This article was published in Truth by Tian Wenfeng, the preferred capital. Edited by Yiou Health University for the reference of the industry.
A few days ago, the National Medical Insurance Bureau, the Ministry of Finance, the National Health and Wellness Commission and state administration of traditional chinese medicine issued a notice on printing and distributing the list of pilot cities for national disease diagnosis related group payment. The notice pointed out that the national DRG payment national pilot working group determined 30 cities, including Beijing, Tianjin and Shanghai, as national pilot cities for DRG payment based on previous applications from provinces (autonomous regions and municipalities) to participate in the national pilot of DRG payment.
In fact, the policy has promoted DRGs for a long time. As early as ten years ago, the hospital where Dr.2 worked was the pilot hospital for the implementation of the national clinical pathway, and in the document 20 15 "Opinions of the General Office of the State Council on the Full Implementation of Serious Illness Insurance for Urban and Rural Residents", it was clearly proposed to promote the reform of payment methods such as payment by disease.
What is the remuneration of DRG?
In essence, DRG (Diagnosis Related Group) is a fixed payment method packaged by disease group. The full name is grouping according to disease diagnosis. According to the severity of inpatients' illness, the complexity of treatment methods, the consumption (cost) of diagnosis and treatment resources, complications, age, hospitalization outcome and other factors, patients are divided into several "disease diagnosis related groups", and then the prices and charging standards are determined by groups.
That is, the inpatients with homogeneous diseases, similar treatment methods and similar resource consumption (cost) are divided into the same group, and the packaging price of each group is determined. Patients suffering from the same disease and the same complications are treated in the same way, and the "one price" package fee is implemented.
After the patient's treatment expenses are packaged and charged, large prescriptions, large inspections and abuse of consumables will increase the cost of the hospital, not the profit.
Under the payment of DRG, the medical behavior of the hospital will return to the treatment itself. Even if doctors want to prescribe more drugs and get more kickbacks for the benefit, they will be forced to give up under the constraint of the hospital and the performance pressure of other medical staff in the same department.
In the case of fixed fees, what hospitals need to do is to reduce expenses, reduce costs and improve efficiency as much as possible on the premise of ensuring medical quality. And for doctors, only by improving their skills can they get more rewards, not other crooked ways! This is also conducive to establishing a better trust relationship between doctors and patients!
What are the main grouping indicators of DRG?
DRGs data indicators have three dimensions: medical service, medical efficiency and medical safety, so as to build a performance appraisal system for inpatients in hospitals.
Medical service: productivity index, which reflects the breadth and overall technical difficulty of medical service.
1, total weight: used to evaluate the total output of inpatient services, that is, the greater the total weight, the greater the hospital output.
2. The number of 2.DRGs: It shows that the treatment cases cover the range of disease types. The larger the number, the wider the scope of diagnosis and treatment services that hospitals can provide.
3. Case Combination Index (CMI): It is the technical difficulty level of evaluating the treatment cases, that is, the index is related to the types of hospitalized cases, and a high value is considered to be difficult to evaluate the hospitalized cases.
4. Coverage MDC, comprehensive evaluation of comprehensive medical technology.
Medical efficiency: efficiency index, reflecting the efficiency of hospitalization service.
1, cost consumption index, the cost of treating similar diseases.
2, time consumption index, the time spent treating similar diseases.
Using cost consumption index and time consumption index to evaluate the performance of the hospital. If the calculated value is around 1, it means it is close to the average level. Less than 1, indicating low medical expenses or short hospitalization time, which is lower than the local average; More than 1, indicating higher medical expenses or longer hospitalization time.
Medical safety: a quality index, which takes the disease itself as the case mortality rate with extremely low mortality probability, and evaluates the risk and safety of low-risk mortality rate in different medical institutions in a certain area.
1, mortality in low-risk group, mortality in cases with extremely low clinical death risk.
2.30-day readmission rate
The death risk score is as follows:
Grouping logic of DRG payment
DRG divides inpatients into different groups according to four core principles of similarity:
Take 60-year-old appendicitis patients as an example.
When patients arrive at the hospital, doctors will group them like this.
(1) First, according to the classification of confirmed diseases, they are classified as digestive system diseases.
(2) According to the treatment method, if it is surgical treatment, it will be divided into the relevant basic groups of appendix disease group according to the severity of appendicitis.
(3) Finally, according to the patient's individual situation and the factors affecting resource consumption, such as complications, age, gender, etc. They are divided into related subgroups.
With the help of DRG grouping and index evaluation analysis, through the comparison between MDC departments, we can comprehensively evaluate the service scope, technical difficulty, service efficiency and medical quality of various disciplines and sub-disciplines in the hospital. For the case group with high cost and time-consuming index, we should focus on the problem of over-medical treatment. For the case group with low time consumption index, combined with the two-week readmission rate, we focused on the decomposition of hospitalization problems.
Why should we change the payment method of medical insurance?
In the past, the growth rate of medical insurance fund expenditure exceeded the growth rate of income for a long time, and medical insurance reimbursed the hospital according to the service items provided by the hospital, which meant that all the payment risks were borne by medical insurance. The number of patients participating in outpatient service ranges from a dozen to hundreds. This is not conducive to the effective management of medical insurance funds:
DRGs is a payment system in which medical insurance institutions and hospitals reach an agreement on payment standards for diseases. When the hospital receives patients who participate in medical insurance, the medical insurance institution pays the hospital according to the prepaid standard of diseases, and the excess is borne by the hospital.
This payment method takes into account the interests of patients, hospitals, medical insurance and other aspects. Its effects are: controlling expenses, ensuring quality and improving management level. For example, encouraging hospitals to strengthen medical quality management, forcing hospitals to take the initiative to reduce costs, shorten hospitalization days, and reduce the payment of induced medical expenses to obtain profits, which is conducive to cost control. This has also brought a revolution to hospital management and promoted hospital quality management, economic management and information management.
What impact does the reform of medical insurance payment method have on the pharmaceutical industry? How should pharmaceutical companies adapt to the new reform of medical insurance payment methods?
(1) Yes, the hospital.
Paying by disease group shows that the payment method of medical insurance in China has changed from the original quantity payment method to the quality payment method, which is helpful to encourage hospitals to strengthen medical quality management and force hospitals to actively reduce costs to obtain profits. Reform stimulates the endogenous motivation of medical institutions to "control costs and improve quality". On the one hand, it can effectively promote mutual supervision of hospitals, curb waste and realize healthy competition and restriction mechanism of medical institutions; On the other hand, considering the reasonable increase of hospital cost control pressure.
(2) For doctors and medical workers.
Incentive payment mechanism forces hospital management to enter a new era, allowing hospitals to operate independently around high quality and low price. On the premise of ensuring medical quality, in order to reduce costs and stimulate the enthusiasm of employees, the hospital will take the initiative to establish internal performance appraisal and internal distribution system, which will have a revolutionary impact on the hospital.
(3) Weakening the medical insurance catalogue.
In the case of DRG payment, for hospitalization, drugs in the list and drugs outside the list are hospital expenses. Doctors can use off-list drugs as long as they are cost-effective.
Hit pharmaceutical companies hard.
The implementation of DRG will bring two changes. Hospitals will be limited to relatively constant income and must consider income, not just income. This means that expanding sales is not necessarily beneficial to hospitals. It is necessary to choose the examination and treatment scheme more scientifically and reasonably, and also to reduce drug abuse. Avoid "minor illness and big cure" and excessive medical treatment from the root.
Under the reform of DRGs, medical insurance, hospitals and internal management all force medical service providers to pursue the lowest price and achieve the best treatment effect. Drugs with low price and good curative effect, and drugs with higher cost performance will be more popular. In the past, hospitals and doctors used drugs more maliciously, and the practice of consuming resources with low cost-effective products or safe and ineffective drugs will be significantly changed.
DRG makes the sales of pharmaceutical companies change from the sales of a single product to the sales of a group of products. This means that pharmaceutical companies need not only the sales data of a single drug, but also the possibility of product combination sales in a certain field for a certain disease group. Most of the hospital's procurement data will rely on medical insurance, sold by group and sold by product group, which is of great value to pharmaceutical companies.
When DRG is fully rolled out, the structure of the whole pharmaceutical industry will undergo great changes. Safe and ineffective magic drugs, old products with malicious changes in dosage form specifications, a large number of auxiliary drugs and traditional Chinese medicine injections with very expensive prices and doubtful curative effects will be hit hard, including therapeutic products and innovative drugs such as Buchang Pharmaceutical, Baiyi Pharmaceutical, Jingfeng Pharmaceutical, Livzon Pharmaceutical and Zhendong Pharmaceutical, which will open up the payment space, and some low-level pharmaceutical companies with kickbacks as the main way will die in batches, but they still exist.
With the audit of the Ministry of Finance to crack down on commercial bribery and the rapid arrival of the second batch of "4+7" centralized procurement, the whole pharmaceutical unit will face heavy losses in a relatively long period of time. There are no eggs under the nest.
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