Article 1 In order to implement the "Opinions of the Central Government of the PRC on Deepening the Reform of the Medical Security System" (Zhongfa [2020] No. 5), safeguard the lawful rights and interests of the social medical insurance participants, safeguard the security of the social medical insurance fund, promote the social insurance The sustainable development of the system, according to the "General Office of the State Council on further deepening the reform of the basic medical insurance payment method of the guiding opinions" (State Council [2017] No. 55) "Office of the State Medical Security Bureau on the issuance of the total budget of the regional point method and the total value of payment according to the type of illnesses pilot work program notice" (medical insurance office issued [2020] No. 45) spirit, combined with the city's actuality, developed the "Liaoyuan City Basic medical insurance regional points method of total budget and pay by the value of the disease (DIP) implementation measures (trial)" (hereinafter referred to as "measures").
Article 2 < /strong>"Measures" referred to as "regional point method of total budget and pay by the value of the disease (DIP)", refers to the coordinated area of the medical insurance department in the basic medical insurance fund under the premise of the total budgetary control of the fixed-point medical institutions during the billing period of hospitalization cases incurred by the value of the medical costs. The medical expenses incurred by the designated medical institutions during the settlement period are quantified in terms of points, and the points and unit price of the points are determined for the designated medical institutions to participate in the settlement, on the basis of which the settlement and distribution of basic medical insurance hospitalization expenses among the designated medical institutions is carried out.
Article 3 The total medical expenses incurred by the medical insurance participants hospitalized in the designated medical institutions shall be settled by the medical insurance agency in accordance with the principles of "budget management, total control, disease assignment, monthly pre-settlement and annual liquidation", and the designated medical institutions shall be in accordance with the principle of "DIP". "DIP" settlement.
Article 4 integrated area medical insurance agencies and fixed-point medical institutions to settle the basic medical insurance for employees, urban and rural residents, basic medical insurance participants incurred hospitalization costs, the application of this approach.
Chapter 2: Establishment of the DIP Disease Catalog Library
Article 5 Establishment of the DIP Disease Master Catalog.
The disease types referred to in the Measures are combinations of the main diagnostic name of the disease with the procedure and operation codes. The master directory is formed by the standardized method of big data to condense the *** characteristics of diseases and treatment modalities, reflecting the general laws of diagnosis and treatment, based on the number of cases to form the convergence of the core disease and integrated disease, and *** the same data characteristics of the formation of hierarchical directory layer by layer aggregation.Article 6 The establishment of the auxiliary catalog.
Auxiliary directory: The auxiliary directory uses big data to extract the specific characteristics of diagnosis, treatment, and behavioral norms, to correct the severity of clinical diseases, complications/comorbidities, and the consumption of resources incurred by medical behavioral norms, to objectively fit the cost of healthcare services and to be paid, which is complementary to the main directory.Chapter III: Determination of disease score
Article 7 Determination of disease standard score.
The average hospitalization cost of all cases as a benchmark, set a benchmark score of 100 points, the standard score of the disease to determine the proportionate relationship between the average historical cost of the designated medical institutions and the benchmark cost, the specific formula is: RWi standard = mi/M × 100 M: the average cost of all cases. mi: the historical average hospitalization cost of cases within the portfolio of category i (can be determined by the weighted average of three years of previous data).Article 8 Determination of disease category pricing score. p> Chapter IV Disease Score Coefficient Setting
Article 9 Medical institution level coefficient.
For a single disease, different levels of hospitals consume significant differences in medical resources, can not use a uniform multiplier relationship without discrimination, the need for a single disease on the basis of the standard score, adjusted by the coefficient of the level of the organization. The level of medical institutions is divided into three grades according to the level recognized by the health department: Grade III, Grade II, Grade I and the following three grades (not divided into A and B, etc.), and the coefficient of each grade of medical institutions for a single type of disease is determined based on the ratio of the weighted average cost of the disease and the average cost of all cases of the disease in the previous three years for all levels of medical institutions.Article 10 medical institutions assessment coefficients.
(a) assessment indicators: health insurance agencies and designated medical institutions year-end settlement of the health insurance fund temporarily set three DIP assessment indicators, including: the average cost per unit growth rate, repeat hospitalization rate growth rate, the cost of participants in the directory of medical insurance accounted for three indicators; in the process of practice, according to the needs of health care security departments and designated medical institutions to consult with the dynamic adjustments or increases or decreases. 1. The growth rate of average hospitalization cost. Inpatient average cost = the total cost of hospitalization of patients discharged during the settlement period ÷ the total number of patients discharged during the settlement period; Inpatient average cost growth rate = [(average cost of hospitalization during the settlement period - average cost of hospitalization during the same period of the previous year) ÷ average cost of hospitalization during the same period of the previous year] × 100%; Average cost growth rate indicator = (average cost growth rate of hospitals in the same class during the settlement period + 2) ÷ ((average cost growth rate of the hospital during the settlement period)). Average cost growth rate of this hospital during the settlement period +2). 2. Repeat hospitalization growth rate. Repeat hospitalization rate = [(total number of discharges during the settlement period - total number of discharges during the settlement period + 1) ÷ total number of discharges during the settlement period] × 100%; Repeat hospitalization rate growth rate = [(repeat hospitalization rate during the settlement period - repeat hospitalization rate during the same period of the previous year) ÷ repeat hospitalization rate during the same period of the previous year] × 100%; Repeat hospitalization rate growth indicator = (repeat hospitalization rate growth rate of hospitals of the same grade during the settlement period + 2) ÷ ( repeat hospitalization rate growth rate of this hospital during the settlement period + 2). hospitalization rate growth indicator = (hospital of the same level during the settlement period + 2) ÷ (the rate of growth of repeat hospitalization rate in this hospital during the settlement period + 2). 3. The percentage of costs that are covered by the Medicare Catalog. The proportion of costs within the directory of medical insurance = the cost of discharged patients within the directory of medical insurance during the settlement period ÷ the total medical costs of discharged patients during the settlement period × 100%; The proportion of costs within the directory of medical insurance = the proportion of medical costs of the medical institution during the settlement period ÷ the average proportion of medical costs of hospitals of the same level during the settlement period. The total medical costs of discharged patients do not include patients' voluntary choice of special medical services, medical consumables, diagnostic and therapeutic fees beyond national regulations or agreements, drug costs, etc.). (ii) assessment coefficients: the average cost growth rate, repeat hospitalization rate growth rate, the proportion of participants in the directory of medical insurance costs in accordance with the ratio of 3 : 3 : 4 into the assessment coefficients. Formula: assessment coefficient = (average cost growth rate indicators × 30%) + (repeat hospitalization rate growth rate indicators × 30%) + (medical insurance directory cost ratio indicators × 40%).Previously, when the designated hospital medical insurance service is less than one year or the number of discharges is 0, the assessment coefficient of the agreement hospital for the current year is 1.
Article 11 Coefficients of the external specialist diagnosis and treatment of diseases.
In order to further alleviate the insured people to seek medical treatment in a different place, "difficult to see a doctor, see a doctor expensive" problem, and effectively reduce the economic burden of the majority of patients, so that the people at home can enjoy high-quality, efficient medical services, foreign experts to the local clinic services can be carried out to tilt the payment policy of the health insurance fund to set up the external expert diagnosis and treatment of the type of disease. The score of the incentive adjustment coefficient.Article 12 High-tech medical technology adjustment factor.
In order to support the city's designated medical institutions to carry out "high-precision" medical service projects, to enhance the core competitiveness of Liaoyuan City medical technology, enhance the sense of access to the insured masses, can be voluntarily declared by the medical institutions, health insurance data analysis, extensive consultation, expert evaluation, set the corresponding points to stimulate the adjustment coefficient.Highly advanced medical technology and external experts diagnosis and treatment of diseases occurring in the same case, select the higher coefficient for the calculation of points, but not double incentives.
Article 13 grassroots disease coefficients.
In order to further implement the hierarchical diagnosis and treatment system, to encourage primary health care institutions to carry out medical services and higher hospital referrals to the grassroots, to facilitate the people's access to medical care, can choose the appropriate community health centers and township health centers in the implementation of the same level of treatment at all levels of medical institutions coefficients.Chapter V Other special diseases and the provisions of the score
Article 14 of the need for long-term hospitalization and the average daily cost of more stable psychiatric, medical rehabilitation, tuberculosis type of disease, can be used in the form of a bed-day score; at the same time, combined with the clinical pathway and the historical average number of days of hospitalization. days to set the standard hospitalization days for a single type of disease, the implementation of a step-down segmentation of the calculation of points.
In the standard hospitalization days within the case of the standard bed value, more than the standard hospitalization days of the part of the implementation of the step-down. That is: exceeding the standard hospitalization days 30% (including 30%) of the following, the disease bed days points down by 30%; exceeding the standard hospitalization days 30% -50% (including 50%), the disease bed days points down by 50%; exceeding the standard hospitalization days more than 50%, the disease bed days points down by 70%.Article 15 In order to further enhance the allocation of medical and health resources and the effectiveness of the use of health care, encouraging medical institutions to improve the level of management, control unreasonable medical expenses, reduce the burden of insured patients, suitable for daytime diagnosis and treatment, daytime surgical treatment of diseases can be included in the payment by the value of the disease.
Article 16 In order to promote the city's traditional Chinese medicine inheritance and innovative development, give full play to the original advantages of traditional Chinese medicine in the maintenance and promotion of people's health in the unique role of the clinical value as the guide to the advantages of traditional Chinese medicine services, services focusing on the characteristics of traditional Chinese medicine, Chinese medicine can be selected advantages of obvious, clear treatment paths, suitable for day treatment of traditional Chinese medicine characteristics of the disease into the scope of the payment of value, to realize the benefits of the patient's health, and to achieve the goal of the patient's health, and to achieve the goals of the patient's health. Value-added payment scope, the realization of Chinese and Western medicine with the same disease, the same effect, the same value, so that insured patients in the outpatient Chinese medicine day treatment to enjoy the hospitalization treatment.
Chapter 6: Calculation of Settlement Points
Article 17 The calculation of settlement points for enrolled cases.
Specific cases whose principal diagnosis and surgery/operation match the definition of the catalog disease are enrolled cases. (a) If the actual medical expenses incurred in the enrolled cases are between 0.5 times (inclusive) and 1.5 times (inclusive) of the base cost of the corresponding categories of diseases in the catalog, they are treated as routine cases, and will be awarded the billing points for the categories. (2) The actual medical costs of the enrolled cases are less than 0.5 times the base cost of the corresponding category of the catalog, for the cost of ultra-low cases; the case settlement score = the current hospitalization medical costs of the insured ÷ the base cost of the category × the pricing score of the category of the disease. (c) The actual medical costs of the enrolled cases are higher than the base cost of the corresponding diseases in the catalog 1.5 times to 2.5 times (inclusive), for the cost of ultra-high cases. The case settlement score = the type of pricing score + [(the case of hospitalization in the current hospitalization costs - the type of benchmark costs × 1.5) ÷ the type of benchmark costs] × the type of pricing score. (d) for some of the special condition, complex treatment, medical service consumption and medical costs more than the directory corresponding to the base cost of the disease 2.5 times, as a special case to implement the "special case single negotiation"; by the fixed-point medical institutions to submit an application, the medical security department regularly organize the relevant experts to assess and score a reasonable determination of the score. After evaluation: 1. the case of the current incidence of reasonable hospitalization costs less than the base cost of the disease 2.5 (including) times, the case score calculated in accordance with the standard score; 2. the case of the current incidence of reasonable hospitalization costs greater than the base cost of the disease 2.5 times, the case settlement score = the current incidence of hospitalization costs of the insured person × the score rate of the expert evaluation ÷ the base cost of the disease x the pricing score of the disease.Article 18 Calculation of the settlement score for unlisted cases.
The unlisted cases are still included in the points settlement system, and the formula for calculating the points is as follows: Unlisted cases settlement points = total medical costs incurred by the insured person in the current hospitalization × 80% ÷ benchmark costs × benchmark pointsArticle 19 For incomplete treatment, without a clear diagnosis of the disease, according to the unlisted cases to determine the points of the disease.
Article 19 For incomplete treatment and no clear diagnosis, the score of the disease is determined according to the unenrolled cases.
Chapter VII Budgetary Management
Article 20 The budgetary management of the expenditures of the integrated fund under total control is implemented. The basic medical insurance funds for urban workers and urban and rural residents are budgeted and accounted for separately.
At the beginning of the year, the medical insurance agencies at all levels, based on the actual payment situation of the medical insurance fund in the previous three years, combined with changes in the number of insured persons and the age structure, policy adjustments, changes in the level of treatment and changes in the level of medical consumption, and other factors, scientifically formulate the budget plan for the annual expenditure of the integrated fund for urban and rural workers and residents. The budget program is prepared by all levels of health insurance agencies, by the municipal health insurance agencies will be examined and reported to the Municipal Finance Bureau, the Municipal Bureau of Medical Protection after approval of the implementation. Municipal health insurance agencies regularly report to the Municipal Finance Bureau, the Municipal Health Protection Bureau of the implementation of the situation.Article 21 The medical insurance agency and the designated medical institutions in the mid-year settlement of the medical insurance fund to implement the monthly pre-payment. At the beginning of the year, according to the previous year's actual payment of the total amount of medical institutions integrated fund of the monthly average of one month's working capital in advance, from the second month, according to the realization of the month's valuation points and the budget points of the month the unit price of the calculation of the monthly integrated fund disbursement amount.
The total monthly budget = the total budget of the city's hospitalization costs for the year/12; The unit price of the month's budget score = the total monthly budget / the total score realized by the city's medical institutions in the same month; Monthly pre-payment of the amount of the integrated fund = (the total value of the medical institution's monthly realization of pricing × the unit price of the month's budget score - audit deductions) × 90%.Chapter 8: Year-end Settlement
Article 22 The hospitalization expenses within the scope of payment by the basic medical insurance co-ordination fund incurred by the insured at the agreed medical institution are settled on the basis of disease points. The total amount paid by the integrated fund for settlement of hospitalization expenses = the total value of points realized by the medical institution in the current year × the unit price of the settlement points for the current year;
The amount paid by the integrated fund for annual settlement of hospitalization expenses = the total amount paid by the integrated fund for annual settlement of hospitalization expenses - the total amount of the integrated fund advanced in advance in the month; The unit price of the settlement points for the current year = the total amount of hospitalization expenses that can be paid by the integrated fund for the current year ÷ the total amount of settlement points realized by all the medical institutions in the city in the current year The year to realize all the cases settlement points sum. Article 23 The determination of the total amount of hospitalization expenses payable by the integrated fund for the year. Town and city workers and urban and rural residents of the basic medical insurance fund according to the value of the payment of hospitalization medical expenses for the year the total amount of funds can be allocated for: the year the total income of the integrated fund minus the risk reserve, the province of the medical platform for medical settlement of medical expenses, the allocation of residents of the major disease insurance premiums, the allocation of the funds of the individual medical account, outpatient treatment expenditures, the payment of incidental reimbursement treatment, and other provisions should be paid for by the integrated fund. expenses.Article 24 When a designated medical institution undertakes the task of treating a large number of patients with acute and critical illnesses due to emergencies and other special circumstances, and the medical expenses increase substantially over the total amount of the integrated fund allocated to the institution, it shall pay out of the reserved risk reserve according to the stipulated procedures, and pay out of the balance of the previous years when the reserved risk reserve is exceeded, and if it is still insufficient to pay out, it shall be arranged by the budget of the financial department. Budgetary arrangements by the financial sector to ensure the smooth operation of the fund.
Chapter IX Supervision and Management
Article 25 Medical security departments at all levels should be established to remind beforehand, in the event of the monitoring, after the audit of the regulatory mechanism, to take the daily audit, special inspections, the annual assessment and other methods, to strengthen the management of the settlement of medical costs by the value of the disease.
Article 26 Establishment of the medical institutions mutual review system, the medical insurance department should be organized annually on a regular basis or from time to time, the experts of different levels of medical institutions mutual review of the previous year's key diseases and cost of abnormal cases to assess the difference between the large, re-adjustment of the score and the assessment coefficients of the medical institutions.
Article 27 The establishment of the integrity mechanism, the integrity of the lower level or included in the "blacklist" of the medical institutions to increase the frequency of supervision, and depending on the circumstances of the medical institutions to reduce the level of the next year assessment coefficients.
Chapter X Supplementary Provisions
Article 28 Participants hospitalized in the designated medical institutions, hospitalization costs do not reach the starting standard of the Basic Medical Insurance Coordination Fund, or more than the annual limit of the Basic Medical Insurance Coordination Fund to pay for hospitalization, is not included in the value of the settlement. All the hospitalization expenses are included in the value-added settlement scope. All the hospitalization expenses refer to the hospitalization expenses that are included in the value-added settlement by disease type.
Article 29 The settlement of hospitalization expenses incurred by the insured in the designated medical institutions and the standard of treatment shall be carried out in accordance with the current policy of Liaoyuan City urban workers and urban and rural residents' basic medical insurance, and shall not be affected by the Measures.
Article 30 designated medical institutions and municipal, county and district medical insurance agencies for hospitalization costs between the settlement cycle, the participants in the designated medical institutions in the settlement time shall prevail, January 1 to December 31 of each year for an annual cycle; the first day of the month to the last day of the month for a monthly cycle.
Article 31 These measures shall be interpreted by the Municipal Bureau of Medical Security.
Article 32 These Measures shall come into force on January 1, 2022.