The Guiding Opinions make it clear that the main goal of the reform of medical insurance payment method is to further strengthen the budget management of medical insurance fund from 20 17 and fully implement the diversified payment method based on disease payment. The state has selected some areas to carry out pilot payment by disease diagnosis related groups (DRGs). By 2020, multiple compound medical insurance payment methods adapted to different diseases and different service characteristics will be widely implemented nationwide, and the proportion of payment by project will be significantly reduced.
The main contents of the reform:
The first is to promote the reform of the classification of medical insurance payment methods and implement a variety of composite payment methods. According to the characteristics of different medical services, we will promote the classification reform of medical insurance payment methods. In-patient medical services are mainly paid according to diseases and people related to disease diagnosis (DRGs), and long-term and chronic hospitalization medical services can be paid according to bed days; Primary medical services can be paid per head, and actively explore the combination of per head payment and chronic disease management; For complex cases and outpatient expenses that are not suitable for package payment, they can be paid according to the project; Explore payment methods that meet the characteristics of Chinese medicine services.
The second is to pay attention to the payment according to the disease. For diseases with clear diagnosis and treatment plan, admission standard and mature diagnosis and treatment technology, in principle, payment by disease will be implemented, and day surgery and qualified outpatient treatment of traditional Chinese and western medicine will be gradually included in the scope of payment by disease. Establish a negotiation and consultation mechanism to reasonably determine the payment standard for diseases of Chinese and Western medicine.
The third is to carry out the pilot project of group payment according to disease diagnosis (DRGs).
The fourth is to improve the payment methods such as per head and per bed day. To promote outpatient co-ordination and per capita payment, we can start with chronic diseases with clear treatment plan standards and evaluation indicators. For mental illness, hospice care, medical rehabilitation and other diseases that require long-term hospitalization and the average daily cost is relatively stable, you can pay by the bed day.
The fifth is to strengthen the supervision of medical insurance on medical behavior. Improve the management of designated medical insurance agreements, comprehensively promote the intelligent monitoring of medical insurance, extend the medical insurance supervision from medical institutions to the medical service behavior of medical personnel, and realize the shift of supervision focus from medical cost control to dual control of medical cost and medical quality. Conditional local medical insurance agencies can advance a part of the medical insurance fund to medical institutions according to the agreement to support the operation of medical institutions.