At present, the medical expenses of patients in China are paid according to the service items. In recent years, the reform and exploration of medical expenses payment methods have gradually formed a composite payment system in some areas, which focuses on service items, supplemented by single disease quota, service unit quota and total control payment, and patients with special chronic diseases pay according to head quota.
The national reform goal advocates the implementation of multiple compound payment methods;
Generally speaking, payment by disease is mainly implemented, and payment by disease is implemented for diseases with clear diagnosis and treatment plan, admission standard and mature diagnosis and treatment technology. At the same time, carry out the pilot work of DRGs payment and actively explore the establishment of DRGs payment system.
Second, the general situation of DRGs
DRGs are related groups of disease diagnosis. According to the patient's medical record, refer to the relevant medical grouping elements (main diagnosis after discharge, complications or complications, major surgery, etc.). ), according to ICD- 10 disease diagnosis code and ICD-9-CM operation code, cases with similar clinical diagnosis operation and resource consumption are divided into the same group, and the codes of relevant groups are compiled to determine the payment standards of each group.
DRGs paid patient settlement process
(A) grouping principle
According to the severity of the disease+the complexity of the operation+the degree of resource consumption.
(2) Grouping rules
(1) Clinical similarity: severity of disease and complexity of operation;
(2) similarity of resource consumption;
(3) Appropriate number of groups (DRGs number).
(3) Relative weight
After scoring all diseases according to diagnostic DRGs, each disease has a score, which is a relative number, that is, the relative weight of DRGs.
Medical insurance payment and hospital charges simultaneously promote DRGs:DRGs payment amount = relative weight x flat rate. As shown in the following table:
Three. Principles and objectives of implementing DRGs
On the basis of the reform of medical price system, it is the best scheme for China's medical and health system to get rid of the current predicament by implementing a comprehensive package payment for inpatients with DRGs as the main payment method and the synchronous linkage reform of outpatient and community medical service payment, changing the medical service from post-payment system to pre-payment system and establishing the operation and compensation mechanism.
(a) the integration of revenue and expenditure, so that the majority of patients benefit.
At present, China's medical insurance system can only control the total medical expenses within the scope of the medical insurance catalogue. The expenses outside the public medical care, commercial insurance and medical expenses paid by patients at their own expense are not within the scope of the medical insurance catalogue, nor are they within the control scope of the medical insurance payment reform costs.
According to the reform of payment mode of DRGs, the problems of hospitalization expenses, medical insurance payment and patient payment should be considered as a whole, so that patients can determine their own conditions and diagnosis and treatment methods, and at the same time, the cost standard should be clarified to prevent the possibility of extra charges in hospitals. At the same time, the reform of DRGs payment method tries to increase the actual reimbursement ratio of medical insurance, reduce the economic burden of patients, and make the majority of insured patients benefit from medical reform as much as possible.
(2) Comprehensive packaging to control the unreasonable increase of medical expenses.
Through the reform of DRGs payment method, we will promote the reform of supporting systems such as medical care and medical insurance incentive mechanism, and make the hospital payment method change from the traditional "payment by project" to "DRGs prepaid mixed payment method with full cost and comprehensive package payment".
We should implement the method of "over-expenditure is not made up, and the surplus is retained", change the diagnosis and treatment behavior of hospitals and medical staff, urge hospitals to treat diseases, control over-diagnosis and treatment, standardize medical behavior, reduce medical expenses and optimize the cost structure, so as to control the increase of unreasonable expenses.
(3) grading pricing to promote the formation of grading diagnosis and treatment mode.
On the basis of ensuring medical quality, setting different payment standards for different diseases in different levels of medical institutions will have economic leverage on the behavior of both supply and demand sides.
Guide hospitals to treat patients with diseases that meet their own diagnosis and treatment ability: guide some simple diseases, common diseases, frequently-occurring diseases and some outpatient clinics to sink to primary hospitals; Guide hospitals at or above the county level to refer patients with chronic diseases with stable conditions and clear diagnosis, and take the initiative to undertake difficult patients; Encourage and guide patients to primary hospitals, alleviate the shortage of resources in large hospitals, and further promote the formation of graded diagnosis and treatment pattern.
(four) comprehensive performance evaluation, the establishment of medical quality and cost control system.
DRGs payment method can divide similar medical records in different hospitals into the same group. According to this grouping, with the help of DRGs system, administrative departments can objectively evaluate different medical institutions and different diagnosis and treatment specialties, and apply them to the reform of payment mechanism to further realize the evaluation of medical service efficiency, medical service capacity and medical safety.
Fourth, the challenge to the hospital.
(A) hospitals bear the unreasonable risk of cost overruns of DRGs.
If the DRGs standard is unreasonable, the patient's medical expenses will overrun, resulting in a decrease in medical income and a decrease in medical balance.
(2) Large hospitals, especially some provincial specialized hospitals, suffered losses due to the large number of critically ill patients referred by grass-roots units.
Large hospitals are bound to undertake the "two-way referral" of critically ill patients, who have many complications and high treatment costs. If such patients increase, the risk of hospital loss will also increase.
(3) DRGs performance evaluation will force hospitals to strengthen cost management and improve efficiency, which is a great pressure for hospitals.
DRGs can give hospitals enough enthusiasm to reform the salary system, forcing them not to rely on prescribing drugs and using consumables to increase their income. How to strengthen cost control and control through cost management and efficiency improvement will be a new problem faced by hospitals.
Verb (abbreviation of verb) Suggestions and Countermeasures
The reform of payment mode of DRGs will form a management mode centered on cost and quality control, change the traditional management mode of public hospitals, improve the quality of medical services, establish a hospital performance evaluation system, rationally develop medical insurance payment, and promote the development and unification of medical technology.
For public hospitals, the work can be improved from the following aspects:
(1) Hospital leaders attach importance to strengthening organizational security and making implementation plans.
The hospital has set up a leading group and office for the reform of DRGs payment methods, headed by hospital leaders, responsible for the organization and coordination of the reform, and a payment method reform office under it is responsible for the implementation of specific work. Define DRGs grouping, grouping standards, operation process and settlement, and formulate corresponding supervision mechanism and supporting measures.
(B) determine the DRGs payment standards and settlement methods
After the diseases are grouped, the payment standard of each group of diseases is calculated according to the average cost of each DRGs disease group, the total fund budget and the weight of the rate level. On this basis, the weight of difficult disease groups is increased, while the weight of simple disease groups is reduced, and finally the cost standard of disease groups suitable for hospitals is formed.
Hospitals, patients and medical insurance departments charge and settle accounts according to DRGs payment standards and prescribed compensation ratio. Four major diseases such as new technology projects, critical cases, difficult cases and major diseases are settled separately.
(C) determine the DRGs payment operation process and supervision mechanism
First, the doctor in charge fills in the first page of medical records and manages the settlement; The second is to implement the linkage between doctors' diagnosis and treatment and payment mode reform; The third is to check the accuracy of the main diagnosis and coding in the medical record room before settlement to ensure the accurate grouping of grouping equipment.
For diseases and participating groups that exceed the cost standard, special evaluation will be conducted every month, and the payment system reform office will monitor the operation of DRGs system and analyze the disease indicators of participating group services regularly.
(d) Developing DRGs clinical pathway management information and payment system.
The hospital reformed the payment information system of DRGs, integrated the functions of grouping, statistics, settlement, auditing and monitoring of DRGs, established an information-based clinical pathway system, and realized the automatic generation of doctor's orders, automatic recording of variance analysis, automatic summary of path forms, and automatic analysis of indicators such as disease participation rate, completion rate, average hospitalization expenses and average hospitalization days, thus realizing the informationization of hospital payment reform.
(E) Strengthen medical quality management to make up for the deficiency of DRGs payment.
The medical quality control department of the hospital standardizes the medical staff's diagnosis and treatment behavior, reduces the readmission rate of individual cases, and rewards the surplus of DRGs by establishing the medical service process quality management system, medical risk prevention and control system, and implementing clinical pathway management, so as to achieve the overall goal of standardizing medical behavior, reducing medical risks, controlling medical expenses and improving medical quality.