The reform of payment methods within three years will cover all co-ordination areas in the country
Medical insurance payment is more scientific and refined (policy interpretation)
Registering, checking, and taking medicines are the most familiar procedures for going to the hospital to see a doctor. During this process, if you are a medical insurance participant, after the threshold is exceeded, a portion of each expense will be borne by the medical insurance fund.
That is to say, in the money we see a doctor, the medical insurance fund is paid to the hospital in proportion.
Starting this year, within three years, the payment method of medical insurance will undergo a comprehensive change.
A few days ago, the National Medical Insurance Administration released the "Three-Year Action Plan for the Reform of DRG/DIP Payment Methods", which clarifies that from 2022 to the end of 2024, all coordinating regions in the country will carry out payment by disease diagnosis-related group (DRG)/disease type score (DIP). By the end of 2025, the DRG/DIP payment method will cover all eligible medical institutions that provide inpatient services.
At first glance, the reform of payment methods is a matter between the medical insurance fund and the hospital, and has little to do with ordinary insureds.
In fact, this reform is not only related to the use of medical insurance funds, but also to the interests of the insured.
Payment mechanism is the key to improving the efficiency of medical insurance fund use
For a long time, my country's traditional medical insurance payment method is to pay by item. According to all the medicines, medical service items, and medical consumables used in the diagnosis and treatment process, how much is settled and how much is settled, the patient and the medical insurance fund shall bear the part that needs to be paid according to the actual cost. .
This medical insurance payment method is relatively easy to implement, and it is more in line with the actual situation of my country's medical and health system in the past.
With the continuous improvement of people's living standards, the rigid demand for medical treatment is gradually released, and the drawbacks of traditional payment methods are becoming more and more obvious: it is easy to breed excessive medical behaviors such as "big prescription" and "big inspection".
This not only causes a waste of medical resources, but also makes the insured spend more money and the medical insurance fund spends more.
"The Party Central Committee and the State Council attach great importance to the reform of medical insurance payment methods. The "Opinions of the Central Committee of the Communist Party of China and the State Council on Deepening the Reform of the Medical Insurance System" clarifies the four mechanisms of medical insurance treatment, financing, payment and supervision. The payment mechanism is the key to improving the efficiency of medical insurance funds. mechanism." Huang Huabo, director of the Medical Service Management Department of the National Medical Insurance Administration, said that the "14th Five-Year Plan for National Medical Insurance" clearly requires continuous optimization of the medical insurance payment mechanism.
Promoting the reform of medical insurance payment methods is not only the need for the high-quality development of medical insurance, but also the need for the high-quality development of hospitals, and the need for the people to obtain higher-quality medical insurance and medical services.
In fact, the practice and exploration of the reform of medical insurance payment methods has not stopped, and it has gradually developed from a single project-based payment method to a multi-complex medical insurance payment method.
According to different diseases and the characteristics of different medical services, the reform of medical insurance payment methods shall be promoted by classification.
For inpatient medical services, explore payment by disease type and by group related to disease diagnosis; explore bed-day payment for long-term and chronic disease inpatient medical services; and actively explore the combination of per capita payment and chronic disease management for primary medical services.
With the development of medical technology, the development of clinical pathways, and the requirements for the refined management of medical insurance funds, it is imperative to explore and innovate more scientific, refined and standardized medical insurance payment methods.
Treating diseases and pricing scientifically, forcing hospitals to control costs and increase efficiency
The new DRG/DIP payment method is moving from problem-solving, start-up, and pilot to comprehensive promotion.
The so-called DRG payment refers to payment by group related to disease diagnosis.
That is, according to factors such as disease diagnosis, disease severity, and treatment methods, patients are divided into diagnosis-related groups with similar clinical symptoms and resource consumption.
On this basis, medical insurance pays according to the corresponding payment standard.
DRG payment began in the 1980s, and more than 40 countries have applied it to medical insurance pricing or fund budgeting. It is one of the more advanced and scientific payment methods recognized in the world.
After the establishment of the National Medical Insurance Bureau, my country's own payment version CHS-DRG has been formed on the basis of integrating the main local versions. The implementation in my country has shifted from decentralization to unity, and gradually standardized.
The so-called DIP payment means payment based on the value of the disease. Under the total budget mechanism, the point value is calculated according to the total annual medical insurance payment, the proportion of medical insurance payment and the total score of the cases in each medical institution to form a payment standard. Standardize payments.
Compared with traditional payment by project, DRG/DIP payment is a more scientific and refined medical insurance payment model, which can help hospitals to take into account clinical development while managing expenses.
"In the past, when paying for traditional items, medical insurance paid the hospital according to the total amount of each item multiplied by the unit price, and paid the hospital according to the reimbursement ratio. The hospital would have the urge to provide more medical items to increase income." National Medical Insurance DRG Payment Technology Zheng Jie, head of the steering group and director of the Beijing Medical Insurance Affairs Management Center, said.
He said that after the implementation of DRG, for medical institutions, the era of increasing revenue and expanding the size of beds by volume is over, which will force hospitals to improve quality control costs and increase efficiency.
On the basis of assessing the service quality of medical institutions, the medical insurance department shall clarify the policy of surplus retention, and reasonably share the overspending.
Therefore, medical institutions will pay more attention to the cost control of drugs and consumables, compress the water in the treatment, and implement a more efficient management model.
In the process, patients can also avoid unnecessary medical expenses.
The new payment method can achieve mutual benefit and win-win for the three parties
According to the ideal model of DRG/DIP payment method reform and design, medical insurance funds, hospitals and patients should achieve a win-win situation.
For medical insurance, DRG/DIP payment is more scientific and standardized, and can better optimize medical services.
The limited medical insurance fund can be used to purchase higher-quality services for the insured and improve the efficiency of the medical insurance fund.
For hospitals and doctors, the new payment method will motivate hospitals and doctors to consciously and proactively regulate medical services, control costs, and reduce waste of resources.
On the other hand, it will guide medical institutions to improve their ability to diagnose and treat diseases, and use high-quality services and technology to attract patients to the hospital for medical treatment.
For the insured patients, after the hospital controls the cost, the corresponding charging items will be reduced, the patient will spend less on seeing a doctor, and the personal burden will be reduced.
In reality, can the ideal model be realized?
Before the official launch of the new payment method, since 2019, the National Medical Insurance Administration has successively launched DRG payment pilots in 30 cities and DIP payment pilots in 71 cities.
Wuhan, Hubei is one of the first batch of DRG pilot cities, and all the second-level and above designated medical institutions in the city are included in the pilot.
From January to October 2021, when the number of case combinations in the city is basically the same, the average cost of hospitalization will drop from 14,992 yuan in January to 13,712 yuan in October, and the average cost per time will be reduced by 9%.
The adjustment of the income and expenditure structure of medical institutions has begun to show, and the proportion of common diseases and frequently-occurring diseases has been significantly reduced.
The cumulative balance of the employee medical insurance pooling fund has changed from negative to positive, reversing the trend of shortfalls in the current year for seven consecutive years, and the risk of fund expenditure has been initially resolved.
In Liupanshui, Guizhou, after the DRG payment reform, in 2021, the growth rate of total inpatient medical expenses will drop by 2.51% compared with 2019, and the growth rate of hospitalization expenses paid by the city's medical insurance will drop by 8.87% compared with 2019. Yuan dropped to 6,385.09 yuan, a year-on-year decrease of 5%; the average hospitalization cost of urban workers dropped from 10,572.79 yuan to 8,342.34 yuan, a year-on-year decrease of 21.09%; the average hospitalization days dropped from 9.99 days to 9.21 days, a year-on-year decrease of 7.8%.
Ying Yazhen, vice president of the National Medical Insurance Research Institute and vice president of the China Medical Insurance Research Association, believes: "The implementation of DRG/DIP payment will effectively change the long-term disadvantages of passive payment of medical insurance, extensive development of hospitals, and heavy burden of patients seeing a doctor. In other words, it is a mutually beneficial and win-win reform.”
Our reporter Sun Xiuyan