November 2020
The NHPA issued the Notice on Issuing the List of Pilot Cities for Total Budgeting under the Regional Points Method and Payment by Value of Diseases, and the Notice on Issuing the Technical Specifications for the National Health Insurance Payment by Value of Diseases (DIP) and the Database of the DIP Disease Catalogue (1), and the disease-type value-based payment (DIP) pilot cities" and "Notice on the issuance of the technical specifications of the National Health Insurance DIP (DIP) and the DIP disease catalog database (version 1.0)June-July 2021
The NHPA organizes the first batch of cross-research and evaluation of the pilot cities for the reform of the healthcare payment method. Supervise the mid-term work progress of the pilot citiesJuly 2021
The NHPA issued the "Regulations on the Management of DIP (Disease-Informed Payment) Healthcare Security Administration (for Trial Implementation)October - November 2021
The NHPA organized the second batch of healthcare insurance payment method reform pilots and carried out cross-research and evaluation of the first batch of pilot healthcare insurance payment method reforms. The Bureau organizes the second batch of pilot cross-research and evaluation of health insurance payment method reform, and assesses the actual payment work situation of the pilot cities in the final periodNovember 2021
The NHPA issues the Circular on the Three-Year Action Plan for the Reform of the DRG/DIP Payment MethodsDecember 2021
71 DIP Pilot Cities Entered Actual Payment in Batches, and the First China CHS-DRG/DIP Payment Conference was Held in BeijingApril 2022
NHPA Issued the Circular on the Convergence of the Use of Functional Modules of the Payment Methods Management Subsystem DRG/DIPDefinition of DIP
Diagnosis-Intervention Packet (DIP) is a complete management system established with the advantage of big data, which explores the "disease diagnosis+treatment" ********. DIP is a complete management system built on the strength of big data, which exploits the *** characteristics of "disease diagnosis + treatment modality" to objectively classify case data and form a standardized positioning of each disease and treatment modality combination in a certain regional range of full-sample case data, objectively reflecting the severity of the disease, the complexity of the treatment, the level of resource consumption, and the norms of clinical behavior, which can be applied to health insurance payment, fund supervision, hospital management and other fields. Under the total budget mechanism, the point value is calculated based on the total annual health insurance payment, the proportion of health insurance payment, and the total score of each medical institution's cases. The medical insurance department forms the payment standard based on the disease score and score point value, and realizes the standardized payment for each case of medical institutions, and no longer pays by the cost of medical service items.Scope of application of DIP settlement
The total medical expenses incurred by medical insurance participants (including employees' social medical insurance and urban and rural residents' social medical insurance participants) hospitalized in designated medical institutions shall be settled by the medical insurance agency in accordance with the principle of "budgetary management, total amount control, disease type assignment, monthly pre-settlement and annual liquidation". The total medical expenses incurred by hospitalized medical institutions will be settled by the medical insurance administration organization in accordance with the principle of "budget management, total control, assignment of values to disease categories, monthly pre-settlement, and annual liquidation", and will be settled with the designated medical institutions in accordance with DIP. The total medical expenses incurred by the designated medical institutions that have the corresponding diagnosis and treatment subjects and actually carry out the business of treating the corresponding types of diseases are included in the scope of DIP.(I) the application of the scope of business
DIP settlement should only be used for the time being in the DIP pilot fixed-point medical institutions should be paid by the medical insurance fund of hospitalization costs, by the medical insurance agency in accordance with the DIP standards and payment policies for the settlement of fixed-point medical institutions. For the time being, the settlement of hospitalization expenses between the participants and the medical institutions will be settled and enjoyed in accordance with the established policy, and will not be affected by the DIP settlement for the time being.(2) the scope of the application of medical institutions
DIP settlement rules for the time being should only be applied to carry out the DIP pilot all medical institutions, not to carry out the DIP pilot medical institutions continue to extend the original settlement methods and policies.(C) the application of the scope of disease
DIP based on massive data samples, based on the corresponding relationship between diagnosis and treatment, natural clustering combinations, group refinement, the coefficient of variation within the group is small, the difference between the groups is stable, with real data, objective attributes, close to the diagnostic and treatment behavior, and easy to be accepted by the medical treatment, the patient, the insurance three parties. At present, the DIP directory covers nearly 99% of all cases, except psychiatric, rehabilitation and nursing long-term hospitalization cases, which achieves a balance between convenient operation and fine application and reduces the risk of medical insurance payment.Criteria and conditions for applying DIP directory library to health insurance payment
DIP directory library is a basic application system that determines stable grouping and integrates it into the unified directory management on the basis of the exhaustive and clustering of the combination of diagnosis and treatment modalities of the diseases, and supports the grouping of the application of the normalization. The effectiveness of DIP grouping has a great impact on the application effect. If the grouping performance of DIP is poor, it will lead to a lack of precision in the payment standard, and more cases of high and low costs in DIP. Therefore, in principle, after the construction of the local DIP directory database is completed, it is necessary to consider the corresponding grouping effectiveness. Calculation of disease score The disease score is a standardized unit of different discharge cases, which can be used to evaluate and compare the output of hospital medical services and form the basis of payment. Specific formula is: RWi=mi/M where M refers to the average hospitalization cost of all cases, mi refers to the average hospitalization cost of cases in the combination of category i. In order to comprehensively reflect the development trend of diseases and costs over the years, the average cost is calculated by the time-weighted form of the past data of the past three years. 2019:2020:2021=1:2:7.Calculation of DIP point value
(1) DIP budget point value
The DIP budget point value is determined at the beginning of each year, based on the total hospitalization costs covered by the payment method, and establishes the estimation model of the health insurance funds, supports the comprehensive budget management of the health insurance fund, and is the basis for the implementation of the health insurance process by the designated medical institutions. The budget point value is determined at the beginning of each year, based on the total cost of hospitalization covered by the payment method. The calculation method is as follows: Budget point value = weighted average annual total hospitalization costs / ∑ (DIP point value * corresponding to the number of cases) The annual total hospitalization costs are calculated using a weighted average, similar to the calculation process of the DIP point value, and the weighting of the total cost of the first three years of hospitalization is still 1:2:7.(II) DIP settlement point value
DIP settlement point value at the end of each year or the beginning of the second year to determine the total health insurance budget as a prerequisite for the calculation of payment standards, and the annual settlement with the designated medical institutions. The calculation method is as follows: Settlement point value point value average value = (the total amount of the year's health insurance fund can be used for DIP payment / health insurance reimbursement rate) / ∑ (DIP points * corresponding to the number of cases of disease)Calculation of the fund to pay for the cost of the
(a) the calculation of the payment standards of the disease group<
Patient group payment standard is formed on the basis of DIP directory library, the value of the point value of the health insurance cost standard that can be used for the liquidation of the fixed-point medical institutions, each combination of diseases have a corresponding patient group payment standard, based on the DIP point value to calculate and settle the cost, the specific formula is as follows:
Patient group payment standard = DIP point value * point value of the settlement
Patient group payment standard
(2) health insurance payment method
For general disease group hospitalized patients, medical insurance agencies in accordance with the DIP results of the settlement of hospitalization costs of the designated medical institutions, the specific formula is: health insurance fund according to the DIP should be paid to the designated medical institutions of the total hospitalization costs = ∑ ∑ ∑ ∑ [(the hospitalization of the participants belong to the DIP) Total hospitalization expenses payable by the medical insurance fund to the designated medical institution according to DIP = ∑ [(DIP payment standard of the group to which the insured person is hospitalized - out-of-pocket expenses - specific out-of-pocket expenses - starting line)*Medicare reimbursement ratio] - ∑ proposed deductions Note: If there is an extreme phenomenon, such as the out-of-pocket expenses are greater than the difference between the payment standard of the group and the specific out-of-pocket expenses and the starting line, which will result in the outcome of the payment of the DIP being ≤0, then the DIP will pay the amount as 0.DIP payment development status
According to statistics, the 71 national DIP pilot cities covering China's basic health insurance participants 319 million people. In addition to the national pilot, there are currently 38 cities in 11 provinces (autonomous regions) to carry out provincial DIP pilot reform, further expanding the coverage.