Registration, examination and taking medicine are the most familiar processes for going to the hospital. In this process, if you are a medical insurance insured, after exceeding the starting line, each expense will be borne by the medical insurance fund. In other words, the medical insurance fund is paid to the hospital in proportion to our medical treatment money.
Starting this year, in three years, the payment method of medical insurance will undergo comprehensive reform. Recently, the National Medical Insurance Bureau issued the three-year action plan for the reform of DRG / Dip payment method. It is clear that from 2022 to the end of 2024, all overall planning areas in the country will carry out the reform of payment method according to disease diagnosis related grouping (DRG) / disease score (DIP). By the end of 2025, DRG / Dip payment method will cover all qualified medical institutions carrying out inpatient services.
At first glance, the reform of payment method is a matter between the medical insurance fund and the hospital, which has little to do with the 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, China’s traditional medical insurance payment method is to pay by project. According to the amount of all drugs, medical service items and medical consumables used in the diagnosis and treatment process, the patient and the medical insurance fund shall bear the part they need to pay respectively according to the actual cost.
This kind of medical insurance payment method is relatively easy to implement and is more in line with the actual situation of the past China Meheco Group Co.Ltd(600056) 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 inspection”. This not only causes a waste of medical resources, but also makes the insured spend more money and the medical insurance fund spend more.
“The CPC Central Committee and the State Council attach great importance to the reform of medical insurance payment mode. The opinions of the CPC Central Committee and the State Council on deepening the reform of medical security system defines four mechanisms: medical insurance treatment, financing, payment and supervision. The payment mechanism is a key mechanism to improve the use efficiency of medical insurance funds.” Huang Huabo, director of the medical service management department of the national medical insurance administration, said that the “14th five year plan” for universal medical security clearly requires continuous optimization of the medical insurance payment mechanism. Promoting the reform of medical insurance payment mode is not only the need of high-quality development of medical insurance, but also the need of high-quality development of hospitals, but also the need of the people to obtain higher quality medical insurance and medical services.
In fact, the practical exploration on the reform of medical insurance payment mode has not stopped, and has gradually developed from a single payment by project to a multiple compound medical insurance payment mode. According to the characteristics of different diseases and different medical services, we will promote the reform of medical insurance payment methods by classification. For inpatient medical services, explore grouping payment according to disease type and disease diagnosis; Explore long-term and chronic inpatient medical services and pay per bed day; For primary medical services, actively explore the combination of capitation payment and chronic disease management.
With the development of medical technology, the development of clinical pathway and the requirements of fine management of medical insurance fund, it is imperative to explore and innovate more scientific, more refined and more standardized medical insurance payment methods.
treatment due to illness and scientific pricing force the hospital to control fees and increase efficiency
The new DRG / Dip payment method is moving from problem solving, starting and pilot to comprehensive promotion.
The so-called DRG payment refers to the payment by groups related to disease diagnosis. In other words, according to the factors such as disease diagnosis, disease severity and treatment methods, patients are divided into diagnosis related groups with similar clinical symptoms and resource consumption. On this basis, medical insurance will pay according to the corresponding payment standards.
DRG payment began in the 1980s. At present, more than 40 countries have applied it to medical insurance pricing or fund budget. It is one of the more advanced and scientific payment methods recognized in the world. After the establishment of the National Medical Insurance Bureau, on the basis of integrating the main local versions, China has formed its own payment version chs-drg, which has the characteristics of integration and compatibility, the most complete coverage, unified coding, clinical balance and data assurance, which also marks the gradual standardization of the implementation of DRG in China from decentralization to unification.
The so-called dip payment is to pay according to the score of the disease. Under the total budget mechanism, the point value is calculated according to the total annual medical insurance payment, the proportion of medical insurance payment and the total score of the cases of various medical institutions to form the payment standard and realize the standardized payment for each case of medical institutions.
Compared with the traditional payment by project, DRG / Dip payment is a more scientific and refined medical insurance payment model, which can help hospitals take into account clinical development while managing expenses.
“In the past, when paying by traditional items, the medical insurance paid to the hospital according to the reimbursement proportion according to the sum of each item multiplied by the unit price. The hospital will have the impulse to provide more medical items to increase income.” Zheng Jie, head of DRG payment technical guidance group of national medical insurance and director of Beijing medical insurance affairs management center, said.
He said that after the implementation of DRG, for medical institutions, the era of increasing income by volume and expanding the scale of beds is over, which will force hospitals to improve quality control fees and efficiency. On the basis of assessing the service quality of medical institutions, the medical insurance department shall clarify the balance retention policy and reasonably share the overspending. 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 among three parties
According to the ideal model of DRG / Dip payment reform design, the three parties of medical insurance fund, hospital and patients should achieve win-win.
For medical insurance, DRG / Dip payment is more scientific and standardized, and can better optimize medical services. We can use the limited medical insurance fund to buy higher quality services for the insured and improve the use efficiency of the medical insurance fund.
For hospitals and doctors, the new payment method will encourage hospitals and doctors to consciously and actively standardize medical services, control costs and reduce resource waste. On the other hand, it will also guide medical institutions to improve the ability of disease diagnosis and treatment, and attract patients to the hospital with high-quality service and technical level.
For insured patients, after the hospital controls the cost, the corresponding charge items become less, the cost of seeing a doctor is less, and the personal burden is reduced.
In reality, can the ideal model be realized? Before the formal implementation of the new payment method, since 2019, the national medical insurance administration has launched DRG payment pilot in 30 cities and dip payment pilot in 71 cities.
Wuhan, Hubei Province is one of the first batch of DRG pilot cities, and all designated medical institutions at or above the secondary level in the city have been included in the pilot. From January to October 2021, when the number of cases in the whole city was basically the same, the average cost of hospitalization decreased from 14992 yuan in January to 13712 yuan in October, and the average cost decreased by 9%. The adjustment of revenue and expenditure structure of medical institutions has begun to show, and the proportion of admission and treatment of common and frequently occurring diseases has decreased significantly. The accumulated balance of the employee health insurance overall planning fund has changed from negative to positive, reversing the trend of gap for seven consecutive years, and the risk of fund expenditure has been preliminarily resolved.
In Liupanshui, Guizhou, after the DRG payment reform, in 2021, the growth rate of total hospitalization expenses decreased by 2.51% compared with 2019, and the growth rate of hospitalization expenses paid by the city’s medical insurance decreased by 8.87% compared with 2019; By the end of 2021, the average hospitalization cost of urban and rural residents decreased from 6725.07 yuan to 6385.09 yuan, a year-on-year decrease of 5%; The average hospitalization cost of urban employees decreased from 10572.79 yuan to 8342.34 yuan, a year-on-year decrease of 21.09%; The average length of stay decreased from 9.99 days to 9.21 days, a year-on-year decrease of 7.8%.
Ying Yazhen, vice president of the National Medical Security Research Institute and vice president of China Medical Insurance Research Association, said: “the implementation of DRG / Dip payment will effectively change the disadvantages of passive payment of medical insurance, extensive development of hospitals and heavy burden of patients. It is a mutually beneficial and win-win reform for the three parties.”
