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The National Health Insurance Bureau issued a document


The National Health Insurance Bureau held a meeting to announce important standards, and one of the payment methods for medical insurance, the basic standard for DRG payment, officially moved from decentralization to unification.

On the morning of October 23, the National Medical Insurance Bureau convened a meeting to officially announce the “Notice on the Technical Specifications and Grouping Scheme for the Trial of Disease-Related Groups (DRG) Payment Countries” (hereinafter referred to as the “Notice”), including the National Medical Security DRG Group and The payment technology specification (hereinafter referred to as "technical specification") and the "national medical security DRG (CHS-DRG) grouping plan" (hereinafter referred to as "grouping plan") two documents, the medical insurance payment method ushered in important changes. The grassroots physician commune (jicengyishi) was invited to attend the conference.

What is DRG payment?

Before we understand the contents of the Notice, let us explain what is DRG payment.

DRG, namely, Diagnosis Related Groups, referred to as DRG, is translated into Chinese for disease diagnosis related groups.

According to the patient's age, gender, length of hospital stay, clinical diagnosis, the patient is divided into the diagnosis related groups with similar clinical symptoms and resource consumption, and the price, fee and medical insurance payment standard are determined by the group. The payment method is widely used in the world. .

To put it bluntly, it is to divide the related diseases into one group, to make the package payment, and not to pay for the item as before. For example, see pneumonia, according to the severity of the symptoms are divided into several levels, the previous "blood test" and "filming" are a charge, DRG payment is the implementation of the check-up according to the disease and symptom level, the various symptoms required for pneumonia diagnosis The test, all according to pneumonia and the corresponding symptom level, packaged and paid, no longer a separate charge.

CHS-DRG becomes the sole standard for DRG payment

Since the 1980s, after more than 20 years of development, several DRG versions have been formed.

In order to ensure the smooth implementation of DRG paid country pilots, the National Medical Insurance Bureau compiled the National Medical Security Disease Diagnosis Related Group (CHS-DRG) Grouping and Payment Technical Specification based on the previous experience of DRG pilots in various regions.

CHS-DRG has become the only standard for the implementation of DRG payment by the national medical insurance department. The “Notice” requires all pilot areas to strictly follow the CHS-DRG standards and carry out pilot work according to the unified deployment of the National Medical Insurance Bureau. The national medical insurance department implements the DRG standard. Consistent and healthy development.

In June this year, the National Medical Insurance Bureau and other four departments identified 30 cities as pilot cities for disease-related diagnostic group (DRG)-paid countries, and called for “developing a set of standards, improving a series of policies, establishing a set of procedures, and cultivating a The goal of the team and the creation of a set of models is based on the three-step three-step promotion strategy of “top-level design, simulation operation, and actual payment”.

The 30 pilot cities are:

Beijing, Tianjin, Handan, Linyi, Wuhai, Shenyang, Jilin, Harbin, Shanghai, Wuxi, Jinhua, Hefei, Nanping, Shangrao, Qingdao, Anyang, Wuhan City, Xiangtan City, Foshan City, Zhangzhou City, Zhangzhou City, Chongqing City, Panzhihua City, Liupanshui City, Kunming City, Xi'an City, Qingyang City, Xining City, Urumqi City, Urumqi City ( directly under the Corps, 11th Division, Twelve divisions)

Adhere to the integration of divisions, pilot "one game of chess", precise "localization"

Adhere to the integration of divisions and divisions, and gradually form a DRG payment system with Chinese characteristics. The "Notice" requires each pilot city to follow the basic principles, scope of application, definition of nouns, and data requirements, data quality control, standardized uploading specifications, grouping strategies and principles, weights and rate determination, etc. as determined by the Technical Specifications. Carry out related work.

It is necessary to strictly implement the “grouping plan”, and develop a local subdivided DRG group according to the unified group operation guide and the actual situation in each place. The purpose is to create a pilot "one game of chess", accurate "localization", the specific payment in line with the actual situation, so that CHS-DRG becomes the "universal language" in the field of national medical insurance.

CHS-DRG achieves full coverage of disease treatment

CHS-DRG is coded in the National Health Insurance Edition ICD-10 (including 2048 categories of disease diagnosis, 10172 suborders, 33392 items), ICD-9-CM3 coding (including surgery and operation of 890 suborders, 3666 details) Based on 1,3002 entries, all critical and short-term (within 60 days) hospitalizations can be covered.

Traditionally, it pays for a single disease. Once a complex case is encountered, the medical institution does not exceed the payment standard, and the hospitalization fee may be transferred. Otherwise, it will fall into the situation where the more complicated cases of incurable diseases are lost. The CHS-DRG payment method can basically achieve full coverage of hospitalization expenses and achieve full coverage of disease treatment.

DRG payment is significant: optimize services and reduce costs

The widespread implementation of DRG payments will have the following three major impacts:

First, promote standardized medical behavior

The implementation of the DRG paying country pilot work, changing the previous model of paying by project, shifting to paying for the disease group, and converting medicines and consumables into costs will prompt hospitals and doctors to change the past prescriptions for patients, using precious drugs, consumables and large-scale drugs. Check for unreasonable medical practices such as equipment.

Doctors will consciously standardize medical behaviors, improve the effectiveness of medical resources utilization, actively seek quality and efficiency to obtain reasonable income, and promote the dynamic mechanism of hospital operation from expansion to connotation development.

Second, medical services are transparent

Through the DRG grouping, the past clinical medical behaviors are “unmatched” into “comparable”, and how many cases are admitted to the hospital, and the difficulty is clear at a glance.

The level of treatment in the same disease group can be quantified. Medicare pays and the masses have a transparent and open platform for medical treatment.

The third is to improve the satisfaction of the people

By implementing DRG payment, we can compress and check the water in treatment, effectively reduce the “big prescription” and “big inspection”, reduce unnecessary medical expenses for the people, and enable the public to obtain more high-quality and efficient medical services and improve medical satisfaction.

The CHS-DRG payment reform will help build China's health and increase the sense of gain of the broad masses of the people.

In addition, the meeting pointed out that for cases that cannot be settled by DRG, it is necessary to further promote the multi-component medical insurance payment system based on the case-based payment of big data, daily bed-based payment and per-person payment.

With the widening of the pilot areas, CHS-DRG payment will become an important part of China's multi-component medical insurance payment system. These payment methods will coexist, make up for the shortcomings of various methods, standardize the form of medical institutions, and reduce the medical insurance fund. Unnecessary waste ultimately benefits the public.

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