The significance of the reform of payment methods is definitely not a simple "saving money" and "controlling costs", but based on the actual needs of medical care, insurance and patients and the consensus of the industry. The purpose of the reform is to establish a payment mechanism that is consistent with the interests of the public and the value pursuit goals of all parties in the medical, medical and medical insurance sectors.
**. Attach great importance to the reform of medical insurance payment methods. In 2019, the 11th meeting of the Committee for Comprehensively Deepening Reform emphasized the need to establish an effective and efficient medical insurance payment mechanism. In February 2020, the Communist Party of China issued the "Opinions on Deepening the Reform of the Medical Security System", proposing to implement a multi-faceted and composite medical insurance payment method based on payment according to the type of disease. In February 2021, the General Secretary of the Communist Party of China made important instructions on deepening the reform of medical insurance payment methods and improving the efficiency of medical insurance use at the 28th collective study of the Political Bureau of the Communist Party of China.
The report of the 20th National Congress of the Communist Party of China made it clear that it is necessary to deepen the reform of the medical and health system and promote the coordinated development and governance of medical insurance, medical treatment and medicine. This not only reflects the full affirmation of the policy practice in the field of medical security in China in the past five years, but also gives medical insurance an important task in guiding the coordinated governance of the "three medicines".
The medical insurance payment method is an important tool for medical insurance to play a strategic purchasing role, coordinate the supply of medical services, and guide the allocation of medical and health resources.
The purpose and significance of the reform: to achieve more efficient payments
Deepening the reform of medical insurance payment methods is a key link to ensure that the masses have access to high-quality medical services and improve the efficiency of use. However, when it comes to the reform of payment methods, there are still many people who believe that the purpose of health insurance reform is to save money. In reality, this is not the case at all. If medical insurance simply holds the mentality of saving money and controlling costs to formulate payment reform policies, it is neither realistic nor likely to succeed. As an important bridge between medical care and medical insurance, a truly effective payment method must be acceptable and satisfactory to both parties, and can achieve the respective value goals of medical care and medical insurance at the same time. The purpose and significance of the reform of medical insurance payment methods are mainly in the following three aspects.
First, this is an inevitable requirement for the development of the medical insurance system. Medical security is a major institutional arrangement to reduce the burden of medical treatment for the masses, improve people's livelihood and well-being, and maintain social harmony and stability. The development of the medical insurance system has entered the stage of improving quality and efficiency, and more emphasis is placed on the improvement of management capabilities. The "Opinions on Deepening the Reform of the Medical Security System" clearly put forward the need to improve the four major mechanisms of treatment guarantee, financing operation, medical insurance payment and supervision, among which medical insurance payment is the key mechanism to ensure that the masses have access to high-quality medical services and improve the efficiency of use. How to pay the raised medical insurance** more efficiently is an important responsibility of medical insurance workers. After all, the purpose of the reform is not to blindly save money, but to improve the predictability of the smooth and healthy operation of medical insurance. The payment method is a set of fine and efficient management tools, medical insurance workers should make good use of this tool, focus on clinical needs, reasonable diagnosis and treatment and appropriate technology, in the context of constantly adapting to the development and innovation of medical service models, through the implementation of more efficient medical insurance payment, the past difficult to compare with each other medical service behavior becomes visible and comparable, through the scientific evaluation and evaluation of the quality of medical services, to continuously enhance the incentive and restraint role of medical insurance in the field of medical services.
Second, this is an objective requirement for the coordinated reform of medical insurance and medical care. Information asymmetry is a significant feature of the medical field, due to the problem of doctor-patient information asymmetry and the weak substitutability of the medical and health service industry, medical patients are in a special position of vulnerability and dependence, and the quality of medical services cannot be judged. The purpose of the state to establish a medical security system, in addition to dispersing the cost burden risk of the insured when suffering from a serious illness through the law of large numbers, is also to establish a scientific and reasonable management and restraint mechanism, in the face of relatively strong medical service institutions, can maximize the voice of the insured, so as to maximize the interests of the insured people. All sectors of society generally believe that the current difficulty of China's medical reform lies in the supply-side reform, and its focus lies in how to change the operating mechanism of medical institutions. Medical insurance payment is an effective lever for the coordinated promotion of demand-side management and supply-side reform in the field of medical reform, which can have a far-reaching impact on the sustainable and healthy development of medical and health undertakings, and can not only play an engine role in promoting hospitals' active cost control and cost reduction, but also play a synergistic role in the construction of a hierarchical diagnosis and treatment system. At present, the operation mechanism of China's medical institutions has entered the stage of having to change, for example, the number of beds per 1,000 people in China has been higher than that of many developed countries, and it is impossible to build hospitals, branch hospitals, and expand hospitals in a simple and extensive way to become a long-term plan for the sustainable development of medical institutions, and the operation mechanism of medical institutions needs to be changed urgently, which requires not only their own active transformation, but also effective external promotion.
Third, this is a practical requirement to better protect the medical treatment of the insured. The general secretary profoundly pointed out: "The fundamental purpose of our establishment of a universal medical insurance system is to relieve all the people of their worries about illness and medical treatment. "Focusing on people's health is the fundamental starting point of medical reform. Providing fair and appropriate treatment is an intrinsic requirement for improving people's health and well-being, and it is also the original intention and goal of medical insurance workers. At this stage, the most concerned about the insured people is how to effectively solve the problem of difficult and expensive medical treatment. Excessive diagnosis and treatment is a pain point that the current insured people have a strong reaction to, and the reform of the payment method can not only help the insured reduce the medical burden, reduce the hospitalization cost and length of hospitalization, but also reduce the excessive diagnosis and treatment and unreasonable expenditure while ensuring the quality and safety of medical services for the insured patients, so that the people's satisfaction with medical treatment continues to improve. At the same time, DRG DIP payment can also help medical institutions to achieve "same treatment and same payment", which better reflects fairness and equalization, and improves the accessibility of medical services for the masses.
Medical insurance is the "medical money" and "life-saving money" of more than 1.3 billion insured people in the country, and whether the operation is stable is of great significance to the entire medical industry. It is not difficult to spend the money, but how to achieve more efficient payment, provide stable and effective cost protection for the insured, and provide continuous and stable funds for medical institutions**.
It needs to be reiterated once again that the significance of the reform of payment methods is definitely not a simple "saving money" and "controlling costs", but based on the actual needs of medical care, insurance and patients and the consensus of the industry. No reform can happen overnight, and neither will the reform of payment methods. The purpose of the reform of medical insurance payment method is to establish a payment mechanism that is consistent with the interests of the public and the value pursuit goals of all parties such as medical care, insurance and patients.
Progress and effectiveness of reform: a win-win situation for medical care, health care and patients
After the establishment of the National Health Insurance Administration, it has comprehensively and vigorously promoted the reform of DRG DIP payment methods, which has initially shown the positive effects of strengthening the internal management of medical institutions, changing the operation mechanism, improving the convenience of the masses to seek medical treatment, reducing the cost burden, improving satisfaction, strengthening the medical insurance management methods, and improving the performance of medical insurance.
First of all, from the perspective of the promotion and coverage of DRG DIP payment method reformAt present, 11 provinces (autonomous regions and municipalities directly under the central government) of Beijing, Tianjin, Hebei, Inner Mongolia, Shanghai, Zhejiang, Shandong, Henan, Guangdong, Guangxi, and Chongqing, as well as the Xinjiang Production and Construction Corps, have achieved full coverage of the reform of payment methods in all coordinated regionsThere are 282 co-ordinated regions across the country that have carried out DRG DIP payment method reform, accounting for 71% of all co-ordinated areas in the country, and have completed the phased goals proposed in the "DRG DIP Payment Method Reform Three-Year Action Plan". At the same time, the coverage targets of medical institutions, disease types and medical insurance** in each co-ordinated area have also been basically achieved. It can be said that the whole country is unified.
First, the linkage between the upper and lower levels, internal and external coordination, standards and norms, and a new mechanism of efficient medical insurance payment is being formed.
Secondly, from the perspective of the improvement of the governance capacity of medical insuranceWith the widespread application of the two payment methods of CHS-DRG payment with Chinese characteristics, disease payment and DIP payment combining the point method, the situation of "passive payment" of medical insurance in the past has undergone major changes, and the strategic purchasing role of medical insurance is truly being played. At the same time, various localities have also established key mechanisms such as negotiation and consultation, dispute handling, and individual discussion of special diseases, so that the determination of grouping and weighting is more scientific and reasonable, and special situations such as extremely high-cost cases and the use of new technologies and projects can be more properly handled. In reality, medical problems are often more complex, and there are often individual differences, we can neither rely solely on big data to formulate payment standards, nor can we make a standard to adapt to all medical conditions, after all, even in the face of the same patient, different doctors may make different judgments and treatments, then it is necessary to set up a dispute resolution mechanism to allow everyone to communicate and negotiate to form a final consensus. In addition, in order to better protect the health rights and interests of seriously ill patients, medical insurance departments at all levels across the country are also constantly improving and improving the mechanism of single discussion for special diseases, so as to avoid the situation of passing the buck to patients as much as possible. In short, with the comprehensive promotion and deepening of the reform of payment methods, medical insurance workers are also constantly optimizing and improving various key mechanisms to serve various special situations, with the purpose of making the formulation of policies more in line with the development status and future direction of the medical industry.
Again, from the point of view of the operation of medical institutions,The reform of payment methods is actively playing a guiding role, encouraging medical institutions to actively control costs, actively standardize behaviors, actively optimize processes, and seek benefits from hospital internal management. The management mechanism of "surplus retention and overexpenditure sharing" encourages medical institutions to scientifically standardize medical service behaviors and reduce unnecessary costs. Practice has proved that in 2022, compared with the previous pay-per-project period, medical institutions in 101 national DRG DIP payment method reform pilot cities received a total of 6.9 billion yuan of surplus retention, and the enthusiasm of medical institutions to embrace the reform has increased significantly. Not only that, the admission of medical institutions is also more reasonable, the efficiency of medical services has been significantly improved, and the time consumption index and cost consumption index have decreased significantly. Since the DRG DIP payment method reform provides a scientific and comparable classification method for medical quality and hospital management, medical institutions can scientifically and proactively adjust the structure of the diseases admitted and treated, carry out refined management, and make the diseases admitted to large hospitals more in line with their own functional positioning. At present, many co-ordinated areas have formulated 50-100 types of diseases at the grassroots level, and through the "same disease, same treatment, and same price", patients with mild symptoms can remain at the grassroots level, so as to promote hierarchical diagnosis and treatment.
Finally, from the perspective of the feelings of the massesDRG DIP payment mainly changes the payment method of hospitals and medical insurance, and does not affect the behavior of the insured, and medical institutions and patients in most areas still implement project-based billing and payment, so the settlement process is "undisturbed" for patients. At the same time, as medical institutions begin to actively control costs, drugs and consumables that are not needed in the first place are decreasing, and for the insured, the medical expenses and length of hospital stay are also showing a downward trend. Data from many places show that the average cost of patients has decreased significantly, the level of self-responsibility has been generally controlled, and the sense of gain of the masses has been significantly enhanced. Not only that, because DRG payment based on standardized clinical pathway management has made complex medical behaviors more intuitive, and the "incomparable" to "comparable" between various hospitals, departments and diseases has changed from "incomparable" to "comparable".
The future and focus of reform: in-depth development
Although the DRG DIP payment method reform has achieved many positive results, there is still a lot of work to be done in the future.
First, it is necessary to emphasize improving the ideological position and building consensus on reform. There are still various voices in society, such as some people who believe that the implementation of payment reform will inevitably affect the quality of service of medical institutions. In fact, the goal of the reform of payment methods is to improve the efficiency of use and change the shortcomings of long-term medical insurance "passive payment", extensive development of hospitals, and heavy burden of patients. In the face of all kinds of misunderstandings in society, the whole medical insurance system should unify thinking, maintain determination, and constantly promote the coordinated reform of medical institutions. On the one hand, medical institutions should fully understand and agree with the purpose and significance of the reform of payment methodsOn the other hand, in response to the relevant problems raised by medical institutions, the medical insurance department should also further optimize the working mechanism to make the policy design more perfect and reasonable.
The second is that each co-ordinated area should benchmark against the table, conscientiously implement the "three-year action plan for the reform of DRG DIP payment methods" proposed by the "three-year action plan for the reform of DRG DIP payment methods", and make overall work arrangements. First of all, it is necessary to do a good job in organizing and promoting the mechanism, formulate a detailed work plan, and clarify the goals, tasks, and time arrangementsStrengthen organizational leadership, clarify personnel arrangements and specific responsibilities, and clarify time limit requirements;Strengthen work scheduling, find and solve problems in a timely manner, and refine and summarize work experience in a timely manner. Secondly, if you want to smoothly promote the reform of DRG DIP payment methods, you must have a business backbone who is familiar with relevant principles and working methods to support, not only the medical insurance system needs capable organizers and business backbones, but the medical system also needs corresponding business experts to cooperate in the implementation. Thirdly, it is necessary to do a good job in the learning and exchange mechanism, give full play to the demonstration and guiding role of the pilot areas, organize exchanges and learning inside and outside the system, avoid lessons and detours to the greatest extent, and learn experience to guide practice to the greatest extent.
Third, it is necessary to make good use of policy tools, improve relevant mechanisms such as negotiation and consultation, and individual discussion on special diseases, and steadily promote reform. Although the payment method is based on big data and expert discussions, it is certainly not possible to comprehensively cover all aspects of medical services. Local medical insurance departments must make good use of relevant mechanism innovations such as negotiation and consultation, single discussion of special diseases, and payment with traditional Chinese medicine characteristics, give full play to their subjective initiative, let medical institutions take the initiative to participate and fully discuss, and continuously improve their participation in reform.
Fourth, it is necessary to implement dynamic adjustment, which is in line with clinical reality. Medical behavior is constantly changing and progressing, and the medical insurance department also needs to adjust the payment rules according to the situation. In addition to providing cost protection for the insured, medical insurance also plays an important role in providing clinical services. Therefore, in the process of promoting the reform of payment methods, it is necessary to pay attention to the collection of opinions and the timely adjustment of grouping, weights and rates, and establish a communication and consultation mechanism for key links, so as to promote fairness through openness and enhance the transparency and credibility of medical security work.
Fifth, we need to strengthen data analysis and achieve data empowerment. With the full completion of the national unified medical insurance information platform, there will be richer and more comprehensive medical insurance data to provide basic support for the reform of payment methods. The medical insurance department should make good use of these data and do a good job in model analysis to continuously optimize payment methods. In fact, medical insurance data can not only empower medical insurance management, but also has great significance for hospital management. Scientific medical insurance data analysis can effectively improve the operational efficiency of medical institutions and better promote the supply-side reform of medical services, thereby helping the coordinated development and governance of medical insurance, medical care and medicine. （zgyb-2023.12）
Author |Huang Xinyu is the Director of the Department of Pharmaceutical Service Management of the National Health Security Administration.
* |China Medical Insurance.
Edit |Fu Meiru Liu Xinyu.
Hot Article
To promote the reform of medical insurance payment methods, the National Health Insurance Administration has done these things.
This nationally eye-catching conference on the reform of medical insurance payment methods conveys new requirements for reform What is the role of the medical insurance department in the reform of DRG DIP payment methods?