According to the news of China** Network on January 10, recently, some doctors reported that after the reform of payment according to the disease group (DRG), hospitals are afraid of losses and dare not admit patients with complex conditions;Some netizens said that their relatives were hospitalized for less than 15 days and were forcibly transferred by many hospitals on the grounds that "medical expenses have exceeded the upper limit of DRG reimbursement".
After receiving the messages from netizens transferred by China's ** network, the National Health Insurance Bureau carefully studied and handled it and made the following reply:
Deepening the reform of medical insurance payment methods is an important decision-making deployment made by the medical security system, and it is also an inevitable requirement for the development and improvement of the medical security system itself and the continuous improvement of the efficiency of use. Since 2019, our bureau has carried out pilot projects of payment by disease group (DRG) and payment by disease score (DIP), and promoted the work of multiple composite payment methods based on payment according to disease type. DRG is based on different diagnoses, different methods and different patient characteristics, and each inpatient case corresponds to different diagnosis-related groups, so that complex medical behaviors can be compared and evaluated. Payment according to disease score (DIP) is to use the advantages of big data to collect the data of all samples of cases within a certain area, through the combination of "disease diagnosis" and "** method", exhaustively form DIP diseases, and select DIP diseases covering the vast majority of cases to become the core diseases, and determine the payment standard of diseases. DRG DIP is a specific form of payment according to the type of disease, which can significantly expand the scope of diseases covered, improve the management fineness, and effectively control the risk compared with the traditional single-disease payment. In the pilot work of DRG DIP, a set of technical specifications, grouping plans and handling procedures have been formed, and various mechanisms such as core element adjustment, performance evaluation, dispute resolution, and total budget management have been continuously improved. At the same time, with the implementation of various coding standards for medical insurance information business, the quality of medical insurance settlement lists and related data reporting in pilot areas has been significantly improved.
DRG DIP reform has continued to make efforts in using the "life-saving money" of the insured, and the leverage of medical insurance has emerged, which has taken a key step in guiding the coordinated development of medical insurance, medical care and medicine. The level of personal burden in the actual payment area has generally been reduced, and the convenience of the masses in seeking medical treatment has been improved by the same price for the same disease in the same city at the grassroots level. The medical insurance department uses scientific management tools to guide medical institutions to improve the quality of medical records and strengthen the management of clinical pathways. In practice, some medical institutions have extensive management, and directly regard the average cost of diseases as the maximum "limit", which harms the income of medical personnel and the rights and interests of the insured. Please report the relevant situation to the medical insurance department in time, and the local medical insurance department will deal with it in a timely manner according to the regulations.
The National Health Insurance Administration said that in the next step, our bureau will improve the management and adjustment mechanism of core elements, improve the performance management and operation monitoring mechanism, form a multi-party participation evaluation and dispute resolution mechanism, and establish a coordinated promotion mechanism for relevant reforms in accordance with the requirements of the "Three-year Action Plan for the Reform of DRG DIP Payment Methods". Highlight the three core elements of disease group (disease type), weight (score) and coefficient, so that the grouping is closer to the clinical needs and local reality, so that the weight (score) more reflects the labor value of medical staff, and through coefficient management, promote the sinking of medical services, and greatly improve the performance of medical service resources and medical insurance.
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