Medical Insurance Payment "DRG Era" Gradual Progress, Supporting Measures Need To Be Improved.

"When we pay for the DRG payment (according to the disease diagnosis related group payment), we should see the favorable part, and also consider the possible negative effects. We should prevent such negative effects very early." Recently, Shao Xiaojun, a visiting professor at the University of Rosenheim in Munich, Germany, said in an interview with an economic reporter in twenty-first Century.

With the issuance of DRG payment and related policies in 30 provinces and municipalities across the country, the heat of DRG payment has been rising and the degree of concern has gradually increased. Recently, as one of the 30 pilot cities in DRG, 74 medical institutions in Wuhan have been identified as the first batch of national DRG payment pilot units.

However, Shao Xiaojun pointed out that China must do the corresponding supporting measures in promoting DRG, including ensuring the level of medical services and the quality of drug use. It also needs to learn from the experience of other countries. There are some problems to be avoided in the implementation of DRG, such as neglect of the quality of nursing services.

Guo Qiyong, chief expert of Neusoft Wang Hai and President of product and data research institute, pointed out to the twenty-first Century economic report reporter that the DRG payment in China is aimed at achieving the two objectives of medical cost control and grading treatment. "The standard of each province is different, and the pace of advance is not consistent. But as a country's overall policy and strategy, the payment mode of DRG will be the main payment mode for the development of medical insurance in the next 3-5 years in China."

At the same time, Guo Qiyong also stressed that doctors do not want to use "DRG thinking" to see a doctor, doctors still need to focus on patients. "The future promotion of DRG payment method, when considering the cost control, is also indispensable for medical quality and service guarantee."

Simulated operation in 2020

In June 5th, the national health insurance agency issued the notice on the list of national pilot cities according to the diagnostic group of diseases, calling for speeding up the pilot work of the national payment group for disease diagnosis related group (DRG), and identifying 30 cities as the pilot cities for DRG payment.

Under the unified leadership of the national DRG payment pilot working group, the 30 cities should follow the three steps of "top level design, simulation test and actual payment" to ensure the completion of the tasks at all stages, ensure the simulated operation in 2020, and start the actual payment in 2021.

DRG is a case mix program in the world. It is a group of disease diagnosis. According to the principle of grouping, it is divided into a series of disease groups according to the similarity of disease diagnosis, age, complication, concurrent disease principle and tens of thousands of diagnoses.

Neusoft's CEO segment, Cheng Hai, told the twenty-first Century economic analysis reporter that medical institutions will try to raise the level of diagnosis and treatment and avoid excessive medical treatment under the pressure of a certain amount of payment quota. In the same price and the same illness, how to reduce the cost while ensuring the quality of the hospital, doctors need to constantly seek the best surgical nursing care plan and medication plan.

"Big hospitals have siphon effects on resources and patients. However, since the beginning of this year, the national health and Health Committee has emphasized the development of primary hospitals and the development of county hospitals and medical communities. In addition, the effect of the pilot implementation of DRG has seen a marked increase in the number of visits to primary hospitals. Taking Yuxi as an example, we can see clearly the promotion of DRG payment reform to grading diagnosis and treatment. When large hospitals encounter some common diseases and basic diseases, they will measure and calculate expenditures and costs. If they fail to make payments, they will recommend diverting them to county hospitals or community hospitals, and even cooperate with experts in sinking consultations. Although the volume of business in large hospitals has decreased, it has focused on disease groups with higher degree of difficulty and income has not decreased. At the same time, the number of common diseases and basic diseases in county hospitals increased. Duan Cheng Hui gave an example to the twenty-first Century economic news reporter.

Duan Chenghui believes that DRG is essentially a payment tool, and the payment is based on the rate of payment. The basis of the rate comes from the cost of the real medical service. DRG's payment has obvious value medical characteristics. The so-called value medical service refers to the completion of disease diagnosis and treatment with appropriate means at a certain cost.

Matching actions need to be matched.

Although DRG was first promoted abroad, China has tried in recent years. At present, there are 4 mainstream versions in the Chinese market, namely, the BJ-DRG of the Beijing Medical Insurance Association, the CN-DRG of the National Health Protection Committee, the medical and health authority, and the Beijing Health Committee Information Center, the CR-DRG of the National Health Protection Commission's grass-roots health division, and the C-DRG of the National Health Development Commission's health development research center, which are applied to different scenarios and objectives respectively.

In October 23rd, the national health insurance agency issued a notice on the technical specification and grouping scheme of the national panel on the diagnosis and distribution of disease diagnosis (DRG), which includes 2019 medical care institutions No. 36, including the national medical insurance DRG grouping and payment technology specification and the national health care DRG (CHS-DRG) grouping scheme.

According to the circular, the pilot cities should carry out relevant work in accordance with the unified technical specification and grouping plan, and create a "chess game" in the pilot, so as to accurately localize the CHS-DRG so as to become the "universal language" in the field of national health insurance.

In the view of Duan Cheng Hui, the above versions are also "suit measures to local conditions". Our country will not set up a set of DRG rate standard to pay for details, but it should be localized. This localization is not just a province, even to the city level, there should be a dynamic rate standard based on the classification of country groups. "Since China's social security financing has always been a city unit, this will facilitate the localization of DRG payments. Until every city has its own rate standard to achieve the same price in the city. This is the symbol of DRG's final maturity.

In this regard, Guo Qiyong also expressed his agreement and pointed out that the actual situation is different in all provinces and municipalities, and the standards are different. "The Beijing medical insurance system was first implemented by DRG, and is now being promoted throughout the country. However, it is impossible for DRG to cover all the disease payment patterns. DRG must be a common disease. There is a certain proportion of DRG to manage it. The provinces and cities are uneven, some cities are making progress faster, and some cities are slower."

Shao Xiaojun also emphasized that in the promotion of DRG, we should do a good job in supporting work. In the development process of DRG, the whole top-level design is very important. DRG is not only a matter of medical insurance, but a system developed jointly by Wei Jian, the whole medical system and our payment side, so that we can effectively promote and protect the quality of medical care. At the same time, we need to borrow the experience of Germany and other countries to prevent the negative effects of DRG promotion process.

It is understood that there are some typical negative effects in the promotion of DRG in Germany and other countries. As many hospitals choose to reduce costs due to fixed payment and allow patients to leave hospital ahead of schedule, patients are still not cured. They will still have medical expenses and even re hospitalization. The package of nursing services to the DRG payment operation will directly lead to a decline in the quality of care.

The view reached by the industry is that we need to do a good job of DRG matching from various angles such as informatization, and do fine management. Duan Cheng Hui pointed out to the twenty-first Century economic news reporter that DRG will focus on the control of service capabilities, quality, efficiency, safety and medical expenses, but in this process, information technology is particularly important.

"At the stage of data collection, the checklist, the interconnection and exchange of information on the front page of medical records, the accusation, detection, inspection and feedback of medical data, and the transformation of related systems. In the process of DRG grouping, the maintenance and management of our subdivision groups and the grouping services of DRG are also realized through the analysis of big data through the means of informatization. When the payment standard is calculated, the weight rate and simulation calculation, the display and verification of data, and the publicity of the results in different rounds of negotiations are also achieved through informatization. Even in the aspect of supervision and evaluation, the construction of some information platforms for intelligent supervision in many areas requires the improvement of information tools.

Duan Chenghui pointed out that through the whole system design of medical insurance DRG and the specific links of the technology, information is inevitable at present, and it can help the smooth implementation of the whole DRG payment of medical insurance. At the same time, it can provide more technical means and help for DRG payment, including the fine management of medical insurance and the meticulous management of hospitals.