The considerations behind the introduction of The New Medical Insurance Policy in Beijing? Interview with Zheng Jie, head of the Drg technical guidance group of the National Medical Insurance

"The main role of DRG is to standardize medical behavior, and supporting medical innovation is the 'icing on the cake', but it cannot be erased from its most basic 'charcoal in the snow' function

"According to the mature experience of the world, it must be around the main DRG program, and gradually form a variety of supporting measures to escort

"In the end, those who can pass the exclusion payment standard should be very rare, not large-scale

Recently, the Beijing Medical Insurance Bureau issued the "Notice on Printing and Distributing the Administrative Measures for the Payment of New Drugs Except for CHS-DRG Payment (Trial)" (hereinafter referred to as "Excluded Payment"), proposing that new drugs, new devices and new technologies that have passed the approval can not participate in DRG group payment

Beijing Medical Insurance Bureau

As soon as the news came out, it was like a flood discharge action, so that the innovative pharmaceutical device market that had been closed for a long time ushered in a long-lost "Ganlin"

However, everything cannot be seen from the essence, and if you want to correctly understand the New Deal, you must think about the deep meaning behind it

DRG is one of the important management tools that carry the development of the entire medical industry:

On the one hand, through big data summary decision-making, exit artificial pricing, scientific and reasonable allocation of medical resources, and accurately control the use of

On the other hand, it effectively guides the continuous optimization of medical services, from enterprises to hospitals, step by step to guide the value medical orientation

It is precisely because it carries such an important role that DRG has become the "top stream in the industry", and its every move has attracted much attention, and even many times it has been over-interpreted

As for how big this "exit" will be? What are the internal considerations of the evaluation criteria and threshold design? What will be the exemplary effect of Beijing's New Deal on the whole country? .

Recently, Medical Trend interviewed Zheng Jie, head of the National Medical Insurance DRG Technical Guidance Group and director of the Beijing Medical Insurance Affairs Management Center, and made an exclusive response to the above industry concerns

Zheng Jie, head of the DRG technical guidance group of the National Medical Insurance and director of the Beijing Medical Insurance Affairs Management Center

Zheng Jie is a domestic DRG research expert, participated in the formulation of the CHS-DRG grouping scheme, deeply understood the essence and meaning of DRG, in the face of the excitement of the market after the introduction of the exclusion policy, in the visit, he reiterated many times, "to leave an export for medical innovation is only an extension, must not forget the essence of

Leaving an outlet for medical innovation is only an extension, and the essence of

The considerations behind the introduction of the New Deal?

The considerations behind the introduction of the New Deal?

Medical trend: After the introduction of this policy, the market is like a shot in the arm, this enthusiasm, what do you think? Zheng Jie: Indeed, many people think that this policy is good for medical innovation, the response is very large, but I want to pull back a little, we can not be out of touch with reality, the essence of DRG is to standardize medical behavior, this time except for the supporting mechanism of payment, in order to leave an outlet for medical innovation, this is just an extension of DRG

Medical trend: After the introduction of this policy, the market is like a shot in the arm, this enthusiasm, what do you think? Zheng Jie: The essence of DRG is to regulate the medical behavior of medical trends: what do you refer to as the extension role? Zheng Jie:

Therefore, the drg grouping standard has a strong history, but medicine cannot be unchanged, it must be developed and advanced, there must be newly developed drugs, consumables, and technologies, which is one

Let the new product have the possibility of showing its new formation law

Medical trends: Before other places such as Zhejiang, Guangdong, etc.

Medical trends: Before other places such as Zhejiang, Guangdong, etc.
, there are also some policies to exclude payment, Beijing is not the first, but it is the most systematic, how to consider the timing of the introduction?

Zheng Jie: The reason why it is introduced now is mainly because the construction of the DRG system has
come to this step.
DRG is not perfect, according to the international mature experience, must be around the main program gradually formed a variety of supporting measures for it to escort, now the main program has been determined, the following should be to establish supporting measures, if not built, may lead to policy orientation to amplify its defects, but also for the sake of precautionary considerations
.

Zheng Jie: It must be around the main plan gradually formed a variety of supporting measures to escort it

What are the design review criteria for reflection?

What are the design review criteria for reflection?

Medical trend: The point you just mentioned, when formulating the declaration threshold, such as listing within three years, improving clinical effects, and having a greater impact on the payment standards of drg patient groups, are they all taken into account?

Medical trend: The point you just mentioned, when formulating the declaration threshold, such as listing within three years, improving clinical effects, and having a greater impact on the payment standards of drg patient groups, are they all taken into account?

Zheng Jie: Yes, it is precisely because we know very well what the purpose is, so we set these conditions to make the exclusion more meaningful, without deviating from the essence of
DRG.

Zheng Jie:

For example, one of our conditions is that we need to go through clinical arguments, what is the argument? There are many medical innovations, if you want to encourage from the perspective, you should all invest, but in fact, we can't take so much money from the people to encourage innovation, so let the experts evaluate which products and technologies are worth leaving in the future, which are meaningful real innovations, for those pseudo-innovations, we don't want it to occupy the share, and the point of expert argument is here
.

Medical Trends: How the process of justification ensures fairness and impartiality
.

Medical Trends: How the process of justification ensures fairness and impartiality
.

Zheng Jie: First of all, if experts release water, it is equivalent to losing their future costs, meaningless products, now put in, under drg, once exceeded, they have to bear
it themselves.

Zheng Jie:

Second, in addition to expert arguments, we also need to look at whether big data - DRG groupings and standards formed by historical data include this pharmaceutical device technology
.

If the original historical data is already included, it proves that it is already within our calculation range and standard, and it will certainly not pass
.

There is also a situation, that is, the current products, technology to replace the previous, but there is no big cost difference, such as low-value consumables, general medicine, there is no need to exclude, except for the main products that cause a greater impact on costs
.

Medical Trends: Have you calculated before the introduction of policies how many innovative products and technologies can meet the requirements?

Medical Trends: Have you calculated before the introduction of policies how many innovative products and technologies can meet the requirements?

Zheng Jie: It is now in the review stage, it is not known, there is no way to give accurate quantification, but our control is very strict, and in the end, we can pass the exclusion payment standard, which should be very individual, not a large range
.

Zheng Jie: In the end, those who can pass the exclusion payment standard should be very rare, not a large range

The main role of DRG is to standardize behavior, and supporting medical innovation is the "icing on the cake", but its most basic function cannot be erased
.

Therefore, the role of exclusion payment is not so great, we are just standardizing clinical behavior at the same time, respecting the law of real clinical development in the future, and giving a reasonable release space
.

If you want to give it too much expectation, DRG will become tainted and will not go on, because it is contrary to the
original intention.

If you want to give it too much expectation, DRG will become tainted and will not go on, because it is contrary to the
original intention.

Medical Trends: How to pay for innovative products and technology plans included this time?

Medical Trends: How to pay for innovative products and technology plans included this time?

Zheng Jie: This is very important
.
Exclusionary payment means that it is not included in the DRG package fee and can be charged separately and paid
separately.
But it does not change the current policy provisions of the National Medical Insurance Bureau, which is Class A is Class A, Class B is Class B, and Class C has to pay for
itself.

Zheng Jie:

It must be emphasized that the exclusion of payment does not mean that all reimbursement is included, this is not a concept, but it is not within the scope of packaging, and the directory management regulations and reimbursement policy implementation are still the same
.

Exclusionary payments do not imply that they are all included in the reimbursement

Medical trend: there was previous doctor feedback, after the implementation of DRG, doctors in the face of seriously ill patients are headaches, accept it, the cost is too high; Not accepting is prevaricating patients, so is there an exclusion payment for seriously ill patients this time?

Medical trend: there was previous doctor feedback, after the implementation of DRG, doctors in the face of seriously ill patients are headaches, accept it, the cost is too high; Not accepting is prevaricating patients, so is there an exclusion payment for seriously ill patients this time?

Zheng Jie: Yes, special cases are also one of the key directions of this policy, and at the end of the year, we will calculate an account and pay for special cases in proportion to alleviate the worries of doctors and hospitals
.

Zheng Jie:

Are exclusion payments universal?

Are exclusion payments universal?

Medical trend: Beijing's position in the domestic medical market is still very special, some people have proposed that for areas where medical insurance funds are stretched, the exclusion payment policy is relatively reluctant, what do you think?

Medical trend: Beijing's position in the domestic medical market is still very special, some people have proposed that for areas where medical insurance funds are stretched, the exclusion payment policy is relatively reluctant, what do you think?

Zheng Jie: Yes
.
I think that according to the work deployment of the National Medical Insurance Bureau, it will definitely expand, but it may not form a nationwide scope
.
Beijing's medical resources are relatively concentrated, the ability to innovate is relatively strong, generally speaking, leading the backward medical market for 5-10 years, then there is an appeal
for exclusion of payment.

Zheng Jie: I think that according to the work deployment of the National Medical Insurance Bureau, it will definitely expand, but it may not form a nationwide scope
.

For other smaller medical markets, one is that what cannot be cured is sent to the north, Shanghai and Guangzhou, and there is no such appeal
.

Second, the demands of different regions are different, and the medical market, which is relatively leading and academically leading such as Beijing, Shanghai and Guangzhou, may be the general demand
of the whole country.
However, in the non-super-large medical market, many of the content that needs to be excluded has long been put into clinical use in first-tier cities
.

So it's a very regional job
.
We do not encourage the initiative to expand the scope, the more the better, but according to the actual needs, the exception of the exception can be.

We do not encourage the initiative to expand the scope, the more the better, but according to the actual needs, the exception of the exception can be.

Medical Trends: Beijing took the lead in introducing a new policy, can it be regarded as a signal released by the Medical Insurance Bureau - it is gradually making up for the shortcomings of DRG?

Medical Trends: Beijing took the lead in introducing a new policy, can it be regarded as a signal released by the Medical Insurance Bureau - it is gradually making up for the shortcomings of DRG?

Zheng Jie: Rather than releasing a signal, I prefer to interpret it as releasing an attitude - DRG is not only a constraint, but also a diversion.

It is a scientific system that matches the objective laws of medicine, and we have the attitude of walking with medical
progress.

Zheng Jie: DRG is not only a constraint, but also a diversion

The significance of this orientation is more important
for Beijing than the substantive significance.

Future-oriented positive cycles?

Future-oriented positive cycles?

Medical trend: Beijing's current declaration materials have been collected, the fastest time to start trial operation?

Medical trend: Beijing's current declaration materials have been collected, the fastest time to start trial operation?

Zheng Jie: After receiving the materials, we will argue the data, and after another month, the trial estimate is in the fourth quarter
.

Zheng Jie: The trial estimate is in the fourth quarter

Medical trends: From the experience of foreign countries, such as Germany, there is a complete path from excluded payment to the future inclusion of DRG long-term payment, will our policy also have such a mechanism?

Medical trends: From the experience of foreign countries, such as Germany, there is a complete path from excluded payment to the future inclusion of DRG long-term payment, will our policy also have such a mechanism?

Zheng Jie: It will be
.
After 2-3 years, fully release the law, have enough data to accumulate, we will package and group again, and return to the process
of normalization.

Zheng Jie:

Medical Trends: Even after the perfect policy is implemented, it will encounter various problems, what do you think is the biggest challenge after the implementation of this policy?

Medical Trends: Even after the perfect policy is implemented, it will encounter various problems, what do you think is the biggest challenge after the implementation of this policy?

Zheng Jie: That is the gap
between the high expectations of the market and the actual effect.
Under the high expectations, enterprises find that our essence is not like this, which may produce a gap, which is the difference between the needs of the market and our actual capabilities, an eternal contradiction
.

Zheng Jie:

Medical Trends: To what extent do you think this policy has been implemented, and can it be said that it has achieved a successful guiding role?

Medical Trends: To what extent do you think this policy has been implemented, and can it be said that it has achieved a successful guiding role?

Zheng Jie: Go to the false and save the truth
.
Through this policy, if we can standardize medical behavior at the same time, we can find the clinical direction of future development and realize the real clinical value, I think it will be called
success.

Zheng Jie: Go to the false and save the truth
.