Accurately aligning with clinical practice - empowering medical institutions through the reform of health insurance payment methods
Date：Jul 24,2024 Information source：Internet
Recently, another heavyweight document on the reform of health insurance payment methods was released by the National Health Insurance Administration, the "Notice on Issuing the Grouping Scheme for Payment by Disease Group (DRG) and Disease Score (DIP) 2.0 Version", which was publicly released. This indicates that the grouping scheme of DRG/DIP is about to enter the 2.0 era, and at a deeper level, the document not only plans for the implementation of the new grouping, but also puts forward specific requirements around "improving settlement and clearing level" and "strengthening reform coordination". Upon closer reading, a clear attitude is evident between the lines: the reform of medical insurance payment methods will release more goodwill towards healthcare institutions.
The grouping scheme is closer to clinical practice. The national DRG and DIP technical guidance groups have collected historical data from more recent years on a larger scale, repeatedly conducted research and argumentation, and solicited opinions and suggestions from multiple parties, with the aim of better improving the scientific and accurate grouping. The optimization and improvement of DRG2.0 version are highlighted in three aspects: firstly, it has optimized and improved 13 disciplines with concentrated clinical opinions, including critical care medicine, blood immunology, oncology, burns, oral and maxillofacial surgery, as well as combined surgery and composite surgery issues; Secondly, based on the coding principles and consensus of ICD-10 and ICD-9-CM3, disease diagnoses that cannot be used as the primary diagnosis and surgical procedures that are routine and can be performed in outpatient settings will be excluded as grouping rules, reducing the occurrence of QY and 0000 groups in medical institutions; Thirdly, the calculation of MCC/CC table introduces genetic algorithm and considers anesthesia grading, which is more in line with clinical medical needs. The optimization and improvement of DIP2.0 version focus on four aspects: firstly, using "main diagnosis+main operation+related operation" for clustering, which is conducive to the value of clinical diagnosis and treatment such as bilateral surgery and transfer; Secondly, based on the "random" combination of "diagnosis+surgical operation", the judgment of resource consumption is added, and only necessary surgical operations that cause a significant increase in resource consumption are independently grouped to promote a more scientific grouping; Thirdly, the number of disease groups has decreased, especially with the core disease group adjusted from 11553 to 9520, resulting in an increase in concentration; The fourth is to reduce the number of diseases with names containing "unspecified", "other", etc., making the diagnosis of diseases more clear. Both upgraded versions of the grouping scheme focus on solving the problems encountered in the actual payment process, which will be closer to clinical practice and more in line with medical needs.
Special case discussions highlight the importance of rational diagnosis and treatment. Due to the severity of the disease and the complexity of medical service behavior, DRG/DIP payments have set up channels for special case negotiation, especially in the early stages of reform. Due to factors such as data quality and grouping awareness, it is easy to encounter more complex and costly exceptions than expected. At this time, it is even more necessary to fully utilize the function of the special case negotiation mechanism. However, in practical applications, there are certain differences in the standards and proportions included, as well as the methods and frequency of evaluation in different regions. In particular, some regions are too strict and too tight, while others are not standardized or scientific enough, resulting in medical institutions being unable to apply, pass or even dare not apply. In this document, more optimization and standardization have been made for the special disease single discussion: firstly, the time requirements are more clear, and expert review and evaluation must be organized on a monthly or quarterly basis, which means that at least one special disease single discussion must be organized every quarter. Secondly, the inclusion ratio has been relaxed, generally not exceeding 5% of the total discharged cases of DRG and 5 ‰ of DIP, which is relatively lenient for medical institutions. The difference in the ratio of DRG and DIP is mainly due to the different grouping principles and thickness of the two, that is, there are usually thousands of DIP diseases, while the number of DRG diseases is generally around 600-800 groups. The third aspect is that the inclusion of cases is more diverse, and medical institutions can independently declare severe cases treated due to illness, cases related to new technologies, long hospital stays, or high hospitalization costs.
Of course, in the process of implementation, the medical insurance department should also strengthen the review and management of special disease cases, promote the standardized operation and stable implementation of this mechanism. For example, in order to better clarify the inclusion situation and criteria, attention should be paid to clustering cases of specific diseases, and sufficient preparations should be made for upgrading local sub groups; For example, more methods such as online direct review, cross review in different locations, and learning to assist in review can be adopted to enhance the ability and efficiency of review; For example, to grasp the standards for the review of special disease cases, special disease cases should be treated as a "channel" rather than a "gate", problems in the case should not be found with a microscope, and the rationality of the case should not be criticized. Medical institutions must be willing to declare and dare to declare. In short, it is necessary to enable medical institutions to make good use of the individualized consultation system for specific diseases, promote clinical physicians to work with light equipment, provide reasonable diagnosis and treatment, and treat patients well.
The grouping scheme is closer to clinical practice. The national DRG and DIP technical guidance groups have collected historical data from more recent years on a larger scale, repeatedly conducted research and argumentation, and solicited opinions and suggestions from multiple parties, with the aim of better improving the scientific and accurate grouping. The optimization and improvement of DRG2.0 version are highlighted in three aspects: firstly, it has optimized and improved 13 disciplines with concentrated clinical opinions, including critical care medicine, blood immunology, oncology, burns, oral and maxillofacial surgery, as well as combined surgery and composite surgery issues; Secondly, based on the coding principles and consensus of ICD-10 and ICD-9-CM3, disease diagnoses that cannot be used as the primary diagnosis and surgical procedures that are routine and can be performed in outpatient settings will be excluded as grouping rules, reducing the occurrence of QY and 0000 groups in medical institutions; Thirdly, the calculation of MCC/CC table introduces genetic algorithm and considers anesthesia grading, which is more in line with clinical medical needs. The optimization and improvement of DIP2.0 version focus on four aspects: firstly, using "main diagnosis+main operation+related operation" for clustering, which is conducive to the value of clinical diagnosis and treatment such as bilateral surgery and transfer; Secondly, based on the "random" combination of "diagnosis+surgical operation", the judgment of resource consumption is added, and only necessary surgical operations that cause a significant increase in resource consumption are independently grouped to promote a more scientific grouping; Thirdly, the number of disease groups has decreased, especially with the core disease group adjusted from 11553 to 9520, resulting in an increase in concentration; The fourth is to reduce the number of diseases with names containing "unspecified", "other", etc., making the diagnosis of diseases more clear. Both upgraded versions of the grouping scheme focus on solving the problems encountered in the actual payment process, which will be closer to clinical practice and more in line with medical needs.
Special case discussions highlight the importance of rational diagnosis and treatment. Due to the severity of the disease and the complexity of medical service behavior, DRG/DIP payments have set up channels for special case negotiation, especially in the early stages of reform. Due to factors such as data quality and grouping awareness, it is easy to encounter more complex and costly exceptions than expected. At this time, it is even more necessary to fully utilize the function of the special case negotiation mechanism. However, in practical applications, there are certain differences in the standards and proportions included, as well as the methods and frequency of evaluation in different regions. In particular, some regions are too strict and too tight, while others are not standardized or scientific enough, resulting in medical institutions being unable to apply, pass or even dare not apply. In this document, more optimization and standardization have been made for the special disease single discussion: firstly, the time requirements are more clear, and expert review and evaluation must be organized on a monthly or quarterly basis, which means that at least one special disease single discussion must be organized every quarter. Secondly, the inclusion ratio has been relaxed, generally not exceeding 5% of the total discharged cases of DRG and 5 ‰ of DIP, which is relatively lenient for medical institutions. The difference in the ratio of DRG and DIP is mainly due to the different grouping principles and thickness of the two, that is, there are usually thousands of DIP diseases, while the number of DRG diseases is generally around 600-800 groups. The third aspect is that the inclusion of cases is more diverse, and medical institutions can independently declare severe cases treated due to illness, cases related to new technologies, long hospital stays, or high hospitalization costs.
Of course, in the process of implementation, the medical insurance department should also strengthen the review and management of special disease cases, promote the standardized operation and stable implementation of this mechanism. For example, in order to better clarify the inclusion situation and criteria, attention should be paid to clustering cases of specific diseases, and sufficient preparations should be made for upgrading local sub groups; For example, more methods such as online direct review, cross review in different locations, and learning to assist in review can be adopted to enhance the ability and efficiency of review; For example, to grasp the standards for the review of special disease cases, special disease cases should be treated as a "channel" rather than a "gate", problems in the case should not be found with a microscope, and the rationality of the case should not be criticized. Medical institutions must be willing to declare and dare to declare. In short, it is necessary to enable medical institutions to make good use of the individualized consultation system for specific diseases, promote clinical physicians to work with light equipment, provide reasonable diagnosis and treatment, and treat patients well.