"Chinese Expert Recommendations for the Diagnosis and Treatment of Acute Cerebral Infarction under DRG/DIP Payment Method" released, deepening medical reform and benefiting the people!

The reform of medical insurance payment method is an important measure to deepen the reform of the medical system and medical security system, standardize the diagnosis and treatment behavior, reduce the burden of the people and ensure the smooth operation of the medical insurance fund, and the implementation of diagnosis-related group (DRG) and diagnosis-treatment package (DIP) payment is an important part of the implementation of
medical insurance payment reform.
The new situation of medical reform has brought new challenges to the sustainable development of hospitals, and also put forward new requirements
for the standardized diagnosis and treatment and management of medical staff.
As acute cerebral infarction is the most important disease causing death and disability in adults in China, there is still a lack of consensus on diagnosis and treatment under the background of the new medical reform in China, so it is imperative to formulate guidance and treatment recommendations for acute cerebral infarction under the DRG/DIP payment method
.

Implementing medical insurance reform and formulating consensus on diagnosis and treatment under new payment methods are important measures

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On December 29~31, 2022, the "Chinese Stroke Conference and the 12th National Cardiovascular and Cerebrovascular Disease Forum" jointly organized by the National Center for Neurological Diseases, the Chinese Preventive Medicine Association and the Chinese Geriatric Health Care Medical Research Association was grandly held
online.
On the 30th, at the "Thematic Forum on the Prevention and Treatment of Cerebrovascular Disease", the "Chinese Expert Recommendations for the Diagnosis and Treatment of Acute Cerebral Infarction under the Diagnosis-Related Groups or Diagnosis-Treatment Package Payment Method" (hereinafter referred to as the "Recommendations") formulated by the Physician Branch of the Chinese Medical Doctor Association organized by the domestic cerebrovascular disease related experts to establish an expert recommendation writing group was officially released
.

Professor Zeng Jinsheng said that the Recommendations are of great significance to how to standardize the prevention and treatment of cerebrovascular diseases in the new environment

Professor Zeng Jinsheng, corresponding author of the Recommendation, Vice President of the First Affiliated Hospital of Sun Yat-sen University and leader of the Department of Neuroscience, introduced the entire background and writing process
of the Recommendations on behalf of the Cerebrovascular Disease Expert Group of the Neurologists Branch of the Chinese Medical Doctor Association.
Professor Zeng Jinsheng said that stroke is the most important cause of disability and death in China's population, especially acute cerebral infarction, which accounts for more than 80% of inpatients in neurology, but how to standardize the diagnosis and treatment of acute cerebral infarction under the DRG/DIP payment method, there is no relevant consensus and guidelines
.

Ischemic cerebrovascular disease has only "cerebral infarction" and related diagnostic entries in ICD-10 (International Classification of Diseases, 10th edition), and the background of the formulation of this Recommendation is not only related to the classification of cases, but also to
national policies.
Professor Zeng Jinsheng said that as early as 2017, China issued the "Opinions on Deepening the Reform of the Medical Security System", which specifically mentioned the diversified and composite medical insurance payment methods based on payment according to the type of disease, of which the most important is the DGR/DIP payment method
.
Therefore, under the leadership of President Yu Shengyuan, President Xie Peng and President Chen Xiaochun of the Physician Branch of the Chinese Medical Doctor Association, the expert group formulated this Recommendation for the first time
.
Its purpose and significance is to strictly diagnose and treat acute cerebral infarction, standardize the filling in of the first page of medical records and medical insurance settlement lists, and cooperate with the medical insurance department to promote medical insurance reform
.

Strengthen the awareness of DRG/DIP payment and change the concept of disease diagnosis and treatment

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Professor Ma Luning of the First Affiliated Hospital of Sun Yat-sen University analyzed the overview of DRG/DIP payment methods from the perspective of medical insurance administrators

The Recommendations point out that DRG is divided into several diagnostic groups
based on factors such as age, disease diagnosis, and comorbidities.
The DRG payment method means that on the basis of DRG, the medical insurance management department no longer pays the medical institution according to the actual cost of the patient in the hospital, but pays according to the payment standard of the diagnosis-related group that the case enters
.
DIP is a disease-based payment
under the total budget.
The DIP payment method means that the medical insurance management department forms a payment standard based on the score of the disease and the value of the point value, and realizes standardized payment for each case of the medical institution, and no longer pays
the cost of medical service items.
DRG/DIP is a payment method
based on the type of disease, based on the medical insurance settlement list, and based on the total medical cost as the control goal.
At the same time, the implementation of DRG/DIP payment also needs to adhere to the integration of payment and supervision, and severely crack down on fraud and insurance fraud
such as high arbitrage value.

Expert advice

• During the diagnosis and treatment of cerebral infarction, you should be familiar with the basic concepts and key points of DRG/DIP payment methods

  
  

• Clinicians should pay attention to establishing cost awareness, and on the premise of ensuring medical quality and safety, reasonable diagnosis and treatment, and eliminate violations

  
  

Following clinical guidelines and treatment paths is an important means to balance quality control costs

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Professor Yang Shanshan of the First Affiliated Hospital of Harbin Medical University interpreted the diagnostic process and principles of acute cerebral infarction under DGR/DIP mode

Under the DRG/DIP payment method, in order to better fit the differentiated payment of the medical insurance system, the main diagnosis of acute cerebral infarction and the diagnosis format of complications or comorbidities should be strictly standardized, so it is necessary to clarify the relevant concepts and principles
of diagnosis.

The primary diagnosis refers to the disease identified by the medical institution as the main cause of the patient's hospitalization, and the other diagnosis refers to the disease during the patient's hospitalization that affects the treatment received and/or the length of the hospitalization.

The main diagnosis should follow the principle of sequencing and classification, and avoid "high compilation and high dependence", that is, ordinary cerebral infarction diagnosis cannot be classified as severe cerebral infarction or hypochondriac comorbidities/complications
.
Complications refer to diseases that are directly caused by the primary diagnosis and have a causal relationship
with the primary diagnosis.
Comorbidities refer to diseases that are not directly related to the main diagnosis and complications, but have a certain impact on the course of this medical treatment, excluding previous diseases
that do not affect this hospitalization.

Expert advice

• The main diagnosis of acute cerebral infarction directly determines the relevant grouping of patients for the diagnosis of core diseases, and should be as accurate and detailed as possible

  
  

• The complications or comorbidities of acute cerebral infarction should be filled in in order according to the principle of severity from severe to mild and consumption of medical resources from more to less

  
  

• Clinicians should communicate closely with the case coding department to ensure the accuracy of the main diagnosis and complications or comorbidities of acute cerebral infarction

  
  

• Although the DGR/DIP payment method has not yet been implemented in emergency and outpatient clinics, it is still recommended to fill in the diagnosis and related operations of acute cerebral infarction in the emergency green channel, which is conducive to the improvement of payment management in the future

  
  

Professor Dang Chao of the First Affiliated Hospital of Sun Yat-sen University interpreted the green channel diagnosis and treatment and hospitalization recommendations for patients with acute cerebral infarction

DRG/DIP payment advocates the rational use of medical resources and limits excessive diagnosis and treatment
.
Therefore, the primary problem facing the diagnosis and treatment of acute cerebral infarction is how to balance the contradiction
between improving the quality of diagnosis and treatment while reasonably controlling medical costs.
At present, strict adherence to clinical guidelines and implementation of clinical pathways are considered to be an important means
to balance this contradiction.
The inpatient treatment process of acute cerebral infarction mainly includes general management and specific treatment
.
Specific management requires selection of therapies such as intravenous thrombolysis, bridging or direct endovascular intervention, antiplatelet therapy, anticoagulation, and fibrillation and volume expansion to restore blood perfusion or prevent recurrence
, depending on the patient.
In addition, China's guidelines also recommend the use of drugs
including human urinary kinikrein to improve the collateral circulation of cerebral blood flow.

Human urinary kininase is a class I chemical new drug
developed in China to improve cerebral blood circulation.
The "Guidelines for the Diagnosis and Treatment of Acute Ischemic Stroke in China 2018" formulated and released by the Neurology Branch of the Chinese Medical Association and its cerebrovascular disease group pointed out that in addition to restoring macrovascular recanalization, the degree of compensation of cerebral collateral circulation is closely related to the prognosis of acute cerebral infarction, and it is recommended to carry out further clinical research to find drugs or methods
that are conducive to improving cerebral collateral circulation.

Expert advice