The Shijiazhuang Municipal Medical Security Bureau actively carried out the pilot work of "pre-hospitalization" management

In order to effectively use medical resources, reduce the burden of medical treatment on patients, and improve the operation performance of the medical insurance fund, the Shijiazhuang Municipal Medical Security Bureau innovated the management model, combined with the actual situation of the city, and publicly selected three medical institutions from 20 alternative medical institutions, the Municipal People's Hospital, the First Hospital of the Medical University, and the Provincial Fourth Hospital, as pilots, and carried out the pilot work
of "pre-hospitalization" management from June 1, 2022.

 

"Pre-hospitalization" management refers to the diagnosis of some diseases is clear, the condition is relatively stable, and patients undergoing elective surgical treatment, due to bed shortage and other reasons, first conduct routine admission examination and examination and specialty necessary examination and examination in the outpatient clinic, and arrange formal admission
according to the bed situation.
After formal hospitalization, the cost of routine admission examination and specialist necessary examination and examination (hereinafter referred to as "advance expenses") incurred in advance is calculated together with the costs after formal hospitalization, and the medical insurance fund is reimbursed
together with regulations.
On the one hand, it has accelerated the turnover of hospital beds, so that high-quality medical resources can benefit more patients; On the other hand, it shortens the hospitalization time of patients, reduces the burden of medical treatment for patients, and reduces the expenditure of medical insurance funds accordingly, truly achieving a win-win situation for
patients, hospitals and medical insurance.

 

In order to do a detailed and practical job of "pre-hospitalization", really try out methods, test results, try out characteristics, and better serve medical institutions and patients, our bureau combined with the specific situation of many tertiary medical institutions in Shijiazhuang City, strong needs of the masses, and complex treatment, in accordance with the principle of "unified standards, standardized procedures, voluntary institutions, and pilot first", focusing on the following four aspects:

 

First, unified standards, standardize the process

 

"Pre-hospitalization" is a special type
of hospitalization between outpatient and inpatient.
It is necessary not only to solve the problem of how to include the cost of examination in the "pre-hospitalization" stage into the reimbursement, but also to deal with special circumstances
such as no actual hospitalization due to various circumstances after the pre-hospitalization.
To this end, our bureau, together with medical institutions, has formulated a unified "pre-hospitalization" management standard and process
in the city according to clinical pathways and medical insurance policies.
The first is to produce a "pre-hospitalization flow chart", which specifies the various medical procedures from the pre-hospitalization procedure to the discharge, so that doctors and patients can "see easily and understand clearly" from the beginning; The second is to clarify the specific scope and reimbursement policy of "pre-hospitalization" management, as well as the reimbursement method after withdrawing from the "pre-hospitalization" model, so that patients can spend money to "report clearly and be steadfast"; The third is to implement "one-stop" settlement, we require pilot medical institutions to carry out information system transformation in accordance with the above requirements, to achieve "one-stop" reimbursement, direct settlement, so that the people do not run the wrong road; The fourth is to formulate the "Reference Clauses for informed consent of pre-hospitalized patients", which stipulates that patients enjoy rights and obligations to comply, and medical institutions should inform them in advance, so that patients can "voluntarily choose" and avoid various disputes
.

 

Second, refine management, the implementation of "four ones"

 

The important task of the task of "pre-hospitalization" management is to explore which medical institutions, which departments, and which diseases are suitable for development, which can maximize the bed turnover rate of medical institutions and reduce the cost
of medical treatment for patients.
To this end, we put forward the work idea
of "one hospital, one policy, one disease and one policy, one disease and one policy".
The first is to implement "one court, one policy.
"
Considering the characteristics of the numerous tertiary medical institutions in our city and the different functional positioning, we propose that the medical institutions should self-declare the diseases according to the service capacity and patient needs, and carry out
the assessment and approval by the medical insurance department.
During this period, we organized clinical experts from medical institutions other than pilot institutions to evaluate
the 148 diseases declared by the three pilot medical institutions in accordance with the principle of "fairness and justice and ensuring safety".
Experts issued evaluation opinions from multiple dimensions such as the maturity of surgery and treatment methods, the professionalism and characteristics of the disease, and the coverage of patient population.

According to expert opinions, we eliminated 9 diseases, further clarified the corresponding surgical methods and access conditions for 6 diseases by medical institutions, and finally determined 139 diseases to carry out pre-hospitalization management, including 35 municipal people's hospitals, 75 first hospitals of medical universities, and 29 provincial fourth hospitals
.
The second is to implement "one disease and one policy.
"
We require pilot medical institutions to formulate their pre-hospitalization work plans, clarify internal assessment management measures and information transformation plans, and file them with
the medical insurance department.
In particular, it is necessary to clarify the specific departments carried out by each disease, the specific items included in the routine inspection and inspection, and the specific indicators such as the average hospital stay and the total hospitalization cost to be saved, which are used for self-management and post-evaluation and regulatory assessment
of the medical insurance department.
The third is to implement "one disease and one policy
.
" Before the 25th of each month, the medical institution submits the "Monthly Report on the Basic Information of Pre-hospitalized Patients" to the medical insurance department, and the medical insurance department analyzes the number of cases carried out by each disease, the cost of patients, and the reasons for withdrawing from the pre-hospitalization management, so as to lay a good foundation
in advance for supervision and inspection, assessment and evaluation, as well as the next step of disease adjustment, pilot expansion and other work.

 

Third, strengthen supervision and ensure safety

 

The implementation of "pre-hospitalization" management should not only ensure the reimbursement of "pre-hospitalization" examination costs, but also prevent the use of "pre-hospitalization" to evade the supervision
of medical insurance costs.
To this end, our bureau has strengthened the daily supervision and special inspection of pre-hospitalized patients in pilot medical institutions, carried out key inspections of violations such as false billing, excessive (repeated) inspections, imposters, outpatient hospitalization, etc.
, fully used the method of combining big data analysis and on-site inspection, conducted a comprehensive verification of the hospitalization of pre-hospitalized patients on a regular basis every month, punished medical acts that violated relevant policies in accordance with laws and regulations, and included violations in the assessment and evaluation
.

 

Fourth, dynamic management, compaction responsibility

 

The first is to strengthen evaluation and consolidate responsibilities
.
At the beginning of the pilot, our bureau established a special file for each pilot medical institution, and at the end of each quarter, the pilot medical institutions were evaluated on the actual average hospitalization days, total hospitalization costs, average hospitalization costs, pooled fund expenditures, and patients' personal burdens, etc.
at the end of each quarter, and after half a year, the overall assessment was carried out, and the medical institutions and diseases that could not meet the expected management goals of pre-hospitalization and had violations of the rules would be disqualified
from the pilot.
The second is dynamic management and timely expansion
.
According to the "Work Plan", other designated medical institutions at the second level and above in the city can also select suitable diseases according to the service capacity and patient needs, and apply for pre-hospitalization management
.
For those that meet the conditions, the handling agency shall approve the implementation
at any time.

 

Since the pilot work of "hospitalization" in our city has been carried out for more than 1 month, with the strong support of the Provincial Medical Insurance Bureau and the active cooperation of the pilot hospitals, it has achieved phased results
.
At present, a total of 206 patients have participated in the "pre-hospitalization" in advance, involving 30 departments, 72 diseases, and settling medical expenses of 4.
3836 million yuan
.
After preliminary analysis, the per capita savings of 210 yuan, the average compression of hospitalization of 2.
49 days, the average increase in bed turnover of 10-15%.

We commissioned a third party to actually survey some patients, and the satisfaction rate reached 100%, which initially realized the reform expectations
of reducing patient hospitalization costs, accelerating the turnover of medical institution beds, and reducing the expenditure of medical insurance funds.