The medical insurance payment method is an important lever to regulate the behavior of medical services and guide the allocation of medical resources, and is known as the "bull nose" of medical insurance management and deepening medical reform. On November 26, the National Medical Insurance Bureau issued the "Notice on Printing and Distributing the Three-Year Action Plan for the Reform of DRG/DIP Payment Methods", which stipulates the roadmap and timetable for the implementation of DRG/DIP from the top-level design level, and blows the "clarion call" of the new medical insurance payment method reform.
The Action Plan calls for accelerating the full coverage of DRG/DIP payment method reform on the basis of the initial results achieved in the three-year pilot. From 2022 to 2024, we will fully complete the task of reforming drg/DIP payment methods and promote the high-quality development of medical insurance. By the end of 2024, all co-ordinated areas in the country will carry out the reform of DRG/DIP payment methods.
Dongying City, as the earliest city in Shandong Province and the earliest city in the country to explore the implementation of medical insurance payment methods according to disease classification, has many favorable conditions such as high degree of hospital recognition, good quality of medical case data, and complete medical insurance supporting policies when changing from traditional disease classification scores to DIP upgrades. Since the approval of the DIP national pilot, Dongying City has adhered to the concept innovation, thinking breakthrough, system integration, and policy integration, actively explored the "443" model, effectively strengthened the goals of cost control, cost reduction, quality assurance, and efficiency improvement, and successfully created a DIP national pilot Dongying model.
In the "443" model, the first "4" is the "four strengthening" to build a solid foundation for payment methods, that is, to strengthen system construction, strengthen data analysis, strengthen implementation paths, and strengthen technical support. The second "4" is the "four combinations" to broaden the application scenarios of payment methods, that is, to pay attention to the combination with the "three medical linkage", to pay attention to the combination with the construction of the national medical insurance credit system, to pay attention to the combination with fair medical treatment, and to pay attention to the combination with intelligent monitoring. "3" is the "three benefits" to ensure the smooth operation of the payment method, that is, accurate payment makes the use of the fund more efficient, stimulates vitality to improve medical technology, and improves quality and reduces fees to make the insured enjoy benefits.
At the specific work level, with the help of Guoxin Health's experience and technical advantages in the field of comprehensive medical insurance management services and digital transformation over the years, Dongying DIP has achieved three innovations: First, innovative implementation of the "DIP fund pre-allocation and medical insurance credit rating linkage" mechanism. Combined with the national pilot construction of the municipal medical insurance fund supervision credit system, the proportion of medical insurance fund pre-allocation is organically combined with the credit rating of medical institutions, and the higher the credit rating, the higher the proportion of fund pre-allocation, and the higher the enthusiasm of medical institutions. At the same time, we actively explore the application of the medical behavior of medical institutions in the implementation of DIP to the evaluation of medical insurance credit rating. The establishment of the above mechanism effectively connects the two major national pilots of DIP and the construction of the medical insurance fund supervision credit system, and is also the first in the country. The second is to innovatively explore the auxiliary directory system. According to the design ideas of the "National Medical Security Payment by Disease Classification (DIP) Technical Specification and DIP Disease Catalogue Library (Version 1.0)", it took the lead in exploring the implementation of the auxiliary directory system. Mainly according to the severity of the disease suffered by the patient, the key indicators such as the number of days in hospitalization, the outcome of discharge, complications and comorbidities, radiotherapy and chemotherapy are considered, and an auxiliary catalogue is formed to promote the improvement of the medical technology level of medical institutions. Up to now, 486 diseases in Dongying City have enabled auxiliary catalogs to achieve micro-calibration of disease payment. The third is to innovatively implement the "employee treatment coefficient" policy. In view of the fact that the proportion of residents in the insured population is significantly higher than that of employees, and the hospitalization costs of residents are significantly lower than those of employees, the treatment coefficient of employees is set up to reflect the difference in the actual medical insurance treatment between employees and residents. The setting of this coefficient is conducive to guiding the convergence of hospitalization expenses of insured residents and employees, and ultimately realizing the same disease and division of employees and resident medical insurance.
The most fundamental reform of medical insurance payment method is to solve the problem of excessive medical treatment to a certain extent from the top-level design, through the establishment of a standardized clinical path, to achieve reasonable diagnosis and treatment, treatment due to disease, stimulate the endogenous force of the hospital to control medical costs, and finally make the medical service system into benign operation, and realize the tripartite linkage of medical insurance, medical affairs and medicine in the hospital.
It is understood that the Dongying DIP software information system was completed and put into use at the end of March 2021, and on August 1, 2021, Dongying officially launched the actual payment of DIP, and the current operation is in good condition. In the first three quarters of 2021, the total cost of inpatient medical treatment in Dongying increased by 3.8% year-on-year compared with 2020, far lower than the year-on-year increase of 8.12% in 2020 compared with 2019. After the formal implementation of DIP payment, the treatment guarantee of the insured people as a whole tends to be stable, and the cost of medical treatment for the masses in high-level medical institutions (such as tertiary hospitals) has declined. For example, after the implementation of DIP in Dongying People's Hospital, in September 2021, under the circumstance that the number of discharges and the number of fourth-level surgeries have increased significantly, the average cost of discharged patients will be reduced by more than 1,000 yuan year-on-year. The setting of key indicators in the DIP policy system is conducive to the treatment of medical institutions due to diseases and encourages them to improve their medical technology. For example, Dongying Shengli Oilfield Central Hospital actively adapts to the needs of DIP management and strives to improve its own medical technology level, and the hospital has carried out 79 new technologies and new projects in the first half of 2021 alone, an increase of 33.9% over the whole year of 2020. In addition, Dongying City has also carried out medical insurance fund supervision for DIP payment methods, which effectively reduced the violations of medical institutions and ensured the safe operation of medical insurance funds.
In the next step, Dongying City will continue to implement the dynamic adjustment of disease scores, make efforts in exploring the medical insurance rating evaluation system, building a long-term supervision mechanism, establishing an operation correction mechanism, and continuously summarize experience with the help of the professional services and technical support of third-party forces such as Guoxin Health, so as to achieve high-quality development of the reform of medical insurance payment methods in Dongying City.
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