1 Promoting the synergy between hospitals and health insurance
Against the backdrop of the aging of China's population, and the ever-expanding number of people covered by the health insurance, there is a huge pressure on the health insurance fund, and therefore the health insurance is bound to The first demand is to control the growth of costs. For the sake of its own development, hospitals have a strong need to obtain more balances. In the case of project-based payment, health insurance and hospitals have conflicting demands, the relationship between the two sides to "game" as the main, "synergistic" as a supplement, which is also we can not really form a "three medical linkage". This is also one of the fundamental reasons why we have not been able to form the "three medical centers". Under the mechanism of DRGs-PPS, the medical insurance has measured the established payment standard for each group based on the demand for cost control. At the same time, in order to obtain a reasonable balance, hospitals are bound to reduce the consumption of various resources in the process of diagnosis and treatment. This behavior of hospitals, on the one hand, make their own better income, and at the same time is bound to support the demand of medical insurance cost control. That is to say, in the DRGs-PPS mechanism, health insurance and hospitals in the interests of the same, its relationship from the previous "game" to "synergy".2 To achieve the synergy of cost control and quality of care
Under the DRGs-PPS mechanism, the DRGs payment standard as the basis of the health insurance prepayment to the hospitals, which enables the hospitals to know the maximum limit of the consumption of resources in advance of the provision of health care services, and the hospitals must control the level of cost at the DRGs, and the hospitals will be able to control the level of cost at the DRGs. The DRGs payment standard becomes the critical point of profit and loss of the project, thus mobilizing the hospitals' motivation to cut costs, improve diagnosis rate and shorten hospitalization days in the process of providing services. Therefore, there is no doubt about the function of DRGs-PPS in cost control. However, how to avoid a decline in the quality of medical services while controlling costs, DRGs-PPS also has a unique advantage in medical quality control: in addition to being an advanced medical payment tool, DRGs are also a very good tool for medical evaluation. It comes with a whole set of index system, which can scientifically and objectively evaluate medical services, and this feature can be an effective supplement to medical quality control. More importantly, the implementation of DRGs-PPS will inevitably lead to the birth of real clinical pathways. This is because, in order to control the cost of medical institutions to ensure that the quality of medical indicators to meet the requirements of the payer, will inevitably seek to "both ensure the quality of medical care and take into account their own cost control," the treatment plan, and as a unified standard for the requirements of the clinicians, and this will become the true meaning of clinical pathway. Thus completing the clinical path from the "government requirements to achieve" to "hospitals themselves require the realization of" the transformation, and solve the problem of hospital self-propulsion, the implementation and promotion of clinical path will no longer be difficult, the United States and other countries after the implementation of the DRG payment situation is strong evidence of this. The fact that this is not the case is a good example of how the DRG payment has been implemented in the United States.3 Promoting the rational allocation of healthcare resources
How does DRGs-PPS achieve the rational allocation of healthcare resources? First, it smoothes out the value sequence of hospitals and doctors, allowing for the formation of hierarchical diagnosis and treatment. Take a disease as an example, such as simple appendicitis, DRG will be this disease package, assuming that both secondary and tertiary hospitals, medical insurance payment standard is 5500 yuan. The hospital will calculate the actual cost of the disease, including labor, supplies, equipment, etc. The cost of large hospitals is generally 7,000 to 8,000 yuan, which is not enough to cover expenses. At this point, it can tell the next level of hospitals, this kind of disease you can stay in the hospital, or suggest that the patient in the local treatment, without the need for referral. If the doctors below feel that they cannot solve the problem themselves and need to be consulted, the big hospital will then send doctors to the lower level hospitals. The whole process does not require any administrative instruction to intervene, the hospitals themselves take the initiative to triage patients, and the hierarchical diagnosis and treatment is formed naturally. Secondly, DRGs-PPS can adjust the payment standard, improve the medical service capacity in a targeted way, and make the medical resources be effectively distributed and utilized. In the case of the initial completion of the cost-control goals, the fund has a certain balance, according to the local disease situation, targeted to the need to focus on the development of regional or clinical specialties to support the capacity. The way of support is of course to intentionally adjust the payment standards of hospitals or disease groups in these areas, so that the hospitals themselves can generate the impetus for targeted development, thus effectively supplementing and improving the local medical service capacity. In Taiwan, the DRGs-PPS payment system has been supplemented with policies such as CMI plus, children plus, and mountainous and outlying island areas plus, which have played a very positive role in the effective distribution and utilization of medical resources.The system of DRGs-PPS
As a whole, DRGs-PPS can be divided into three major systems: standardization, settlement, and supervision. The DRGs-PPS standard system includes three major components: data standards, grouping standards, and payment standards. The establishment of these standards is the basic prerequisite for the realization of DRGs-PPS. At present, before the national standards are fully determined, each region should choose the appropriate standards according to its own situation, rather than passively waiting for the emergence of national standards. Because the quality of historical data is crucial to the realization of DRGs-PPS. Regardless of what standard is realized, it is conducive to the improvement of data quality, which will certainly lay a solid foundation for the subsequent realization of the real DRG payment. DRGs-PPS settlement system in the DRGs-PPS standard system, as the daily operation of the health insurance guarantee, contains the data processing and grouping, monthly settlement and end-of-year liquidation of the three major elements. In order to effectively achieve the relevant goals, generally speaking, DRGs-PPS settlement needs to be divided into two major parts: monthly settlement and year-end settlement. The year-end settlement relies on the results of the annual assessment, which can effectively achieve the "target management" of the hospital by the medical insurance. DRGs-PPS is not a perfect mechanism, because of its packaged payment, based on the characteristics of the code, it is bound to produce hospitals decomposition of hospitalization, high coding, low standards of admission, the cost of transferring the patient or outpatient and other moral hazards. In order to effectively solve these problems, it is necessary to build a set of perfect DRGs-PPS-based health insurance supervision system. Generally speaking, DRGs-PPS-based health insurance supervision system consists of three parts: daily audit, annual assessment and long-term evaluation. While forming comprehensive supervision before, during and after the event, it distinguishes between different stages of supervision in the short, medium and long term.Construction of DRGs-PPS standard system
The construction of the standard system is a prerequisite for the implementation of DRGs-PPS, and its significance is to ensure the consistency, openness, and stability of the overall system in the realization of the process. The construction process includes improving data standards, selecting grouping standards and measuring payment standards.1 Improving data standards
The focus of improving data standards is to improve the control mechanism of the first page of the case, and to unify ICD coding standards. Disease classification code and surgical operation classification code is the main basis for DRG grouping, DRG grouping for the selection of the main diagnosis of the disease requires a high degree of grouping of the most basic data, which directly affects the results of DRG grouping. Therefore, hospitals need to establish a perfect case management system, maintain the information system disease code library and surgical operation code library to ensure the accuracy of the first page of the case code and surgical operation code. According to the quality control situation of medical cases, the professional staff of the Medical Insurance Bureau will regularly count and summarize the error situation of the first page of medical cases in each hospital, analyze and evaluate them, and ask the hospitals to rectify the quality of medical cases if there are any quality problems in the medical cases. And the medical insurance bureau needs to continue to track the improvement of the situation, in accordance with the case of the first page of the evaluation criteria into the hospital year-end performance appraisal, so that you can quickly and significantly improve the quality of the first page of the hospital case.2 Establishment of grouping standards
The establishment of grouping standards requires attention to two key points. One is the maturity of the grouping standard itself, and the other is how to complete the localization of the relative weights. DRG system only needs to be docked with the hospital's electronic medical record system case home page, through the DRG grouping software, to complete the disease grouping. For payment by DRG, after the grouping is completed, it is necessary to select the payment range (time range, medical insurance type range, hospital level range) according to the actual local historical data for weighting and rate calculation. It is necessary to clarify whether different levels of hospitals and different types of health insurance use uniform rates, and it is recommended that different types of health insurance be measured separately according to the different levels of hospitals. If there is a cap on the total amount of control in the current policy of the Health Insurance Bureau, the total amount of the cap can be considered as a substitute for the total cost when calculating the rate.3 Measurement of payment standards
Measurement of payment standards is the most complex part of the construction of the standard system. The process of measuring payment standards generally needs to face the two major problems of historical data quality and reasonable pricing.DRG group payment standards are equal to the relative weight of the DRG group multiplied by the rate to get. However, the DRGs-PPS payment standard is not a static indicator, and needs to be dynamically adjusted according to the cost factor, price factor, and the application of new technology and new therapies. The medical insurance department should carry out prospective research on the payment of DRGs in the formulation of the payment standard at an appropriate time, and take the diagnostic and treatment means of diseases into account in the grouping factors, so as to avoid the situation that hospitals reduce or even give up the use of new technologies in order to reduce the cost. It is necessary to make a scientific and reasonable prediction of the cost of the DRG group, and to adjust and improve it in the course of practice.Construction of DRGs-PPS settlement system
The establishment of DRGs-PPS settlement system includes determining the type of medical insurance payment, payment rules and payment process, automatic sorting of the settlement data of the cases, distinguishing between single-type cases, cases not included in the group, normal-value cases, very low value, very high value and other special value cases. The final medical insurance payment is made according to the corresponding method, which mainly includes DRG payment, single disease payment and program payment. The construction of DRG year-end settlement and health insurance fund management system realizes DRG-based health insurance cost control analysis, total fund management, budget management, year-end performance evaluation and settlement. In accordance with the requirements of DRG payment methods and other relevant policies and regulations, it provides comprehensive management of the annual assessment and liquidation data of DRG "management, cost, efficiency, safety" and other indicators of designated medical institutions, so that the year-end assessment and liquidation work can be developed in the direction of "scientific, efficient and reasonable". The development of the year-end assessment and liquidation work is in the direction of "scientific, efficient and reasonable". It sets the assessment dimensions and indicators, approves the assessment and results, and realizes the statistical analysis of performance assessment indicators at the municipal, district, hospital and departmental levels.Constructing the DRGs-PPS regulatory system
Before we talk about how to construct the DRGs-PPS regulatory system, we first need to understand the difference between the DRGs-PPS regulatory system and the medical insurance regulatory system under the project payment. First of all, under the DRGs-PPS payment method, the medicines, medical consumables, and tests used by patients become the cost of medical services, so the focus of monitoring has changed from the cost details to the overall reasonableness and accuracy of the cases. Second, from the point of view of the Health Insurance Bureau, another major regulatory objective is to monitor whether the quality of care in hospitals has been significantly reduced as a result of rational cost control. Key indicators such as average cost per visit, average hospitalization days, CMI, total weight, low-risk group mortality rate, and medium-low-risk group mortality rate are included in the scope of assessment to strengthen the monitoring role of health insurance on medical services. And the DRGs method as an important means of objective quantitative evaluation of hospital service capacity, service performance and medical quality, and gradually increase the proportion of quantitative evaluation methods in the hospital assessment.In short, the DRGs-PPS health insurance supervision system can be summarized as: daily audit to catch the typical, the annual assessment of the control index, long-term evaluation to do value guidance.
1 Daily audit to catch the typical
First, the health insurance should be based on the DRGs-PPS daily audit, which completely simplifies the previous health insurance program payment under the health insurance drugs and charges for item details of the audit, because in the DRG payment method patients use drugs, medical supplies and testing become diagnosis and treatment. DRG intelligent audit is mainly for the overall audit of hospitalized cases, through data analysis and intelligent coding, the use of statistics and inverse operations to monitor and manage hospital cases, to prevent hospitals from high coding, disaggregation of hospitalization, low-standard admissions and other violations. The system automatically audits cases, drills down and analyzes abnormal cases and manually audits them, realizes information communication with medical institutions, and supports audit management.2 Annual assessment of control indicators
Secondly, the health insurance should establish an annual assessment system to ensure that the health insurance annual fee control, quality control and other goals to achieve. The indicators of the annual assessment should be based on the payment program formulated at the beginning of the year, the average cost and total cost growth rate, the cost growth rate of each DRG group and the proportion of the indicators into the scope of the performance assessment, to strengthen the health insurance on the monitoring of medical services. At the same time, it also provides hospitals in the integrated area with data analysis services on case quality control, medical service performance, medical quality management, medical safety, etc., which can be used for hospitals' refined management and to improve the efficiency and quality of DRG-related clinical work. DRG methodology is also used as one of the important means of objective and quantitative evaluation of hospital service capacity, service performance and medical quality, and gradually increases the proportion of quantitative evaluation methods in hospital accreditation.3 Long-term evaluation as a value guide
Finally, the health insurance should effectively monitor and evaluate the local medical service capacity, medical quality and safety, medical service efficiency, patient burden, patient health status and other aspects. The first is to effectively evaluate the effect of the DRGs-PPS payment reform. At the same time, the realization of these monitoring and evaluation can enable the health insurance to understand more clearly the demands of local patients, grasp the distribution and utilization efficiency of medical resources, and provide a factual basis for the subsequent development of more reasonable reform measures.Summary
Payment of health insurance according to DRG-related disease groups is a major trend for future development. The establishment of DRGs-PPS as the mainstream of the health insurance payment system will help to ultimately realize the health insurance fund expenditure can be controlled, hospitals have the incentive to control costs, the quality of service has to be guaranteed, and the insured people to benefit from the health care reform goals of multiple **** win.