Disease Related Groups (DRGs) is a payment method that balances the risk of the insurer with the risk of the service provider, and takes into account cost control and quality assurance.
DRGs (Diagnosis Related Groups, referred to as DRGs) into China's medical care, for the new health insurance and agricultural cooperation to realize the difficulties in the process of payment of DRGs, how to solve it, we come to further explore.
First of all, we say that DRGs applied to health insurance and new rural cooperative medical payment system reform, is an emerging model, all over the world in the discussion, in Beijing took the lead in launching the application. At the same time, the state has issued a grouping program, which cites the concept of DRGs for short-term inpatient case combination tools developed by scholars from the United States, providing effective help for the application of DRGs in China, with an objective evaluation of its advantages and disadvantages, and pointing out that it needs to be localized in the actual application.
In the face of the documents issued by the state one after another, DRGs as a payment system reform to promote the application of a new payment method for hospitals has posed a great challenge. Facing the past rough payment management system, the new payment method is bound to become the mainstream of the payment system reform. But we know that from the crude payment management model, in the process of change to the DRGs payment system to go through a process, in this process, we can think about it, there is a step-by-step process, the first easy to be followed by the difficult, from the crude to the refined is the road we must walk through.
Medicare fund payment facing the largest group of medical institutions, its measurement based on the most important basis is the first page of the case, and primary care institutions of the first page of the degree of completeness, diagnostic accuracy compared with tertiary care hospitals have a certain degree of difference between the types of diseases, the measurement of the sample size is insufficient, and the number of disease articles within the clinical pathway and the control of a single disease is very small.
Tertiary hospitals are relatively speaking, the basic information is slightly better, while the second level a hospital basic information is worse, which brings great difficulty to DEGs payment, goodwill medical management in a city of the new rural cooperative DRGs disease payment, encountered many difficulties due to incomplete information, in the face of the use of the state promulgated a strict grouping for the new rural cooperative payment system, with the local management and hospitals **** with the come to Explore a model suitable for China's new rural cooperative payment national conditions.
This model is relative to a certain region, a part of the hospital, after researching its reality to make a set of payment reform suitable for the situation here. This way to meet the following conditions:
1, the new rural cooperative fund can afford. After reasonable calculations, combined with the fund of the general market, a reasonable budget risk control, rationalization of the fund risk, so that the new rural cooperative fund in the controllable range.
2. Acceptable to medical institutions. Reasonable measurement of the cost of medical institutions, to encourage medical technology income to improve, reduce the proportion of drugs, consumables, inspection income, the balance of the funds as a hospital technology risk subsidies, especially in the current medical fee price adjustment is not in place under the premise of the high-risk, high-difficulty types of diseases, to encourage the development of hospital technology and innovation.
3. Meet the people's demand for medical care. Adapt to the national three-level diagnosis and treatment requirements, through the DRGs disease group payment method, encourage medical institutions to rationally triage patients, according to the hospital level incentives for therapeutic behavior. Beneficial to dissolve the medical institutions at the county level, due to the seriousness of the situation of patients shirking the mobilization of the occurrence of patients, prompting patients to seek medical treatment at the grassroots level.
4, to meet the national standards for public hospital control, or to the direction of the development of this standard, such as the average cost per visit to be reduced, the proportion of drugs, materials to a reasonable proportion of the patient's security does not decline, reduce the rate of transfer and so on.
5. The accounting process is simple, without increasing the burden and difficulty for clinicians, through the evaluation of the degree of risk of the disease, the choice of doctors to participate in it, the use of Goodwill Medical Management APP, mobilizing doctors to participate in the evaluation of the risk of the disease of the health insurance payment of the enthusiasm, as an important reference basis for the apportionment of the cost of measurement of the disease.