The core standard of DRGs has been published! Big policies affecting 4000 pharmaceutical companies

If it is a breakthrough to reduce the drug price and control the cost through volume purchase, DRGs is to change the medical behavior, reduce the proportion of irrational drug use, promote the drug companies to improve the product value, and ultimately achieve the goal of sustainable medical insurance cost With the latest two standards issued by the state health insurance bureau, it is obvious that the window period for pharmaceutical enterprises to change their business ideas and product structure to meet the requirements of the new market in the future is very short! After the pilot implementation of "DRG payment" in 30 cities nationwide in May, another heavy standard of National Medical Security Bureau has been officially released! On October 16, 2019, the National Medical Security Bureau officially issued the notice on printing and distributing the technical specifications and grouping schemes of DRG paid country pilot, which contains two important standards, namely, the national medical security DRG grouping and paying technical specifications and the national medical security DRG (chs-drg) grouping scheme It is worth noting that the importance of these two standards is not common "The technical specifications and grouping plan are authoritative and professional standards formulated under the unified guidance of the state, forming the basic compliance of national medical DRG (chs-drg) Chs-drg is the only standard for DRG payment in the national health insurance department " Xiong Xianjun, director of the medical service management department of the National Medical Security Bureau, described the importance of the two standards at a special policy interpretation meeting organized by the National Medical Security Bureau on the 23rd In short, the introduction of the technical specifications means that the national DRG payment pilot will have unified technical specifications and guidance standards in the future; the introduction of the grouping scheme means that each pilot city must follow the unified grouping operation guidelines given in the grouping scheme in the next practical implementation of the DRG payment group, and then combine with the local actual situation, from the The local subdivision DRG group (DRGs) is established In the meeting, director Xiong Xianjun also clearly described the logic of the current national DRGs pilot work, which can be summarized as "three years and three steps", that is, "do a good job in top-level design this year, simulate operation next year, and start actual payment next year" In an interview with e-medicine manager, director Xiong Xianjun also said that he would also consider pushing DRGs across the country based on the actual situation of the pilot work For pharmaceutical companies, whether the next product can enter the DRG payment group of corresponding diseases has become a key action to determine the fate of the product to some extent But obviously, with the latest two standards issued by the state health insurance bureau, the window period for pharmaceutical enterprises to change their business ideas and product structure to meet the requirements of the new market in the future has been very short! In fact, in recent years, in addition to the 4 + 7 volume procurement, the discussion about DRGs should be the most attractive one in the industry The so-called DRG, English for diagnosis related groups, translates into "disease diagnosis related groups" This idea was born in the United States in the 1960s It is essentially a case mix tool with risk adjustment function Its basic idea is that different disease types, or similar cases with different treatment methods, or similar cases with different individual characteristics should be distinguished It focuses on the two dimensions of "clinical process" and "resource consumption" The grouping results should ensure that the clinical process and resource consumption of cases in the same DRG are similar Because of its outstanding risk adjustment function and convenient for management, it was gradually adopted by other countries In China, DRG has been studied and applied since 1980s 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 formally stated that pilot payment by disease diagnosis related group (DRG) should be carried out nationwide By May 30, 2018, the National Medical Security Bureau had held a video conference to launch the DRG payment pilot project in China, and announced the list of 30 DRG pilot cities, including Beijing, Tianjin, Handan, Hebei, Linfen, Shanxi, etc., which became a landmark event to promote DRG pilot projects in China The "technical specifications" and "grouping plan" released this time are two programmatic standards issued after 62 million case data were collected in 30 pilot cities nationwide for big data statistical analysis and verification, and they are also compiled on the basis of summing up the experience of DRG pilot projects in previous regions Such a job is not easy After more than 20 years of development, there have been several DRG versions in China, among which there are four mainstream authoritative versions, namely bj-drg of Beijing Medical Insurance Association, cn-drg jointly developed by the medical administration and Health Administration Bureau of the national health and Health Commission and the information center of Beijing Municipal Health and Health Commission, cr-drg of the basic health department of the national health and Health Commission, and Research on health development of the national health and Health Commission The c-drg of the center is applied to different scenes and targets respectively The grouping rules and application management of these versions are similar, but there are some differences in covering diseases, operation scope and application targets, so it needs to be integrated and summarized "For example, the common disease of varicose veins of the lower limbs, the patients are treated in hospital, the medication is basically the same, but different versions will be divided into different DRG groups, such as BJ version, peripheral vein disease group, Cr version, lower extremity vein disease group, CN version, other vein disease group." Zheng Jie, deputy director of the medical insurance center of Beijing Medical Insurance Bureau, gave an example at the meeting, saying that it is necessary to integrate different versions The chs-drg released this time is a combination of the above four mainstream versions "At the time of initial integration, all versions of ADRG were grouped into pharmaceutical companies, with a total of 638 There were nearly 100000 combinations of diseases and treatments, but most of them were repetitive." Zheng Jie said that the final chs-drg compressed the ADRG group to 376, with a weight removal rate of 41% The final combination of disease diagnosis and surgical operation was compressed from 95689 to 73550, with a total of more than 20000 removed From a macro point of view, DRGs system is a concrete embodiment of deepening the reform of medical insurance payment mode Its purpose is to promote the fine management of medical insurance, improve the use efficiency of medical insurance fund, give full play to the basic role of medical insurance in medical reform, so as to effectively safeguard the health rights and interests of the insured However, from the micro level, the implementation of DRGs system is likely to be a nearly reconstructed impact on the future market pattern of Chinese pharmaceutical enterprises This needs to start from the basic logic of DRG grouping and the actual running program Taking the grouping scheme as an example, the newly released grouping scheme has identified 26 main diagnostic categories, namely MDC; and 376 core DRG groups, namely ADRG In the actual DRG work, the formal grouping procedure should be divided into three steps: The first step is to divide into 26 MDCs according to disease diagnosis, such as endocrine system, blood system or immune system; The second step is to further subdivide it into 376 ADRG groups according to whether it is operated or not, medical medication, etc It is worth noting that these two steps can't be changed no matter in the next 30 DRG pilot cities or in the DRG trials started by local governments What local governments should do is to develop local sub DRG groups, i.e DRGs, which can also be understood as the actual DRG payment group according to the actual situation of each region, that is, the third step, and then the medical insurance department will make unified payment according to DRGs And the same as the single disease payment mode before this, whether it is single disease payment or DRG, is actually a payment method based on disease diagnosis Its function is to control the total medical expenses of each case It regards the whole process of medical service as a unit, and compensates the medical institutions according to the determined medical expense standard, instead of paying according to each service item implemented in the diagnosis and treatment process The actual payment amount is only related to the "disease type" of each case, and has nothing to do with the actual cost of treatment In this way of payment, if the cost of treatment exceeds the standard of disease payment, the hospital will lose money Therefore, before providing services, the hospital must consider whether the services provided are necessary and appropriate, which will also promote the hospital to actively demand the most reasonable treatment process, and actively avoid large prescriptions, repeated examinations, unnecessary expensive examinations and the use of valuable instruments, so as to achieve the purpose of reducing operating costs and improving work efficiency Obviously, in this case, with the generic drugs, under the same guarantee of treatment, the medical institutions must have the power to purchase cheaper products; with the original research products and domestic imitation products, the hospital also has enough power to purchase domestic imitation drugs that pass the consistency evaluation of the quality and efficacy of the generic drugs The overall market pattern will change directly under the promotion of the reform of medical insurance payment mode At present, the National Medical Security Bureau has begun to deploy the implementation of chs-drg payment First, according to the requirements of DRG grouping operation guide and DRG payment standard calculation method formulated by the state health insurance bureau, the pilot cities bring in the data of their own cities on the basis of ADRG, develop their own DRGs, and calculate the payment standard According to the requirements of DRG payment country pilot, the pilot cities will start the simulation operation in 2020 Secondly, the pilot cities and their regions (provinces and regions) should start to establish a local pilot work talent team, covering medical insurance, information, statistics, medical records and clinical talents, and report to the DRG paid national pilot technical guidance group for filing Work with the DRG payment country pilot expert group to form the organizational guarantee, talent base and technical support for DRG payment country pilot in all regions "At present, the national level is a team of 99 experts, who will work in different areas and direct business guidance The state will train experts and provinces, prefectures and cities Provinces and cities should also carry out training for medical institutions level by level Cultivate a group of professional and management talents who understand DRG " Xiong Xianjun said at the meeting Third, the medical insurance departments in the pilot cities should further improve the scientific total budget management, and establish multiple and compound payment methods for medical insurance Carry out pilot work monitoring, evaluation and intelligent monitoring, and rely on big data analysis to strictly monitor the possible illegal behaviors such as decomposing hospitalization, highly dependent diagnosis and prevarication of patients under DRG payment, so as to find and correct them as soon as possible Four is that the medical insurance departments of pilot cities should actively cooperate with the local health departments to require medical institutions to implement the relevant disease diagnosis and treatment routines, achieve reasonable inspection, rational drug use and reasonable treatment, and explore the standardized clinical path management under the DRG payment mode To clarify the impact of DRGs on the pharmaceutical industry, we need to start with the transformation of the concept of medical insurance payment mode and the purpose of reform In recent years, the concept of medical insurance payment in China has undergone seven changes, reflecting four key words: process, refinement, efficiency and value The first is to change from post payment system to prepayment system; the second is to change from single payment mode to multiple payment mode; the third is to change from emphasis on input to emphasis on process and result; the fourth is to change the result index from emphasis on service quantity and cost to emphasis on quality