The policy of charging and paying by diseases in provincial public hospitals refers to the Notice on Charging and Paying by Diseases in Municipal Public Hospitals, which mainly includes: strictly implementing the charging standards for diseases, clarifying the medical insurance payment policy, establishing an access and exit mechanism, and strengthening the management of charging and paying by diseases.
Legal basis:
Notice on the implementation of disease-based payment in municipal public hospitals
First, strict implementation of disease charges.
1. According to the historical cost data and real-time cost data of 106 diseases collected by the hospital in the early stage, fully combining the clinical pathway of each disease, the category of medical institutions, the functional orientation, the graded diagnosis and treatment, the reasonable growth rate of medical expenses and other factors, taking into account the payment ability of medical insurance funds and the burden level of patients as a whole, and referring to the cost standards of the same diseases in other provinces, according to the principle of "incentive and restraint", the nodosity of our province was studied and formulated. This standard is the charging standard of provincial public hospitals. Local development and reform, health and family planning, human resources and social security departments can formulate specific charging standards for diseases implemented by local secondary and tertiary public hospitals on the basis of not exceeding the above standards.
2. The charging standard according to diseases includes all the expenses incurred during the hospitalization of patients, that is, all the expenses incurred during the whole process of diagnosis, treatment, examination, surgery, anesthesia, beds, nursing, medicines and medical consumables, etc., when patients are admitted to the hospital and receive standardized diagnosis and treatment according to the disease management process, and finally discharged from the hospital to reach the clinical efficacy standard. Among them, "end-stage renal disease" refers to the monthly expenses of diagnosis, treatment, examination, drugs, medical consumables, etc. in the process of renal replacement therapy (hemodialysis and peritoneal dialysis) after the patient is diagnosed, excluding the expenses of hospitalization due to complications or other accompanying diseases during the treatment period.
3, according to the provisions of the "excluded content" of consumables, and patients voluntarily choose single rooms, suites and special wards, the part where the bed fee exceeds the standard of double rooms stipulated in the Notice of Provincial Development and Reform Commission on Re-publishing the Bed Price of Provincial Public Hospitals (Xiangfa Reform Price [2065438+07]1KLOC-0/2) can be stipulated separately. In addition, the hospital shall not charge other fees.
4, according to the disease charges, no longer according to the project charges, the hospital can no longer issue a "daily charge list" to patients. According to the medical expenses settled by diseases, the hospital should still transmit information such as project expenses to the medical insurance agency according to the current regulations.
Second, clarify the medical insurance payment policy.
1. The expenses incurred by the insured in the provincial public hospitals for a long time and included in the management of disease charges shall be settled according to the standard of disease charges, with no deductible, and shall be borne jointly by the individual and the overall fund (see Annex 2 for details). Local human resources and social security departments, in combination with the local charging standards for diseases and the actual payment capacity of medical insurance funds, formulate medical insurance payment policies for the above-mentioned diseases in local secondary and tertiary public hospitals on the basis of not less than the payment level of provincial public hospitals.
2, according to the provisions of the disease management fees can be charged separately, included in the scope of medical insurance payment, according to the relevant policies and regulations of medical insurance settlement (see Annex 3).
3. For patients who voluntarily choose single rooms, suites and special wards, the bed fee beyond the standard of double rooms in general wards is not included in the disease charging standard, and the patient pays for it himself.
4, into the disease cost management according to the disease charges and medical consumables fees that can be charged separately (within the maximum payment limit standard), and fully included in the scope of major illness insurance compliance fees. Medical expenses that meet the requirements of mutual medical assistance for employees with serious illness, payment policy for serious illness insurance for urban and rural residents and medical assistance policy shall continue to be implemented in accordance with relevant regulations. If the original diseases covered by the medical insurance system for urban and rural residents are within the scope of 106 diseases, the payment standard specified in this document shall be implemented, and the self-sufficient part will no longer be included in the payment scope of serious illness insurance for urban and rural residents; If it is not within the scope of 106 diseases, it will continue to be implemented in accordance with the original safeguard policy.
Third, establish access and exit mechanisms.
"End-stage renal disease" 65438+ renal replacement (hemodialysis, peritoneal dialysis) is implemented according to the relevant norms and clinical pathways formulated by the National Health and Family Planning Commission.
2. In the same hospitalization process, patients need to perform two or more major surgical/therapeutic methods for diseases, or the actual diagnosis and treatment path obviously deviates from the prescribed clinical path due to complications, complications, patients' serious illness, special physique and other reasons. , you can withdraw from the collection and payment according to the disease, still charge according to the project, and the medical insurance settlement is still carried out according to the original payment method. According to the disease withdrawal payment should promptly inform the patient and report to the medical insurance agency for verification.
3. Strictly control the negative mutation rate of clinical pathway management according to diseases (the ratio of the number of cases whose main diagnosis and main operation/treatment methods are in line with 106 diseases, but the total number of cases whose main diagnosis and main operation/treatment methods are in line with 106 diseases), and the negative mutation rate of long provincial hospitals shall not exceed 20%.
Four, strengthen the management of payment by disease.
1. First, all relevant medical institutions should earnestly strengthen their leadership over the work of charging and paying according to diseases in our hospital, scientifically formulate plans, standardize work management, and strengthen organization and implementation. Pay close attention to the establishment and improvement of the access and exit mechanism for the implementation of disease-based payment. At the same time, timely inform patients of the relevant regulations and charging standards for payment according to diseases. The second is to ensure medical quality and reasonable diagnosis and treatment. Not because of the implementation of disease charges shuffle patients; Do not refuse to implement the disease-based charging policy for patients who meet the disease-based settlement policy on the grounds of complications and complications that do not affect the main diagnosis and main operation/treatment methods; Do not shorten the hospitalization time of patients without reason, reduce the clinical pathway of diseases or the content of diagnosis and treatment items and services stipulated by standardized diagnosis and treatment projects, and harm the interests of patients; Not through prescription outsourcing, out-of-hospital inspection or outpatient prescription, outpatient inspection and other ways to pass on the medical expenses within the scope of the prescribed diseases, increasing the burden on patients; It is not allowed to cheat or defraud the medical insurance fund by exchanging diagnosis or decomposing hospitalization and medical expenses. Third, do a good job in controlling fees, and the actual expenses beyond the standard of disease charges shall be borne by the hospital; The balance of the actual cost is lower than the disease charge standard, which is retained as the business income of the hospital. Fourth, in strict accordance with the requirements of the Provincial Health and Family Planning Commission, strengthen the informatization and standardization of hospital medical record management, implement unified classification and coding of disease diagnosis and surgical operation, strengthen the standardized training of medical staff to fill in the front page of hospital medical records, and designate a special person to be responsible for uploading relevant case information to the management information system designated by the Provincial Health and Family Planning Commission in a timely and standardized manner. Fifth, it is necessary to incorporate the implementation of disease-based payment into the annual target responsibility assessment, adjust the internal distribution system, and mobilize the enthusiasm of corresponding departments and medical staff to implement disease-based payment.
2. The medical insurance agency shall incorporate the payment by disease into the agreement management of medical institutions, conscientiously implement the management policy of payment by disease, and timely and fully allocate medical insurance compensation funds if the negative mutation rate is controlled within the prescribed scope; For those who fail to implement the policy of collecting and paying according to diseases and the negative mutation rate is not up to standard, the corresponding medical insurance compensation funds will be deducted. At the same time, relevant assessment indicators are established, and the assessment results are linked to the annual performance bond return. For medical institutions that refuse to implement the policy of charging according to diseases or seriously violate the relevant provisions, their qualifications as agreed medical institutions shall be suspended or cancelled.
3, the development and reform department should increase the supervision and inspection of the implementation of charging standards according to diseases, and investigate and deal with price violations according to law. Health and family planning departments should strengthen the supervision and inspection of the implementation of clinical pathway management in hospitals, incorporate payment by disease into the performance appraisal system of public medical institutions, closely monitor the quality of medical services, and strengthen the evaluation and supervision of changes in disease costs, service efficiency and service quality. The department of human resources and social security should regularly disclose to the public the cost level, personal burden, assessment and supervision of diseases related to public hospitals, and guide patients to seek medical treatment reasonably.