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27 years of game, three rounds of reform experiment of China's medical payment

 Last Update: 2021-11-14
 Source: Internet
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Medical insurance and hospitals share the same prosperity and losses, and reform takes time to solve the endless problems

Picture/pixabay

Medical services have never been purely consumer goods

The relationship between medical insurance, hospitals and patients is always inexplicable

Therefore, the battle between medical insurance and hospitals has never stopped

In the payment process, their respective powers ebb and flow, and once experienced the most prominent moment of contradiction-the hospital publicly stated that it was unable to admit patients due to insufficient medical insurance coverage

The payment method has always been regarded as a lever between medical institutions, medical insurance and patients, guiding hospitals to actively improve service quality and reasonably control service costs

Many countries have experienced critical moments when medical insurance funds will collapse at any time

"The medical insurance fund does not cover the expenditure" frequently appeared in the newspapers, forcing relevant parties to explore new methods of medical insurance payment

Until October 15, 2021, the General Office of the State Council issued a "Implementation Opinions on Deepening the Reform of the Medical and Health System", which put forward the latest timetable for the reform of payment methods.

"By 2025, the proportion of medical insurance funds paid for by disease diagnosis-related groups or disease types will account for 70% of all eligible inpatient medical insurance funds

Both the reformers and the reformed are very nervous

At the beginning of the relationship: pay by project

When some patients are hospitalized for examination, they will take the opportunity to have their whole body checked, which is equivalent to an individual examination

Patients save money and hospital income is guaranteed

The initial contractual relationship established between the hospital and medical insurance is to pay for the service item, which is also the most traditional payment method

A manager of a tertiary hospital in the north said bluntly that this method is the best for hospitals and patients, "simple and direct, and encourage income generation

Under the framework of payment by service items, in order to obtain higher income from insurance balances, hospitals and doctors are willing to increase the amount of services and increase costs
.
"At that time, there were nearly 4,000 paid items in China
.
" An official of the medical insurance system said frankly that such a large volume could not be supervised at all
.

Patients can do additional examinations for a small fee, and doctors can get generous bonuses.
One consequence of this is that there are many examples of wasting medical resources
.
An example that is still frequently cited is that in 2009, 10.
4 billion bottles of medical infusion in China were equivalent to 8 slings for every Chinese person a year, while the international average is about 3 bottles
.

Patients can do additional examinations for a small fee, and doctors can get generous bonuses.
One consequence of this is that there are many examples of wasting medical resources
.

According to data from the World Health Organization (WHO), from 2000 to 2015, China’s per capita medical and health expenditure grew 6.
3 times that of Japan, more than three times higher than France and Germany, and even higher than Brazil and India.
About twice
.

From 2000 to 2015, China's per capita medical and health expenditure grew 6.
3 times that of Japan, more than three times higher than France and Germany, and about twice as high as Brazil and India
.

According to officially disclosed data, the scale of China's medical insurance fund expenditures has continued to increase, with an average annual growth rate of 15.
5% from 2009 to 2018 (see Figure 1)
.

Figure 1: Changes in the revenue and expenditure of the National Medical Insurance Fund from 2002 to 2019

From the perspective of configuration and usage, nearly 90% of the basic medical insurance fund expenditures in 2018 occurred in hospitals, and 70% of them were in hospital services
.
This means that when using payment methods to regulate and constrain the medical behavior of medical institutions, the focus should be on hospitalization expenses
.

Figure 2: Changes in per capita hospitalization fees and outpatient fees in general hospitals from 1998 to 2019

The post-payment mechanism of pay-per-project is generally considered to be one of the reasons for pushing up medical expenses
.
According to data from the World Health Organization, global health expenditure in 2018 reached 8.
3 trillion U.
S.
dollars, accounting for 10% of global GDP
.

The British medical journal "International Journal of Health Care Quality" published an investigation report on overtreatment
.
The report is based on 38 cases in ten different countries.
About one-third of the elderly in the survey respondents received many "meaningless" treatments for life extension within six months of their death
.

Similarly, the United States has also fallen into a medical cost crisis
.
The government accounts for 46% of the total health expenditure in the United States, covering approximately 100 million people
.
From the beginning of 1967, the US hospital average daily cost of services increased by 22% in 1969, the media will then medical condition described as "in the edge of chaos"
.

Project-based payment is considered to be the chief culprit of the medical crisis, and the medical insurance fund that cannot make ends meet is increasingly accused of waste
.
By 1982, the excessive increase in medical expenses had been regarded as a medical cost crisis, and the Reagan administration needed an acceptable solution
.

Project-based payment is considered to be the chief culprit of the medical crisis, and the medical insurance fund that cannot make ends meet is increasingly accused of waste
.

Thus, a global reform experiment to find new payment methods began
.

Relationship Imbalance: An Experiment in the Reform of Payment Methods

If it is said that when paying by item, the hospital and the doctor have no idea how much money is spent
.
In the subsequent exploration of payment methods, it seems to have slipped to the other end
.

"We are thinking all day about whether the money is overspread,
" said a hospital administrator in northern China
.

In December 2007, the then Minister of Health Chen Zhu formally affirmed the "total prepayment system"
.
One month later, the former Ministry of Labor and Social Security approved Jilin Province, Handan City in Hebei Province, Zhenjiang City in Jiangsu Province, and Pingdingshan City in Henan Province to be included in pilot cities for basic medical insurance for urban residents
.

Paying first instead of paying later was the mainstream thinking of China's payment method reform at that time
.
The general consensus among all parties is that this can effectively reduce the use of medical insurance funds
.

The total prepayment is a fixed amount of resources allocated to the medical department or medical system in a certain way, rather than a fixed amount of individuals or organizations, in order to control the overall medical expenditure
.
To put it simply, it is "repayment"
.

A person in charge of a certain city's medical insurance bureau understood that the total budget is a management method, but strictly speaking it is not a payment method
.
From a payment point of view, this method is very rough and even "powerless"
.

A chief doctor of a certain northern hospital still remembers that he was reminded at the end of one year not to admit patients who were too heavy to be hospitalized
.
Because the hospital's annual budget may be used up in October of that year
.

Picture/pixabay

Zhu Hengpeng, deputy director of the Institute of Economics of the Chinese Academy of Social Sciences, once said that this is to pass the pressure of controlling fees to the hospital
.
"The intention is to motivate hospitals to control costs, improve efficiency, and reduce unnecessary waste, but in actual implementation, they always attract medical and insurance fights, and patients suffer
.
"

"The intention is to motivate hospitals to control costs, improve efficiency, and reduce unnecessary waste, but in actual implementation, they always attract medical and insurance fights, and patients suffer
.
"

A report in 2013 mentioned that Ms.
Yang’s husband in Beijing was rejected by a university hospital in Beijing on the grounds of “shortage of beds” because the hospital’s “medical insurance limit has been used up”
.
The Second Xiangya Hospital of Changsha City has also publicly stated that it refuses to accept medical insurance patients
.

Zhu Hengpeng mentioned in the aforementioned article that an important reason is that medical insurance sets an upper limit for payment, and hospitals also forcibly reduce the amount of services in order to fight against it
.

It is the medical insurance that sets the upper limit of payment, and the hospital also forcibly reduces the amount of services in order to fight against it
.

A similar situation has occurred in Taiwan, China, which is in the process of exploring the reform of total prepayment
.

A questionnaire survey of 128 hospitals in Taiwan, China indicated that the vast majority of general hospital directors believe that the total budget system makes hospitals try to keep expenses within budget.
After the fixed limit is exceeded, neither the hospital nor the seriously ill patients will be compensated.
, Resulting in an increase in the phenomenon of shirking patients; 83.
8% of hospital supervisors believe that their hospitals have a certain degree of abandoning patients
.

In addition to shirking patients, a study titled "Analysis of the Impact of Medical Insurance Prepayment System on the Medical Mode of Shanghai Tertiary Hospitals" also found that under the total prepayment system, hospitals will pass on over-budget expenses to patients
.

Under the total prepayment system, the hospital will pass on the over-budgeted expenses to the patient
.

A third-class hospital in Shanghai started pilot total prepayment from 2009 to 2010.
The study took the statistics of discharged patients from the oncology department as an example and found that in 2010, the growth of per capita medical insurance expenditure was indeed declining, only an increase of 2%
.
However, the patient's self-pay ratio has increased significantly to 45%, which is much higher than the average level of 35% in China in 2010
.

The patient's medical experience is not good, and the hospital has no motivation to serve
.
Therefore, the consensus of the industry is that the total prepayment system itself is an auxiliary payment method, which needs to be superimposed with other arbitrary payment methods to form solutions suitable for different backgrounds
.

The total prepayment system itself is an auxiliary payment method, which needs to be superimposed with any other payment method to form a scheme suitable for different backgrounds
.

A document issued by the Office of the Former Ministry of Health Deepening the Reform of the Medical and Health System pointed out that in a comprehensive analysis of the course of domestic and foreign payment reforms, no payment method can "cover the world
.
"

Exploring relationships: various payment methods are here

Since the "Two Rivers Pilot Project", China has encouraged various places to explore various payment methods for 27 years, and the scene has been quite lively
.

Pay according to the type of disease gradually show its head
.
In 2004, the former Ministry of Health issued the "Notice on Launching the Pilot Work of Management of Charges by Disease Type", which kicked off China's experiment on disease-based payment and proposed 30 disease types to be piloted in seven provinces and cities
.

This notice did not propose a clear timetable, which specific diseases can be included in the disease-based fee, and the provinces will formulate rules according to the situation
.
Two years later, 4,198 hospitals in China implemented single-disease (more than five types) price limits, accounting for 22% of the total number of hospitals
.

The loophole is still quite big
.
An expert who has studied medical insurance for many years admitted frankly that the disease-based payment method only selected one type of disease or a few diseases, and the diseases that were not included were still paid according to the service.
In this way, the disease cost of the disease-based payment may be Will be transferred to diseases that do not pay by disease type
.

At that time, only one type of disease or a few diseases were selected for the disease-based payment method, and the diseases that were not included were still paid according to the service.
In this way, the disease fee of the disease-based payment may be transferred to the non-disease-based payment.
Of the disease
.

Zhejiang Jinhua tried to pay per service unit
.
This is a way to divide the parts into the same part according to specific parameters, and then pay for it uniformly
.

A few years later, Shao Ningjun, deputy director of the Jinhua Medical Insurance Bureau, concluded that the biggest shortcoming is that there is no total amount control, and one pays for each receipt.
"From the perspective of medical insurance, if there is no total amount management, even if the cost of a single case is controlled, yes.
The impact of the medical insurance fund is still great
.
"

The relationship between medical insurance and hospitals seems to have recovered
.
The above-mentioned manager of a tertiary hospital in northern China said that after a series of reforms, it has returned to pay per project
.

A vice president of a tertiary hospital in the central region said that according to the project payment, the medical insurance bureau owed the hospital a total of tens of millions of yuan over the years
.
From the hospital's point of view, medical services have been provided, and the medical insurance bureau should pay, but has not paid, so I also want to try new payment methods
.

From the hospital's point of view, medical services have been provided, and the medical insurance bureau should pay, but has not paid, so I also want to try new payment methods
.

In Shao Ningjun's view, the hospital is also very contradictory
.
On the one hand, I want to make new breakthroughs; on the other hand, I am worried that the increasingly stronger medical insurance capabilities will impose greater constraints on them
.

At this time, there is an urgent need for new effective solutions and the establishment of new rules
.
For the medical insurance department, it is urgent to control the excessive growth of the medical insurance fund, and hospitals are not without motivation
.

For the medical insurance department, it is urgent to control the excessive growth of the medical insurance fund, and hospitals are not without motivation
.

Rebuilding relationships: new rules

Shao Ningjun has been looking for more advanced technology
.
He has realized that the reform of payment methods needs to be a system, and a single payment method will not work
.

In August 2015, Shao Ningjun learned from the cooperating third-party intelligent audit team that a Drgs technology is now being used internationally, which can classify disease types
.

Of course, this is just a technology.
In Shao Ningjun's view, Drgs is just an engine, but he wants to build a car-to establish a complete payment mechanism or system
.
In the past, it was the application of a single technology, and he hopes that this time the whole can be formed into a system
.

This technology was used to manage hospitals when it was born in the United States, and it was just a "pure research
.
" In 1983, the United States, which urgently needed to solve the problem of over-medical treatment, implemented it as one of its payment reform programs
.

When Shao Ningjun heard about this technique, his first reaction was that it was a good tool for categorizing diseases in detail, which was hopeful, but he felt painful when he changed his mind, such as being unable to help determine whether a patient should be hospitalized
.

This was also a point that the medical insurance department was very concerned about at the time.
Drgs could not determine whether an inpatient case was appropriate
.
But Drgs can tell how many hospitalized cases have occurred and how many effective medical services are more advanced than unit payment
.

Picture/pixabay

"Combined with the previous reform experience, we must constrain the total amount and formulate a reasonable total medical insurance expenditure budget
.
At this time, we began to consider how to
equalize the amount of services, so we introduced points .
" Shao Ningjun said
.

"Combined with the previous reform experience, we must also constrain the total amount and formulate a reasonable total medical insurance expenditure budget
.
At this time, we began to consider how to equalize the amount of services, so we introduced points
.
"

The so-called total budget is divided into disease groups using the Drgs method, and the price is determined.
The actual hospitalized cases in the hospital are assigned points according to the divided disease groups and the actual payment, and then the specific amount of medical insurance needs to be paid according to the points
.
The core is that the total amount is set so that the overall cost will not be out of balance
.

In 2017, DRG payment was written into the medical reform document issued by the State Council
.
The pilot cities of Beijing, Tianjin, Wuxi, and Jinhua for DRG payment have officially started the DRG payment reform practice
.

Restrictions and incentives coexist, which is also the general tone of China's payment method reform
.

If the hospital has a balance, you can keep the balance in proportion, but you need to pay for the excess
.
Guo Jiayi, deputy dean of Jinhua Central Hospital, thinks that this new method sounds good now, as long as the hospital works hard, the surplus can be used by itself
.

"At that time, we were selected as the pilot, and we were also willing to support
.
" Guo Jiayi said
.

"Finance·Big Health" found in a conversation with medical insurance system personnel that everyone is sensitive to the word "controlling expenses", "It is not necessary to control costs, but everyone's consensus is that there is waste, and it is necessary to improve this situation.

" A health insurance system official said
.

Everyone is sensitive to the term "controlling expenses".
"It is not that expenses must be controlled, but the consensus is that there is waste, and it is necessary to improve this situation
.
"

New relationship: figure it out

When talking about the relationship with the hospital, Xu Weiwei, deputy director of the Zhejiang Provincial Medical Insurance Bureau, said that he is a brother, and he must clearly settle accounts.
"There are common goals, but in the end we still have to figure out the expenses
.
"

"There are common goals, but in the end we still have to figure out the expense account
.
"

In Zhejiang, reformers believe that DRGs can help them in this regard
.

There is a key factor in DRGs, the rational allocation of disease groups, that is, the grouping catalog for disease diagnosis
.
How to put different patients into different groups according to the rules
.

Shao Ningjun believes that the perspective of anatomy to a specific disease group becomes smaller
.
There are hundreds of thousands of cases in Jinhua, and there is no way to analyze them in detail
.
Under the DRGs program, it can be located on a group of patients, so there are only a few thousand cases.
Under this magnitude, it is possible to accurately understand whether there is an improper place in the entire diagnosis and treatment process
.

Under the DRGs program, it can be located on a group of patients, so there are only a few thousand cases.
Under this magnitude, it is possible to accurately understand whether there is an improper place in the entire diagnosis and treatment process
.

The hospital where Guo Jiayi is located has collected data as a pilot and conducted multiple rounds of calculations to see if the data standards can support it
.
This process needs to be constantly corrected.
For example, how to avoid being classified into a disease group of only 5,000 yuan for a type of patient who needs to spend 50,000 yuan in treatment
.

Hospitals and health departments should also accept this grouping plan
.

Fortunately, this technology is well-known to health systems
.
"We have introduced DRG very early as a means of medical quality management
.
" said the person in charge of a third-best hospital in Zhejiang
.

Picture/pixabay

However, there are too many details to communicate
.
At the beginning of the reform, Xu Weiwei spent most of his time communicating with the health system
.
At that time, the DRGs management implemented by the Zhejiang health department used the Shanghai Shenkang version, so it was proposed that the medical insurance should also use the Shenkang version
.
But the National Medical Insurance Bureau has publicly released a unified disease grouping plan
.

"Based on the version of the National Medical Insurance Bureau, we need to communicate with the health department and explain with the hospital
.
" Xu Weiwei said, and the DRG group needs to be constantly adjusted according to actual operating conditions.
For example, the cost of the elderly and children will be discovered in 2021.
Will be relatively high, to create subdivision groups
.

"Based on the version of the National Medical Insurance Bureau, we need to communicate with the health department and explain to the hospital
.
"

Xu Weiwei said, “We clean the data one at a time, the same disease, the resource consumption of different hospitals can be compared
.
Hospitals and doctors also know that excessive medical treatment exists
.
If medical institutions want to question, they must also raise questions.
Basis
.
"

As of September 2020, Zhejiang has announced 998 case groups
.
Similarly, the grouping of cases in other countries has also gone through a long period of running-in
.
The number of DRGs in Germany increased from 664 in 2003 to 1,193 in 2012
.

With disease grouping, pricing is the next step
.

Guo Jiayi believes that the international DRGs route can basically be regarded as treating the same disease at the same time
.
If the same disease is treated at the same time, then the payment between different levels of hospitals is the same
.

The exploration started again from the pilot
.
In 2016, there were seven pilot hospitals in Jinhua, including tertiary A hospitals, Chinese medicine hospitals, specialist hospitals, and township health centers, but different levels of hospitals have different package prices for the same disease group
.
In the calculation, a coefficient of variance is added
.
That is to say, taking into account factors such as different levels of hospitals, historical costs, difficulty in treating diseases, head-to-head ratio, self-expense ratio, etc.
, a coefficient of difference is set when paying
.
In the end, prices for the same disease group in different hospitals are different
.

Taking into account factors such as different levels of hospitals, historical costs, difficulty in treating diseases, head-to-head ratio, self-expenses ratio and other factors, a coefficient of difference is set when paying
.
In the end, prices for the same disease group in different hospitals are different
.

A Shanghai medical insurance expert questioned this, which is different from the essence of DRG, and even continued to follow the mistakes made before
.

Xu Weiwei once responded that in the reform of hospitalization payment, if one step is in place and the payment is made according to the same standard for the same disease group, too much force will result in greater resistance to advancement in the hospital
.

"First carry out the reform plan, and then adjust it slowly", this is also Shao Ningjun's thinking
.

The future of relationships: avoid repeating the same mistakes

Zhejiang medical insurance and hospitals can finally be said to be able to calculate a clear account
.
If we go back to the beginning of the relationship between medical insurance and hospitals, in the end, it is money that is at odds between the two
.

In the Zhejiang reform, the total budget of a single hospital was adjusted to a total designated area, that is, the total plate.
All hospitals in the area share this plate together
.
Shao Ningjun believes that predicting the total plate growth of a region, no matter how much it is, there will be a balance, "there is only so much money for everyone to spend
.
"

It is predicted that the total plate growth in a region will be balanced no matter how large it is or not, "there is only so much money for everyone to spend
.
"

This is also the current practice in various pilot areas
.
The above-mentioned person in charge of the medical insurance system in a certain central region said that the essence will not be the same as before.
The hospital clearly knows that the amount of medical insurance is not enough, and now it is competing with each other to share a big pie
.

This has caused anxiety among some hospital administrators, who worry that the total plate is not big enough and that there are too few points
.
Hospitals rely on reducing medical expenses to obtain more medical insurance balances, but some of them can be kept in hospitals.
Another is to find ways to increase the number of points for converting medical insurance funds to "divide" more medical insurance funds
.

Hospitals rely on reducing medical expenses to obtain more medical insurance balances, but some of them can be kept in hospitals.
Another is to find ways to increase the number of points for converting medical insurance funds to "divide" more medical insurance funds
.

Picture/pixabay

The managers of the above-mentioned northern tertiary hospitals discovered that "the medical expenses of some hospitals have dropped violently
.
" Another vice-president of a tertiary hospital found that in order to take a high point, some hospitals allowed a patient to be hospitalized twice, and the points were doubled after dismantling
.

They are quite worried about how much the rest of the cake can be obtained in their hospital
.
This situation is usually called a prisoner’s dilemma.
Individuals ignore the impact of their actions on the overall in order to maximize their own profits.
The sense of competition allows all individuals to provide more services, leading to a low-price equilibrium
.

This is a test of the wisdom of those in power
.
Xu Weiwei frankly, past audit focused on excessive medical treatment, overcharging and arbitrary charges, it has now become too small to prevent the use of medical services, medicines to reduce the use of supplies, and other means to try to shift critically ill patients to benefit, "which also made in terms of the health insurance sector A new challenge"
.

In the past, the focus of inspections was on excessive medical treatment, overcharging, and indiscriminate charging.
Now it has become to prevent medical institutions from using too few services, reducing the use of medicines and consumables, and shirking critically ill patients to seek benefits.

"I don't know what will happen in the future
.
" The vice president of a tertiary hospital in a certain area of central China sighed
.
Through the screen, he can feel his anxiety about the future
.

Even more disturbed are the doctors
.

"I still don't know what to do
.
" An Anhui doctor said
.
Beginning in early 2021, another payment reform pilot-DIP, is being carried out in his area, which is also a way of paying fees after converting scores according to different disease groups
.

When Zhu Hengpeng analyzed the reasons for the failure of the total prepayment, he mentioned the helplessness of doctors in the payment reform.
The dean decomposed the medical insurance indicators to them.
They were very reluctant but could only obey
.
Once there is an overrun, the doctor needs to bear the loss
.

The top three hospitals where the Anhui doctors are located will deduct 20% of each doctor’s bonus as a reserve fund
.
"Looking at the situation of medical insurance settlement at the end of the year, according to medical insurance rewards and punishments, to see whether or not to deduct, or how much", he is a little envious of his former colleagues who have resigned to private hospitals with a monthly income of tens of thousands of yuan
.

"Contradictions have always existed.
" A member of the Chinese medical insurance system described the relationship between medical insurance and hospitals as symbiosis, where all prosperity will be prosperous, and every loss will suffer.
"Reform takes time to solve the problems that arise
.
"

At the beginning of the DRG payment reform in the United States, the idea of setting 518 diagnostic payment rates for 4,800 hospitals was once regarded as an unlikely but ambitious effort
.
In Germany, it took more than ten years from the pilot DRG payment reform to the full roll out
.
In 2007, it was planned to be implemented nationwide, but it was not rolled out until 2009
.

"We also need time
.
" said the above-mentioned person from the Chinese medical insurance system
.

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