The implementation of the DRGs point payment for the hospitalization fee of basic medical insurance in Zhejiang Province and Hangzhou City is detailed.

On May 11, the Zhejiang Provincial Medical Insurance Bureau issued a notice on the "Regulations on the Payment of DRGs Points for Basic Medical Insurance Hospitalization costs in Zhejiang Province and Hangzhou City (Trial)."
. Article 1 These Regulations are formulated in accordance with the Interim Measures for the Payment of DRGs Points for Hospitalization Expenses of Basic Medical Insurance in Zhejiang Province, in the light of the actual work of basic medical insurance in Zhejiang Province and Hangzhou City.
Article 2 These Regulations shall apply to the designated medical institutions in Zhejiang Province and Hangzhou City that carry out basic medical insurance in-patient medical services. The inpatient medical expenses incurred by provincial, hangzhou and off-site insured persons in Zhejiang Province shall be included in the management of these Regulations.
Article 3 The basic medical insurance treatment of insured persons shall not be adjusted by this Regulation. The term "medical insurance fund" as mentioned in these Regulations refers to the basic medical insurance fund other than the personal account used in the co-ordination area to pay for inpatient medical expenses.article 4
The provincial, hangzhou and districts and counties (cities) of Zhejiang Province shall, taking into account the current year's income budget, major policy adjustments and the quantity, quality and ability of medical services, and shall, together with the departments of finance, health and health, determine the growth rate of the inpatient medical insurance fund expenditure in that year through negotiation. The medical insurance operating institution approves the total budget of the hospital medical insurance fund for the year according to the established growth rate and the total final accountofed portion of the hospital medical insurance fund for the previous year (including the reserved portion, excluding the portion of the budget, excluding the overexpenditure and temporary supplementary budget due to the outbreak of disease. the total annual budget of the
hospital insurance fund is the total final account of the hospital medical insurance fund in the co-ordination area for the previous year. This budget includes the amount of medical insurance fund expenditure of the insured persons in the co-ordination area who are hospitalized locally and off-site, and the inpatient medical insurance fund for employees and urban and rural residents shall be included in the total budget and consolidated accounting.
the total expenditure growth rate of the medical insurance fund in Zhejiang Province and Hangzhou Municipality (including Xiaoshan, Yuhang, Fuyang District, excluding Lin'an District) in 2020, and the other districts and counties (cities) under the jurisdiction of Hangzhou City shall formulate the growth rate of the expenditure of the medical insurance fund and report it to the public health insurance administrative department of Hangzhou For the record. The total amount of the 2019 hospital health insurance fund is based on the expenditure of the hospital insurance fund for the current year.
no adjustment will be made in principle after the budget of the Annual Inpatient Medical Insurance Fund has been determined. If there is a significant difference between the expenditure of the hospital medical insurance fund and the total budget due to objective factors such as policy changes and disease outbreaks, the total budget shall be adjusted reasonably. The adjustment amount shall be determined by the medical insurance administrative departments of each co-ordination area after their calculationands and requests the medical insurance administrative departmenttos to consult with the departments of finance, health and health.
article 6 to establish a mechanism for the sharing of responsibilities for "balance retention and overexpenditure sharing". If there is a balance or overspend in the annual accounts of the inpatient medical insurance fund in the co-ordination area (compared with the total annual budget of the inpatient medical insurance fund in the co-ordination area and the expenditure of the medical insurance fund required for the settlement of the insured person's inpatient medical insurance fund according to the project), the fixed-point medical institution and the medical insurance fund shall be retained or shared according to a certain proportion on the basis of the analysis of the reasons and the clarification of responsibility.
the proportion of appropriate sharing (retention) of the inpatient medical insurance fund is adjusted dynamically according to the fund management performance of the medical insurance fund. Eighty-five per cent of the balance of the annual accounts of the 2020 annual health insurance fund is retained by the designated medical institutions, and 85 per cent of the overspend is shared by the designated medical institutions.
Article 7 Zhejiang Provincial and Hangzhou City will be based on the DRG grouping standards of our province, combined with local practice unified grouping. In principle, the variation coefficient cv 1 in the disease group group, and the overall variance reduction coefficient RIV is 70%.
CV value is the coefficient of variation of health insurance settlement fee in the DRG group, reflecting the difference degree (discreteity) of different samples in the group. Average of samples in CV-DRG/DRG.
the RIV value is the difference between DRG groups, the larger the RIV indicates the higher the differentiation of the DRG grouping system. The sum of the squares/total deviations of the specific DRG-to-average difference.
Article 8 to establish a GROUP of EXPERTs on the drG, which, on the principle of fairness, fairness and openness, undertakes the relevant assessment, evaluation and evaluation of the needs of THE DRG work. The experts make the evaluation opinion sat on the principle of minority obedience to the majority. If the
-targeted medical institution sit against the results of the assessment, it may file a complaint with the provincial and municipal medical insurance administrative departments. Article 9 of the
Inpatient medical services shall be paid mainly in accordance with DRGs technology to determine the part of the DRG disease group, and the costs included in the bed day payment management shall be managed as follows. The determination of the
(i) range and the average bed-day limit
1. Insured persons with annual cumulative hospitalization time of more than 90 days (inclusive) shall be included in the bed-day paid management of cases in the internal medicine DRG group that occur in the second-level and below fixed-point medical institutions. The average bed-day limit for 2020 is tentatively set at 450 yuan
; In addition to the above, in the same fixed-point medical institutions single consecutive hospital stay of more than 60 days (excluding) long-term, chronic disease cases need to be included in the bed day payment, the specific average bed-day limit by the fixed-point medical institutions to apply, reported to the medical insurance agency for validation, in principle, the same level of fixed-level medical institutions average bed-day limit;
3. The above average bed-day limit shall apply to the provincial level of Zhejiang Province and the main urban area of Hangzhou (excluding Xiaoshan, Yuhang, Fuyang, Lin'an District), and the areas other than the main urban area of Hangzhou can be formulated in conjunction with local practical reference, but shall not be higher than the average bed-day limit in the main urban area. The medical insurance operating institution may, in accordance with the actual occurrence of in-patient medical expenses and the income and expenditure of the basic medical insurance fund, adjust it in time and dynamically after negotiations with the designated medical institutions, but in principle, it shall not exceed once a year.
(ii) the determination of the bed day payment standard
1. Where the actual average bed-day fee included in the bed-day payment management by a fixed-point medical institution is less than 85% (inclusive) of the average bed-day limit, the actual average bed-day fee shall be used as the bed-day payment standard
; Where the actual average bed-day fee is 85%-100% (inclusive) in the average bed-day limit, the actual average bed-day fee plus 60% of the difference with the average bed-day limit is used as the bed-day payment standard;
3. Where the actual average bed-day cost exceeds the average bed-day limit, the average bed-day limit shall be used as the bed-day payment standard.
(iii) the conditions for withdrawal from bed-day paid management. If the following conditions are met, the annual liquidation shall be applied for by a fixed-point medical institution, approved by the medical insurance agency, and may be withdrawn from bed-day payment management and incorporated into DRG management, but the same hospitalization case may not be split into DRG and bed-day paid settlement.
1. In a single hospitalization, the number of days of ICU unit therapy (or CCU unit therapy) accounted for more than 50% of the total number of days in hospital
; In a single hospitalization, the diagnosis name is "coma" and the name of the operation and operation is "breathing machine therapy , which is greater than or equal to 96 hours", and the number of days of ventilator treatment is more than 50% of the total number of days in hospital
; With the exception of the two cases mentioned above, the withdrawal rate of other cases does not exceed 5 per cent.
Article 10 Zhejiang Province and Hangzhou City unified DRG points and difference coefficients, the cost difference is not significant DRG, can be gradually eliminated the difference coefficient, to achieve the same disease price. article 11
The medical insurance operators shall set the difference coefficient according to the hospital grade, the per person-to-person ratio, the level of personal burden, the historical cost, the implementation of the catalogue of disease diagnosis and treatment at the county and township levels, the CMI value and so on, of which the hospital grade weight is not less than 60%.
hospital grade is based on the provincial health department grade evaluation documents, and hospitals that do not participate in the grade evaluation shall not, in principle, refer to or be higher than the grade coefficient of the secondary hospital. The method for determining the coefficient of difference sits separately.
Article 12 to optimize the effectiveness of the grouping, more case data samples are retained, and each group of case data samples is cropped by a method with a smaller crop rate. The upper limit of the crop is called the upper crop multiple, and the lower limit of the crop is called the lower cut multiple.
Article 13 DRG is divided into stable DRG and non-stable DRG. The number of cases in the DRG conforms to the requirements of the large number theorem value or the number of cases reaches more than 5 cases and the DRG of CV 1 is stable DRG. The DRG of 5 cases in the group was non-stable DRG. After the DRG of the group of cases 5 and CV-1 is cropped again, the number of cases in the group is 5 and the CV 1 is incorporated into the stable DRG, and the non-stable DRG is added. The incoming cases in stable DRG and non-stable DRG cases were divided into high-multiplier cases, low-multiplier cases and normal cases according to the multiplier relationship between the total cost of the case and the average cost of the current DRG.
(i) high-multiplier cases are cases that can be admitted to the group, but the total cost of hospitalization is higher than the average cost of this DRG a certain multiple and above the cost is too high. High-rate cases are graded according to the following rules:
1. In A DRG with a reference point of less than or equal to 100 points, the total cost of hospitalization is 3 times greater than or equal to the average cost of the DRG
; 2. In A DRG with a reference point greater than 100 points and less than 300 points or more, the total cost of hospitalization is greater than or equal to 2 times the average cost of the DRG
; In A DRG with a reference point greater than 300 points, the total cost of hospitalization is 1.5 times greater than or equal to the average cost of the DRG.
(ii) low-multiplier cases are cases that can be admitted to the group, but the total cost of hospitalization is 0.4 times lower than the average cost of this DRG and below.
(iii) normal cases are cases other than high-multiplier and low-multiplier cases.
Article 14 DRG Base Points are determined as follows.
(i) Stable DRG Base Point - The average cost of the DRG in patients , the average cost of all DRG hospitalizations x 100 (the calculation results are retained by 4 decimal places).
(ii) Non-stable DRG Base Points - The median cost of the DRG , the average cost of all DRG hospitalizations x 100 (the calculation results are reserved for 4 decimal places).
(iii) Bed Day Base Point - The bed-day payment standard , the average cost of all DRG hospitalizations x 100 (the calculation results are retained by 4 decimal places).
Article 15 DRG points are calculated as follows:
(i) DRG points for complete cases of the hospitalization process, DRG base points x DRG differential coefficients, drG points for cases of incomplete hospitalization
the hospital process, DRG baseline points, DRG baseline points, DRG differential coefficients, (actual medical expenses incurred in cases, the average cost of the DRG hospitalization), and the maximum should not exceed the DRG base points.
low-multiplier cases are subject to case requirements for incomplete hospitalization processes.
(ii) Total number of bed-day cases - bed-day base points x number of days of hospitalization.
(iii) the determination of the number of cases in the special disease list. For cases where treatment is too high or cannot be assigned to existing DRG, the fixed-point medical institution may submit a special illness bill to the medical insurance operator, and the medical insurance operator shall organize experts to assess and adjust the corresponding points.
1. The high-multiplier case special disease list approves the additional points . . . the DRG base point x the additional multiple. Additional multiples (total cost of the case - unreasonable medical expenses) - the average cost of the DRG hospitalization - the DRG cap cut multiple. The cutting magnifice is determined in accordance with the rules of Article 13.
2. In cases that cannot be divided into cases in which DRG is already in place, the special illness list approves additional points ( total cost of cases - unreasonable medical expenses) - all DRG hospitalization cost x 100.
3. Cases of withdrawal from bed-day paid management are no longer subject to special illness list discussion, and cases that have been included in bed day paid management and exit from bed-day payment management before annual liquidation shall not be recognized if special illness bills have been negotiated.
(4) For those who are hospitalized again with the same DRG and without reasonable reasons within 15 days after discharge from hospital, the points obtained from the previous hospitalization shall be calculated in half (except for malignant tumor discharge, chemotherapy, inclusion in bed day payment management, etc.). Article 16 of the
encourages the creation of medical peaks, supports targeted medical institutions to carry out new technologies and enhance the capacity of specialized services. Fixed-point medical institutions to carry out new medical technologies in accordance with the provisions of the administrative department of health, after the EVALUATION of the DRG expert group, according to the price of their medical services reasonable to determine the number of points. The specific process is developed by the provincial health insurance operator. Article 17 of the
, in accordance with the characteristics of Chinese medicine services, with the same efficiency and the principle of the same efficiency, select suitable diseases to carry out the DRGs point payment pilot, the specific measures are formulated separately.
Article 18 Inpatient medical expenses of designated medical institutions in the co-ordination area shall be included in the paid management of DRGs. The expenses of the inpatient medical insurance fund incurred by the insured persons in this co-ordination area outside the co-ordination area shall be deducted from the annual budget. The medical insurance operators in each co-ordination area shall carry out monthly advance payment and annual liquidation of the medical insurance fund, and the settlement cycle shall be carried out in accordance with the natural year. Each co-ordination area shall determine the actual value of each point according to the factors such as the total number of points of medical service and the budget index of medical insurance fund expenditure, and shall pay the total point value of each fixed-point medical institution.
Article 19 The hospitalization expenses incurred by off-site insured persons shall be included in the point value calculation and management.
(1) The cost of off-site medical treatment in a fixed-point medical institution managed by the provincial level in Zhejiang Province shall be included in the calculated point value of provincial medical insurance consolidation in Zhejiang Province.
(2) The cost of off-site medical admission of a fixed-point medical institution managed by the Hangzhou urban area shall be included in the value of the medical insurance calculation point in Hangzhou. The combined calculation point value of the two insurance funds, the basic medical insurance for employees and the basic medical insurance for urban and rural residents.
(iii) the cost of off-site medical treatment in designated medical institutions managed by Lin'an District, Luxian County, Jiande City and Yan'an County shall be included in the calculation point of medical insurance in each medical area. The combined calculation point values of the two insurance funds, basic medical insurance for employees and basic medical insurance for urban and rural residents, were consolidated in each co-ordination area.
Article 20 Monthly Expense advance management is as follows:
(1) monthly point value calculation
monthly point value. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The total amount of expenditure of the direct settlement of medical insurance fund by the insured person in this co-ordination area in different places - the total expenditure of the medical insurance fund expenses of the insured person in this co-ordination area due to hospitalization in the operating institution) - the total amount of direct settlement expenses of the monthly off-site insured person in the co-ordination area and the total cost of the hospital hospitalization of the patient at the expense of the self-funded settlement.
the total cost of direct settlement of the hospital of the monthly off-site insured personnel in the co-ordination area , the total cost of direct settlement of the hospital in the city in the co-ordination area , the total cost of direct settlement of the hospital in the province in the province , the total cost of direct settlement of the hospital in the province , and the total cost of direct settlement of the hospital in the co-ordination area by the monthly cross-provincial off-site insured personnel in the co-ordination area.
Monthly Total Points - Total Monthly Total Points for All Medical Institutions in the Co-ordination Area , Additional Total Points - Total Points deducted.
(2) The total budget expenditure of the monthly inpatient medical insurance fund in the co-ordination area
the total expenditure of the monthly inpatient medical insurance fund in the co-ordination area shall be combined with the total expenditure of the hospital medical insurance fund in the co-ordination area in the same month of the previous year as the total expenditure of the current co-ordination hospital medical insurance fund.