2024 is the final year of the three-year action plan for the reform of the national DRG/DIP payment method, which will basically realize the "four full coverage" of the overall planning area, medical institutions, diseases and medical insurance funds, and initially build a new effective and efficient medical insurance payment mechanism. In the process of reform, the national and provincial medical insurance departments are responsible for formulating policy documents, the technical guidance group is responsible for grouping plans, and the medical insurance departments of each coordinating area are responsible for promoting the implementation, and the tripartite division of labor and cooperation has basically taken shape. Based on the current situation, the DRG/DIP policy direction is unswerving, and the grouping plan is becoming more and more mature, but the implementation of the reform is scattered in more than 400 overall planning areas across the country, and the understanding of the connotation of the reform varies greatly among various regions, and the effect of the reform is also very different. Looking forward to the future, the capacity building of each coordinating area will surely become an important task in the new stage of reform. The author believes that the "three calculations" of DRG/DIP budget, settlement and liquidation run through the whole process of payment reform and play a pivotal role, and the basic principles and logical connotations of the "three calculations" of DRG/DIP should be accurately understood.
1. Accurately understand the connotation of the total budget of the DRG/DIP region
(a)
Strengthen the total regional budget and create a fair and orderly reform environment
At the beginning of each year, the DRG/DIP implements regional total budget management, and follows the principle of "determining revenue and expenditure, balancing revenue and expenditure, and having a slight surplus", and comprehensively determines the total regional DRG/DIP budget for the current year based on a series of indicators compiled by the fund. There is no longer a separate total quota for each medical institution, and the autonomy of medical institutions in the development of medical institutions is fully respected. The medical insurance department no longer "shares the cake", but acts as a rule-maker and order manager, guiding medical institutions to attract insured people to seek medical treatment through superb technology, high-quality service and reasonable expenses, so that all types of medical institutions at all levels can find their respective functional positioning and compete in a fair and orderly manner under the regional total budget. In addition, a certain proportion (about 5%) of risk adjustment funds will be set aside in the total regional budget, and the "special funds" will be used for special situations such as special cases and overspending sharing.
It is necessary to avoid fragmentation of the regional total budget. Some co-ordination areas, on the basis of the large regional total budget, are divided into small regional total budgets according to factors such as the level of medical institutions, such as the classification of medical institutions into ABCD... Categories and so on, each category is separately delineated with a total budget. This fragmentation of the regional total budget seems to have a certain reason, but in fact it cannot withstand logical scrutiny, violates the "law of large numbers" and the principle of fairness and justice of the medical insurance fund, and may deviate the direction of payment method reform. For example, Class A medical institutions are generally large tertiary hospitals, Class C medical institutions are generally county-level hospitals, and Class C medical institutions (county hospitals) give full play to the functional positioning of "health gatekeepers" and "minor illnesses do not leave the county", and increase the number of common mild cases by improving technology and service levels, and reduce the number of mild cases admitted by Class A medical institutions (large tertiary hospitals), which should be a situation that the DRG/DIP reform is happy to see. However, because the total budget of the two types of AC regions has been determined in advance, it will cause the rate of Class C medical institutions (county hospitals) to decrease with the increase in the number of incoming cases, the payment standard for each case will also be reduced accordingly, the income will be reduced, and the enthusiasm for the admission of mild cases will be hit, which is contrary to the original intention of the reform of payment methods to guide the orderly sinking of medical resources.
(b)
In accordance with the principle of "determining expenditure by revenue", the budgets for employees and residents are prepared separately
There are two main methods for preparing the DRG/DIP fund budget: one is the growth rate multiplication, which takes the DRG/DIP payment fund expenditure of the previous year as the base, and then considers the growth rate of the medical insurance fund and other factors to formulate the DRG/DIP fund budget for the current year. The second is to subtract item by item, on the basis of determining the total budget of the medical insurance fund for the current year, deduct the fund budget for slow outpatient clinics and remote medical treatment, etc., and the remaining funds will be used as the DRG/DIP fund budget for the current year, and some residents in the overall planning area will adopt this method.
The difference between the two methods is mainly affected by the status of the fund: the employee medical insurance fund is abundant as a whole, and the growth rate multiplication method can accurately and objectively reflect the DRG/DIP medical demand of the year; The overall tension of the resident medical insurance fund can ensure that the total plate of the fund does not wear the bottom by subtraction, but it will cause the residents' DRG/DIP fund to be unequal to the actual demand, the payment standard and the actual medical expenses will deviate greatly, and the payment rate of medical institutions will be low, which is easy to cause medical institutions not to understand. The medical insurance department shall, in line with the principle of "revenue and expenditure, balance of revenue and expenditure, and slight surplus", scientifically and reasonably determine the DRG/DIP budget for employees and residents, and announce it to medical institutions in an appropriate form. For the rigid reduction of the budget of the DRG/DIP fund of residents' medical insurance, it is necessary to fully communicate and explain at the beginning of the year, strive for the understanding and support of medical institutions to the greatest extent, and avoid accumulating problems until the end of the year to inform them, and the two sides do not understand each other and "flip the table".
(c)
Do a good job in the rate (point value) budget to stabilize the expectations of medical institutions
The basic logic of the DRG/DIP prepayment system is to preset the payment standard for each disease and guide medical institutions to strengthen internal cost control with this goal. Payment standard = weight (score) of the disease group × coefficient × rate (point value). Disease group (species), weight (score) and coefficient are the three core elements of DRG/DIP payment, which belong to the constants in the payment standard formula, and should not be adjusted and changed in a payment year. The rate (point value) is a variable in the payment standard formula, which is closely related to the annual fund budget, etc. The medical insurance department shall determine the budget rate (point value) at the beginning of the year, and announce to the medical institution the DRG subdivision group plan or DIP disease catalog, weight (score), coefficient, rate (point value) and other index values, so as to stabilize the expectations of medical institutions.
Budget rate (point value) determination method: the medical insurance department estimates the current year's inpatient service volume (total weight/score), combined with the budget fund and the estimated total hospitalization cost, calculates the budget rate (point value), the formula is: budget rate (point value) = estimated total hospitalization cost / estimated total weight (score), and corrected according to the simulated payment, if the difference between the total cost of simulated payment DRG/DIP and the actual total cost of hospitalization is greater than 5%, the budget rate (point value) should be adjusted by adjusting the budget. If you do not need to change the version of the DRG grouper or adjust the DIP disease catalog, you can also directly use the liquidation rate (point value) of the previous year. With the maturity of the DRG/DIP payment system, the budget rate (point value) will tend to be stable.
2. Accurately understand the connotation of DRG/DIP monthly settlement
(a)
Settle expenses on a monthly basis and play a role in regulating and guiding the payment reform
According to the DRG/DIP payment rules, the medical insurance department shall timely complete the upload of the settlement list of the medical insurance fund, data quality control, case enrollment, communication feedback, and determination of payment results, and settle the expenses with the medical institutions on a monthly basis. There are 3 benefits to monthly billing:
The first is to make medical institutions truly feel the actual payment of DRG/DIP, which is transformed into the driving force to strengthen internal operation and management, and effectively standardize and guide medical behavior;
The second is to sort out all work links, continue to verify whether the business flow, information flow, and capital flow are smooth and connected, timely find and solve problems in data interoperability, medical record quality, etc., and continuously optimize and improve system functions such as DRG/DIP module and integration of industry and finance;
The third is to do a good job in process management, regularly analyze the impact of DRG/DIP payment on medical insurance funds, medical institutions, and insured, and continue to improve and improve the supporting measures for handling and management.
Avoid substituting monthly prepayments for monthly closing. Monthly pre-allocation and monthly settlement are two completely different concepts, monthly pre-allocation is a financial category, which is to allocate a certain amount of funds to medical institutions in advance to alleviate turnover difficulties, and has nothing to do with DRG/DIP payment, and other payment methods can also be pre-allocated. Monthly settlement is a business scope, which calculates the settlement amount according to the number of cases admitted by medical institutions and the enrollment of cases, and in accordance with the DRG/DIP payment rules.
(b)
Strengthen process management and keep the monthly rate (point value) relatively stable
Taking the budget rate (point value) as the monthly settlement rate (point value) and keeping it relatively stable for 12 months of a year can guide medical institutions to form reasonable expectations. It is also conducive to strengthening process management and monthly comparative analysis.
Frequent and excessive fluctuations in monthly (rate) point values should be avoided. On the basis of the total budget at the beginning of the year, some co-ordination areas allocate the budget amount and rate (point value) to each month, which is commonly known as "double insurance", which seems to strengthen the process management of the fund, but in essence, it misinterprets the DRG/DIP prepaid system (PPS) and process management, bringing obvious drawbacks. Monthly rate (point value) = Budget amount allocated to that month / Actual total service volume (total weight/point value). From the actual situation, the service volume of each month is not the same from year to year, and some of them even vary greatly; Months with a small budget allocation may have a larger actual amount of services, which results in a smaller rate (point value) for the month. Throughout the year, the rate (point value) between months and months has changed back and forth, and the difference between peak and low value has reached 20% or even higher, resulting in confusion of goals, and medical insurance departments and medical institutions cannot carry out normal process management.
(c)
Conduct regular operational analysis and reason with facts and figures
Conduct regular operational analysis based on monthly settlement data. The content related to medical institutions in the operation analysis report shall be disclosed and interpreted to help medical institutions identify shortcomings and weaknesses and improve the level of operation and management. Running an analysis can include:
1. The implementation of the DIP fund budget, through regular operation analysis, the medical insurance agency timely discovers the abnormal implementation of the budget progress and the large changes in the number of hospitalizations, etc., so as to correctly respond to and stabilize the expectations of medical institutions. If there is a certain change in the disease spectrum in the later stage of the epidemic and the number of inpatient cases increases significantly, the total regional budget can be appropriately increased under the premise that the support of the medical insurance fund is safe and controllable, so as to meet the needs of medical institutions for reasonable diagnosis and treatment.
2. The data quality of the settlement list, including the completeness of the medical insurance settlement list, the accuracy and consistency of the diagnostic and surgical operation codes, and the DRG/DIP enrollment rate.
3. Analysis of the causes of profit and loss, including the profit and loss of diseases, the profit and loss of medical institutions, benchmark values, etc., to provide reasonable suggestions for medical institutions to strengthen cost control.
4. Medical service capacity, including disease coverage, CMI value, proportion of third- and fourth-level surgeries, hospitalizations and other indicators.
5. The efficiency of medical services, including the cost consumption index, time consumption index, average hospitalization cost, average length of hospitalization, individual self-rate, personal burden and other indicators.
6. Medical code of conduct, including unplanned secondary hospitalization, low-standard admission, etc. Focus on monitoring the decomposition of hospitalization within 7 days, and patients who do not need to be hospitalized can be admitted to the hospital with low standards through outpatient treatment.
7. Expense review, the number of cases of violations such as high set grouping, transfer of hospitalization expenses, and decomposition of hospitalization, the proportion of each medical institution, and illegal deductions.
3. Accurately understand the connotation of DRG/DIP year-end liquidation
The year-end liquidation is the final link of the annual DRG/DIP payment work, and to do a good job in the year-end liquidation, firstly, it can ensure the safety of the fund, and ensure that the DRG/DIP budget fund is reasonably and fully allocated by adjusting the liquidation rate (point value), balance retention and reasonable overexpenditure sharing, etc., and give full play to the rigid constraints of the regional total budget at the beginning of the year; Second, it can ensure the reasonable demands of medical institutions, and special cases arising in the process of DRG/DIP payment can be reasonably handled through expert review, negotiation and negotiation at the end of the year.
(a)
Determine the liquidation rate (pip value)
At the end of the year, the liquidation rate (point value) is determined according to the same formula as at the beginning of the year according to the actual amount of services (total weight/score) incurred in the current year, and the DRG/DIP fund paid to medical institutions is recalculated based on the clearing rate (point value).
Compared with the budget rate (point value), the year-end liquidation rate (point value) should be a slight adjustment of the value, and if there is a large difference, the reasons should be analyzed and properly handled. If the volume of medical services increases reasonably, the fund budget may be increased in accordance with the prescribed procedures to ensure reasonable medical services. If the liquidation rate (point value) is significantly reduced due to factors such as the shortage of resident medical insurance funds, the relevant situation should be communicated and explained to the medical institutions, and the understanding and support should be sought to the greatest extent, and the budget rate (point value) of the resident medical insurance DRG/DIP should be reasonably reduced in the coming year, and the expectations of the medical institutions should be lowered.
(b)
Do a good job of sharing overspending and retaining surpluses
The balance retention mechanism is an important part of the DRG/DIP incentive and restraint mechanism, and the medical insurance department can create a good atmosphere for reform and win the support of medical institutions for the reform to the greatest extent by cashing out the balance retention fund according to the agreement. The overexpenditure sharing mechanism, which shares the overexpenditure costs incurred by medical institutions due to the lack of adaptation to the DRG/DIP reform, can play a certain role in "fault tolerance" in the early stage of reform.
In order to give full play to the incentive and restraint role of DRG/DIP reform, the upper limit of the proportion can be set on the basis of the principle of "surplus retention and reasonable overexpenditure sharing". Setting an upper limit on the overall surplus retention ratio of medical institutions can prevent medical institutions from excessively pursuing surplus and reducing the quality of medical services. Setting an upper limit on the proportion of medical insurance fund contribution for overspending expenses of medical institutions can avoid excessive sharing affecting the safety of medical insurance funds.
(c)
Do a good job in handling special cases
In the process of diagnosis and treatment, medical institutions will produce special cases due to the diagnosis and treatment of difficult and critical diseases, emergency rescue, and rational use of new drugs and technologies, and the cost of special cases is quite different from the payment standard of the disease group (species). Special cases usually cannot be dealt with in a timely manner in the monthly settlement, and experts can be organized to conduct a centralized review at the end of the year, and if the review is passed, the annual adjustment fund will be used to make reasonable compensation.
Special cases are generally divided into two situations: special cases and special cases of single negotiation and payment except for new technologies. The first is the special case of single discussion, which is mainly due to the overall overspending of the overall cost of the case due to the admission and treatment of difficult and critical cases and emergency rescue, and the reason for the overexpenditure involves all aspects of the drugs, medical service items and medical consumables used by the patients. The emphasis is on "one case and one discussion", focusing on the overall compensation of the total cost, focusing on the absorption of critical care medicine and other professional review experts. If the review is passed, the total cost of the case is to be compensated for the part that exceeds the payment standard. Second, the new technology is excluded from the payment, mainly due to the high cost of the new technology caused by the cost of overrun, the reason for the overrun has a single direction, focusing on the clinically necessary, safe and effective, high price of new medical technology (including drugs, medical consumables), emphasizing the "one category, one discussion", focusing on the targeted compensation of the new technology, focusing on the absorption of new technology related clinical professional review experts. If the review is passed, the cost of the new medical technology of the case shall be compensated.
In terms of compensation for special cases, payment by project can be used for compensation, or it can be converted into weighted (score) compensation; In terms of the degree of compensation, it can be compensated in full or in a certain proportion depending on the fund's replenishment.
(iv)
The remaining funds can be redistributed
Liquidation of remaining funds means that after the liquidation of the above links, there is still a surplus in the DRG/DIP budget fund, which can be paid again by adjusting the rate (point value) and so on to ensure the full distribution of the DIP budget fund. Focus on handling the relationship between year-end liquidation and expense review, and complete the DRG/DIP expense review before year-end liquidation. The audit deduction belongs to the available funds of the total DRG/DIP regional budget of the current year, and the audit deduction funds can be re-injected into the DRG/DIP fund pool of the current year at the year-end liquidation, and the compliance cases will be redistributed. This not only effectively revitalizes medical insurance funds but also improves the efficiency of the use of budget funds; There are also sufficient funds to respond to the reasonable demands of medical institutions in special cases, and effectively solve the problem of "urgency" of medical institutions; It can also motivate medical institutions to take the initiative to carry out internal compliance management, forming an endogenous motivation for everyone to supervise violations.
Author | Zhang Zhiyong, Shandong Provincial Medical Insurance Center
Source | China Medical Insurance
Edit | Cui Xiujuan Gao Pengfei
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