In order to further promote the reform of medical insurance payment methods and accelerate the establishment of an effective and efficient closed-loop medical insurance payment mechanism. Recently, the Zhejiang Provincial Medical Security Bureau issued the "Three-year Action Plan for Comprehensively Promoting the Reform of Medical Insurance Payment Methods in Zhejiang Province" (hereinafter referred to as the "Plan"). The plan clarifies that from 2022 to 2024, the plan will promote the reform of outpatient payment methods in stages and iteratively upgrade the inpatient DRG. Payment reform. ● By the end of 2022, complete the top-level design of outpatient payment method reform and information system construction, and continue to promote the revision of the Zhejiang Provincial Medical Security Disease Diagnosis Related Group (ZJ-DRG) subdivision catalog; ● By the end of 2023, all coordinated areas in the province will fully implement outpatient services Reform of the payment method based on capitation combined with outpatient case grouping (hereinafter referred to as: APG); ● By the end of 2024, the payment reform of inpatient DRG and outpatient APG will achieve full coverage of the area, full coverage of fees, full coverage of the population, and full coverage of medical institutions, forming a comprehensive medical insurance payment The closed-loop reform of the whole cycle and management process will comprehensively establish a new medical insurance payment mechanism with a more reasonable medical insurance fund budget, a more scientific classification method, a more powerful collaborative guarantee, and a more effective resource allocation. Different from the three-year action plan for DRG/DIP payment method reform in more than ten provinces, including Guizhou, Anhui, Henan, Inner Mongolia, Gansu, etc., Zhejiang Province promotes the combination of outpatient service and capitation on the basis of full coverage of the DRG payment method reform for hospitalization expenses. The reform of APG payment methods will focus on comprehensive coverage of regions, medical institutions, disease groupings, and medical insurance funds to achieve a closed-loop reform of outpatient and hospitalization fee payment methods.
What is "APG"? APG is the abbreviation of Ambulatory Patient Groups (Ambulatory Patient Groups). It mainly classifies outpatient medical services based on disease type, treatment method, and cost consumption. For example, common colds and hypertension are divided into different disease groups. By calculating the average medical expenses for different categories of patient groups, corresponding patient group points are formed to reflect the volume of outpatient services, and outpatient funds are allocated according to the volume of services. Simply put, the outpatient "APG point method" payment reform is to implement a payment policy reform in outpatient payment that combines outpatient points (APG) with grassroots contracted capitation budget and lump sum use. The "APG point method" payment method for medical insurance outpatient services was pioneered by Jinhua, Zhejiang Province. In January 2020, Jinhua City and Lanxi City took the lead in implementing it. From January 2021, Jinhua City will fully implement it, and build an "safe medical insurance payment" application scenario. Public data show that with the advancement of the "APG Points Method", the annual growth rate of Jinhua City's outpatient fund expenditures dropped from 19.4 to 10, of which the city's outpatient fund is expected to save 88.81 million yuan. Let’s introduce the specific details of Jinhua’s outpatient payment reform:
Jinhua features: total budget, capitation, APG points compound payment It is worth noting that although this Jinhua outpatient payment reform is referred to as “APG points” "Pay by law", but the APG points method is not all of it. Jinhua City’s outpatient payment reform is actually a composite payment method based on a capitation lump sum combined with the APG point method under the total budget. The design of Jinhua outpatient payment basically draws on the design and structure of the outpatient payment systems of the United States and the United States. But it has some unique features in its specific design. The first is to implement total budget management of outpatient medical insurance funds. The total budget manages medical insurance funds separately according to the coordinating areas of cities and counties (cities), including the overall fund expenditures of insured persons at outpatient clinics (including external dispensing of electronic prescriptions) and designated pharmacies at designated medical institutions inside and outside the coordinating area. Among them, outpatient clinic types include general outpatient clinics, chronic disease outpatient clinics and special disease outpatient clinics. The payment methods of the entire coordinated district medical insurance fund are divided into two categories: capitation payment and APG point payment. Different payment methods are adopted according to the specific circumstances. 1. Capitation lump sum: Promote medical institutions to sign contracts with medical insurance insured persons, thereby allocating the outpatient capitation fund of insured persons to contracted medical institutions (or medical groups) for overall use. Any surplus will be retained by the medical institution, and any losses will be borne by the medical institution itself.
For capitation lump sums, the amount of payment per capita is the key to determining the profit or loss of a medical institution. According to reports, Jinhua City uses big data analysis to determine the outpatient capitation fund amount of insured persons based on the outpatient visits of insured persons in the city in the previous two years. The types of outpatient clinics covered by the capitation policy in Jinhua City include general outpatient clinics and chronic disease outpatient clinics, and do not include special disease outpatient clinics for contracted insured persons. 2. APG points: For insured persons who have not signed a contract, the outpatient capitation fund will be jointly used by qualified medical institutions and paid according to the APG point method. Different from the fee rate method, the Jinhua point method reflects the patient group in points, and implements point value floating according to the principle of "determining expenditure based on revenue, balancing revenue and expenditure, and making a slight surplus". At the end of the year, the total fund budget of this part and the total APG of the city's hospitals will be adjusted. Points determine the actual value of each point, which is then used to calculate the payment each medical institution should receive. In July 2020, Jinhua Dongyang City clustered and grouped 1.41 million pieces of data from 16 medical institutions involving various outpatient medical expenses totaling 394 million yuan. The local Medical Insurance Bureau divided the APG grouping of Dongyang municipal hospitals into 761 groups. Grouped into 347 groups. Finally, through the comprehensive analysis of the city's groupings, Jinhua City's outpatient payment pilot identified 1,391 APG groups. By using big data means to analyze the number of historical outpatient cases, the average historical costs of each disease group were reasonably calculated, forming the basis for medical insurance, hospitals, and patients. Payment standards agreed upon by the three parties. Cases that are mainly outpatient surgeries (including anesthesia, drugs, etc.) are classified into the surgical operation APG, in which outpatient surgery-related expenses are included as surgical operation fees, and related examination and inspection fees are included as auxiliary service fees. Cases mainly treated with medical drugs are classified into the internal medicine service APG, in which the expenses related to medical drug treatment are regarded as the enrollment fees of internal medicine services, and the related examination and examination fees are regarded as the enrollment expenses of auxiliary services. Cases focusing on examinations and examinations, as well as outpatient examination fees, general diagnosis and treatment fees, consumables that require additional compensation, nationally negotiated drugs, etc., are all included in the auxiliary service APG. APG benchmark points = average cost per APG case ÷ average cost per case for all APGs × 100. Set level difference coefficients between coordinating districts, between medical institutions, and between pharmacies for chronic diseases. For APGs with little cost difference, the difference coefficient can be cancelled.
Analysis of reform advantages 1. Establish three mechanisms to make fund expenditures safe and controllable. By establishing a total outpatient budget negotiation mechanism, an outpatient "surplus retention and overexpenditure sharing" mechanism and a medical insurance fund total budget adjustment mechanism, we can stimulate Medical institutions have endogenous motivation to achieve the goals of controllable medical insurance funds, improved medical quality, and satisfied insured personnel. 2. Implement capitation APG points to make the medical order more reasonable. The total amount of the medical insurance outpatient co-ordination fund is classified and lumped in the form of capitation fund amount. Scientifically determine the capitation fund amount and classify the types of lump sums, promote the medical insurance fund to tilt towards contracted services and grassroots, alleviate the pressure on large hospitals to seek medical treatment, and a virtuous cycle of "graded diagnosis and treatment" may gradually form. 3. Determine payment standards to make medical insurance payment accurate and efficient. Based on the similarity of clinical processes, resource consumption, etc., and fully considering factors such as outpatient examination fees and nationally negotiated drugs, the city’s outpatient cases are divided into three categories: surgical operations, internal medicine services, and auxiliary services. APGs has been divided into 1,391 groups, and payment standards are reasonably calculated based on big data means, which can improve payment efficiency and make medical insurance payment accurate and efficient. Compared with DRG/DIP, APG is more difficult to implement. This requires medical institutions to have high diagnostic efficiency, technical specifications, strong medical standards and complete infrastructure. At the same time, the support of local medical insurance policies is also essential. Based on the current situation that most regions across the country are still exploring DRG/DIP, it will be difficult to carry out APG in the short term. Jinhua's first implementation of the outpatient APG pilot also illustrates the local strong medical service capabilities and the bold exploration of medical insurance institutions. In terms of system design, Jinhua APG referred to the structure of foreign outpatient payment systems and made some innovations based on local conditions. For example, it also combines contracted personnel quota management in an attempt to join the health management management system. Of course, it will take time to judge the final effect of these designs.
No reform can be achieved overnight and requires optimization and correction through repeated practice. What is certain is that after DRG/DIP, outpatient payment reform will come soon.