior can not be profitable, but because a medical institution to do so, may dilute the region's other medical institutions labor compensation, because you rushed up the total number of points in the region, can make the unit price of points become smaller, that is, points are not worth, so the Program proposed to pay for the characteristics of medical services for diseases, give full play to the role of large data, the development of relevant regulatory indicators, the implementation of large data-based supervision.
, strengthen the quantitative assessment based on disease, promote the transparency of regional medical services, avoid high-set coding, punch points and other behavior.
does the point-to-point method affect medical behavior? 1. As a result of the implementation of regional total budget management (generally to set up districts and cities as a unit, just the lowest medical insurance also implement municipal co-ordination), no longer refine the total control indicators of each medical institutions, but to the project, disease, bed date and other payment units into a certain number, the end of the year according to the total number of points provided by each medical institutions and regional health insurance fund expenditure budget indicators, to arrive at the actual value of each point, according to the actual points of each medical institutions to pay.
, medical institutions no longer have to worry about the total limit, only to see a practical doctor.
However, due to the change in payment methods, medical institutions must establish a compensation system and performance management methods adapted to payment methods, through performance as an effective way to reverse the medical staff's medical treatment behavior, to achieve excellent performance and remuneration.
2. Because of the different disease points, so from the service performance point of view, hospitals should also encourage the treatment of high points of disease, and should not receive low points of treatment of diseases, as far as possible, low points of disease to primary medical institutions to treat, play the benefits of beds.
in particular, the Programme stipulates that the criteria for the score of diseases suitable for diagnosis and treatment at the grass-roots medical institutions and capable of diagnosis and treatment at the grass-roots level shall be consistent at different levels of medical institutions.
should put minor illnesses at the grass-roots level.
also directly stimulate medical institutions to improve the level of diagnosis and treatment and the ability to see major diseases.
3. In accordance with the provisions of the Program, when implementing the reform of the medical insurance payment system under the Points Law, a team of experts, including medical insurance operators, medical institutions and personnel of universities and scientific research institutions, shall be set up to form a system of paid and performance management based on disease value, with the core of quality assurance, cost control, standardized diagnosis and treatment, and improvement of the enthusiasm of medical personnel.
to explore the total cost of outpatient by person, by project, close-knit medical community into points, and with the inpatient service points to form a comparable relationship, to achieve the total regional point method budget.
this requires that the hospital led by the Medical Community should study the payment model in depth and manage all kinds of medical institutions at all levels in the medical community.
4. In the process of the reform of the medical insurance payment system, we have been advocating "establishing and perfecting the consultation and negotiation mechanism between the medical insurance operating institutions and the designated medical institutions", and as medical institutions, we should also adapt to this change and set up our own team of experts for "consultation and negotiation", otherwise we will not be able to meet the needs of reality.
in short, in the reform era, every step of the action will inevitably affect the survival and development of medical institutions, only those who actively change themselves, conform to the trend of development of medical institutions can go further and more smoothly.
health insurance payment system is the most important concern of medical institutions.
.