On The Eve Of Drgs "Mock Test": The Number Of Inpatients Split Up In Large Hospitals Needs To Be Strengthened

Recently, the audit work report on the provincial budget implementation and other fiscal revenues and expenditures of Sichuan Province in 2019 released by the Audit Department of Sichuan Province disclosed the audit situation of some public hospitals and medical insurance funds. The conclusion is that the effect of fee control policy is not obvious, and the management of medical insurance fund is relatively weak.

According to the report, the audit department organized the audit of 11 tertiary public hospitals and the medical insurance funds of the provincial level and two cities, and extended the investigation to 34 hospitals. Among them, the problem of illegal overcharging was still common. The extension found that 20 hospitals split a hospitalization into multiple times in order to avoid the control standard of medical expenses and length of stay of inpatients.

In the view of Xu Yucai, a senior person in the industry who has been paying close attention to the medical reform, the most important and effective way is to promote the reform of medical insurance payment mode. In particular, the general office of the State Council proposed that "by 2020, the reform of medical insurance payment mode will cover all medical institutions and medical services, and the diversified and compound medical insurance payment methods adapted to different diseases and different service characteristics will be implemented throughout the country It's time to pay the bill. In the reform of DRS, we should pay by disease initiative, pay by disease and so on.

2020 is the national pilot simulation test year of disease diagnosis related group payment. More than 30 pilot cities of DRGs national payment have been determined in China. It is expected that the country will be in full swing by 2021. In the view of industry insiders, this new medical insurance payment method will open a new round of game between medical insurance payment and hospital interests, and will also change the development pattern of the pharmaceutical industry.

Simulation of DRGs

The Audit Office of Sichuan Province pointed out that after the implementation of the "two vote system" and "zero price increase" policy, 41.71% of the drug sales prices of the hospitals reviewed had not decreased in 2017. The problem of illegal overcharging is still common. It is found that 20 hospitals split a hospitalization into multiple times in order to avoid the control standard of medical expenses and length of stay of inpatients. In addition, the management of medical insurance fund is still weak. There is a lack of comparison and analysis mechanism for the insured data, and the function of the medical insurance intelligent audit system is not perfect. Spot check shows that there are 11000 repeated insured persons, 140000 false increase insured persons, and 4.518 million yuan of reimbursement expenses for expanding the scope.

Why do a series of policies promote the above phenomenon?

Xu Yucai believes that the two ticket system can artificially reduce the circulation links, but it does not necessarily reduce the circulation costs, because many rigid expenditures in the circulation will not decrease with the decrease of the number of invoices, and it is possible to change the "low opening and high moving" into the "high opening and high walking"; by canceling the drug mark up, the drug bonus income of medical institutions will be lost, but the pharmaceutical interest chain has not been cut off The income problem of hospitals and doctors remains unresolved.

"In terms of medical insurance supervision, the state has made every effort not only to pay attention to fund supervision, but also to the reform of payment methods. However, because many reform policies have not been implemented effectively, local medical insurance departments still follow the traditional per capita cost control mode. In particular, some places mechanically limit the number of days for each hospitalization and the interval between two hospitalization These very specific figures are taken as cost control measures in a few days. Therefore, medical institutions break down hospitalization Xu Yucai pointed out.

Xu Yucai believes that the scientific and effective cost control method is not "two vote system" and "zero price increase", nor strict supervision, but actively promote the reform of medical insurance payment system, especially the payment mode reform such as payment by disease type and payment by disease diagnosis related groups, so as to really exert the subjective initiative of medical institutions in cost control.

On June 18, the State Medical Security Bureau issued the notice of the office of the State Medical Security Bureau on printing and distributing the subdivision scheme of chs-drg (version 1.0), marking the real arrival of the era of DRGs, involving indexes such as the head ratio of inpatients, the average cost of outpatient and residential visits, etc.

For example, the head ratio of inpatients is decomposed after monitoring DRGs. The medical insurance management department conducts a longitudinal comparative analysis on the head ratio of inpatients in each medical institution in this year and the head ratio of inpatients reported in the previous three years, and makes a horizontal comparative analysis on the head ratio of inpatients in each medical institution and the same type of medical institution at the same level in the district. If the data is abnormal, the medical insurance will be listed as the key concern, and the medical insurance management department will check the abnormal data.

Multi party game

Wang Lili, a member of the national technical guidance group and researcher of the National People's Congress HTA and medical policy research center, told the 21st century economic reporter at a recent online meeting that various measures should be taken to ensure the implementation of DRGs in the future.

"The first step, each place first uses the local historical data to carry on the simulation test. The second step is to control the quality of basic data, to ensure the quality of relevant data sources, especially the quality control of medical records, so as to ensure the authenticity, accuracy and traceability of various indicators in the settlement list of medical insurance fund. The third step is to actively promote the pilot work of GDRs. " Wang Lili said.

According to Professor Guo Qiyong, chief expert of Wanghai Kangxin and President of the Research Institute, the change of payment mode will lead to butterfly effect. DRGs will change the diagnosis and treatment mode of doctors, the management mode of hospitals, and the medical treatment mode of patients. The interests of all parties will also be re gambling.

Duan Chenghui, founder and CEO of Wanghai Kangxin, told reporters that the rule changes brought about by the implementation of DRGs make hospitals return to medical services themselves, and hospitals must care about costs and medical resource allocation. In a limited and reasonable use of resources, how to mobilize the cooperation and transformation of doctors, change the management thinking of the hospital has become the primary problem. "In the past 20 or 30 years in the industry, hospitals have been used to earning as long as there are prescriptions and orders. However, after the implementation of DRGs, the doctor's prescription, including the materials used for inspection and medication, will be the cost of the hospital. "

However, it is understood that the DRGs pilot project has been disputed by some hospitals and doctors since it was launched. At the same time, due to the imperfections of DRGs itself, some hospitals reflect that the system also affects its normal operation.

For example, the director of a tertiary hospital said at an online industry exchange meeting that the filling in of cases has caused great trouble to doctors. The staff of information department do not understand medical treatment, and doctors also spend a lot of time to fill in medical records. At the same time, as a basis for payment, no one will spend time reading thick course records, but only obtain key information on the front page of medical records, but it is often very difficult The front page of multiple cases can not reflect the real situation of doctors, which also directly affects the assessment of doctors.

Jin Chunlin, director of the Shanghai Health and health development research center, pointed out that from the perspective of medical business model, the former tendency was to provide more services, and "excessive medical treatment" was relatively common. After DRGs, it may turn into "too little service" due to cost pressure. In the case of appendicitis surgery under the prepayment system, if the patient with complicated appendicitis is encountered, the first thing the hospital thinks of is to refer to the superior or other hospitals as far as possible. In addition, appendicitis patients may be divided into more serious disease groups if this patient is taken over. Finally, in the actual process of appendicitis treatment, hospitals may avoid expensive medical services and shorten the length of stay as far as possible.

"Under the pressure of DRGs cost control, all these will lead to the decline of medical service quality. In the current situation, there are not enough resources to supervise these situations. Therefore, if DRGs are implemented, there may be a run in period, during which the interests of a small number of patients may be sacrificed. " Jin Chunlin pointed out.

In addition to the huge impact on hospitals, the wings of DRGs butterflies will also affect the pharmaceutical industry.

Guo Qiyong pointed out to 21st century economic reporter that DRGs payment reform will also promote hierarchical diagnosis and treatment. The hospital director at the county level said that they would pay more attention to the above-mentioned three-level hospitals for serious diseases. This will also directly affect the suppliers of drugs and medical consumables, and the gold sales space of drugs and medical consumables will be greatly compressed.

In addition, DRGs mainly include common diseases, frequently occurring diseases and some major diseases, which will promote medical institutions and doctors to use mature products with high cost performance. Therefore, it will be more advantageous for the new drugs to catch up with the DRGs grouping reference standard and enter the medical insurance as soon as possible.

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