Medical network on April 1 - from "pay later" to "prepaid", the reform pilot began to explore press disease "packaged" quota in advance. The essence of this "packaging" prepaid is set medicare pay limitation, for each disease "overruns conceit" hoops to make hospital and doctors must find ways to cost control within the limit. 

 

Since 2016, the health care reform will be on the front line of health care to control health care costs grow too rapidly. 

 

In February this year, the ministry of finance, people club department and the state development planning commission jointly issued "on strengthening the basic medical insurance fund budget management give play to the role of medical insurance fund control of the opinions, put forward the comprehensive health care reform of public hospitals, from the" first pay again pay "is not limit to" pay first, then spend money "to pay later quota in advance. 

 

"In the era of" after pay, fujian, zhejiang, guangxi and other places are using health intelligent audit system, with the help of system one by one examination of doctors' prescriptions, prevent excessive prescriptions waste of medical insurance fund. 

 

From "pay later" to "prepaid", the reform pilot began to explore press disease "packaged" quota in advance. The essence of this "packaging" prepaid is set medicare pay limitation, for each disease "overruns conceit" hoops to make hospital and doctors must find ways to cost control within the limit. 

 

But can one pace reachs the designated position will all diseases comprehensive "packaging" in advance, in order to control cost case is very rare. This is because the "packaging" in advance of the two main kinds of operation mode, press disease to pay and pay by grouping diagnosis (DRGs) have their own operation difficulty. 

 

Zhejiang jinhua has been from the beginning in July 2016, all the diseases were classified into the scope of "packaging" in advance, at present has been accused of cost effectiveness. 

 

But in the 21st century economic reporter also found that in the process of jinhua field visit due to the rules of "packaging" inconsistent with many clinical practice, and health care during debugging and pilot hospital communication is not smooth, the "packaged" debug, not in time in the doctor groups also have doubts. 

 

The premise of "packaging" of disease 

 

The disease diagnosis and treatment process of "packaging" is the precondition of quota in advance. 

 

Jinhua city business bureau deputy director of social insurance Shao Ningjun told reporter in the 21st century economy, jinhua has now in accordance with internationally accepted standards, according to the urban district 42 hospitalized 18 months before the medical establishment that decide a dot of more than 210000 cases of hospitalized patients with data, will happen all disease "packaged" into paying 595 groups. 

 

Jinhua is according to the disease diagnosis, hair disease complications, such as cost, patient age factors packaging disease diagnosis and treatment process according to the disease diagnosis group paid (DRGs). 

 

Currently adopted the way packaging try not much in the process of disease diagnosis and treatment. 

 

Among them, Beijing began to implement reforms in 2011. It is understood that the Beijing municipal health bureau first chose six 3 armour hospital tentative 108 DRGs group, give priority to with common cases, about 40% of the cases to the hospital. In addition, the early realization of this disease packaging be fujian sanming. 

 

Other health reform pilot attempts to pay system reform, mainly by macro-reforms. With Beijing, sanming and jinhua according to comprehensive factors finally packaged in different ways, according to macro-reforms main packaging is based on the clinical diagnosis of the disease. 

 

Medical service management, tsinghua university, director of the center, the Johns Hopkins university school of public health, distinguished professor Yang was told reporter in the 21st century economy, single packaging standard determines the packaging will produce tens or even hundreds of thousands of diseases. 

 

"Because of the complication the occurrence of complications, combined with limitless possibilities, human is hard to end." Yang was said. 

 

In practice, therefore, around the main choice of clinical path clear, complications, less complication disease packaging. 21st century business herald reporter observed, the state development planning commission of all previous local health news release, the number of clusters of single diseases, diseases did not break through 1000. 

 

"If it's press macro-reforms, final packaging only hundreds of diseases, quantity and too little." Yang was thought, based on clinical cases to determine the number of disease to work hard to end, management cost is too high, according to macro-reforms feasibility is poor. 

 

All choose to pay by macro-reforms rather than by the DRGs break through the limit in sino-cooperative program in advance, mostly because the latter's operation foundation. This payment method to demand higher informatization level to provide support for data analysis, also called for disease hospital specification management files, provide clear and accurate basis for disease group. 

 

But a higher current informationization level hospital concentrated in the eastern region, and the medical record management does not reach the designated position is also Shared by most hospitals. 

 

"Points method" distribution of medical insurance fund 

 

Disease after packaging, to determine the price of the disease group is no longer based on the actual costs of hospital diagnosis and treatment process, then the disease group how to determine the price? 

 

Shao Ningjun tells a reporter, composed this disease disease group price level and the cost of every hospital levels and the dynamic formation health-care spending fund budget, the dynamic pricing mechanism is called "payment method". 

 

The reporter understands, jinhua itself is a dynamic form of health-care spending budget of the year. Jinhua last year of ginseng protect personnel in the hospital the actual reimbursement funds for base, according to determine the growth rate of total amount of the fund budget. 

 

According to jinhua city human resources and social security bureau deputy director Zhou Yanxiang introduction, fund spending growth rate is based on local development level, the city hospital admissions GDP growth condition, price index, and zhejiang province issued medical determine the growth rate of total cost control target. 

 

Budget funds based on balance "Shared overruns hospital, hospital stay together" the principle of distribution between the city hospital. 

 

"Balance overruns conceit, to", in fact, the most common way is accused of health promoting hospital fee, in anhui last close of couplet of medical and health care is to distribute fund in proportion to the medical couplet body, again by internal medical couplet body to balance "to" the principle of distribution, thus achieve control target. 

 

But also have close medical reform pilot worry about Shared interests in the experience that grassroots medical institutions become big hospital outpatient service, thereby weakening its public service function, so for the last close of couplet of medical reservations. 

 

Jinhua balance "to" the advantage is that it does not need to establish medical couplet body, but through a similar system of "points" to the workload and costs in hospital and medical insurance fund market, interconnected, dynamic distribution of medical insurance fund. 

 

According to Shao Ningjun, jinhua health first according to the first 18 months of hospital treatment costs determine the reference points of each disease group, determine the method is to use the average cost of a particular disease group in all hospitals, divided by the average cost of all cases of illness group. Coefficient of the second step is to determine the cost of every hospital, the specific method is to use the average cost of a disease group divided by all hospital group, the average cost of a disease. The third step is to reference points and cost coefficient multiplication, a disease group is's hospitals can get points. 

 

According to the above method to determine in 595 patients. Each hospital's service through the points and to reflect the total amount. And all the points of the hospital and is the amount of service in the city. Points in the city and divided by the fund budget, is the value of each point. The value of each point multiplied by its points and, is the hospital can receive medical insurance fund in the end. 

 

In the service of the total points as the fund allocation and linkage core, it is difficult to reflect on the efficiency of the medical and hospital internal control of the specification. Jinhua points adjustment mechanism was introduced to this, the health care of quality, satisfaction, accounting control and the assessment results and points. 

 

According to Shao Ningjun, annual appraisal of below 85 points, and each low 1 minute, deduct the 0.5% from the total points, as incentive points. The assessment results above 90 points of the first three medical institutions, according to the weight distribution proportion of service points incentive points. 

 

The reporter learns from jinhua city social security bureau, the reform from the start on July 1, 2016, running for half a year, the hospitalization expenses of pilot hospital growth rate fell 4% year on year. 

 

Jinhua urban social security fund in 2016 spending growth rate is about 7.5%, and the development level of GDP, compared with the previous three years the average growth rate fell by 7.5%, compared with before the reform, the savings of 6.74 million yuan. 

 

Shao Ningjun tells a reporter, a reformed from July to December, 2016, jinhua all expense basic zero growth, part of the pilot hospitals for negative growth. From group, 214 DRGs group costs decline, the overall decline of 16.58%. 

 

Department of "loss" 

 

In the 21st century economic reporter to visit jinhua city central hospital, found that there are still doubts about reform in the doctor. 

 

Xiao-ying wang, director of the health department, told reporters that the hospital identification control direction, also believe that reform is helpful to hospital management, but the problem is the result of the disease group and clinical spec, can not fully reflect the cost of the hospital. 

 

Jinhua city center onset and intensive medicine department is reacting to reform more strongly. 

 

"Now as long as the patient treatment is not well I am particularly worried about, want to turn him to go to other hospital." The haematology department director He Jia told reporters. 

 

He Jia said "bad" refers to the patients with long course of disease, not out of the hospital as soon as possible. They found that, in accordance with the existing reform, patient complications, department "lose" the more severe. 

 

Severe cases of Chen Kun analysis, at present the main basis of grouping diagnosis and main diagnosis and operation is the medical record home page. He found that in the group and approved budget, the main diagnosis accounted for the proportion of big, second, third diagnosis weight cannot be fully embody. 

 

"Cholecystitis was surgery, and later appeared biliary fistula, require surgery, behind the cost is higher." Chen Kun for example. 

 

Chen Kun also found that the existing group not well reflects the length of the course of the disease. With severe craniocerebral injury patients, for example, such patients need a longer with respiratory support, but also is to use breathing machine, nerve internal medicine and surgery in general need only a day or two is removed, cost control in the low level, but in the intensive group, it was completely different. 

 

"In addition to the illness, treatment, can put the time as a weight coefficient is calculated?" Chen Kun advice. 

 

He Jia told reporters that since the reform and practice, onset because patients duration long, become the most serious losses department. 

 

"Group, I found that patients with complications of the cost is lower than patients without complications, instead of loss less, I am baffled, then understand faster because of death, but reduces the loss of the department." He Jia said. 

 

"We are going to be when economists, but also research the rules of the data, the data, but also according to patient's actual budget situation tailored, really very painful. When Chinese doctors to sink down and only from illness to communicate with patients, it is our greatest happiness." Chen Kun told reporters. 

 

For grouping is not in conformity with the clinical practice of medical record feedback, Shao Ningjun said. He told reporters, according to data from the medical record of the count rate has jumped to 4.02% from 1.53% a month, by the adjustment of grouping of reconsideration rate rose to 37.64% from 37.64% a month, but the response rate and adjust the rate of growth slowed since October. 

 

"After a period of time running, response rate and adjust the rate to peak at and then began to decline." Shao Ningjun says, this kind of operation shows that the hospital increasing importance to the problems of medical record, increasing the investment in medical record management, more in-depth understanding of DRGs grouping, a more accurate feedback. 

 

Xiao-ying wang said that only (2016) in July and August, the central hospital of the medical record complaints have more than 200, including more than 100 copies have been adopted. 

 

"We used to use intelligent audit system is to adjust for a long time, I think the payment reform is likely to last for 3 years to 5 years to adjustment in place." Xiao-ying wang said, because of this, we must attach importance to the pilot hospital feedback on health care. 

 

Accelerate collaborative 

 

Health care section chief xiao-ying wang most unsatisfactory, is hospital and health care and technical support of communication. 

 

"To the rehabilitation of hemiplegia encoding rules, for example, should have the following points in the nervous system rules, stubbornly assigned to the signs and symptoms group. Give reason is cost close to that category. Assigned to the nervous system, each case hospital to lose 1000 yuan to 3000 yuan, the symptoms and signs will lose 10000 yuan to 10000 yuan." Xiao-ying wang try to communicate, but failed to give a convincing group basis. 

 

Yang was thought, this is clinical knowledge base for the construction of the problem. Should as soon as possible to the pilot hospital experts into the knowledge base, adjust grouped according to their opinions in a timely manner. 

 

"We need to have a heart end." Xiao-ying wang care hospital of Beijing have been attempts to reform the DRGs at the time of debugging, feedback cycle is long. 

 

Shao Ningjun said at the beginning of the reform, and emphasis on both sides communication cooperation. But due to the time of third party service providers need to configure resources, communication problems need to be accelerated. 

 

In addition, Shao Ningjun in dialogue with the doctor also said many times, when the doctor just need to treat patients according to their duties, must not be losses. Because the current losses are only paper losses, at the end of this year, according to the total points real distribution of medical insurance fund, there will be a dynamic balance. As long as the hospital pay attention to control cost, standardize medical record, and eventually there is no problem. 

 

Obviously, the hospital as a self-sustaining operators, eventually will spread cost and cost control of the pressure to the various departments, various doctors. 

 

"We would also like to only care about patient care, but now it seems that only care about the doctor is not qualified for the treatment of patients." Jinhua hai-jun Chen, director of the center hospital infection branch on health care fully considering the natural rise in medical costs, regulation growth is appreciated, but he also thinks that under the premise that the hospital must be self-sustaining, doctors consider benefit is inevitable. 

 

Improve the basic work to support reform 

 

"Compared to press macro-reforms, more advanced DRGs." Yang was told reporter in the 21st century economy, DRGs packet number about 600 commonly, can cover the entire disease, than a large number of macro-reforms more feasible. 

 

Yang was thought, based on the feasibility of consideration, although a precondition of DRGs more, pay pilot reforms should still try to as soon as possible. 

 

But Yang was said, blocking the DRGs payment and clinical pathway management calls for the reform of the medical record specification for many years, the improvement of the hospital is very limited, its reason lies in its failure to directly with incentives for hospitals, hospital lack of improvement. 

 

"Last year on July 1, start the reform, from the point of big data analysis results, the quality of medical record, the hospital reasonable behavior has a positive guiding role." Xiao-ying wang told reporters, the management level of the hospital clinical pathway in general, to participate in the DRGs payment after reform, the hospital does increase to the requirement of clinical pathway management. 

 

"This means that the clinical pathway, standard medical record, and according to the DRGs payment reform doesn't have to be successively relationship." Yang was said. 

 

On March 30th, Ma Weihang tells a reporter, deputy director of the health development planning commission of zhejiang province, zhejiang province, payment for health care reform attaches great importance to the year at the end of the year has started reform work, all parts of the zhejiang pilot, in addition to jinhua, wenzhou and other places. 

 

Ma Weihang said the medicare payment reform from the premise of the hospital internal, still in zhejiang province to establish and improve the corresponding work (clinical path specification, medical record management). 

 

"If these basic work is not prepared in advance and health care are hard to pay, so we are pushing in the province." Ma Weihang said, for the evaluation of the pilot work, is currently in a simultaneous, when conditions are ripe, will gradually away.