Establishing an efficient medical insurance payment mechanism is one of the goals of medical security system construction in the new period. The reform of payment by disease represented by DRG and Dipper has become the main direction of current reform. In 2020, the Opinions of the State Council City, the Central Committee of the Communist Party of China on Deepening the Reform of Medical Security System proposed to "continuously promote the reform of payment methods" and emphasized to "vigorously promote the application of big data and promote the payment methods of multiple compound medical insurance based on diseases". Judging from the actual demand, the current income growth of China's medical insurance fund is weak, and the growth rate of revenue and expenditure is unbalanced. At the same time, the increasingly vigorous use of medical services and excessive concentration in tertiary medical institutions have forced the reform of medical insurance payment methods based on disease payment to become necessary and urgent.
The basis of medical insurance payment is price, so the reform of payment method is essentially price reform, which needs to reform the pricing unit, payment standard, payment time and quality standard of medical services. Payment by disease is to change the traditional payment by medical service project into payment by disease. As shown in figure 1.
Figure 1 the path of medical insurance payment reform
Second, the concept of payment by disease and its specific forms
Broadly speaking, payment by disease refers to the way of combining some cases of disease diagnosis and treatment and paying according to the results of case combination. According to the number and sequence of disease diagnosis and surgery, and whether the individual characteristics and severity of cases are considered, payment by disease can be divided into several specific forms, such as single disease payment, single disease grouping payment, disease score payment based on big data (DIP), and payment by disease diagnosis related grouping (DRG).
Single-disease payment refers to the payment method that takes the main diagnosis of the disease or the main surgery as the case combination element and sets the payment standard according to the single disease. It was once a long-term reform of the collection method implemented by the medical insurance and health departments. The combination of cases paid for by a single disease must be a disease with relatively standardized diagnosis and treatment and clear criteria for judging curative effect, so the coverage is generally narrow and it is difficult to achieve full coverage of inpatients. By the end of 20 19, although more than 85% of the overall planning areas in China have carried out single-disease payment, its coverage only accounts for 5.8% of the total population. Single disease group payment is a rough further division of single diseases according to the severity of diseases on the basis of single disease payment. But in general, due to inherent limitations, it is difficult for them to become the mainstream of payment by disease.
Payment by disease refers to determining the disease score for the corresponding disease according to the proportion of the expenses incurred by different diseases, and calculating the score according to the total annual medical insurance payment, the proportion of medical insurance payment and the total score of cases of medical institutions under the total budget mechanism. The medical insurance department forms the payment standard according to the disease score and the integral score, and realizes the payment form of medical institution case settlement. Through the big data analysis technology, using the * * * characteristics of the patient's "disease diagnosis+treatment mode", the medical record data are objectively classified to form a case combination, and the medical insurance payment based on this is "DIP based on big data". It reflects the clinical objective reality and is easily accepted by hospitals through the natural exhaustive combination of "disease diagnosis+diagnosis and treatment" for actual inpatients. It is a self-developed case combination method in China. At present, it has been piloted in 7 1 cities such as Guangzhou.
Payment by DRG refers to the system that patients are divided into several related diagnosis groups for management by comprehensively considering their age, disease diagnosis, complications, treatment methods, disease severity and prognosis, resource consumption and other factors. If the payment standard is set for each relevant diagnosis group, the payment will be made according to the relevant group of disease diagnosis. It can scientifically classify and group diseases, and promote the standardization of doctors' diagnosis and treatment behavior and the refinement of medical service management. At present, it is an important tool widely used in various countries to measure the quality and efficiency of medical services and pay for medical insurance. Since 20 19, the national medical insurance has developed CHS-DRG for medical insurance payment based on the development experience of DRG at home and abroad. At present, there are 30 national pilot cities including Beijing and more than 100 provincial pilot cities.
Thirdly, the similarities and differences between DRG and DIP, as well as their respective advantages and disadvantages.
DRG and DIP, as the two most important payment methods according to diseases in China, are essentially concrete forms of case combination, but there are many differences in details such as core concepts and grouping principles, and each has its own advantages and disadvantages. The main differences between them are shown in table 1.
Comparison between table 1 DRG and DIP
Fourthly, the promotion and implementation strategy of DRG and DIP payment at present.
1.DRG and Dipper have their own advantages and disadvantages, and they will develop in parallel in a certain period of time.
DRG and DIP are different technical schemes to pay by disease (disease group), which are helpful to reduce the proportion of payment by project, pay by medical service output, standardize data management and guide medical behavior norms. Because both grouping schemes can group all cases, it is not necessary to mix DRG and DIP. As a whole, one of DRG or DIP should be selected as the main payment method, bed days, people and projects as the auxiliary payment methods, and multiple compound payments should be implemented. However, from an international perspective, choosing DRG payment is the choice of most countries that adopt disease (disease group) payment at this stage, and disease payment is the transitional stage of DRG payment. DRG payment is more conducive to international comparison and exchange, and it is convenient to evaluate the efficiency of medical insurance funds. From a practical point of view, DRG payment combines the needs of clinical practice and simplified management, taking into account not only the classification of clinical disease treatment and the individual characteristics of patients, but also the needs of medical insurance management, making it easier to form a consensus between medical insurance and medical institutions.
2. The specific payment method should be selected according to local conditions.
The choice of medical insurance payment method should be closely combined with the local reality, and comprehensively consider the current situation of local medical insurance basic technical standards, the management ability and reform willingness of the agency, the development level of information system, the supervision ability of medical services, the cooperation status of designated medical institutions, the characteristics of the proposed payment method and other factors. And make comprehensive decisions. In 20 17, the General Office of the State Council issued the Guiding Opinions of the General Office of the State Council on Further Deepening the Reform of the Payment Mode of Basic Medical Insurance (Guo Ban Fa [2017] No.55), proposing that "all localities should proceed from reality, fully consider the factors such as the payment capacity of medical insurance funds, medical insurance management and service capacity, medical service characteristics and disease spectrum distribution, actively explore and innovate, and implement them in line with local conditions. The application of DRG payment needs better information infrastructure and professional team, better medical record quality and standardized diagnosis and treatment process. However, the DIP pilot has relatively low requirements for professional teams and medical record coding quality.
3. Establish a public data pool and data governance mechanism for all payment methods to lay a solid foundation for the reform of payment methods.
At present, DRG and DIP are two parallel payment methods. A region can use DRG or DIP to group all hospitalized cases. The data sources used by the two methods are medical insurance settlement list and charge details, and the data standard is medical insurance information business code. It is necessary to further clarify the minimum data set of DRG and DIP, use unified interface standards to collect data, and form data transmission channels between medical institutions, regional medical insurance departments, provincial medical insurance departments and national medical insurance departments, and submit them in real time or daily. At the same time, it is necessary to formulate a unified data governance mechanism, strengthen data standardization training in medical records, finance and other departments, improve logical verification and intelligent audit of data, and ensure the accuracy of data use. Convenient for seamless switching of various payment methods, avoiding problems such as "repeated construction" and "turning over sesame cakes".
4. Promoting the standardization of clinical diagnosis and treatment of diseases and changing medical service behavior are the core of DRG/DIP reform.
The ultimate goal of medical insurance payment reform is to gradually change the medical service behavior of designated hospitals and doctors, promote the standardization and rationalization of hospital medical service behavior, thereby reducing or reasonably controlling the cost and expenses of medical services, reducing the waste of medical insurance funds, and making the most efficient use of limited medical insurance funds. Therefore, the design of payment mode reform should consider the principles of full coverage of patients, sustainable fund, classification of flow direction, standardization of diagnosis and treatment, rationalization of expenses and technical development, and establish a new sustainable development mechanism to promote the safety of fund expenditure, change doctors' behavior and reduce patients' burden. In this regard, DRG has achieved all-round supervision of the capacity, efficiency and quality of medical services through a series of evaluation indicators, such as case mix index (CMI), cost consumption index, time consumption index and mortality rate of low-risk patients. DIP, on the other hand, supervises the quality of medical records, secondary admission and low-standard admission through the auxiliary catalogue of illegal activities supervision.
5. Actively promote medical insurance and hospital refined management based on DRG and DIP.
The application of DRG and DIP can make use of the transparency of medical behavior and treatment results of regional medical institutions, which is conducive to the targeted and refined management of medical insurance and the refined management within medical institutions. For example, DRG is classified according to clinical anatomical site and treatment category, and one group may have different surgical methods. For example, appendectomy group includes laparoscope and incision, so it is necessary to choose the appropriate operation method in clinic, reduce the cost in the group and get a reasonable balance. DRG puts forward higher requirements for hospital internal management, squeezing out the water brought by high cost. Under DIP, each case combination can be compared in medical institutions in the whole city, and abnormal values can be found through big data, including abnormal expenses, abnormal times of diagnosis and treatment, abnormal times of hospitalization, time and so on. , as a clue to the problem, so as to analyze the risk of secondary admission, low-standard admission, long-term hospitalization and death. After running for a period of time, it can be fed back to medical institutions to balance the data of various case combinations in the city. Through the lateral comparability of cases, we can avoid irregular diagnosis and treatment behavior and squeeze the water brought by irregularities. Promoting the refined internal management of hospitals based on DRG and DIP is an important driving force for the continuous reform of DRG/DIP payment and the landing of hospitals.
6. Strengthening medical insurance supervision is the guarantee for the success of DRG/DIP payment reform.
No payment method is omnipotent, and any medical insurance payment method, including DRG and DIP, has its corresponding advantages and disadvantages. The reform of payment mode only provides a mechanism design to guide the medical service behavior of designated hospitals and doctors to change to a standardized and reasonable direction, so that the medical insurance fund can be used efficiently in a relatively scientific situation. Both DRG and DIP payment are based on the specific forms of disease payment. On the one hand, they can make hospitals actively reduce service costs, improve resource utilization, better control the total medical expenses and avoid overspending of medical insurance funds. On the other hand, they may also lead to risks such as shirking patients, decomposing hospitalization, upgrading diagnosis and reducing services, which may damage the quality of medical care. This requires medical insurance agencies to further strengthen medical insurance supervision to avoid or reduce the occurrence of the above behaviors. For example, strengthen the supervision over the quality of medical records and clinical diagnosis and treatment, conduct targeted spot checks on medical records that may have problems according to the changes of cases paid by diseases, establish relevant expert groups to analyze and evaluate the quality of medical records and clinical diagnosis and treatment processes, urge designated hospitals to standardize their behaviors and make reasonable diagnosis and treatment according to the results of spot checks, and objectively record and encode medical records to ensure the accuracy of case registration.