1. Medical DRG and medical insurance DRG are related but have different concept orientations. Medical DRG and medical insurance DRG are two related but different concept orientations. Medical DRG realizes the comparability, evidence-based and standardization of medical management through case grouping, and pays attention to the rationality of diagnosis and operation selection, the validity of time and cost data, the statistical significance and clinical effect, and the quality and safety of medical care, which is a category of methodology and management tools. However, medical insurance DRG realizes the scientificity, refinement and accuracy of medical service compensation through the weight of patients in medical DRG and the basic rate determined by the fund budget. It not only pays attention to grouping science, reasonable weight and fair rate, but also pays attention to fund payment efficiency, medical resource allocation, clinical technology development, medical behavior guidance, medical process supervision, stakeholder game equilibrium, etc. It is a policy mechanism and policy system category. The correlation between the two is that the average value of disease group quota determined by medical DRG provides the pricing benchmark for coordinating the compensation of medical services in the region, and medical DRG plays a pricing role in the payment policy system of medical DRG.
2. The inherent defects of medical DRG bring policy risks to medical DRG. The inherent defects of pricing logic of medical DRG will bring certain policy risks to medical DRG. The main manifestations are as follows: DRG is based on the principle of homogeneous clinical process, similar complexity and similar resource consumption, which is not conducive to the development of disciplines with less resource consumption such as pediatrics and internal medicine, and it is also difficult to reasonably measure the real medical service cost of inpatients with large cost variation such as ICU, infection and death outcome; Using the average cost method to calculate the weight of each DRG group is not conducive to the cost control of medical institutions, nor does it include the cost consumption of scientific research and teaching in general hospitals, which is easy to lead doctors to set high codes technically; The average fixed package payment rule will inhibit the enthusiasm of hospital clinical innovation to a certain extent, and it will also easily lead to the problems of decomposing hospitalization, selecting mild patients and shirking serious patients. The risk adjustment of the severity of complications is relatively rough, and there is a big contradiction between doctors in difficult and critical diseases and general hospitals.
3. The construction of medical insurance DRG needs to consider the actual situation and accessibility of the overall planning area. To make up for the inherent defects of medical DRG through the construction of medical insurance DRG payment policy system, we need to consider the actual situation and accessibility of the overall planning area. At present, the basic conditions of DRG reform in more than 6 medical insurance co-ordination areas in China are quite different in terms of economic and social development, fund income, medical insurance management ability, hospital operation level and disease spectrum. Therefore, when practicing the reform of DRG payment in cities, it is necessary to find out the reform conditions of the overall planning area itself and judge whether it has the foundation of DRG payment reform.
if a city does not have the foundation for reform, it is suggested that it can continue to pay for a single disease (the initial version of DRG) or implement the disease score payment (the intermediate version of DRG), so as to lay a solid foundation for the reform of the high-level version of DRG payment and create a good policy environment. If it is a city with the foundation of reform, when designing the DRG payment policy system, the tightness of the policy needs to consider factors such as the richness and deficiency of local medical insurance funds, the level of medical insurance management, the growth of medical expenses, the saturation of medical resources development, and the competition pattern of hospitals.
4. The construction of medical insurance DRG policy system needs to adhere to systematic thinking
In the construction of specific medical insurance DRG policy system, we need to adhere to systematic thinking and pay attention to the construction of four policy mechanisms, namely, to build a DRG payment policy system with the whole chain and whole process of "financing (total budget)-pricing (average value of DRG)-pricing (payment rules)-management (operation mechanism)". On the financing level, do a good job in regional total budget, various medical services block budget and DRG overall fund expenditure budget to solve the problem of "where does the money come from?" At the pricing level, we should pay attention to how to make the grouping more stable, the weight calculation more scientific, the clinical disciplines develop reasonably, and the medical insurance resources among different levels of medical institutions are rationally allocated to solve the problem of "reasonable pricing of medical service costs". On the payment level, with reference to the average pricing standard of DRG, payment rules including average payment, inclined payment, excluded payment, exempted payment and innovative payment are established, so that DRG payment can better meet the actual needs of reform in the overall planning area and solve the problem of "fund efficiency payment". At the management level, we should pay attention to the construction of DRG business training, talent team construction, hospital communication, medical behavior supervision, DRG performance appraisal, third-party support and other policy mechanisms to solve the problem of "medical insurance risk management".
5. The medical insurance DRG payment policy system needs to maintain the integration and consistency of regional policies. With the establishment of the National Medical Insurance Bureau, the standardization and integration of medical insurance policies from top to bottom is one of the key contents of deepening the reform of medical insurance system. Considering the current situation that the conditions of DRG payment reform in all regions are mainly at the municipal level, the feasible approach is to set up a provincial DRG payment policy system framework with provinces (autonomous regions and municipalities directly under the Central Government) as units according to the deployment of DRG pilot reform work of the National Medical Insurance Bureau, and set provincial policy mandatory items and self-selection of policies in the overall planning areas, where the mandatory items must be set in each overall planning area, and the self-selection items are set in each overall planning area according to local actual needs. Maintaining the integration of provincial DRG payment policies can, on the one hand, realize DRG settlement in different places outside the overall planning areas in the province, which is helpful to solve the increasingly prominent problem of supervision of medical expenses in different places; On the other hand, it is also conducive to the horizontal and vertical comparison between medical services and medical insurance management capabilities of all overall planning areas and all medical institutions in the province, and to improve the refined management capabilities and supervision level of medical insurance.