The Medical Insurance Bureau issued a notice that there have been new changes in the marketing model of machinery companies

The DRG and DIP have not been settled, and the APG has risen again.
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A few days ago, the Zhejiang Provincial Medical Insurance Bureau issued a notice on the "Three-Year Action Plan for Comprehensively Promoting the Reform of Medical Insurance Payment Methods in Zhejiang Province" (hereinafter referred to as the notice)
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Once the notice was released, it attracted a lot of attention in the medical community.
Many people in the industry said: DRG and DIP have not been clarified, and now there is APG.
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According to the notice, the three-year action plan for the reform of medical insurance payment in Zhejiang Province is in On the basis of the reform of full coverage of the DRG payment method for hospitalization expenses, we will promote the reform of the payment method of outpatient expenses combined with outpatient case grouping (APG).
The closed loop of the reform of the payment method of hospitalization expenses
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Needless to say, the DRG payment reform is to pay according to the relevant groups of disease diagnosis.
Through the form of packaged charging, drugs and consumables are internalized into the operating cost of the hospital, and finally a closed loop of payment and payment is realized, which forces the hospital to reduce costs and control consumables
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Then what is "APG"? What is the impact on the industry? According to the introduction of Zhejiang Provincial Medical Insurance Bureau, in 2022, it is necessary to comprehensively summarize the pilot experience of the reform of outpatient payment methods in the province.
According to factors such as clinical process and medical resource consumption, outpatient visits are divided into surgical operations, diagnosis and assistance 3 It has formed a unified APG payment technical specification and outpatient case grouping scheme in the whole province
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By 2023, the regional total budget will be fully implemented, the incentive and restraint mechanism will be strengthened, and the outpatient per capita contract combined with APG payment will be implemented
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By the end of April 2024, the first round of clearing work for the reform of outpatient payment methods will be completed
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To put it simply, "APG" is somewhat similar to "DRG".
According to the clinical process, resource consumption and other similarities, outpatient consultation fees, general diagnosis and treatment fees, high-value consumables, national negotiated drugs and other factors are fully considered, and outpatient services or items are considered.
Sort by APC group and pay a flat fee for each group
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Under the same conditions, the lower the cost of providing medical services or programs, the greater the balance that a hospital can obtain from medical insurance payments
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The cost of providing these services or items is no longer considered, which puts forward higher requirements on the cost control of the hospital
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Assume that according to the insured person's annual outpatient co-ordination quota (payable on a per capita basis) or the payment standard for outpatient diseases is 500 yuan, drug expenses and medical insurance expenses for inspection and testing are calculated according to the project, 400 yuan, 100 yuan can be "reserved for use"
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In the same way, if the total expenditure for outpatient inspections, services, medicines, etc.
is 700 yuan, the hospital will lose 200 yuan in principle
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Therefore, in order to avoid losses and gain balance, the hospital will reduce the expenditure on medicines and inspections, and minimize the cost
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This means that not only inpatient cases, but also medical insurance will start to accurately control the use of drugs and consumables in the hospital from the outpatient clinic.
For some relatively high-priced drugs and high-value consumables, if not necessary, they will be completely infiltrated.
"Cold Palace".
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Connecting the National Unified Medical Insurance Information Platform to Affect All Machinery Companies As the saying goes, the reform of the national medical insurance payment method depends on Zhejiang, and the model of Zhejiang's medical insurance payment reform is in Jinhua
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As early as 2020, Jinhua initiated the reform of the “APG Points Method” payment method for medical insurance outpatient clinics in the province.
By using big data to analyze the number of historical outpatient cases, reasonably calculate the average historical cost of each patient group, and form a tripartite among medical insurance, hospitals and patients.
agreed payment standards
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Cases with outpatient surgery as the main (including anesthesia, drugs, etc.
) are classified into APG for surgical operation, in which the expenses related to outpatient surgery are taken as the enrollment fee for the surgical operation, and the related inspection and inspection expenses are taken as the enrollment fee for auxiliary services
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Cases with medical drug treatment as the main part are classified into the internal medicine service APG, in which the medical drug treatment related expenses are regarded as the internal medicine service enrollment fee, and the relevant inspection and inspection fees are regarded as the auxiliary service enrollment fee
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Cases based on inspection and testing, as well as outpatient consultation fees, general diagnosis and treatment fees, consumables that require additional compensation, and national negotiated drugs, etc.
, are all included in the auxiliary service APG
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According to the latest news at the beginning of the year, the annual growth rate of Jinhua's outpatient fund expenditure dropped from 19.
4% to 10%, of which the city-level outpatient fund is expected to save 88.
81 million yuan, which has achieved remarkable results
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Therefore, the notice issued by the Zhejiang Provincial Medical Insurance Bureau stated that it will directly rely on the national unified medical insurance information platform and the DRG-related information system standards and DRG functional modules formulated by the National Medical Insurance Bureau to build a comprehensive payment digital platform in the province, and establish outpatient and medical services.
The two major digital payment applications for hospitalization realize the five functions of data collection, case grouping, payment settlement, intelligent auditing, and performance evaluation including outpatient and inpatient data collection, and do a good job in connection, transmission, use, and safety guarantee with national and provincial platforms.
Provide efficient support for the high-quality reform of the province's medical insurance payment method
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Before the end of 2022, the provincial platform will go online
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Before the end of 2023, each coordinating region shall set the rules and parameters of the DRG payment function module in light of local actual conditions
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Before the end of 2024, all coordinating regions will complete the rules and parameter settings for the outpatient payment function module
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There is no doubt that APG payment will have a significant impact on outpatient-related drugs and inspections.
With the promotion of Zhejiang Province, this kind of outpatient per capita combined with APG payment will most likely become a template for national outpatient medical insurance payment.
And it will bloom all over the country in the near future
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Obviously, this is not just an attempt and reform in Zhejiang.
With the continuous reform of the national medical insurance payment method, the goal of medical insurance after the reform is not only to control the cost of consumables, but more attention is gradually shifting to the retention of surplus.

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While the hospital achieves "cost reduction and efficiency increase", the operating model of the hospital is bound to undergo great changes
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For hospitals, while formulating the most "economical and applicable" treatment model, strictly controlling the proportion of consumption, inspection and surgery will become the focus of the future
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Correspondingly, for medical device dealers, the transformation of the hospital business model also means that the marketing model of consumables will also usher in a great change.

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While medical insurance is forcing hospitals to reduce costs, it is bound to push hospitals to conduct a new round of strict screening of distributors and accelerate industry reshuffle
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Attached original text: Municipal Medical Insurance Bureaus: In accordance with the spirit of the National Medical Insurance Administration's "Three-Year Action Plan for the Reform of DRG/DIP Payment Methods", to further promote the reform of medical insurance payment methods in our province, and to speed up the establishment of an efficient and closed-loop medical insurance payment mechanism, the provincial bureau has formulated "Three-Year Action Plan for Comprehensively Promoting the Reform of Medical Insurance Payment Methods in Zhejiang Province"
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It is hereby printed and distributed to you, please organize and implement it carefully
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Zhejiang Provincial Medical Security Bureau March 29, 2022 Zhejiang Province's three-year action plan to comprehensively promote the reform of medical insurance payment methods In order to thoroughly implement the "Opinions of the Central Committee of the Communist Party of China and the State Council on Deepening the Reform of the Medical Insurance System" and accelerate the establishment of an effective and efficient medical insurance payment mechanism, According to the "Three-Year Action Plan for the Reform of DRG/DIP Payment Methods" of the National Medical Security Administration, and in light of the actual situation of the reform of payment methods in Zhejiang Province, this action plan is formulated
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1.
The work objectives are guided by Xi Jinping Thought on Socialism with Chinese Characteristics for a New Era, adhere to the people's health as the center, and aim to accelerate the establishment of an effective and efficient medical insurance payment mechanism.
From 2022 to 2024, Promote the reform of outpatient payment methods in stages, and iteratively upgrade the reform of inpatient DRG payment methods
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At the end of 2022, complete the top-level design and information system construction for the reform of outpatient payment methods, and continue to promote the revision of the sub-group catalogue of Zhejiang Medical Insurance Disease Diagnosis-Related Groups (ZJ-DRG); by the end of 2023, all co-ordination areas in the province will fully implement outpatient per-capita The reform of payment methods in combination with outpatient case grouping (hereinafter referred to as: APG); by the end of 2024, the reform of inpatient DRG and outpatient APG payment will be realized in full coverage of the region, full coverage of expenses, full coverage of the population, and full coverage of medical institutions.
A closed-loop reform of the entire management process, and a new medical insurance payment mechanism with more reasonable medical insurance fund budgets, more scientific classification methods, stronger collaborative guarantees, and more effective resource allocation
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The work tasks focus on four aspects: expanding coverage, building mechanisms, laying foundations, and promoting collaboration.
The reform work will be advanced in stages, focusing on key points, and spiraling, establishing a sound mechanism, focusing on improving quality and efficiency, and completing the reform of payment methods with high quality.
task
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(1) Grasp and expand coverage: achieve four comprehensive coverages
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On the basis of the full coverage of the reform of the DRG payment method for hospitalization expenses, we will promote the reform of the outpatient service based on the head contract combined with the APG payment method.
closed loop of reform
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In 2022, we will comprehensively summarize the pilot experience of the reform of outpatient payment methods in our province.
According to the clinical process, medical resource consumption and other factors, the outpatient consultation will be divided into three categories: surgical operation, diagnosis and assistance, and form a unified APG payment technical specification and Outpatient case grouping scheme
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In 2023, the regional total budget will be fully implemented, the incentive and restraint mechanism will be strengthened, and the outpatient service will be implemented in combination with APG payment
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By the end of April 2024, the first round of clearing work for the reform of outpatient payment methods will be completed
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(2) Establishment mechanism: Establish and improve four working mechanisms
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In the process of promoting reform, all districts and cities should firmly grasp the core of mechanism construction, use about three years to establish and improve four mechanisms, and continuously promote the connotative and refined development of the reform of medical insurance payment methods
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1.
Improve the management and adjustment mechanism of core elements
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Highlight the three core elements of patient groups, points and coefficients, and establish a sound management and dynamic adjustment mechanism
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The DRG payment reform is based on national groupings, combined with local conditions, focusing on optimizing the relevant groups of "one old, one small and one special", and iteratively upgrades the ZJ-DRG version to make it closer to clinical needs
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Strengthen the management of patient group points to make it more reflect the labor value of medical staff and more fairness and justice
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Strengthen the coefficient management of medical institutions, effectively reflect the technical content of medical services, continue to expand the group of patients with the same disease and the same price, guide common diseases, chronic diseases, and frequently-occurring diseases to stay at the grassroots level for medical treatment, promote hierarchical diagnosis and treatment, and greatly improve the performance of medical service resources and medical insurance funds.
Improve the TCM incentive policy, establish an assessment incentive mechanism with TCM treatment rate and average cost as the core indicators and a TCM dominant disease payment mechanism based on the therapeutic value to support the development of TCM according to the characteristics of TCM services; improve the incentive policy for new medical technologies, Establish a new technology selection and withdrawal mechanism, reasonably set the difference coefficient, encourage the application of new technologies, and promote the construction of medical peaks
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Improve the performance management and operation monitoring mechanism
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Strengthen the vertical analysis and horizontal comparison of medical service behavior, establish a performance evaluation and assessment mechanism for the use of medical insurance funds, and make full use of the results of assessment and evaluation to establish an incentive and restraint mechanism, so as to truly play the role of the “bull nose” of medical insurance payment
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In accordance with the requirements of the national medical security management regulations, build a "national-province-city" multi-level monitoring mechanism, and establish an effective and efficient monitoring system
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Form a multi-party evaluation and dispute resolution mechanism
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The medical insurance departments of districts and cities shall establish corresponding technical evaluation and dispute resolution mechanisms, form a new pattern of medical insurance governance featuring multi-party participation, mutual consultation, openness, fairness and impartiality, and establish and improve mechanisms for discovery, research and resolution of disputes, and feedback of results
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Strengthen the construction of professional expert teams and evaluation mechanisms, support the dynamic adjustment of core elements such as patient groups, points and coefficients, and form an excellent environment for collective consultation, benign interaction, and co-management and sharing with medical institutions
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Establish a coordinated promotion mechanism for relevant reforms
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The medical insurance departments of districts and cities should improve the regional total budget management mechanism accordingly; coordinately promote the reform of the bed-day payment and the per-capita payment mechanism, and strengthen the pertinence, adaptability and systematicness of various payment methods; continue to explore traditional Chinese medicine by disease type 、According to the scope, standard and method of payment for efficacy, support and promote the inheritance, innovation and development of traditional Chinese medicine; promote mutual recognition and sharing of inspection results to reduce unnecessary repeated inspections; The coordinated promotion mechanism of policies and measures such as centralized procurement with volume will form a positive superposition effect; simultaneously strengthen payment review management, improve fund supervision mechanism, promote medical institutions to strengthen management, and standardize medical service behavior
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(3) Laying the foundation: Strengthen the four basic constructions
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1.
Strengthen professional capacity building
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Establish an expert database for the reform of medical insurance DRG and APG payment methods in Zhejiang Province, organize the development of a series of training courseware, and cultivate relatively fixed and strong training personnel
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Carry out training for leaders in charge, division (department) leaders and business backbones at different levels
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The medical insurance departments of districts and cities shall conduct rotation training for all designated medical institutions once a year
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2.
Strengthen the construction of information system
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Relying on the national unified medical insurance information platform and the DRG-related information system standards and DRG functional modules formulated by the National Medical Insurance Administration, build the province's comprehensive digital payment platform, establish two digital payment applications for outpatient and inpatient, and realize data collection including outpatient and inpatient data collection, Case grouping, payment and settlement, intelligent auditing, and performance evaluation have five functions, and do a good job in connection, transmission, use and security with national and provincial platforms, and provide efficient support for the high-quality reform of the province's medical insurance payment methods
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The provincial platform will be launched before the end of 2022, and before the end of 2023, each co-ordination area should set the rules and parameters of the DRG payment function module according to the local conditions
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Before the end of 2024, all coordinating regions will complete the rules and parameter settings for the outpatient payment function module
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3.
Strengthen the construction of standards and norms
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In accordance with the unified requirements of the National Medical Insurance Bureau, improve the technical standards and handling procedures within the province
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Strengthen agreement management, and clarify requirements for DRG, APG payment budget management, data quality, payment standards, audit settlement, audit inspection, negotiation, assessment and evaluation in the agreement
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Carry out performance evaluation and assessment, focusing on checking and breaking down hospitalization, high and low sets of medical groups and other violations, and at the same time attaching great importance to and preventing the emerging problem of insufficient medical services after payment
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Strengthen the application of annual evaluation results, and implement rewarding and punishing
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Strengthen the construction of demonstration sites
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The provincial medical insurance department strengthens the guidance and supervision of the construction of national demonstration sites in the province, organizes and coordinates the construction of demonstration hospitals in regions, and carries out the declaration, selection, and publicity of demonstration hospitals, and plays a typical demonstration role
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(4) Promote synergy: Promote the collaborative reform of medical institutions
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It is necessary to guide and coordinate medical institutions to focus on the coordinated reform of coding management, information transmission, quality control of medical records, and construction of internal operating mechanisms, and achieve four in place
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1.
Coding management is in place
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Use the smart medical insurance system to ensure the full implementation of 15 national medical insurance information business codes in designated medical institutions, and realize the landing application of medical insurance disease diagnosis and surgical operations, drugs, medical consumables, medical service items, etc.
Standard" to upload a unified medical insurance settlement list
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Information transmission in place
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All coordinating regions should guide and urge medical institutions within their jurisdictions to benchmark against national standards, carry out detailed implementation of the medical insurance settlement list, implement the transmission needs of data required for payment, and ensure real-time transmission of information, grouping results, and relevant management indicators.
Real-time supervision
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The quality control of medical records is in place
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The medical insurance departments of districts and cities can support and cooperate with designated medical institutions, develop intelligent medical record verification tools, carry out special inspections on the quality of medical records, and improve the completeness, qualification rate, and accuracy of medical record homepages and medical insurance settlement lists submitted by medical institutions
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The internal operation and management mechanism of the hospital has been transformed in place
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All coordinating regions should give full play to the guiding role of DRG and APG payment methods to reform the payment mechanism, management mechanism, and performance appraisal and evaluation mechanism, and promote the fundamental transformation of the internal operation and management mechanism of medical institutions.
While promoting the refined management and high-quality development of hospitals, Improve the performance of medical insurance funds
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Work Requirements The reform of the payment method of medical insurance is a fundamental reform in the medical insurance field, which plays an important role in promoting the healthy development of the medical service market.
The title of quality development and construction of a common prosperity demonstration area should have meaning
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Medical insurance departments at all levels in the province should further improve their ideological understanding, strengthen organizational leadership, improve working mechanisms, and comprehensively promote the reform of payment methods
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(1) Unify thinking and understanding and strengthen organizational leadership
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The medical insurance departments at all levels in the province should further raise their awareness, fully grasp the necessity, urgency and sense of responsibility of comprehensively promoting the reform of medical insurance payment methods, fully understand the great significance of the digitization of payment reform and the realization of closed-loop reform, and ensure that ideas, measures and actions are in place.
in place
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Medical insurance departments at all levels must form a good work pattern of "main leaders personally, in charge of the leaders in the front, and business departments to work together", strengthen systematic thinking, strengthen reform coordination, planning layout and scientific scheduling, and effectively perform main responsibilities, according to three.
The annual action plan requires the implementation of a specific action plan for comprehensively deepening the reform of payment methods
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(2) Innovate working methods and improve working mechanism
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The medical insurance bureaus of districts and cities should formulate detailed implementation rules, clarify goals, tasks, schedules, and quality requirements, and promote the standardization of outpatient payment reform
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The handling agency should formulate handling management procedures and improve the agreement of designated medical institutions, and seriously organize the implementation of reform tasks.
Among them, the provincial handling agencies should earnestly implement their responsibilities, do a good job in the implementation of the reform tasks at the provincial level, and at the same time strengthen the handling at the prefecture level.
Institutional business guidance
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Relevant business departments and units should do a good job of reform coordination to ensure that the province completes the reform tasks on time and with high quality
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(3) Strengthen publicity and guidance and create a good environment
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It is necessary to actively seek the support of local party committees and governments, strengthen communication and coordination among departments, and adopt various forms to do a good job in policy publicity and interpretation and public opinion guidance, so as to form a broad social consensus and create a good and relaxed reform environment
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It is necessary to strengthen the effect evaluation, tell the story of the reform well, use the facts to tell the truth, use the data to tell the effect, timely publicize the progress and effect of the payment method reform, and win the understanding and support of all parties in the society
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