The National Medical Insurance Bureau issued the Notice on Printing and Distributing the General Budget of Regional Integration Method and the Pilot Work Plan of Payment by Disease Grading.

165438+October 2020

The National Medical Insurance Bureau issued the Notice on Printing and Distributing the General Budget of Regional Integration Method and the List of Pilot Cities for Payment by Disease Grading, and the Notice on Printing and Distributing the Technical Specification for Payment by Disease Grading of National Medical Insurance (DIP) and DIP Disease Catalogue Database (version 1.0).

202 1 June to July

The National Medical Insurance Bureau organized the first batch of cross-investigation and evaluation on the reform of medical insurance payment methods, and supervised the interim work progress of pilot cities.

202 1 July

The National Health Insurance Bureau issued the Detailed Rules for the Management of Payment by Disease (DIP) Medical Security (Trial).

202 1 year1month-1month

The National Medical Insurance Bureau organized the second batch of cross-research and evaluation on the reform of medical insurance payment methods, and evaluated the actual payment at the end of the pilot cities.

20211/month

The National Medical Insurance Bureau issued the Notice on Printing and Distributing the Three-year Action Plan of DRG/DIP Payment Mode Reform.

202 1 65438+ February

7 1 DIP pilot cities entered the actual payment in batches, and the first China CHS-DRG/DIP payment conference was held in Beijing.

April 2022

The National Medical Insurance Bureau issued the Notice on Doing a Good Job of Connecting the Use of DRG/DIP Function Module of Payment Mode Management Subsystem.

Definition of inclination angle

DIP is a complete management system based on big data. It explores the * * * characteristics of "disease diagnosis+treatment mode" to objectively classify medical records, form standardized positioning of various combinations of diseases and treatment modes in a certain area, objectively reflect the severity of diseases, the complex state of treatment, the level of resource consumption and clinical behavior norms, and can be applied.

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 number of cases in each medical institution. The medical insurance department forms the payment standard according to the disease score and the integral score, realizes the standardized payment of each case of medical institutions, and no longer pays the medical service project fees.

Applicable scope of inclined settlement

The total medical expenses incurred by the medical insurance insured (including the social medical insurance for employees and the social medical insurance for urban and rural residents) in the designated medical institutions shall be settled by DIP according to the principle of "budget management, total control, disease distribution, monthly pre-settlement and annual settlement". Designated medical institutions with corresponding diagnosis and treatment subjects and actual business, the total medical expenses incurred in the treatment of corresponding diseases are included in the scope of allocation.

(1) the business scope of the application

DIP settlement is only applicable to the hospitalization expenses incurred by the insured in the designated medical institutions of DIP pilot, which should be paid by the medical insurance fund, and the medical insurance agency will settle the designated medical institutions according to DIP standards and payment policies. The settlement of hospitalization expenses between insured persons and medical institutions shall be settled according to the established policy temporarily, and shall not be affected by DIP settlement temporarily.

(2) the scope of medical institutions.

For the time being, the DIP settlement rules are only applicable to all medical institutions that have carried out DIP pilot projects, and medical institutions that have not carried out DIP pilot projects continue to use the original settlement methods and policies.

(3) Applicable disease range

DIP is based on massive data samples, which are naturally clustered and combined according to the corresponding relationship between diagnosis and treatment, with detailed groups, small coefficient of variation within groups, stable differences between groups, true and objective data, close to diagnosis and treatment behavior, and easy to be accepted by doctors, patients and insurers. At present, the DIP catalogue covers nearly 99% of cases except psychiatric cases, rehabilitation cases and long-term nursing cases, achieving a balance between convenient operation and refined application, and reducing the risk of medical insurance payment.

The standards and conditions of applying DIP catalogue library to medical insurance payment

DIP directory database is a basic application system that determines stable grouping and brings it into unified directory management on the basis of exhaustive combination and clustering of disease diagnosis and treatment methods, and supports the normalization of grouping applications.

The grouping efficiency of DIP has a great influence on the application effect. If the grouping efficiency of DIP is poor, it will lead to inaccurate payment standards and more high and low charges in DIP. Therefore, in principle, after the local DIP catalog database is built, the corresponding grouping efficiency needs to be considered.

Calculation of disease score

Disease score is a standardized unit for different discharged cases, which can be used to evaluate and compare the output of hospital medical services and form the basis for payment. The specific calculation formula is:

RWi = m/m

Among them, m refers to the average hospitalization expenses of all cases, and mi refers to the average hospitalization expenses of cases in the first category of diseases. In order to fully reflect the development trend of diseases and expenses over the years, based on the past data of the past three years, the average expenses are calculated in the form of time weighting. If the current year is 2022, the historical data of the previous three years will be used, according to 20 19: 2020: 202 1 year =

Calculation of score point value of dip angle

(A) DIP budget point value

DIP budget point value is determined at the beginning of each year. Based on the total hospitalization expenses covered by this payment method, it is an important index for designated medical institutions to establish an estimation model of medical insurance fund to support the comprehensive budget management of medical insurance fund.

The calculation method is as follows:

Average score of budget score = weighted average annual total hospitalization expenses /∑(DIP score * corresponding disease cases)

Among them, the total annual hospitalization expenses are calculated by weighted average method, which is similar to the calculation process of DIP score. The weight of the total hospitalization expenses in the first three years is still 1:2:7.

(b) value of inclined settlement point

The value of DIP settlement point is determined at the end of each year or the beginning of the second year based on the total medical insurance budget, which is used to calculate the payment standard and conduct annual liquidation with designated medical institutions.

The calculation method is as follows:

Average settlement score = (total amount of medical insurance funds available for DIP payment/proportion of medical insurance reimbursement in the current year) /∑(DIP score * number of cases corresponding to diseases)

Calculation of fund payment expenses

(A) the calculation method of payment standard for sick groups

The payment standard of disease group is the medical insurance expense standard which can be used for the liquidation of designated medical institutions on the basis of DIP catalogue and score. Each disease group has a corresponding disease group payment standard, and the expenses are calculated and settled according to DIP score. The specific calculation formula is as follows:

Payment standard of disease group =DIP score * settlement point value

(2) the calculation method of medical insurance payment.

For inpatients grouped by general diseases, the medical insurance agency shall settle the hospitalization expenses of designated medical institutions according to the DIP results, and the specific calculation formula is as follows:

According to DIP, the total hospitalization expenses that the medical insurance fund should pay to the designated medical institutions = ∑ [(payment standard-out-of-pocket expenses-deductible line of the sick group in the DIP group where the insured is hospitalized) * medical insurance reimbursement ratio]-∑ It is suggested to deduct the expenses.

Note: If extreme phenomena occur, such as the out-of-pocket payment is greater than the difference between the payment standard of the sick group and the specific out-of-pocket payment and deductible line, which will result in the DIP payment result being less than or equal to 0, then the payment will be made as 0.

Development status of DIP payment

According to statistics, 7 1 DIP pilot cities nationwide cover 3190,000 people's basic medical insurance. In addition to the national pilot, 38 cities in1/kloc-0 provinces (autonomous regions) have carried out the pilot reform of provincial DIP, and the coverage has been further expanded.