"Start early and catch up late" DRG payment standard is officially unified

On October 23, the State Medical Security Bureau issued the notice on printing and distributing the technical specifications and grouping schemes for DRG paid national pilot projects, and officially published two technical standards, namely, the national medical security DRG grouping and paying technical specifications (hereinafter referred to as the technical specifications) and the national medical security DRG (chs-drg) grouping scheme (hereinafter referred to as the grouping scheme) The notice requires each pilot city to carry out relevant work in accordance with the unified technical specifications and grouping scheme, to create a "chess game" for the pilot, to "localize" accurately, and to make chs-drg a "common language" in the field of national medical insurance It can be predicted that with the real release of the leverage power of medical insurance payment, the era of "medicine for medicine" is completely over, and the Chinese pharmaceutical industry will be completely subverted soon The technical specification regulates the basic principle, scope of application, definition of terms, data requirements, data quality control, standardization upload specification, grouping strategy and principle, weight and rate determination method of DRG grouping According to the grouping plan, chs-drg is the unified standard for DRG payment, including 26 major diagnosis categories (MDC), 376 core DRGs (ADRG), 167 surgical operation ADRG groups, 22 non-surgical operation ADRG groups and 187 medical diagnosis ADRG groups For the significance of the two technical standards, Xie kongbiao, general manager of Beijing Jingfeng Pharmaceutical Group Co., Ltd., said that this means that the prologue of medical reform has officially opened Strictly speaking, some medical reform policies issued by the state before are "drug reform", not real "medical reform" Lin Zirong, deputy general manager of Kaifeng Kangnuo Pharmaceutical Co., Ltd., also pointed out that "technical specifications" and "grouping plan" are authoritative and professional documents formulated in the National Health Insurance Bureau, forming the basic compliance of DRG (chs-drg) of the National Health Insurance Bureau, and uniformly using medical insurance disease diagnosis and operation, medical service projects, drugs, medical consumables and medical insurance for the medical insurance departments of pilot cities 5 information business codes such as settlement list provide standards DRG payment will promote the fine management of medical insurance, improve the use efficiency of medical insurance funds, and improve the security level of the insured In fact, DRG has been exploring all over China for more than 30 years However, the reform of "getting up early" is "catching up late" For the reasons why DRG payment was not promoted smoothly in the past, Lin thinks there are five aspects: first, when there was no medical insurance bureau in the past, it was "Jiulong water control" Drug registration and production, rational use, medical insurance payment were managed by different ministries and commissions, which made it difficult to achieve unity in system design After the establishment of the medical insurance bureau, it can break through the top-level design and promote implementation through a department Second, hospitals at all levels and regions have great differences in standard formulation Doctors will also communicate with patients and their families about specific problems of medical insurance payment due to different conditions and treatment needs of patients in their work Their time and energy are hard to support, and it is easy to cause disputes between doctors and patients in medical insurance payment Third, it is difficult for new drugs to enter the medical insurance, clinical pathway and guidelines immediately, which is not conducive to encouraging new drug innovation Dynamic adjustment of DRG grouping and payment is particularly important Fourth, in the past, DRG payment standards were not unified, and even the phenomenon of hedging could not be completely eliminated In addition, there was no unified coding standard for medical consumables, and the implementation of medical insurance level in private hospitals was uneven, and other factors China's medical insurance payment system is a multiple composite payment method under the guidance of total budget Fifth, technical constraints will make the medical insurance bureau, hospitals, doctors at all levels have a complex workload Provincial and municipal medical insurance bureaus and hospitals need to be equipped with corresponding information engineers to complete data conversion through a unified docking software The medical insurance bureau may even need new technology support including blockchain, especially the access of new technology based on diagnosis and treatment data basis and clinical evaluation Xie kongbiao believes that although the exploration and implementation of DRG payment has been carried out before, there is not much breakthrough in key technologies, and the policy level is not well prepared In the future, DRG payment may encounter other problems when it is pushed forward, such as whether the supporting policies of the medical system and payment method can be issued in time, and whether the new compensation mechanism of the hospital can be established As we all know, DRG payment reform includes DRG grouping and payment Among them, standardized and scientific grouping is an important prerequisite for DRG implementation, and accurate payment is an important guarantee for DRG implementation The published group plan established 376 ADRG (core DRG) groups, allowing further subdivision under ADRG, and made more detailed provisions on subdivision methods For this "grouping scheme", Lin Zirong said that at the beginning of the integration of DRG versions, a total of 638 ADRG groups were formed, including 95689 combinations of disease diagnosis and operation, a large part of which is the difference formed by each version in the process of self grouping over the years, that is, the same disease diagnosis and treatment methods were divided into different disease groups in each version, which has been given to the hospital for a long time The doctor brought some troubles This time, through version fusion demonstration, seeking consensus and eliminating differences, we unified the ADRG group to 376, including 73350 combinations of disease diagnosis and operation, 262 combinations of ADRG difference group and 22339 combinations of disease diagnosis and operation, which made the managers' baton more clear and definite, and avoided the repeated management work of hospitals and doctors In terms of accurate payment, the technical specification makes it clear that DRG rate and payment standard calculation follow the principle of "regional total budget, giving reasonable growth space of medical expenses, the same disease and price of the same level hospitals, considering the difference of service ability between medical institutions, multi angle verification, and win-win situation of medical insurance and patients" In Xie kongbiao's view, whether the three parties of medical insurance and patients can achieve a win-win situation depends on "medical" and "patient" In hospital, we need to establish a reasonable compensation mechanism For patients, who speaks for them? After all, patients belong to the vulnerable groups in these three parties How to achieve high-quality service is still a big problem when calculating the cost Lin Zirong also analyzed that the overall design starting point of the medical insurance bureau is good, but the regional development of the country is unbalanced, the construction of credit system is relatively backward, and the clinical diagnosis and treatment is scientific It is impossible to have "clear provisions" in all the rules and regulations The following problems still exist to realize the three-way win-win of medical insurance patients First, there are limitations in the scope of application The classification basis of DRGs is diagnosis and operation, which is more suitable for cases (such as acute inpatient cases) whose diagnosis and treatment methods have significant impact on resource consumption and treatment results Traditional Chinese medicine and ethnic medicine are not included in the standard Second, it is easy to have adverse selection for patients Because the same payment standard is adopted for patients with different conditions of the same disease, under the constraint of the established resources, medical institutions will be more willing to "avoid the heavy and take the light", that is, to select patients with less disease and shift the blame on patients with more serious disease Third, there is moral hazard, which is easy to cause hospitals to reduce the necessary services for patients, and also to cause disputes between patients' demands for hospital services and medical insurance payments Fourth, it leads to the lack of innovation in medical institutions, and it is difficult to obtain higher returns through the investment of advanced technology The grouping and payment based on the status quo lead to the hospital's medical innovation and newly discovered diseases are not easy to be adopted immediately Fifth, formalism will deepen Medical insurance bureaus and hospitals need to increase more information processing, supervision and feedback personnel In order to meet the standards, the phenomenon of meeting the standards will occur Lin also reminded that the local medical insurance bureau is in the dominant position of absolute voice and discretion among the three parties of "medical insurance patients" If there are differences on grouping according to standards or payment for grouping, how to define punishment is a problem, and it is possible to cause related lawsuits around these problems In addition, among the "three win-win" goals of DRG payment, only the "medicine" is missing Therefore, some people in the industry said that the pharmaceutical industry does not need to pay too much attention to and interpret "DRG payment" Lin does not agree with this view "First of all, China's policies in the field of medicine and health have been introduced frequently The enterprises have been numb to the three-year pilot implementation of this kind of warm boiled frog policy In addition, the DRG related grouping scheme has 930 pages, which is not easy to understand at one time, so the response is not so intense." Secondly, the lack of voice in this policy-making is also one of the reasons why the industry has little response In addition, many insiders believe that DRG payment, which was first implemented in the United States, has not played a restraining role in the rapid rise of medical expenses and may not succeed in the pilot project in China Therefore, innovative pharmaceutical enterprises need to make efforts in clinical pathway, guidance and consensus Many generic pharmaceutical enterprises can do a good job in consistency evaluation and volume procurement For the time being, traditional Chinese medicine does not use DRGs management and has no impact It is impossible to judge whether it is good or bad " Xie kongbiao also believes that pharmaceutical enterprises should attach importance to DRG Although there is no mention of drugs, the demand for drugs is rigid With the promotion of DRG, the demand will rise steadily Once the national promotion, drugs will truly achieve high prices and high quality, the gray area will be less and less, and the whole industry will change dramatically So, how will DRG payment reform affect drug companies? How to deal with it? Xie kongbiao said that in the future, drug competition will definitely change in three aspects: cost, quality and brand The marketing mode of drugs in public hospitals will change, especially generic drugs, and high-priced generic drugs will disappear Lin Zirong suggested that since DRG payment is based on a fixed amount of payment for each similar disease group, the hospital must consider the use cost of drugs and consumables, so the significance of the original reference drug sales data of pharmaceutical enterprises has greatly decreased, and the marketing department and medical department of the enterprise should study countermeasures carefully The first is to sort out the existing key varieties in time, select the varieties with hospitalization as the main market, usually injection as the main market, intervene in the clinical pathway and guidance work in advance, form a favorable basis for academic status, and try to rely on coding Secondly, enterprises should understand the dynamics and development of DRG reform by means of their own terminal teams or business companies, and adjust their marketing strategies in the understanding Grouping and encoding will eventually lead to a balanced drug ecosystem and identify the location Moreover, after purchasing with quantity, the medicine that is too cheap has no profit, and the medicine that is too expensive can't be covered by medical insurance We can consider to lay out the market outside the hospital, increase the strength that has been laid out, act as soon as possible without laying out, and do not spend the money of medical insurance The medical insurance bureau doesn't care about you Finally, we should continue to pay attention to the liberalization of Internet drug sales Recently, we have been studying relevant laws and regulations In the future, we may transfer the slow disease drugs to the Internet and drugstores.