Multivariate payment of health insurance will be fully implemented,payment by disease species is the direction of reform

Chenghui Shuangda

The General Office of the State Council recently issued the Guiding Opinions on Further Deepening the Reform of the Payment Method for Basic Medical Insurance(hereinafter referred to as the Opinions), proposing to further strengthen the budget management of the medical insurance fund from 2017 onwards. The multivariate compound payment method based on disease payment is fully implemented. Experts believe that the medical insurance payment system reform will become the key mechanism of medical service cost control under the premise that the medical insurance market has been formed in our country and medical insurance payment has become the main source of compensation for public hospitals.

Health care payment classification reform fully implemented this year

The "Opinions" clearly stated that the main goal of the reform of medical insurance payment methods is to further strengthen the budget management of medical insurance funds from 2017 onwards, and to comprehensively implement multiple compound payment methods based on disease payment. The state has selected some regions to carry out pilot tests for payment according to the relevant groups for disease diagnosis(DRGs). By 2020, multi-variate and multi-variate medical insurance payment methods adapted to different diseases and service characteristics will be implemented nationwide, and the proportion of project payments will drop significantly.

Chenjinfu, director of the medical insurance department of the Ministry of Human Resources and Social Security, said that because of the problems such as the irrational structure, uneven distribution of medical and health resources, and the weak capacity of basic services in China, the deep-seated institutional and institutional contradictions still need to be solved. The role of medical insurance payment in regulating the behavior of medical services and guiding the allocation of medical resources has not yet been fully played. As medical reform continues to advance, the key reform tasks of establishing a graded medical treatment system, promoting the reform of public hospitals, launching contract services for family doctors, and controlling the excessive growth of medical expenses have also put forward new requirements for the reform of medical insurance payment methods.

The main elements of this reform are: First, we will push forward the reform of the classification of medical insurance payment methods and implement multiple composite payment methods.According to the characteristics of different medical services, the reform of medical insurance payment methods will be promoted. Hospital medical services are mainly paid for according to the type of disease and according to the relevant groups of disease diagnosis(DRGs), and long-term and chronic Hospital medical services can be paid on the basis of beds; For basic medical services, people can pay per head, and actively explore the combination of paying per head and chronic disease management; For complex cases and outpatient fees that are not suitable for packaging, they can be paid on a project-by-project basis; We will explore payment methods that meet the characteristics of TCM services.

Second, is to focus on the implementation of payment by disease type. In principle, for diseases with relatively clear diagnosis and treatment plans and admission standards, and mature diagnosis and treatment techniques, the payment for diseases according to the type of disease is implemented, and day surgery and qualified outpatient treatment of Chinese and Western medical diseases are gradually included in the scope of payment according to the type of disease. We will establish a negotiation and consultation mechanism to determine the appropriate payment standards for Chinese and Western medical diseases.

Third, we will carry out pilot projects to pay for disease diagnosis related sub-groups(DRGs).

Fourth, we will improve payment methods such as head and bed day. The promotion of the overall payment of the outpatient clinic by head can start with the standard of treatment plan and the evaluation of chronic diseases with clear indicators. For illnesses such as mental illness, palliative care, and medical rehabilitation that require long-term hospitalization and have a relatively stable daily cost, beds can be paid on a daily basis.

Fifth, we will strengthen the supervision of medical treatment. We will improve the management of fixed-point agreements for medical insurance, comprehensively push forward the intelligent monitoring of medical insurance, extend medical insurance supervision from medical institutions to medical personnel's medical service activities, and shift the focus of supervision from medical expenses control to medical expenses control and medical quality control. Local medical insurance agencies with conditions may prepay medical insurance funds to medical institutions as agreed upon in the agreement to support the operation of medical institutions.

Modification of hospital management model driven by payment mode

It is worth noting that the "Opinions" specifically emphasized the establishment of mechanisms, "a sound incentive and restraint mechanism for medical insurance to medical behavior, and a control mechanism for medical expenses." "We will establish and improve an open and equal negotiation and consultation mechanism between medical insurance agencies and medical institutions." Some experts believe that the ultimate goal of establishing a mechanism is to increase the enthusiasm of medical institutions for self-management and promote the transformation of medical institutions from scale expansion to connotation development: "One of the ultimate goals of this reform is to: Through the reform of health insurance, it finally promotes the transformation of the overall operation and management model of medical institutions, from extensive scale expansion to the refinement of services. The change in the way health care is paid for, with clear directions and tools, will also guide the health service to change direction, improve health care quality and control costs. "

With the development of science and technology, growing consumer demand and the aging of the population, the cost of health care will become higher and higher, and the ability of health insurance funds to pay is limited. In fact, medical cost control has become the basic trend of medical management in all countries in the world. The practice of international medical insurance reform proves that under the medical insurance system, relying on the demand-side cost sharing system alone, it is difficult to effectively control the continuous growth of medical expenses, and through the reform of medical insurance payment system to explore the supply side cost control, it can improve the incentives and constraints of supply side cost control. It is understood that many countries are currently actively engaged in health insurance payment reform to improve the incentive to pay by service items with a tendency to cost inflation.

"The reform of the health insurance payment system is intended to reshape the distribution mechanism of health care resources, with health insurance payments as the lead, and will lead the allocation of health care resources in line with the basic health insurance system. This is an inevitable change under the universal health insurance system. Experts interviewed by the Economic Reference newspaper said that in the modern healthcare market, a social insurance system consisting of three parties: the demand side, the supply side and the paying side. As a third party, medical insurance institutions or medical insurance systems play a key role in regulating the "group purchase" of medical services and medical expenses, not only protecting the health rights and interests of the people, but also ensuring the effective supply of medical services. And through the cost sharing and payment mechanism to restrain the behavior of supply and demand, especially for medical services, in order to maximize the distribution and use of medical resources.

Payment by disease species is the direction of reform

It is worth noting that payment by type of disease and payment by groups related to disease are given high priority. The payment according to disease-related groups mainly refers to DRGs. From the experience of countries and regions in the world, DRGs are not only a tool to effectively control hospitalization costs, but also an important means to help hospitals change their models.

The full name of DRG is grouped according to disease diagnosis. It is based on the patient's condition, the complexity of the treatment method, the degree of resource consumption(cost) of diagnosis and treatment, and the factors such as complications, complications, age, and hospitalization. Patients are divided into several "disease diagnosis related groups", which can then be packaged in groups to determine prices, fees, and medical insurance payment standards. Since DRGs are packaged and paid according to groups, Gaochu will no longer pay, which will prompt the hospital to consider the need for drug consumables and inspections, and to refine the cost of managing hospital services.

Yangyansui, director of the Employment and Social Security Research Center of Tsinghua University, said that from an international perspective, from 1980 to 2010, third-party payments for medical expenses began to pay attention to the quality of medical care, using "disease species" and "disease group"(DRG) as payment units. As of 2014, the social health insurance of Austria, Chile, the Czech Republic, Lithuania, France, Germany, Hungary, Japan, the Netherlands, Poland, Slovenia, Switzerland and the United States among the OECD countries has entered the quality payment stage. Regardless of whether public hospitals or private non-profit hospitals are using DRG methods for performance evaluation and management, medical insurance and medical institutions associations are using DRG data for dialogue and setting the value of medical insurance payments.

Experts say the significance of the pay for quality method is that past catalogues and prices based on administrative power and connections have become less binding, and what is really binding is the results of the medical data analysis. This result reassures the government and society. It convinces medical institutions and actively controls costs. It leaves the patient and society with an improvement in the quality of medical service. At present, there are several pilot areas in our country that have set up groups to pay according to disease diagnosis. Although there are still many places that do not have the conditions for this work, they can be an important part of the medical payment reform. The future will still be the general trend.

"With the advent of this reform, our health insurance payments will be transferred from the quantity payment method to the quality payment method". Mr Yangyansui said that the era of quantitative value was the initial stage of the development of a third-party payment system, which would be phased out after it had completed its mission, and that the future quality payment method would greatly increase the value of doctors.


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