The main purpose of the DRG/DIP payment method reform is to guide medical institutions to change the current extensive and large-scale expansion operation mechanism, and turn to pay more attention to connotative development, pay more attention to internal cost control, and pay more attention to reflecting the technical value of medical services. Under the condition of limited medical insurance costs in the DRG/DIP disease group, hospitals not only need to face the improvement of medical insurance settlement rate, but also share the financial pressure of "deflation and depreciation".
1
Impact of DRG/DIP payments on hospitals
Under the regional total budget of DRG/DIP, the pre-settlement rate/point value is calculated according to the weight/score of the DRG/DIP disease group, and the total weight/total points of the DRG/DIP of the hospital are liquidated according to the settlement rate/point value after assessment.
Hospital DRG/DIP pre-settlement = total weight of hospital DRG/DIP / total points × DRG/DIP pre-settlement rate / point value
Hospital DRG/DIP liquidation = total weight of hospital DRG/DIP / total points × DRG/DIP liquidation rate / point value - hospital DRG/DIP pre-settlement - medical insurance assessment deduction fine
DRG/DIP医保结算差额（医保盈亏）=医院DRG/DIP总医疗费用-DRG/DIP医保清算
Hospital DRG/DIP Medical Insurance Settlement Rate = DRG/DIP Medical Insurance Liquidation/Hospital DRG/DIP Total Medical Expenses× 100%
Under the DRG/DIP payment method, the hospital will have two operational results, the first is to achieve the "surplus" of DRG/DIP medical insurance settlement through lean management of internal control, and the second situation is the "loss" of DRG/DIP medical insurance settlement.
According to the post-payment of the project, doctors can only get better medical insurance settlement by doing more projects, and there is no way to confirm the payment of medical insurance without doing projects, and the motivation of hospital doctors to take the initiative to reduce costs is insufficient; Compared with the payment according to the project, the DRG/DIP payment is based on the prepayment system, and there is a prepayment standard for each DRG/DIP disease group, and the balance is retained for overspending and dividing the order, and excessive defensive inspection and excessive quality and medicinal materials will become the cost of the hospital rather than the income, and the impact and impact on the hospital is very huge.
2
Identification and prevention of the "Top 10 Risks" of DRG/DIP payment
There are "10 major risks" in DRG/DIP payment methods, and more attention needs to be paid to how to identify risks and prevent risks from causing greater losses to medical insurance and hospitals.
The first risk is the "risk of vicious competition". DRG/DIP payment is based on the total regional budget, and the hospitals in the region compete with each other, which helps to improve the efficiency of medical services. Therefore, under the DRG/DIP payment, it is necessary to give full play to the internal control mechanism of the hospital in order to effectively prevent the occurrence of the phenomenon of "bad money driving out good money".
The second risk is the risk of unreasonable budget amounts. Therefore, how to reasonably determine the regional inpatient medical insurance budget and prevent the adverse impact of the high proportion of patients who are transferred to the region and the total amount of DRG/DIP inpatient medical insurance in the region is also affected by the level of financing and the total amount of medical insurance. Therefore, the best way is to improve the capacity of medical services, reduce the proportion of outward transfer patients, and increase the amount of DRG/DIP medical insurance budget based on the packaging of the medical insurance budget of the regional medical community, and give full play to the internal control mechanism of the medical community.
The third risk is "the risk of unreasonable weight/score". DRG/DIP weight/score, generally based on 7:2 in the previous three years; According to the calculation of the average historical medical expenses at one time, due to the unreasonable price of medical charges, the medical expenses are inflated due to the use of medicines, examinations, and consumables, especially with the implementation of centralized procurement of drug consumables and the adjustment of medical service prices, the calculation basis has changed greatly, and the risk of unreasonable DRG/DIP weight/score has been greatly increased. How to adapt to the new situation, re-calculate the weight/score, and prevent the greater risk caused by the unreasonable weight/score.
The fourth risk is "the risk of rate/pip value depreciation too fast". The DRG/DIP rate is affected by the total budget, the total weight of the regional DRG/DIP \ the total score, etc., especially the implementation of DRG/DIP, and the data collected in many places during the epidemic period, resulting in the calculation not taking into account the rebound of medical demand after the epidemic, as well as the acceleration of population aging, and the realistic changes in vicious competition in hospitals, resulting in the rapid depreciation of DRG/DIP rate/point value, which leads to an increase in the risk of hospital economic operation. Therefore, hospitals not only need to pay attention to their own DRG/DIP operations, but also have insight into the DRG/DIP operations of hospitals in the region.
The fifth risk is "the risk of digestion of medical insurance losses". DRG/DIP payment, some hospitals have a large medical insurance loss, from the perspective of medical insurance, the whole region may be the whole region accounting hospital medical insurance is not a loss, but the impact on each hospital is different, DRG/DIP market competition mechanism determines that "the best are better, the weak are weaker", for the medical service capacity is not high, the management foundation is weak for the hospital, resulting in a large amount of medical insurance loss, digestion difficulties. Therefore, hospitals need to take DRG/DIP payment as an opportunity to strengthen internal risk investigation and promote hospital cost reduction, quality and efficiency improvement, so as to achieve high-quality hospital development.
The sixth risk is the "risk of medical care". Under the DRG/DIP payment model, preventing "medical excesses" as one of the important reform goals, in the case of relatively stable DRG/DIP prepayment, the hospital's awareness of cost control has been significantly improved, and the medical insurance balance may be excessively pursued, and the items and examinations that should be done are not done, and the diseases that can be treated at one time are decomposed into several hospitalizations, resulting in insufficient medical services, resulting in hidden dangers in medical quality, and early discharge should not be discharged, which should be taken as a key focus.
The seventh risk is "low code and high code risk". "Low code and high number" mainly makes cases enter the high-weight and high-score DRG/DIP diseases by adjusting the main diagnosis and surgical operation code of the disease, inflating the diagnosis, inflating the surgery, and inflating the secondary diagnosis, so as to obtain better medical insurance payment and settlement. "Low code and high number" is the focus of the crackdown on "fraud and insurance fraud", therefore, hospitals need to strengthen the risk identification of low code and high code to avoid legal risks.
The eighth risk is "high code and low code risk". In order to prevent risks, some hospitals or doctors take "high codes and low codes" to make improper profits, and the attention is not high at present, mainly due to the "adverse selection" caused by the defects of DRG/DIP payment policies. According to the definition of fraud and insurance fraud, it can be included in insurance fraud, therefore, hospitals should strengthen internal control and prevent legal risks.
The ninth risk is "passing the buck to the patient's risk". Under the DRG/DIP payment model, in order to excessively pursue the "medical insurance balance", most of the expenses squeezed by minor illnesses are relatively easy to generate surpluses, and the possibility of squeezing expenses for major illnesses is relatively difficult to pursue the balance will also be reduced. Doctors are more inclined to think between "0.3/0.5-1", and for anything more than 1, there will be no balance. Therefore, hospitals should prevent the influence of doctors' low willingness to treat serious illnesses or even prevarication of patients, affecting the construction of hospital disciplines, and then affecting the quality brand of hospitals.
The tenth risk is "low-standard hospital admission risk". Under the DRG/DIP payment model, a basic number of patients is required to receive medical insurance income. The vast majority of hospitals will have a single performance incentive policy for admission, which is to increase the admission rate and increase medical insurance income. Under the DRG/DIP payment model, hospitals pay more attention to "grabbing work points", if the medical service capacity is insufficient, they can't grab the "high points/score" diseases, grab the "low points/score" diseases, or even low-standard admission to the hospital to "make points/scores", otherwise, they will be eliminated from the competition in the same competition.
3
Top 10 internal control measures of hospitals under DRG/DIP payment
Under the limited medical insurance fund resources, hospitals should not only ensure the quality and safety of medical care, but also obtain reasonable benefits, and satisfy patients, so as to empower and promote hospitals to strengthen internal control and management, so as to comply with the general trend of DRG/DP payment method reform.
Internal Control Measure 1: QE Value Analysis of Cost Path Promote Clinical Pathway to Standardize "Medical Service Behavior"
Under the DRG/DIP payment, according to the grouping rules, based on the ratio relationship between the average medical cost and the average average cost of the disease group in the previous three years, it is uniformly standardized as the DRG/DIP weight/point/score. It is calculated as follows:
DRG/DIP weight/points/score = average cost of the DRG/DIP in the previous three years (7, 2, 1)/average cost of discharged patients in the previous three years (7, 2, 1)×100 (1000)
As can be seen from the formula, the DRG/DIP weight/points/score represent the regional average, and multiply it by the rate/point value to form the average cost, which is the benchmark (target) value of the regional industry cost.
According to the regional DRG/DIP weight/points/score and rate/point value, the hospital calculates the average cost of each DRG/DIP as the benchmark (target) value of the regional industry cost, compares the average cost of each DRG/DIP of the hospital with it and calculates the QE value, and takes the cost path as the internal control measure to reverse the management of the clinical path and promote the standardization of medical service behavior.
QE value calculation of DRG/DIP = Average cost of DRG/DIP of the hospital / Average cost of DRG/DIP of the region
The QE value is greater than 1, indicating that the average cost of DRG/DIP in the hospital is at the lower level of the middle compared with the regional average, and the resource consumption is large, and there is a certain room for decline.
The QE value is less than 1, indicating that the average cost of DRG/DIP in the hospital is at the upper middle level compared with the regional average, and the resource consumption is appropriate.
In short, through the analysis of the QE value of the cost path, it provides decision-making reference data support for promoting clinical pathway management, which is conducive to standardizing the behavior of medical services, striving to reduce the consumption of medical resources, and improving operational efficiency.
Internal Control Measure 2: Calculate DRG/DIP Coverage to Promote "Open Source"
Under the DRG/DIP payment, the hospital should first calculate the coverage rate and check the shortcomings of the hospital's discipline development by comparing the types of diseases seen by the hospital and its departments with the regional DRG/DIP. Calculation formula:
DRG/DIP覆盖率=本院（科室）DRG/DIP病组数/区域DRG/DIP病组数×100%
Combined with the requirements of the grade evaluation of tertiary public hospitals, the coverage rate of ICD-10\ICD-9-CMI3 was calculated, and the lack of disease capacity of hospitals was analyzed.
For the disease groups that cannot be diagnosed and treated, it is the hospital that needs to strengthen the discipline construction to focus on, strive to improve the ability of medical services, strengthen the adjustment of disease structure, improve the breadth of medical services, and realize the "open source" of hospitals. ”
Internal control measure 3: Calculate the DRG/DIP budget income and medical insurance profit and loss account to reasonably "reduce costs"
Under the DRG/DIP payment, just like the upper limit of income set for each disease group, the limited medical insurance funds determine whether the actual medical expenses of the hospital and the proportion of medical insurance settlement are more or less, which determines how much compensation the hospital can pay and invest.
DRG/DIP Budget Income = Number of DRG/DIP Disease Groups× DRG/DIP Weight/Score× DRG/DIP Rate/Point Value× Institutional Coefficient
From this formula, it can be seen that the number of DRG/DIP disease groups, the proportion structure of high and low weight/score disease groups, can be controlled by the hospital, and the DRG/DIP rate/point value and institutional coefficient are not controllable by the hospital. Therefore, hospitals should strengthen the internal control of the number of DRG/DIP disease groups and the proportion structure of high and low weight/score disease groups, so as to improve the efficiency of hospitals.
DRG/DIP医保盈亏=DRG/DIP实际医疗费用-DRG/DIP预算收入
As can be seen from the formula, if it is greater than 1, the hospital will have a medical insurance surplus, and less than 1, the hospital will have a medical insurance loss. Through the profit and loss accounting of medical insurance, the parameters provided for hospitals to reasonably reduce costs.
Internal Control Measure 4: Medication Analysis, Optimization of Rational Drug Use, and Reduction of "Drug Proportion"
Under the condition of limited DRG/DIP payment funds, the adjustment of income structure has become the top priority, and drugs account for a large proportion of income, and how to reasonably reduce the proportion of drugs requires internal control.
各DRG/DIP药占比=各DRG/DIP药品收入/该DRG/DIP医疗收入×100%
At this time, the proportion of drugs calculated is different from the usual calculation, not the average drug proportion, but based on the proportion of drugs refined to each DRG/DIP disease group, so that the calculation is more reasonable, not affected by the change of disease structure, and is more conducive to strengthening internal control.
The main indicators of internal control to reduce the proportion of drugs include the utilization rate of basic drugs, the utilization rate of centralized procurement drugs, the intensity of antimicrobial use, etc., which can be compared and analyzed by the drug behavior of different doctors for the same disease to find a rational way to use drugs and achieve the purpose of reducing the proportion of drugs.
Internal control measure 5: consumables analysis, optimization and rational use of materials, reducing the "proportion of consumption"
In the same way, under the condition that DRG/DIP payment funds are limited, how to reduce the proportion of consumption also needs to take DRG/DIP payment as an opportunity to increase internal control.
各DRG/DIP耗占比=各DRG/DIP耗材收入/该DRG/DIP医疗收入×100%
各DRG/DIP耗占比=各DRG/DIP耗材收入/该DRG/DIP执行医疗收入×100%
At this time, the consumption proportion calculated is different from the usual calculation, which is based on the consumption proportion of each DRG/DIP disease group, which is not only the proportion of income, but also the denominator is the medical service income of the implementation of the disease, so that the calculation is more reasonable, not affected by the changes in medical and technical examination income and drug income, and is more conducive to strengthening internal control.
The main indicators of internal control to reduce the proportion of consumption include the proportion of DRG/DIP consumption, the utilization rate of consumables for centralized procurement, etc., which can be compared and analyzed by comparing and analyzing the consumables behavior of different doctors with the same disease type to find reasonable methods of material use and achieve the purpose of reducing the proportion of consumption.
Internal control measure 6: Reasonable analysis of medical technology examination and reduction of "proportion of medical technology examination"
Under the traditional project-based payment, due to the unreasonable pricing of medical services, hospitals need to make up for it by doing more medical and technical examinations. Defensive medical technology examination refers to the excessive medical technology examination that doctors need to expand in order to prevent the expansion of medical risks, in order to reduce the proportion of drugs and consumption, and need to expand the denominator to increase, in order to make up for the unreasonable increase in the price of medical service items, and in order to increase the performance salary.
Under the DRG/DIP payment, the income from defensive medical technology examination has also become the cost of the hospital under the prepayment mechanism. How to reasonably inspect and reduce the proportion of medical and technical examinations also requires internal control.
The internal control method of reducing the proportion of medical technical examinations, changing the performance incentive model under DRG/DIP payment, and resolutely cutting off the relationship linked to the income of medical technical examinations can not only prevent the policy risks that are not linked to income, but also prevent the economic risks brought by excessive medical and technical examinations to hospitals. Referring to the clinical pathway, the evaluation index of the proportion of medical technology examination in the DRG/DIP disease group was set up, and the mutual recognition index of medical technology examination was assessed.
Internal Control Measure 7: Improve the quality of the first page of medical records
DRG/DIP payment is different from project payment, which is based on the hospitalization fee settlement list, and DRG/DIP is based on the first page of the case, so the quality requirements for the first page of the case are higher, and it is necessary to enter the right group, fill in the first page of the case accurately and completely, and ensure that the case group is correct, so as to obtain better medical insurance settlement compensation. The quality of the first page of the medical record is particularly important in the DRG/DIP payment, and it is also very important for the performance of the national examination, and the seven national examination indicators are derived from the first page of the medical record. Therefore, hospitals should strengthen the internal control of the first page of medical records.
The main ways to strengthen the internal control of the first page of medical records are, first, to strengthen the training of medical record management personnel to ensure that they are familiar with the DRG/DIP payment rules and accurately assign appropriate case groups to patients. Second, strengthen the review of the quality of medical records to ensure the accuracy and completeness of the information on the first page of medical records. Third, the diagnosis should be cleared into the right group, the main diagnosis and the secondary diagnosis should be reasonable, and the diagnosis should not be recorded in order to obtain better medical insurance settlement compensation. Fourth, the performance appraisal support, the establishment of a sound internal appraisal mechanism, the DRG/DIP payment and the performance appraisal of medical staff, mobilize the enthusiasm of medical staff, improve the quality of the first page of medical records, prompt them to pay attention to medical costs, improve the efficiency of medical services.
Internal Control Measure 8: Move the management threshold forward to promote "quality improvement"
DRG/DIP payment is based on the refinement of each patient, each patient corresponds to each attending physician, and managing the doctor's "one pen" plays a key role in DRG/DIP management. Therefore, under the DRG/DIP payment, the internal control management threshold should be moved forward to the doctor's side.
The main methods of internal control on the doctor's side cover the need for doctors to have a clear understanding of the DRG/DIP weight/score, DRG/DIP budget income, QE value analysis gap, and attention to the rationalization of medical expenses, rational use of drugs, reasonable use of materials, and reasonable medical technology examination. Strengthen and increase the proportion of medical service income, increase the adjustment of disease structure, promote the improvement of diagnosis and treatment level, and achieve "quality improvement" to improve the quality and efficiency of hospital operations.
Internal Control Measure 9: Settle DRG/DIP Cost Account and Profit and Loss Account to Achieve "Cost Reduction and Efficiency Increase"
Under DRG/DIP payment, it is necessary to calculate the medical cost account, and analyze the real medical profit and loss, so as to provide data support for the analysis of DRG/DIP disease value management.
DRG/DIP disease value management, including clinical value (RW/CMI value), medical added value (medical profit and loss), social value (disease aggregation), patient value (patient self-payment level, patient satisfaction), carry out the "Boston" four-quadrant comprehensive analysis, determine "strategic diseases, dominant diseases, suitable diseases, and disadvantaged diseases", and provide reference for discipline construction, disease structure adjustment, and performance evaluation.
Internal Control Measure 10: Strengthen the construction of DRG/DIP informatization to support the "intelligence" of internal control
The traditional medical service charging method is mainly based on project payment, while the DRG/DIP payment mechanism is based on medical records, and divides the disease diagnosis and treatment process into different disease groups or diseases, so as to realize the packaged payment of medical expenses, and it is necessary to improve the level of medical record management to ensure the accuracy, completeness and timeliness of medical record data. In addition, it is necessary to strengthen medical quality control and cost management to improve the efficiency of medical services and reduce medical costs. The payment mechanism of DRG/DIP based on the principle of big data analysis poses new challenges to the analysis and application of medical data, and puts forward higher requirements for the risk management ability of hospitals. It is necessary for hospitals to increase the construction of informatization, support internal control through informatization and intelligence, and dig deep into the information in the case data with the help of big data analysis technology, including in-depth analysis of disease classification, surgical coding, medical expenses and other data, so as to realize the rational allocation of medical resources, improve the quality of medical services, reduce medical costs, and improve hospital efficiency. At the same time, hospitals need to continuously optimize data collection, storage, processing, and analysis to ensure data security and reliability. In the process of informatization construction, a sound internal control risk management system is established through intelligence, including real-time monitoring and analysis of medical record data, medical expenses, clinical pathways, etc. Through the identification and assessment of risk factors, hospitals can take measures in advance to reduce medical risks and ensure medical safety.
In short, the reform of DRG/DIP payment methods poses great challenges to the extensive management of hospitals, so only by strengthening internal control and plugging leakage can we obtain a better medical insurance settlement rate and ensure the sustainable development of hospitals.
Source | Qin Yongfang: Medical and health financial accounting, economic research
Edit | Cui Xiujuan Gao Pengfei
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