Understanding of the reform of medical insurance payment mode

The implementation of DRG/DIP can effectively avoid the disadvantages of paying by project. DRG/DIP takes disease/disease group as the pricing unit and payment basis, and is no longer funded by medical institutions, which is beneficial to medical insurance to promote medical institutions to pay attention to refined management and provide services according to clinical needs. The medical quality and safety of patients are better guaranteed and the cost is more reasonable. DRG payment refers to the payment according to the relevant groups of disease diagnosis, and the diseases are divided into different groups according to the severity of the disease, the complexity of treatment methods and the cost of treatment, and the payment standard of medical insurance is formulated. Generally speaking, the more serious the disease, the more complicated the treatment, and the higher the medical insurance payment standard. Institutionally, DRG is divided into "rough group" according to clinical anatomical site and treatment category, and there may be different treatment methods in one group, which is convenient for medical institutions to compare the cost differences of different treatment methods in the same case combination in the hospital and encourage medical institutions to adopt treatment methods with low resource consumption on the premise of ensuring quality; At the same time, it is consistent with the idea of clinical management according to departments and classified treatment according to diseases, which is easy to understand in clinic and is conducive to focusing on the management of abnormal disease groups. Technically, DRG grouping is more detailed, the identification of diseases is more accurate, and the adjustment of coding behavior of medical institutions is more obvious. DRG focuses on using the cost data of case combination to calculate the weight. Under the condition that the current cost data is not perfect, we can adjust the weight of case combination by various methods, which can eliminate the influence of some unreasonable diagnosis and treatment on the patient group cost, thus ensuring the weight of case combination to be more reasonable. Moreover, DRG can guide medical institutions to standardize the clinical path of similar diagnosis or surgical cases when treating patients, improve the homogeneity of case diagnosis and treatment within the group, and then realize the DIP payment of "the same disease and the same operation" according to the disease score. It uses big data, takes "disease diagnosis and treatment methods" as the payment unit, combines diseases, determines the payment standard of each disease according to the total amount of medical insurance funds, and pays the hospital according to this standard.

The significance of implementing DIP payment is mainly manifested in three aspects:

First, the medical insurance fund is safer and more effective. DIP has established a mechanism of measurement, analysis and comparison based on diseases, which can form an abnormal cost discovery mechanism and a process control mechanism based on big data disease grading, as well as a comparison mechanism between diagnosis and treatment norms and clinical pathways, and create a "fair, just and open" supervision and payment ecology;

Second, protect the health of patients. DIP guides medical institutions to improve the level of refined management, improve the internal cost control system, respect the inherent laws of complexity and uncertainty of medical services, and has unique technical advantages in purchasing value medical care. At the same time, in the case of limited regional medical insurance, in order to get more medical insurance payment, hospitals will not only pay more attention to disease grading and be willing to serve more patients, but also be willing to do more intractable diseases and critical diseases to get higher scores, so that the phenomenon of shirking serious patients will be reduced and patients will benefit;

Third, follow the law of medical service and determine DIP according to the complexity and difficulty of the disease.

The definition of 1 DIP: DIP based on big data is a complete management system established by taking advantage of big data;

2. The mechanism of DIP: Fractional payment based on DIP establishes a unified standard system and resource allocation model through group positioning and payment standards, so as to enhance the transparency and fairness of management, and enable the government, medical insurance and hospitals to establish communication channels under a unified standard framework, and replace mutual games with effective cooperation;

3. Overall principle: top-level design, overall coordination; Data-driven, standards first; Respect objectivity and scientific calculation; Open and transparent, full supervision; Supply and demand balance, multi-party * * * win;

4. Application basis: DIP score payment application system, based on the economic principles of "randomness" and "mean" and the big data theory, through the real massive medical record data, finds the inherent laws and correlations between diseases and treatments, extracts and combines data features, compares the average consumption of diseases and treatment resources in the region with the average consumption of all sample resources, forms a DIP score, and collects it in the DIP catalog;

5. Scope of application: DIP score payment is mainly applicable to the settlement of hospitalization medical expenses, and psychiatric, rehabilitation and nursing cases with long hospitalization time should not be included. The adaptability and expansibility of DIP can be explored and applied to the formulation of outpatient payment standards and the reform of payment standards in medical institutions.

Legal basis:

Opinions of the State Council Central Committee on Deepening the Reform of Medical Security System.

Article 4 Establish an effective medical insurance payment mechanism.

Medical insurance payment is the key mechanism to ensure people to obtain high-quality medical services and improve the efficiency of fund use. It is necessary to focus on clinical needs, rational diagnosis and treatment, and appropriate technology, improve the management of medical insurance catalogue, agreement and settlement, implement more efficient medical insurance payment, better protect the rights and interests of insured persons, and enhance the incentive and restraint role of medical insurance in the field of medical services.

(twelve) improve the dynamic adjustment mechanism of medical insurance catalogue. Based on the fund's affordability, adapt to the basic medical needs of the masses and the progress of clinical technology, adjust and optimize the medical insurance catalogue, include drugs, diagnosis and treatment items and medical consumables with high clinical value and excellent economic evaluation into the scope of medical insurance payment, and standardize the payment scope of medical service facilities. Improve the dynamic adjustment mechanism of medical insurance catalogue and improve the negotiation system of medical insurance access. Reasonably divide the responsibilities and powers of the central and local catalogues, and each region shall not make its own catalogue or adjust the limited payment scope of medical insurance drugs, and gradually realize the basic unification of the scope of medical insurance drugs nationwide. Establish the evaluation rules and index system of medical insurance drugs, diagnosis and treatment items and medical consumables, and improve the exit mechanism.

(thirteen) innovative medical insurance agreement management. Improve the management of basic medical insurance agreements, and simplify and optimize the procedures of designated application, professional evaluation and negotiation of medical institutions. Incorporate qualified medical institutions into the scope of medical insurance agreement management and support the development of new service models such as "Internet+medical care". Establish and improve the management mechanism of cross-regional medical treatment agreements. Formulate assessment methods for designated medical institutions to fulfill the agreement, highlight the assessment and evaluation of behavior norms, service quality and cost control, and improve the exit mechanism of designated medical institutions.

(fourteen) continue to promote the reform of medical insurance payment methods. Improve the total budget method of medical insurance fund, improve the negotiation mechanism between medical insurance agencies and medical institutions, promote collective consultation of medical institutions, scientifically formulate the total budget, and link it with the medical quality and performance evaluation results of the agreement. Vigorously promote the application of big data, promote the payment method of multiple compound medical insurance based on disease types, and promote the payment by disease diagnosis group, medical rehabilitation, chronic mental illness and other long-term hospitalization by bed, and outpatient special chronic diseases by head. Explore separate payment for medical services and medicines. Adapt to the development and innovation of medical service model, improve the payment method and settlement management mechanism of medical insurance fund. Explore the implementation of lump-sum payment to the contract medical consortium, strengthen supervision and assessment, retain the balance, and share the cost overruns reasonably. Conditional areas may prepay part of medical insurance funds to medical institutions as agreed, so as to ease the pressure of fund operation.