New payment method for medical insurance helps three parties win-win
Zhang Chuanchuan
According to reports, since the National Medical Insurance Administration issued the "Three-Year Action Plan for DRG/DIP Payment Method Reform" (hereinafter referred to as the "Plan") in November 2021, several provinces have successively released their own three-year action plan for DRG/DIP payment method reform. plan, and promote the implementation of national policies to be effective.
According to the requirements of the "Plan", from this year to the end of 2024, all co-ordination areas in the country will carry out the reform of this payment method. By the end of 2025, this payment method will cover all qualified medical institutions that provide inpatient services, basically achieving the goal of Full coverage of species and full coverage of medical insurance funds.
DRG and DIP are two similar medical insurance payment methods.
DRG is paid by disease grouping, grouped according to the patient's disease diagnosis, treatment method and treatment cost, and then packaged and paid according to the group.
DIP is based on big data and pays by disease category. It combines the grouping principle of DRG with the analysis of massive clinical real data to determine the grouping of diseases, and then combines the total amount of medical insurance funds in the overall planning area to determine the payment standard for each disease. , and pay the hospital according to this standard.
Broadly speaking, both DRG and DIP are packaged and paid by disease, and the difference is mainly in the basis of disease grouping.
For a long time, my country's medical insurance payment has adopted the method of paying by project, that is, the actual medical expenses are calculated according to the project according to the number of projects checked and the number of drugs prescribed, and the patient and the medical insurance fund shall respectively bear the part that needs to be paid.
Pay-by-item has the advantages of simple application and easy operation. It is a payment model widely used in the early stages of medical insurance development in various countries.
But once a hospital has a revenue-generating motive, fee-for-item encourages the hospital to provide unnecessary medicines and tests to patients, creating over-medical conditions.
At present, national medical insurance has entered a stage of high-quality development, which puts forward higher requirements for the management of medical insurance funds. It is imperative to explore and innovate more scientific, refined and standardized medical insurance payment methods.
It is against this background that in the past three years, the National Medical Insurance Administration has actively promoted the pilot work of two new payment methods, DRG and DIP, and launched a new three-year action plan on the basis of summarizing the pilot experience.
Medical insurance payment is an important lever to regulate medical service behavior and guide the allocation of medical resources.
The implementation of DRG/DIP payment method reform will help to encourage medical institutions to actively standardize medical service behavior, improve the level of diagnosis and treatment and service quality on the basis of saving costs, make the limited medical insurance funds more efficient, and realize the realization of medical insurance, hospitals and patients. A win-win situation for the three parties.
New payment methods can help achieve high-efficiency governance of medical insurance.
The package payment method encourages medical institutions to actively control costs to expand the balance, and medical insurance changes from passive to active, which can effectively restrain excessive medical treatment and unreasonable rise in medical expenses, and improve the efficiency of medical insurance funds.
The advancement of this reform will also drive the standardization and informatization construction of medical insurance, establish an effective and efficient medical insurance intelligent monitoring system, and realize the supervision of medical insurance funds from manual selection and review to big data. change to improve regulatory efficiency.
New payment methods will help to achieve high-quality development of hospitals.
After the implementation of DRG/DIP payment, inspections, medicines, consumables, etc. have changed from the hospital's income to the cost. The increase of the hospital's business volume may increase the income but not the profit. It will encourage the hospital to pay attention to medical cost control, reduce the water in medical services, and actively Improve management and operation efficiency.
The new payment method requires the same disease and the same price, which will encourage hospitals to identify their own functional positioning, strengthen the construction of advantageous disciplines, and attract patients to the hospital for medical treatment by improving the level of diagnosis and treatment and service quality.
New payment methods help achieve high-quality medical care for patients.
It is the fundamental purpose of the reform of medical insurance payment methods to reduce the medical burden of the people and improve people's well-being.
Implementing DRG/DIP payment to avoid excessive medical treatment can naturally reduce the burden of patients seeking medical treatment and save more "life-saving money" for the common people; the reform will also force hospitals to actively improve management and operation efficiency, improve the level of diagnosis and treatment and service quality, which is beneficial to patients Enjoy better diagnosis and treatment services and medical experience.
With the continuous advancement of the reform, the information construction of hospitals and medical insurance will continue to be improved, and patient medical treatment and medical insurance settlement will be more convenient.
This year is the first year of the three-year action plan for the reform of the DRG/DIP payment method. It is certain that with the comprehensive deepening of the reform, the efficiency of medical insurance fund use and the quality of medical services will continue to improve, and the public's sense of access to medical treatment will be more obvious.
(The author is a professor and doctoral supervisor of the School of Economics, Zhejiang University)