Transferring medical expenses to outpatient clinics after DRG implementation? This reform is launched, and the income of medical personnel may decline

Recently, the Zhejiang Provincial Medical Insurance Bureau issued the notice of the "Three-year Action Plan for Comprehensively Promoting the Reform of Medical Insurance Payment Methods in Zhejiang Province", which clarified the three-year reform timetable:

By the end of 2022, form a unified outpatient payment technical specification and outpatient case grouping scheme in the province;

By the end of 2023, all co-ordinated areas in the province will fully implement the reform of outpatient payment methods combined with APG; at the end of April 2024, the first round of liquidation of outpatient payment method reform will be completed;

By the end of 2024, full coverage of inpatient DRG and outpatient APG payment reform areas, full coverage of fees, full coverage of populations, and full coverage of medical institutions will be achieved.

Different from other provinces, Zhejiang for the first time proposed to iteratively upgrade the reform of inpatient DRG payment methods, while promoting the reform of outpatient APG payment methods in stages, and creating a closed loop of reform of outpatient and inpatient fee payment methods.

DrG can effectively curb the rapid growth of hospitalization costs, but it will bring a side effect: in order to avoid the control of inpatient costs, hospitals may discharge patients early, or transfer inpatient expenses to outpatients, resulting in a sharp increase in outpatient costs.

At present, the mainland is establishing and improving the outpatient mutual assistance guarantee mechanism for employee medical insurance, continuously expanding the scope of outpatient protection and increasing the reimbursement ratio, and the growth rate of outpatient medical expenses in various places is obvious. It is foreseeable that in the future, with the full rollout of DRG, the growth of outpatient medical expenses will be more rapid.

In this case, is there a payment method that can block the outpatient end like DRG/DIP, promote the reform of outpatient medical behavior, and control the unreasonable growth of outpatient medical expenses?

This is where the outpatient APG payment method comes into being.

Similar to drg logic, APG associates patients' medical needs with hospital costs by dividing outpatients into manageable groups with homogeneous clinical resource use, prompting hospitals to be more proactive in cost management and reducing waste.

This payment method has been implemented in the United States, Europe and other countries and regions, and the effect of cost control is obvious. The APG mentioned in the three-year action plan for the reform of medical insurance payment methods in Zhejiang Province is the experience of Jinhua, the first "crab eater" in China. Will this be a model for payment methods for outpatient health insurance across the country?

Combining outpatient APG with the point method to effectively control costs, are there also problems inherent in DRG and DIP point payment methods such as high sets of coding and discouraging the enthusiasm of medical staff?

"Hospitals and medical staff need to be prepared, if this payment method is fully rolled out, it will have an important impact on outpatient volume and income, especially for small hospitals that are not competitive, it will be more difficult to survive." Zhao Heng, founder of latitude Health, a medical strategy consulting firm, told the health community.

DRG facilitates the shift of inpatient medical services and costs to outpatients

International experience shows that after the implementation of the reform of inpatient payment methods such as DRG, although the growth rate of inpatient medical expenses has been effectively controlled, it may lead to the transfer of services and costs, the transfer of traditional inpatient medical services and costs to outpatient services, and the growth of the number and cost of outpatient medical services.

In 1983, after the introduction of the DRG prepayment system in the United States, the growth rate of hospitalization expenses decreased from 14.5% in 1984 to -6.6% in 1992, while the cost of outpatient treatment increased sharply.

In 2016, after the implementation of DRG payment in Jinhua City, the goal of improving the quality and efficiency of the medical insurance fund was better achieved. However, in the same period, the growth rate of outpatient medical insurance fund expenditure reached about 20%, which was much higher than the growth rate of inpatient medical insurance fund expenditure.

With the continuous expansion of the scope of outpatient protection in the mainland and the continuous improvement of the reimbursement ratio, it is likely to bring about a surge in outpatient expenses and increase the pressure on fund payment and supervision and management.

At present, the mainland outpatient medical insurance payment is mainly based on the traditional project-based payment, according to the actual cost of designated hospitals and pharmacies, medical services are seriously fragmented, and medical insurance lacks a reasonable reimbursement mechanism for outpatient medical services.

Courtesy of the public platform

Therefore, it is imperative to effectively control outpatient costs.

"In order to avoid possible cost transfers, it is necessary to carry out collaborative reform of outpatient payment methods to control the unreasonable growth of outpatient medical expenses." Liao Zangyi, a postdoctoral fellow at the Medical Service Governance Research Center of Tsinghua University, once wrote an article.

International experience shows that the Outpatient Case Grouping (APG) is an effective measure to reasonably compensate for medical costs and control medical expenses – the prepayment system reform based on APG has become one of the directions.

What if there is a big difference in costs within a group?

DrG, as a kind of inpatient medical service prepayment system, is based on DRG grouping - first the inpatients are grouped according to the severity of the disease and the level of resource consumption, and then each patient group is given a unified payment price "in advance" to pay the hospital, so as to standardize the inpatient medical behavior and control related costs.

The APG grouping logic is similar to DRG, that is, cases with similar clinical characteristics, resource consumption and cost are grouped together, and the patients in the group have similar clinical resource consumption, and the patient resource consumption between different groups is compared by "weight".

However, unlike DRG, which uses "diagnosis" as the primary grouping variable, outpatient cases usually lack a clear diagnosis, so APG takes "operation" as the primary grouping variable, and then combines diagnosis, population sociological characteristics (such as gender, age), and resource consumption (such as cost, cost) to group cases.

Depending on whether there is an important "operation", APG divides outpatient cases into three main categories: the critical operation group, the internal medicine service group and the auxiliary service group.

Within each large group, the group is subdivided according to other information (such as the location, type, age, complexity, etc.) of the operation to cover the various types of patients who appear in the outpatient clinic.

In this process, unlike DRG, a hospitalized case can only be placed in one DRG group, and a payment standard is determined that covers all the costs of diagnosis, surgical procedures, auxiliary examinations and medicines in that group. The cost of outpatient services varies greatly (in general, the cost of "ancillary services" is relatively high), resulting in a large difference in costs within an APG group.

To this end, APG divides an outpatient case into multiple APG groups, such as surgery-based cases that also contain important examinations and tests, and the surgery-related expenses are divided into the APG group for important operations, and the related examinations and tests are divided into auxiliary services APG groups.

Correspondingly, in order to calculate the payment criteria for a patient to be divided into multiple APG groups, the method of weight compound multiplier is generally used - that is, the package payment of different disease combinations or the discount payment of adjusting the weight of the disease group.

In this way, APG groupings can be flexibly combined between different modules and can also solve the problem of diversity of patient needs, such as patients undergoing two surgeries and one X-ray in one visit, i.e. being assigned 3 APG.

Similar to DRG, by grouping and pre-setting payment standards, APG payments can both ensure that medical resources are properly reimbursed, and can also incentivize medical institutions to reduce the provision of unnecessary medical services and save health insurance funds.

How did Jinhua, the "first to eat crab", do it?

In order to control the increase in outpatient medical expenses brought about by the implementation of DRG, in January 2020, Zhejiang Jinhua began to implement the reform of paying by head and combining "APG" point method under the total budget, becoming the first place in the country to use APG, and the municipal level and Lanxi City took the lead in implementing it, and from January 2021, the city was fully implemented.

Jinhua's reform is actually a combination of total prepayment + head packing + APG grouping + point method, and APG payment is only part of it - for contracted personnel, the outpatient head fund will be "packaged" to the contracted medical institutions (mainly for the grass-roots social health service centers, etc.), and for the insured who have not signed up, the APG point method (mainly for hospitals, etc.) is used.

Specifically, the first is to establish a localization grouper system: Jinhua Huayang City clustered and grouped 16 medical institutions involving a total of 1.41 million yuan of various types of outpatient medical expenses, according to the clinical process, resource consumption and other similarities, considering the outpatient consultation fee, general diagnosis and treatment fee, high-value consumables, national negotiating drugs and other factors, through the use of big data means to analyze the number of historical outpatient cases, reasonably calculate the average historical cost of each disease group, and divide the outpatient cases in Jinhua East City into surgical operations, diagnosis, Auxiliary three categories, a total of 1391 sub-groups were obtained.

The second is to determine the specific payment method. For the diagnostic team, the "packaged fee" payment is implemented (Chinese medicine is paid by post), the surgical operation team is paid by the "packaged fee" for the main operation and the "discount" payment for the secondary surgery, and the auxiliary group is paid by the "package fee" or "project".

The third is to determine the number of points in the disease group, similar to the DRG weights. Among them, the APG benchmark point = the average cost of the APG case / the average cost of all APG cases × 100, and the specific outpatient disease group points are the sum of the points of the surgical operation group, the diagnostic group and the auxiliary group.

Finally, according to the principle of "fixed income and expenditure, balance of payments, and slight balance", the floating point value is implemented, that is, the rate of each point value is not fixed, depending on the current budget and the total number of points in the region, the point value may be high or low - if the budget is large, the number of points is small, the point value is high, and if the budget is small, the point value is low.

"Some medical staff should be prepared for declining incomes"

On the one hand, because the patient group sets a fixed point value (price), it will prompt the hospital to suppress unnecessary examination and treatment, reduce waste, and reduce the burden and cost of medical treatment from the source; on the other hand, the point value floating method is based on "fixed expenditure by revenue", and the cost control effect is outstanding, and it is generally impossible to overrun - this is the internal logic of the APG point method.

According to the data revealed by Jinhua City in December 2021, the annual growth rate of outpatient fund expenditure in Jinhua City has dropped from 19.4% before the reform to 10%, of which the municipal outpatient fund is expected to save 88.81 million yuan.

After determining the payment limit for the ward, is there any possibility that APG will experience under-service or prevarication of severe illness similar to DRG?

"It will definitely be affected to some extent, so it is also necessary to introduce a similar 'special disease list' policy like DRG." Zhao Heng told the health community.

In addition, Zhao Heng believes that the negative effects of the floating point value in DIP may also appear in the outpatient APG point method: because the point value is not fixed, the hospital and the doctor cannot calculate the due rate before settlement, in this case, the doctor will often increase the amount of service to obtain more points, in this case, because the large hospital has more advantages in expanding the outpatient clinic, it will drive the large hospital to continue to expand, which will cause a large squeeze on the small hospital. "Competition between outpatient clinics in hospitals has increased, and for small hospitals that are not very competitive, the income of medical staff will definitely be affected."

At the same time, as the total number of services and total points increases, it often leads to "depreciation of points" - although hospitals provide more services, they cannot get more payments, and even their incomes may be reduced, and their enthusiasm is discouraged, which is not conducive to the further advancement of reform.

Some experts believe that outpatient head-to-head combined with APG has the greatest impact on auxiliary drugs and proprietary Chinese medicines. The unit price of outpatient proprietary Chinese medicines is not high, but the daily treatment cost is relatively high, and in order to achieve rapid onset, they are used in combination with Western medicine. If the doctor finds that it can be effective without using proprietary Chinese medicines, he will withdraw the proprietary Chinese medicines to avoid losses and strive for a balance.

Jinhua also proposed in the pilot policy to "explore the implementation of the same disease and the same price of traditional Chinese and Western medicine, and select suitable diseases to carry out the pilot project of paying according to the value of curative effect combined with APGs point payment".

So, what about drugs with high prices and good efficacy? At present, many primary medical institutions adopt a single prescription amount limit, which is very restrictive for such drugs. When paid per head in outpatient clinics combined with APG payments, the unit price and the amount of a single prescription are not important, what is important is the basis of health economics, which is the total cost of the entire course of the disease.

Some experts have questioned how to calculate the medical expenses caused by complications after the implementation of head-to-head combined APG payment?

And, doctors change their diagnosis and treatment behavior to fight for medical insurance balances to have preconditions: whether and how is the medical insurance balance related to department performance?

Will the future be rolled out in full swing?

"In addition to promoting reasonable outpatient reception in hospitals and curbing the rapid growth of the number and cost of outpatient medical services, APG payments can also help measure outpatient output, promote competition between outpatient clinics in different hospitals, and improve the standardization and standardization of outpatient services." Professor Yang Yansui of Tsinghua University strongly agreed with the reform of the APG point method implemented by Jinhua.

After Zhejiang Province, will other provinces follow suit? Is it possible to spread throughout the country? The relevant staff of Yantai Medical Security Center told the health community that Yantai Outpatient Clinic is currently mainly based on the management of head fees according to disease types, supplemented by payment by project, and is preparing to transition to "outpatient disease score".

However, although APG has obvious cost control effects, it cannot be implemented if it wants to, but like DRG, it relies on the settings of the external environment.

First, a team of professionals is required to regularly group maintenance updates:

The speed of outpatient treatment is fast, there are constantly new technologies, new treatment methods are generated, and only regular, timely and continuous update and maintenance of APG can ensure that the group truly reflects the actual clinical diagnosis and treatment.

"This requires a dedicated team of clinicians, data analysts, programmers, and economists dedicated to maintaining the update group." Liu Xingchen of the Institute of Hospital Management of Tsinghua University wrote in the relevant paper.

Secondly, it is necessary to improve the outpatient electronic medical record, coding and information system:

APG needs a large number of data resources such as outpatient medical records to support in the implementation process, as well as unified diagnosis and operation coding, accurate and informative cost information, and efficient information systems. It can be said that the more standardized the medical record writing, the more accurate the encoding, and the smoother the data transmission, the more accurate the grouping of APG.

Finally, it is necessary to establish appropriate supervision and management measures to prevent high sets of coding:

In APG payment, the clinician chooses the operation and diagnosis, which directly determines the medical expenses incurred by the patient. In order to prevent high sets of coding and transfer costs, it is necessary to supervise the whole process of doctors' diagnosis and treatment behavior, and establish an intelligent audit system to monitor hospitals based on clinical pathways.

For example, because ancillary services are packaged and paid, hospitals can move patients to a non-medical setting for examination, and non-medical facilities can provide separate billing, so it must be possible to identify assistive devices ordered by the hospital's outpatient department but provided by non-medical environments to prevent cost shifts.

Based on this, combined with the current situation that most regions of the country are still groping for DRG, it may be difficult to carry out APG in the short term.

Due to the large number of outpatients in mainland hospitals and the large number of patients per unit time, the construction and promotion and application of outpatient electronic medical records have always been the shortcomings of various hospitals. The quality, management, data storage and interface construction of outpatient medical records need to be further improved.

Fortunately, the basic work of APG's coding specifications and information systems has certain similarities with DRG, and the DRGs payment method reform that is being promoted and implemented can lay the foundation for the improvement of the future outpatient case information system for hospital inpatient cases, finance and medical insurance information systems.

However, regardless of whether the reform of outpatient APG payment method will be fully promoted in the future, it is certain that after DRG, in order to prevent the transfer of inpatient expenses to outpatients, the monitoring and management of outpatient funds will definitely come.

Health Community Exhibits

Written by | Valley Will