The advent of the DIP payment era makes the people feel the dividends of the medical insurance reform

In November 2021, the National Medical Insurance Administration issued the "Three-Year Action Plan for the Reform of DRG/DIP Payment Methods".
On the basis of the initial results of the three-year pilot program, it will accelerate the full coverage of the reform of DRG/DIP payment methods.
It is clear that from 2022 to the end of 2024 The reform of DRG/DIP payment methods will be carried out in all coordinating regions across the country.
By the end of 2025, DRG/DIP payment methods will cover all eligible medical institutions that provide inpatient services
.

For the coming DRG/DIP payment era, Ying Yazhen, Vice President of the National Medical Insurance Research Institute of Shouyi Medical and head of the National Medical Insurance DIP Payment Technical Guidance Team, discussed how DIP can help the reform of payment methods, how to connect various medical insurance system reforms, and how to benefit Insured patients and other perspectives expounded her views
.

Ying Yazhen, Vice President of the National Medical Insurance Research Institute of First Medical and Head of the National Medical Insurance DIP Payment Technical Guidance Group

Joining hands with DRG to help the reform of payment methods

Joining hands with DRG to help the reform of payment methods

Paid by Disease Points (DIP) is an original payment method in China
.

It is based on big data and collects a large number of real-world cases, according to the grouping rules of "diagnosis + operation", groups cases, and pays medical insurance according to certain settlement rules

First of all, the basic grouping path and principle of DIP is based on the grouping of real cases, based on the principle of similar disease diagnosis and similar clinical process, according to the classification and coding of disease diagnosis and code and surgical operation as the standard, and the combination formed objectively through big data clustering At the same time, DIP truly reflects the changes of clinical disease types with full sample data, which can form a dynamic response with the development of clinical technology and support the development of the medical and health industry and hospitals
.

First of all, the basic grouping path and principle of DIP is to group according to real cases,

Secondly, the grouping results of DIP are more detailed and the enrollment rate is higher
.

The DIP big data method forms a natural grouping through the comparison of the whole sample data, and uses the critical value of the number of cases as the middle number, and directly takes the disease above the critical value as the core disease, a total of more than 14,000 groups, and divides the critical value The lower DIP is clustered again to form a comprehensive disease, which maximizes the needs of clinical cases for enrollment

Secondly, the grouping results of DIP are more detailed and the enrollment rate is higher

Finally, within-group differences in DIP disease were smaller

Each pilot city shall determine the medical insurance payment standard by itself based on the local medical insurance policy, the scale of the local medical insurance fund, the historical expenses of medical institutions and other actual conditions
.

In 2021, 71 national pilot cities have fully realized the actual payment according to DIP, and it has also been verified from the practical level that DIP payment is generally applicable and can be summarized and promoted nationwide to promote the high-quality development of medical insurance

In addition, Shanghai and Tianjin launched DRG and DIP pilots at the same time, as dual pilot cities, to explore how the two payment methods can be better integrated to jointly facilitate the reform of medical insurance payment methods
.

The two dual pilot cities do not carry out the reform of DRG and DIP payment methods at the same time in one institution, but determine the use of a fixed payment method with each medical institution, such as the medical institution under the Shenkang Hospital Development Center in Shanghai.

Realize the dynamic connection of various medical insurance reforms

Realize the dynamic connection of various medical insurance reforms

Since the establishment of the National Medical Insurance Bureau, it has actively carried out the state-organized centralized drug procurement and drug catalog access negotiations, fully promoted the reform of DRG, DIP and other payment methods, strengthened the supervision of medical insurance funds, and strived to improve the level of medical insurance informatization and intelligent management.
The chain is full of power
.

The characteristics of DIP payment make it dynamic connection with new medicines, consumables, service items and standards

The principle of DIP is based on the core technology of big data, using the massive data in the real world to restore the full picture of the disease, and objectively fitting the cost and price of medical services through the mining of disease characteristics and laws
.

The key of DIP is the grouping of data.

With the implementation of various medical insurance system reforms, especially the centralized procurement of pharmaceutical consumables and the negotiation of drug catalogues, the cost of medical treatment for the masses has been reduced
.

In the early stage of these reforms, there will be a process of cost connection.

In the actual payment process of DIP, as long as these items are actually consumed by medical institutions, medical insurance needs to be comprehensively measured, and the relationship between the structural changes in expenses and the medical insurance payment standards should be balanced, so that medical institutions have the motivation to provide better Medical services, without affecting the institution's disposable income
.

Guide hospitals to provide more efficient medical services

Guide hospitals to provide more efficient medical services

Under the original project-based payment method, due to the serious information asymmetry between doctors and patients in medical treatment, it is easy to lead to "over-consumption", and it is easy to breed excessive medical behaviors such as "big prescriptions" and "big inspections"
.
For example, some medical institutions tend to over-medicate, over-use drugs, and prefer to use expensive new technologies, new materials, new drugs, etc.
, resulting in rising medical costs
.
This not only causes a waste of medical resources, but also makes the insured spend more money and the medical insurance fund spends more
.

The reform of medical insurance payment methods, including DIP, allows medical institutions and doctors to return to the original positioning of treatment, and ultimately changes the medical service behavior of medical institutions and doctors through value guidance, promotes the standardization and rationalization of doctors' medical service behavior, and reasonably controls medical services.
Costs and expenses, reduce the waste of medical insurance funds, and make the most efficient use of limited medical insurance funds
.

After adopting DRG or DIP payment methods, medical institutions no longer have the urge to "over-serve", but instead try to save resource consumption and improve the quality of medical services in medical institutions
.
Hospitals need to improve the level of diagnosis and treatment, service quality, and efficiency on the basis of saving costs, in order to admit more patients and maximize benefits
.
Under the hospital's performance standards, doctors need to improve their technology to get more remuneration, give up unnecessary drugs and examinations, and avoid wasting medical resources
.

At the same time, in order to prevent hospitals from reducing service quality in order to reduce costs, the reform of payment methods will be carried out in a two-pronged approach.
While paying attention to cost management in medical insurance assessment, it will also cooperate with the health department to strengthen the attention to medical quality and safety
.
In the reform of payment methods, medical insurance emphasizes that it is health-oriented and result-oriented.
On the basis of treatment safety, the rationality of medical expenses shall be assessed, and medical insurance shall be paid according to quality
.
For medical institutions, the lower the cost, the better
.
For example, it is clearly stipulated in the DIP that the payment fees for cases with abnormal expenses should be adjusted, and the cases whose fees are lower than 50% of the payment standard of the combination of diseases are regarded as ultra-low-cost cases.
The medical insurance for these cases will be converted on the basis of the payment standard.
Then settle with the medical institution
.

Through the reform of payment methods, guide medical institutions to optimize medical service behaviors, so that people can experience more standardized services and enjoy more reasonable expenses when seeing a doctor
.
After the reform, people do not need to do the examinations when they go to the doctor, the diseases that can be solved in the outpatient department do not need to be hospitalized, the hospitalization cycle for seeing the same disease is shortened, and the service is more high-quality.
Through the above medical experience, the common people really feel The dividends of Medicare payment reform
.