1 Promote the coordination between hospitals and medical insurance.
Under the background of China's aging population and the expanding population covered by medical insurance, the pressure on medical insurance fund is enormous, and medical insurance must take controlling the cost growth as the first appeal. Hospitals strongly demand more balance for their own development. In the case of project payment, the demands of medical insurance and hospitals conflict, and the relationship between them is mainly "game" and supplemented by "cooperation", which is one of the fundamental reasons why we have not really formed the "three medical linkages" so far. Under the DRGs-PPS mechanism, medical insurance calculates the established payment standard for each group according to the demand of controlling expenses. At the same time, in order to achieve a reasonable balance, hospitals will inevitably reduce the consumption of various resources in the process of diagnosis and treatment. This kind of behavior of hospitals, on the one hand, makes them get better benefits, and at the same time, it will inevitably support the demands of medical insurance control fees. That is to say, under the DRGs-PPS mechanism, the interests of medical insurance and hospitals are consistent, and the relationship between them has changed from the previous "game" to "cooperation".
2. Realize the coordination of cost control and medical quality.
Under the DRGs-PPS mechanism, the payment standard of DRGs, as the basis for medical insurance to pay the hospital in advance, can make the hospital know the maximum amount of resource consumption before providing medical services, so the hospital must control the consumption level within the payment standard of DRGs to make a surplus, otherwise it will lose money. DRGs payment standard has become the critical point of the project profit and loss, thus mobilizing the enthusiasm of the hospital, tapping the potential to save costs, improving the diagnosis rate and shortening the hospitalization days in the process of providing services. Therefore, the role of DRGs in controlling fees is beyond doubt.
However, how to control the cost and avoid the decline of medical service quality? DRGs PPS also has unique advantages in medical quality control. DRG is not only an advanced medical payment tool, but also a good medical evaluation tool. It comes with a set of index system, which can evaluate medical services scientifically and objectively, and this feature can be used as an effective supplement to medical quality control. More importantly, the implementation of DRGs-PPS will surely lead to the birth of a real clinical pathway. This is because, in order to control the cost and ensure that the medical quality index meets the requirements of the payer, medical institutions must seek a treatment scheme that can not only ensure the medical quality but also control their own costs, and require clinicians as a unified standard, which will become a real clinical path. So as to complete the transformation of clinical pathway from "the government requires realization" to "the hospital itself requires realization". After solving the problem of hospital self-driving, the implementation and popularization of clinical pathway will no longer be difficult, which is strongly proved by the implementation of DRG payment in the United States and other countries.
3. Promote the rational allocation of medical resources.
How does DRGs PPS realize the rational allocation of medical resources?
First of all, the value sequence of hospitals and doctors is smoothed, and the situation of graded diagnosis and treatment is truly formed. Taking a disease as an example, such as simple appendicitis, DRG packages the disease, assuming that the compensation standard of medical insurance is 5500 yuan for both secondary and tertiary hospitals. The hospital will calculate the actual cost of the disease by itself, including labor, consumables, equipment, etc. The expenses of large hospitals are generally seven or eight thousand yuan, and the income can't meet the expenses. At this time, it can tell lower-level hospitals that such diseases can be treated in hospital, or suggest that patients be treated on the spot without referral. If the following doctors feel that they can't solve the problem and need consultation, the big hospital will send doctors to the lower hospitals for home visits. The whole process does not require any administrative instruction intervention, and the hospital actively diverts patients, and the graded diagnosis and treatment naturally takes shape.
Secondly, DRGs-PPS can improve the ability of medical service by adjusting the payment standard, so that medical resources can be effectively allocated and utilized. When the medical insurance initially achieves the goal of cost control and the fund has a certain balance, it can give targeted support to the regions or clinical specialties that need to be developed according to the local disease occurrence. Of course, the way of support is to intentionally adjust the payment standards of hospitals or sick groups in these areas, so that hospitals can generate targeted development momentum, thus effectively supplementing and improving local medical service capabilities. In the payment system of DRGs-PPS in Taiwan Province Province, China, policies such as CMI bonus, children's bonus and mountainous islands bonus have been supplemented, which has played a very positive role in the effective distribution and utilization of medical resources.
DRGs PPS system description
Generally speaking, DRGs PPS can be divided into three systems: standard, settlement and supervision.
DRGs-PPS standard system includes data standard, grouping standard and payment standard. The establishment of these standards is the basic premise to realize DRGs PPS. At present, before the relevant national standards are fully determined, each region should choose the appropriate standards according to its own situation, instead of passively waiting for the emergence of national standards. Due to the realization of the whole DRGs-PPS, the quality of historical data is very important. No matter what kind of standards are reached, it is conducive to the improvement of data quality and will inevitably lay a solid foundation for truly realizing DRG payment in the future.
As the daily operation guarantee of medical insurance, DRGs-PPS settlement system in DRGs-PPS standard system includes data processing and grouping, monthly settlement and year-end settlement. Generally speaking, DRGs-PPS settlement needs to be divided into two parts: monthly settlement and year-end settlement. The year-end liquidation depends on the annual assessment results, which can effectively realize the "target management" of hospital medical insurance.
DRGs-PPS is not a perfect mechanism, because of its characteristics of packaged payment and coding, it will inevitably lead to moral hazard such as hospital subdivision hospitalization, high code and low standard admission, and shifting the expenses to patients or outpatient clinics. In order to solve these problems effectively, it is necessary to establish a perfect medical insurance supervision system based on DRGs PPS. Generally speaking, DRGs PPS medical insurance supervision system consists of three parts: daily audit, annual evaluation and long-term evaluation. While forming comprehensive supervision before, during and after the event, we should distinguish the supervision methods in different stages of short-term, medium-term and long-term.
Constructing DRGs-PPS standard system
Constructing standard system is the premise of DRGs-PPS implementation, and its significance lies in ensuring the consistency, openness and stability of the whole system in the implementation process. Its construction process includes perfecting data standards, selecting grouping standards and calculating payment standards.
1 perfect data standard
The key to improve the data standard is to improve the control mechanism of the first page of medical records and unify the ICD coding standard. Disease classification coding and surgical classification coding are the main basis of DRG grouping. The classification of DRG requires the selection of the main diagnosis of diseases, and it is the most basic data of classification, which directly affects the results of DRG classification. Therefore, the hospital needs to establish and improve the medical record management system, maintain the disease coding database and surgical operation coding database of the information system, and ensure the accuracy of the first page coding and surgical operation coding of the medical record. According to the quality control of medical records, the professionals of medical insurance bureau regularly summarize the errors on the first page of medical records in hospitals, analyze and evaluate them, and ask hospitals how to rectify the quality of medical records in view of the existing medical records. Moreover, the medical insurance bureau needs to track the improvement and incorporate it into the year-end performance appraisal of the hospital according to the evaluation standard of the first page of medical records, which can quickly and obviously improve the quality of the first page of medical records.
2. Establish grouping standards
The establishment of grouping standards needs to pay attention to two major points. One is the maturity of the grouping standard itself, and the other is how to localize the relative weight. The DRG system only needs to connect to the homepage of the hospital electronic medical record system and complete the disease grouping through the DRG grouping software. For DRG payment, the payment range (time range, medical insurance type range and hospital grade range) should be selected after grouping, and the weight and rate should be calculated according to the local historical actual data. It is necessary to know whether different levels of hospitals and different types of medical insurance use uniform rates. It is suggested that different types of medical insurance be calculated separately according to different levels of hospitals. If the current policy of the medical insurance bureau has an upper limit of total amount control, it can be considered to replace the total cost with the upper limit of total amount when calculating the rate.
3 Measure the payment standard
Calculating the payment standard is the most complicated part in the construction of the standard system. In the process of calculating the payment standard, we generally need to face up to two major problems: the quality of historical data and reasonable pricing. The payment standard of DRG Group is equal to the relative weight of DRG Group multiplied by the rate. However, the payment standard of DRGs—PPS is not a static indicator, which needs to be dynamically adjusted according to cost factors, price factors and the application of new technologies and new therapies. The medical insurance department should make a prospective study on the payment of DRG patients in time when formulating the payment standard, and take the diagnosis and treatment of diseases into consideration of grouping factors to avoid the situation that hospitals reduce or even give up using new technologies to reduce costs. It is necessary to scientifically and reasonably predict the composition of DRG disease, and constantly adjust and improve it in practice.
Construction of DRGs- payment spirit settlement system
The establishment of DRGs-PPS settlement system includes determining the payment type, payment rules and payment process of medical insurance, automatically sorting out the settlement data of cases, and distinguishing single-disease cases, non-grouped cases, normal cases, extremely low-value cases, extremely high-value cases and other special-value cases. Finally, medical insurance payment is carried out through corresponding methods, mainly including DRG payment, single disease payment and project payment.
The construction of DRG year-end final accounts and medical insurance fund management system can realize medical insurance cost control analysis, fund total management, budget management, year-end performance assessment and liquidation based on DRG. According to the relevant policy requirements such as DRG Payment Method, the annual assessment and liquidation data of DRG in designated medical institutions are comprehensively managed to make the year-end assessment and liquidation work develop in a scientific, efficient and reasonable direction. Set the assessment dimensions and indicators, examine and approve the assessment and results, and realize the statistical analysis of performance assessment indicators at the city, district, hospital and department levels.
Constructing DRGs-PPS supervision system
Before we talk about how to construct the DRGs-PPS supervision system, we must first understand the difference between the DRGs-PPS supervision system and the medical insurance supervision system under project payment.
First of all, under the payment method of DRGs-PPS, the drugs, medical consumables and examinations used by patients all become the cost of diagnosis and treatment services, so the focus of monitoring has changed from expense breakdown to auditing the rationality and accuracy of the whole case.
Secondly, from the perspective of the medical insurance bureau, another major regulatory goal is to monitor whether the medical quality of hospitals has dropped significantly due to reasonable cost control. Key indicators such as average cost, average length of stay, CMI, overall mortality rate of heavy and low-risk groups, and mortality rate of middle and low-risk groups will be included in the assessment scope to strengthen the monitoring role of medical insurance on medical services. DRGs method is considered to be one of the important means to objectively and quantitatively evaluate hospital service capacity, service performance and medical quality, and the proportion of quantitative evaluation method in hospital evaluation is increasing gradually.
In a word, the DRGs-PPS medical insurance supervision system can be summarized as follows: the daily audit pays attention to the typical, the annual assessment and control indicators, and the long-term evaluation as the value orientation.
1 typical daily audit
First of all, the daily audit of medical insurance should be based on DRGs-PPS, which completely simplifies the audit of drugs and charges in medical insurance under the payment of medical insurance items, because the drugs, medical consumables and examinations used by patients under DRG payment have become the cost of medical services, not the means for hospitals to obtain income. DRG intelligent audit is mainly aimed at the overall audit of hospitalized cases. Through data analysis and intelligent coding, the hospital medical records are monitored and managed by statistics and inverse operation to prevent the occurrence of irregularities such as high coding, decomposition of hospitalization and low standard hospitalization. The system automatically reviews cases, and the abnormal cases are drilled and analyzed and manually reviewed to realize information communication with medical institutions and support audit management.
2 Annual assessment control indicators
Secondly, medical insurance should establish an annual assessment system to ensure the realization of annual cost control and quality control of medical insurance. The indicators of annual assessment should be based on the payment plan made at the beginning of the year, and the growth rate of the average cost and total cost, the growth rate and proportion of each DRG group should be included in the scope of performance assessment, so as to strengthen the monitoring role of medical insurance on medical services. At the same time, it also provides medical record quality control, medical service performance, medical quality management, medical safety and other data analysis services for hospitals in the overall planning area, which is used for fine management of hospitals and improves the efficiency and quality of clinical work related to DRG. DRG method is regarded as one of the important means to objectively and quantitatively evaluate hospital service capacity, service performance and medical quality, and the proportion of quantitative evaluation method in hospital evaluation is increasing gradually.
3 Long-term evaluation of value orientation
Finally, medical insurance should effectively monitor and evaluate the local medical service capacity, medical quality and safety, medical service efficiency, patient burden and patient health status. First, effectively evaluate the effect of DRGs-PPS payment reform. At the same time, the realization of these monitoring and evaluation can make medical insurance more clearly understand the demands of local patients, grasp the efficiency of distribution and utilization of medical resources, and provide factual basis for formulating more reasonable reform measures in the future.
abstract
It is a general trend in the future that medical insurance is paid according to DRG-related disease groups. The establishment of DRGs-PPS, as the mainstream medical insurance payment system, will help to achieve the goal of multi-win medical reform with controllable medical insurance fund expenditure, motivated hospital expenses control, guaranteed service quality and substantial benefits for insured people.