Medical network - April 5 relative to set the price of medicine health care payment, we will deepen reform of the pharmaceutical and health care system comprehensive implementation of the provincial scheme, payment for health care reform is more focused on press macro-reforms, which according to the disease diagnosis related group of style (DRGs), which is mentioned in several provinces. 

 

Data according to the planning commission official website, 2016 18 third rate in Beijing hospital routine inspection using DRGs and part of the county hospital hospital evaluation on the application of DRGs, guangdong, Inner Mongolia, jiangsu, jiangxi, sichuan, yunnan and other 6 provinces (area) has been carried out according to the analysis of the hospital, in the province has set up a platform for performance evaluation of DRGs. Thus, at present the DRGs is more as a way of hospital daily supervision and evaluation in the implementation of. 

 

In the medicare payment reform "prepaid", under the trend of DRGs is seen as a more scientific method of payment in the future. DRGs, then, whether can really solve the "prepaid" hospital "pick light patients, pick profitable" ills? If the medical insurance cost is not enough? 

 

DRGs struggling for 5 years 

 

Looks beautiful, fully implemented is unclear 

 

So-called press disease group (DRGs), is a kind of packaging pay system, is currently in the United States, Germany, Australia and so on more than 30 countries and regions, is the payment method is internationally recognized more scientific and reasonable payment of medical expenses. 

 

Press disease group (DRGs) paid mainly according to patients' age, disease diagnosis, complications, complications, treatment, disease severity and curative effect of many factors, such as the diagnosis, treatment, medical expenses, hospitalized patients of similar points into the quota for some disease group. 

 

In fact, Beijing has started in 2011, part of the designated hospitals pay by grouping disease (DRGs) pilot work, the first batch of pilot hospital of Beijing university people's hospital, Peking University third hospital, Beijing friendship hospital affiliated to the capital university of medical sciences, Beijing chaoyang hospital affiliated to the capital university of medical sciences, xuanwu hospital, capital medical university, Beijing tiantan hospital affiliated capital medical university. Visible from pilot hospital, DRGs was more in tertiary hospitals, mainly involved in the hospital medical service, the quality performance evaluation work, 2 class hospital may only preliminary have the requirement of application of DRGs. 

 

Released by the city level 2 above hospitals from 2015 Beijing DRGs (diagnosis related groups) to evaluate the results of the two important indicators, the difficulty of diagnosis and treatment of difficult diseases (CMI) difficulty coefficient disease and to cure the disease "breadth" (number of sets of medical records covering the DRGs) can be seen, the role of the second class above hospital is more solve the intractable diseases, especially need complex surgical disease, these diseases often need to be hospitalized, the basic is consistent with the goal of diagnosis and classification. 

 

At Beijing DRGs payment pilot payments, ginseng protect personnel to pay part includes hospital pay below fees, top line specified in the above fees, health care, individual in proportion to the expenses; Disease group quota standards and ginseng protect personnel to pay the costs of health care related difference shall be paid by medical insurance fund. 

 

Beijing group differences were smaller, the number of cases of relatively concentrated 108 disease group for the pilot range of diseases. Shown in the table below, Beijing 2011 rules, 108 diseases in all kinds of norm pay more than $100000, to pay the highest amount of DRGs is coronary artery bypass, not with PTAC with cardiac catheterization and operation for 94800 yuan. Quota pay standards are mainly concentrated in 5000 yuan to 50000 yuan between. 

 

 

 

The average hospitalization days, only in the hospital with more than 25 days DRGs is brain dysfunction important complications and associated with disease, standard is 25.44 days. The average hospitalization days were mainly between 10 to 20 days, not in the hospital for five days following the standard. 

 

Published in 2015 from Beijing to treat disease scope breadth rankings, tertiary hospitals in the operation of the medical records covering the DRGs group number about 650. 

 

Given grading medical safeguard mechanism a variety of measures, such as follow-up to establish positive approval is expected to more than 10 days in hospital patients with good prognosis in the future will be referred to the vertical cooperative medical couplet body, with total health care payment model calculation, which is the key point is to conform to the provisions of the referral hospitalized patients can continuous line of computing starting process was established, in the guangdong province deepening comprehensive reform of medical care system implementation plan "visible in guangdong in establishing relevant supporting measures. 

 

Given the DRGs need technology, information system and some of the standard cost and total cost accounting basic work, such as short-term national push harder, is expected in the near future are mainly in Beijing, Shanghai and other good information system and technical conditions of the big cities to explore and for future implementation of standards. 

 

Total amount in advance or DRGs? 

 

If the medical insurance cost is insufficient, which way is "patient" 

 

For hospital services, past medical insurance payment is take the project to pay. According to the project payment will lead to the provider will be as much as possible to provide relatively high price of the project (" profitable "), or even unnecessary services (" excessive medical treatment "), as far as possible to provide a low price of the project. And this is also a "medicine cure" the root cause of the "price distortion", therefore, it is not enough to control drug payment standard. 

 

Future reform take total prepaid or DRGs is still not clear, however, from "pay later" to "prepaid" basic clear trend. 

 

Total in advance is a kind of typical "prepaid", in the service before the buyer in accordance with the standards of fixed in advance (or in an organization, or to a service object of the measuring unit) will be relatively fixed sum of money allocated to the service provider. Either by an agency in the past on the basis of the total cost incurred in the history of the real amount shall be paid in advance, or implement "capitation payment" on the basis of the total in advance (= total reward by head count), financial risk is transferred to the service provider. In order to keep the balance of payments, the service provider will have the biggest driver of cost savings, appear even "choose" patients, reduce the necessary service and so on. 

 

Hospital once executive pay disease diagnosis related group (DRGs) payment, if you have a clear diagnosis, patients with the disease service in accordance with the buyer in advance decided based on different disease diagnosis related standard of cost classification grouping paid (usually according to the national or regional diagnosis related group estimates the average costs) and allocated to the supplier. This is a kind of conditional prepaid system, financial risk borne by the service provider and the purchaser jointly. Take this payment, because it is according to different kinds of diseases in the treatment of different input costs and set a different payment amount, so although service providers will have the power and pressure to control costs, but the cost of pressure is not as big as prepaid total cases, effective regulation can prevent and reduce the "diagnosis" and "select" disease patients, rejection, the phenomenon of critically ill patients, so as to let the supplier control costs and ensure quality. 

 

Now many areas of social security fund in order to ensure that it is not the bottom of the "wear" and to the hospital to take low quota time all fee or the annual total cost control, cost overruns won't pay for the crude, vulgar, many hospitals are policy makers, as spending approaches charged fee standards (usually around October each year), the hospital began to health care costs than shuffle patients of social security. Thus, when the policy goal is to control the medical treatment cost, foreseeable take total prepaid can yet be regarded as a kind of effective method, but the problems will be monitored the perfunctory response, inadequate service. 

 

And DRGs can prompt the supplier both cost and quality, and the implementation of the DRGs can reversed transmission hospital for based on actual definite diagnosis and reasonable cost calculation of compensation must carry out the standardization of clinical pathway and informatization construction, which in turn will help the payer is dynamically adjusted to be more objective, scientific, precise, payment standard and implement effective supervision. So who planning commission tend to be in hospital service is paid according to the disease diagnosis related group (DRG) approach as the foundation, in order to pay according to the project, according to the performance pay way to add the new compound payment system. 

 

But, whether to take total prepaid or DRGs, very key point is that each year disposable medical institutions of medical insurance cost is match with people's increasing clinical demand. If the medical insurance cost is insufficient, inadequate service is inevitable, so more is to promote the role of DRGs and disease treatment informatization subtilized the hospital management level. 

 

DRGs implementation is no longer "Wolf" 

 

When drugs are no longer income but cost, drug firms must be under pressure 

 

Released in May 2016, the health development planning commission on printing quality of hospital medical record home page data fill in specification (provisional) and hospital medical record home page data index (2016 version) quality management and control, in reference to use disease diagnosis related group (DRGs) areas of hospital performance evaluation, should be used in clinical ICD - 10 and clinical ICD - 9 - CM - 3. 

 

Who planning commission data standardization management through the clinical diagnosis and treatment of "four unification", unified medical record home page written specification, classification of diseases coding, unified operation code, medical terminology, promoting medical information in the industry, interconnection, barrier-free applications, which will pay for according to the disease diagnosis related group reform (DRGs) laid the foundation. 

 

In October 2016, the medical quality management methods, including the medical quality management tools including disease diagnosis related group (DRGs) performance evaluation, as realize the goal of medical quality management and continuous improvement measures adopted by the, method and means. That means the DRGs will be medical institutions of quality inspection standards, performance appraisal will strongly promote medical institutions to carry out the DRGs. 

 

In December 2016, the health development planning commission issued the notice about the clinical path implementation related diseases, a total of 1010 clinical pathway has been released in the Chinese medical association website, provide the reference for the family planning administrative department of public health and medical institutions to use, and require reasonable estimates of single macro-reforms, through clinical path according to the disease diagnosis group pay pay (DRGs) payment payment standard, promote reform of payment. 

 

From the point of the policy, countries are committed to promoting the DRGs, the currently executing bottleneck temporarily difficult in clinical pathway. 

 

For drug companies, the medical service price paid under the direction of reform, the drug will be a cost rather than income, medical institutions for choosing drugs will more and more attention to cost performance (drug economics factors). Given the chemical medicine generics can often refer to foreign guide, eager to prove themselves in or clinical value in prescription drugs, more often sign up is the independent research and development of new medicines and proprietary Chinese medicine in our country.