The DRG payment method has changed the traditional pay-by-project model to pay-by-disease, which helps to motivate medical institutions to improve service quality and promote the rational allocation of medical resources. In mainland China, the reform of DRG payment methods has become a focus of deepening the reform of the medical insurance system. Especially in secondary care institutions, the implementation of this payment system has a profound impact on optimizing the operational strategy of medical institutions, improving the quality of medical services, and improving the medical experience of patients.
Taking the First Affiliated Hospital of Jiangxi Medical College (hereinafter referred to as the First Affiliated Hospital) as an example, this paper discusses how secondary hospitals should adjust their operation strategies to adapt to the new medical insurance payment system and improve the operational efficiency and medical service quality of the institutions under the DRG payment reform.
The First Affiliated Hospital is a public second-class general hospital with outstanding specialty characteristics and operates in accordance with the model of large specialty and small comprehensive. At present, there are 260 beds and 365 beds are actually open; It has 22 clinical departments and 10 medical technology departments. In 2022, the hospital provided 201658 outpatient services and 9,242 discharges. As a second-level general hospital, the volume is not large, the types of diseases are not abundant, and most of the disease groups have no obvious advantages in the weight rate. Therefore, how to steadily promote the implementation of DRG payment reform in accordance with the deployment and requirements of the medical insurance department has become a new challenge.
Based on the situation of the hospital, the First Affiliated Hospital has established a multi-department linkage and cooperation mechanism for medical insurance, information, medical records, quality control, medical affairs, medicine and equipment in the hospital in accordance with the guiding ideology of "changing concepts, building mechanisms, promoting linkage, and seeking practical results", so as to form a work situation with clear responsibilities and rights and joint management, and ensure the steady progress of the hospital's DRG payment reform.
Main practices
The First Affiliated Hospital is one of the first batch of DRG payment reform pilot hospitals in Shangrao City, which entered the DRG simulation payment pilot on August 1, 2021, and officially implemented DRG payment since January 2022. The management of the hospital attaches great importance to the DRG payment reform, and has promoted a series of work since the pilot operation.
The first is to strengthen organizational safeguards. As a new type of medical insurance payment method, the effective implementation of DRG payment is inseparable from a strong organizational guarantee. To this end, the hospital first set up a leading group headed by the president to ensure that the reform direction is correct and the policy implementation is strong. The leading group has a special working group, composed of heads of medical, nursing, finance, information and other relevant departments, which is specifically responsible for the daily management and coordination of DRG payment.
In the simulated payment stage, the hospital also set up a cost calculation team and a group demonstration group. The cost estimation team is mainly responsible for the preliminary calculation of the cost after the DRG grouping according to the historical data, and provides reference for the subsequent payment standard formulation. The group demonstration group is mainly responsible for the demonstration of the disease grouping to ensure the scientificity and rationality of the grouping. The two teams worked closely together to support the DRG's paid simulation.
After entering the payment stage, the linkage communication between the hospital's medical insurance, medical records, information and other departments is particularly important. The First Affiliated Hospital refines the responsibilities of each department, clarifies the communication process, and ensures the smooth flow of information and accurate data. Among them, the medical insurance department is responsible for docking with the higher-level medical insurance institutions to ensure the smooth implementation of the payment policy; The medical records department is responsible for the sorting and archiving of medical records, and provides accurate data support for payment; The information department is responsible for the development and maintenance of the system to ensure the information operation of DRG payment; The medical department is responsible for ensuring the quality of medical services and reducing the cost of diagnosis and treatment; The nursing department pays attention to the care needs of patients and improves the efficiency of care; The finance department is responsible for the financial accounting and supervision of DRG payments to ensure the compliance of the use of funds. While clarifying the responsibilities of each department, the hospital DRG reform leading group has established a DRG payment supervision and assessment mechanism to track and supervise and evaluate the implementation process.
The second is to carry out multiple rounds of publicity and training. First of all, through warm-up publicity, we should dispel the mentality of "confusion", overcome the psychology of "fear", eliminate the expectation of "set", and strengthen the awareness of "compliance". For the relevant policy documents, the hospital carried out propaganda and interpretation at different levels, so that the staff of the hospital could deeply understand the inevitability and necessity of the DRG payment reform, and enhance the consciousness of taking the initiative to participate in the reform. Secondly, the method of "inviting external experts + internal training" was adopted to carry out special training such as "Writing Specifications and Whole Process Quality Control of Medical Records on the Home Page", "Classification of Diseases and Surgical Operations and Disease Coding and DRG Application", and "Introduction to DRG Grouping Rules" to improve the ability of clinicians to write medical records. It is determined that the third-party software system will not be used for the time being, so as to eliminate the expectation of clinicians' "code sets", promote the interaction between clinical and medical records, and gradually develop good medical record writing habits. Finally, on the basis of sorting out the medical insurance policy, the members of the leading group went deep into various clinical departments to learn together with clinical medical staff, and forwarded cases of fund supervision violations through the working group from time to time, carried out warning education, and strengthened compliance awareness.
The third is to make good use of the scientific research strength of colleges and universities to promote reform. Data analytics plays a crucial role in the DRG payment reform process. Through in-depth mining and analysis of data, hospitals can more accurately grasp the operation of DRG payment, and provide a scientific basis for adjusting and optimizing payment strategies. In the process of DRG payment, the hospital closely combines medical practice, teaching and training and scientific research to form a strong synergy of data analysis. Data in medical practice is the basis of DRG payment analysis, and hospitals can provide strong support for the formulation and adjustment of payment standards by collecting and analyzing clinical data to understand the disease characteristics, treatment process and cost of different DRG groups. At the same time, through the introduction of statistics, data science and other related courses, the understanding and mastery of data analysis methods and tools by medical staff will be strengthened.
The fourth is to ensure the quality of the first page of the medical record. Under the DRG payment model, the quality of the medical record homepage is directly related to the accuracy of DRG grouping and the fairness of payment. Therefore, it is crucial to ensure the completeness, timeliness, accuracy and standardization of the first page of the medical record. In order to ensure the quality of the first page of medical records, the hospital has taken a number of measures.
Firstly, a detailed workflow for homepage upload and quality control of CHS-DRG was developed. The process stipulates that the staff of the medical record room is responsible for collecting the patient's medical record information and conducting preliminary collation to ensure the integrity of the medical record information and avoid missing key information. Secondly, provide doctors with guidance on filling in the information on the home page of the medical record, clarify the requirements and specifications for filling, and ensure that the doctor can accurately and completely fill in the information on the home page. Thirdly, a special review link was set up to review the first page of the medical record one by one. The content of the review includes but is not limited to the basic information of the patient, diagnostic information, surgical operation information, etc., to ensure the accuracy of the information on the homepage. After the review is passed, the information on the home page of the medical record is uploaded to the hospital information system to ensure the timeliness and traceability of the information. Finally, the quality control evaluation of the information on the first page of the medical record is regularly evaluated, and the problems found are fed back to the relevant departments and doctors in a timely manner, and they are urged to rectify in accordance with the "four characteristics" requirements of completeness, timeliness, accuracy, and standardization.
Fifth, strengthen information technology support. Information technology can not only improve the efficiency of data processing, but also ensure data quality and security, and provide a solid technical guarantee for DRG payment. The hospital has formulated a DRG data transmission management workflow, and completed the comprehensive upgrade of the information system and the transformation of the corresponding interface on schedule to ensure the standardization, completeness, accuracy and timeliness of the uploaded information. Improve the construction of the underlying medical fee directory database of HIS, complete the update and coding verification of the charging dictionary database of drugs, consumables and diagnosis and treatment items in April 2021, and do a good job of dynamic maintenance according to the latest catalog issued in the past two years. With the continuous development of medical technology and the in-depth advancement of DRG payment reform, information systems need to constantly adapt to new needs and challenges. To this end, the hospital regularly evaluates the performance and functionality of the information system, optimizes and upgrades it in a timely manner to ensure that it can always meet the needs of DRG payments. DRG payment involves a large amount of sensitive data, such as patient personal information, disease diagnosis, etc. As a result, the hospital has implemented strict data encryption, access control, and auditing measures to ensure that data is not illegally obtained or misused.
Sixth, strengthen the supervision and assessment of medical behavior. Medical affairs and quality control take the "three reasonables" as the starting point, and strengthen the supervision and assessment of medical behavior. The quality control department publishes a monthly quality control report to report the medical quality control situation and DRG operation data. The rational drug use system was launched, and the clinical drug use was further standardized through various special reviews, medical records, and doctor's order review. At the same time, establish an annual score card management system for the rational use of drugs by clinicians.
Seventh, strengthen the coordination and communication of the medical insurance department. First of all, the medical insurance department, as the leading department of the DRG payment reform of the hospital, has formulated a detailed implementation plan and operating procedures, clarified the responsibilities and tasks of each department within the hospital, and ensured that the DRG payment reform is carried out in an orderly manner within the hospital. Second, build a communication platform. Internally, to ensure the smooth flow of information between various departments of the hospital, through regular coordination meetings, the establishment of information sharing mechanisms, etc., to understand the difficulties and problems encountered by each department in the implementation of DRG payment, and to give timely guidance and help. Externally, the medical insurance department actively strengthens communication and coordination with the medical insurance department, timely feedback to the medical insurance department on the problems and suggestions encountered by the hospital in the implementation of DRG payment, strives for policy support, and actively cooperates with the medical insurance department to carry out the review and settlement of DRG payment to ensure smooth communication between the hospital and the medical insurance department. Finally, the Health Insurance Department focuses on communication with patients. Through health education and setting up consultation windows, we will publicize the relevant knowledge of DRG payment reform to patients, answer the questions of the masses, improve the public's awareness and satisfaction with the DRG payment reform, and create a good social atmosphere for the smooth progress of the reform. In the process of communication and coordination, the medical insurance department pays attention to collecting and sorting out feedback from all aspects, and carefully analyzes and studies these opinions, finds out the root causes and solutions of problems, and continuously improves and optimizes the DRG payment process and mechanism.
Initial results and results
A total of 15,168 cases were included in this study in 2022 and 2023, including 6,558 cases in 2022, 1,619 cases (24.69%) were included in employee medical insurance, and 4,939 cases were included in resident medical insurance, accounting for 75.31%; In 2023, there will be 8,610 cases, including 1,907 cases of employee medical insurance, accounting for 22.15%, and 6,703 cases of resident medical insurance, accounting for 77.85%.
Let's start with the results of the DRG indicator. In 2023, there will be 8,610 inpatient cases in the hospital, 306 DRG groups, 8,670.11 DRG, 1.01 CMI, 0.97 time index, 1.02 expense index, and 2 RW ≥ cases, accounting for 2.92%. Compared with 2022, the number of cases increased by 23.88% year-on-year, the number of groups decreased by 2.29% year-on-year, the total weight of DRG increased by 24.41% year-on-year, CMI increased by 2.97% year-on-year, the time index decreased by 3.09% year-on-year, the expense index decreased by 8.82% year-on-year, and the number of RW≥2 cases increased by 5.48% year-on-year (see Table 1).
Then look at the results of the top 10 DRG indicators in the DRG grouping order. In 2023, the top three DRG groups are lens surgery, vitreous, retina, choroidal surgery, cornea, sclera, and conjunctival surgery. Compared to 2022, the order is unchanged. Except for CC19, BX29 and NE19, the time consumption index was lower than that before the reform. Except for CJ19 and BX29, the cost consumption index is smaller than before the reform (see Table 2).
Experience and think
First, the DRG payment reform will help promote the refined management of secondary hospitals. DRG payment is a mechanism that combines both incentives and constraints. Constraints, that is, to promote secondary hospitals to diagnose and treat patients more accurately, so as to reduce medical costs, reduce or avoid waste of medical resources, improve the quality and efficiency of medical services, and thus increase the economic benefits of hospitals. Incentive, that is, to motivate secondary hospitals to strengthen internal management and cost accounting, continuously improve the quality of medical services and the competitiveness of hospitals, and ensure the completeness and accuracy of the information on the first page of medical records. The reform practice of the First Affiliated Hospital proves that in 2023 compared with 2022, with the increase of the total weight of DRG, the time consumption index and cost consumption index and other indicators will decrease year-on-year, indicating that the DRG reform has played a promoting role in strengthening internal management and reasonably controlling medical costs in secondary hospitals. With the deepening of DRG reform, the level of refined management, medical technology and quality, and even the overall competitiveness of secondary hospitals will continue to improve.
The quality of a hospital's services has a direct impact on patient satisfaction and the hospital's reputation. Secondary hospitals need to continuously improve the quality of services to meet the needs of patients and improve the competitiveness of hospitals. The DRG payment reform has brought many benefits and development opportunities to the operation of secondary hospitals, including enhancing the motivation for refined management, controlling medical costs, promoting collaboration with higher-level medical institutions, and enhancing competitiveness. These favorable opportunities will help secondary hospitals maintain a steady development trend in the fierce competition in the medical market.
Second, the DRG payment reform will help secondary hospitals adjust their operational strategies and expand their development space. Secondary hospitals should adjust their income structure, reduce the proportion of income from drugs and examinations, carry out health management and chronic disease management, broaden service areas, and increase revenue sources. Hospitals should establish a sound cost control system to reduce medical costs through reasonable procurement, reduce inventory, and improve equipment utilization efficiency, especially to actively participate in the reform of centralized procurement of drug consumables carried out by national organizations and inter-provincial alliances. At the same time, strengthen internal management, reduce unnecessary waste and loss, and improve the efficiency of resource utilization.
Third, the DRG payment reform will help secondary hospitals improve service quality and market competitiveness. The key factor why the First Affiliated Hospital has achieved a year-on-year reduction in time consumption and cost consumption in the DRG reform is that the hospital has a high-level medical team. This also reveals that in order to achieve greater and better development in medical insurance reforms such as DRG payment, secondary hospitals must improve the diagnosis and treatment level of doctors and attract people with high-level diagnosis and treatment, so as to expand the development space of hospitals. At the same time, secondary hospitals should establish a scientific performance appraisal mechanism to conduct a comprehensive assessment of doctors' diagnosis and treatment behavior, medical quality, cost control, etc. Through performance appraisal, doctors are encouraged to actively participate in the DRG payment reform and improve the operational efficiency and quality of medical services in hospitals. At the same time, secondary hospitals should strengthen the construction of informatization, use informatization means to improve management efficiency and medical quality, and realize the sharing and optimal allocation of medical resources through the construction of electronic medical record systems and remote consultation systems. （ZGYB-2024.06）
Original title: Research on the operation strategy of secondary hospitals under the DRG payment reform
Author | Liu Yiwen, Yu Dequan, Ye Jin, Yao Ping, Jiangxi Medical College, Shangrao Medical Insurance Service Center, The First Affiliated Hospital of Jiangxi Medical College
Source | China Medical Insurance
Edit | Liu Ying buys Xiaofei
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