Starting from this year, within three years, the payment method of medical insurance will undergo a comprehensive change. A few days ago, the National Medical Insurance Bureau issued the "Three-year Action Plan for the Reform of DRG/DIP Payment Method", which made it clear that from 2022 to the end of 2024, the reform of DRG/DIP payment method will be carried out in all overall planning areas of the country, and by the end of 2025, DRG/DIP payment method will cover all eligible medical institutions that provide hospitalization services.
At first glance, the reform of payment method is a matter between medical insurance fund and hospital, and has little to do with ordinary insured. In fact, this reform is not only related to the use of medical insurance funds, but also related to the interests of the insured.
Payment mechanism is the key to improve the efficiency of medical insurance fund.
For a long time, the traditional payment method of medical insurance in China is based on projects. According to all drugs, medical services and medical consumables used in the diagnosis and treatment process, the patients and the medical insurance fund shall bear their own expenses, and those that need to be paid shall be paid according to the actual expenses.
This medical insurance payment method is relatively easy to realize, and it is also in line with the actual situation of China's past medical and health system. With the continuous improvement of people's living standards, the rigid demand for medical treatment is gradually released, and the disadvantages of traditional payment methods are becoming more and more obvious: it is easy to breed excessive medical behaviors such as "big prescription" and "big examination". This not only wastes medical resources, but also makes the insured spend more money, and the medical insurance fund spends more money.
"The CPC Central Committee and the State Council attached great importance to the reform of medical insurance payment methods. The Opinions of the Central Committee of the State Council on Deepening the Reform of Medical Insurance System clarified four mechanisms of medical insurance treatment, financing, payment and supervision. Payment mechanism is the key mechanism to improve the efficiency of medical insurance fund. Huang, director of the medical service management department of the National Medical Insurance Bureau, said that the "14 th Five-Year Plan" of national medical insurance clearly stated that it is necessary to continuously optimize the medical insurance payment mechanism. Promoting the reform of medical insurance payment method is not only the need of high-quality development of medical insurance, but also the need of high-quality development of hospitals, and it is also the need for people to obtain higher-quality medical insurance services.
In fact, the practical exploration of the reform of medical insurance payment method has never stopped, from the initial single payment by project to the multi-component medical insurance payment method. According to the characteristics of different diseases and different medical services, the reform of medical insurance payment methods will be promoted by classification. For inpatient medical services, explore the payment according to the disease type and the population related to disease diagnosis; Explore long-term chronic disease hospitalization medical services and pay by bed day; For primary medical services, actively explore the combination of per capita payment and chronic disease management.
With the development of medical technology, the development of clinical pathway and the requirement of refined management of medical insurance fund, it is imperative to explore and innovate more scientific, refined and standardized medical insurance payment methods.
Treatment due to illness and scientific pricing forced the hospital to control fees and increase efficiency.
The new payment method of DRG/DIP is moving from solving problems, starting and piloting to comprehensive promotion.
The so-called DRG payment refers to the payment according to the disease diagnosis of the relevant groups. That is, according to the factors such as disease diagnosis, severity and treatment methods, patients are divided into diagnosis-related groups with similar clinical symptoms and resource consumption. On this basis, pay medical insurance according to the corresponding payment standard.
DRG payment began in 1980s. At present, more than 40 countries have applied it to medical insurance pricing or fund budget, and it is recognized as one of the more advanced and scientific payment methods in the world. After the establishment of the National Medical Insurance Bureau, CHS—DRG, a payment version in China, was formed on the basis of synthesizing local major versions, which has the characteristics of integration, compatibility, most comprehensive coverage, unified coding, clinical balance and data guarantee, which also marks the gradual standardization of DRG in China from decentralization to unification.
The so-called DIP payment means paying according to the disease score. Under the general budget mechanism, the score is calculated according to the total annual medical insurance payment, the proportion of medical insurance payment and the total score of cases, and the payment standard is formed to realize the standardized payment of each case in medical institutions.
Compared with the traditional project-based payment, DRG/DIP payment is a more scientific and detailed medical insurance payment model, which can help hospitals to manage costs while taking into account clinical development.
"In the past, when paying by traditional items, medical insurance was paid to the hospital according to the reimbursement ratio after each item was multiplied by the unit price, and the hospital would have the impulse to provide more medical items to increase income." Jie Zheng, head of the National Medical Insurance DRG Payment Technical Steering Group and director of the Beijing Medical Insurance Affairs Management Center, said.
He said that after the implementation of DRG, the era of increasing income and expanding bed size for medical institutions is over, which will force hospitals to increase quality control fees and improve efficiency. On the basis of assessing the service quality of medical institutions, the medical insurance department makes clear the balance retention policy and reasonably overspend and share. Therefore, medical institutions will pay more attention to the cost control of drugs and consumables, compress the water in treatment and implement a more efficient management model. In this process, patients can also avoid unnecessary medical expenses.
The new payment method can achieve mutual benefit and win-win for all three parties.
According to the ideal mode of DRG/DIP payment reform design, medical insurance funds, hospitals and patients should achieve a win-win situation.
For medical insurance, DRG/DIP payment is more scientific and standardized, which can optimize medical services. We can use the limited medical insurance fund to buy higher quality services for the insured and improve the efficiency of the medical insurance fund.
For hospitals and doctors, the new payment method will encourage hospitals and doctors to voluntarily standardize medical services, control costs and reduce waste of resources. On the other hand, it will also guide medical institutions to improve the ability of disease diagnosis and treatment, and attract patients to hospitals with high-quality services and technical level.
For the insured patients, after the hospital controls the cost, the corresponding charging items are reduced, the patient's medical expenses are reduced, and the personal burden is reduced.
In reality, can the ideal model be realized? Before the new payment method officially landed, since 20 19, the national medical insurance bureau has carried out DRG payment pilot in 30 cities and DIP payment pilot in 7 1 city.
Wuhan, Hubei Province is one of the first batch of DRG pilot cities, and all the designated medical institutions at the second level and above in the city are included in the pilot. From 202 1 to 10, under the condition that the number of cases in the whole city was basically the same, the average hospitalization expense decreased from 1 14992 yuan to 112 yuan, and the average expense was reduced. The income and expenditure structure of medical institutions was initially adjusted, and the proportion of common diseases and frequently-occurring diseases was significantly reduced. The accumulated balance of the employee medical insurance pooling fund turned from negative to positive, which reversed the trend of the gap for seven consecutive years, and the fund expenditure risk was initially resolved.
After the reform of DRG payment in Liupanshui, Guizhou, the growth rate of total hospitalization expenses decreased by 2.5 1% in 200219, and the growth rate of hospitalization expenses paid by medical insurance in the whole city decreased by 8.87% compared with 20 19; At the end of 20021,the average hospitalization expenses of urban and rural residents decreased from 6,725.07 yuan to 6,385.09 yuan, a year-on-year decrease of 5%; The average hospitalization expenses of urban workers decreased from 10572.79 yuan to 8342.34 yuan, a year-on-year decrease of 21.09%; The average hospitalization days decreased from 9.99 days to 9.2 1 day, a year-on-year decrease of 7.8%.
Ying Yazhen, vice president of National Medical Insurance Research Institute and vice president of China Medical Insurance Research Association, said: "The implementation of DRG/DIP payment will effectively change the long-standing disadvantages of passive payment of medical insurance, extensive development of hospitals and heavy burden on patients. For the three parties, it is a mutually beneficial and win-win reform. "
People's Daily (February 65438+March 02, 2022)