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Recently, the three departments of Foshan Municipal Medical Insurance Bureau, Health Bureau and Social Security Bureau of Guangdong Province jointly issued a notice to make corresponding arrangements
for the city's inpatient medical expenses in 2022 according to DRG payment and the fixed settlement of employee maternity insurance inpatient groups.
Foshan is an important prefecture-level city in the Pearl River Delta, with a developed economy and a population of nearly 10 million
.
Foshan People's Hospital is a famous tertiary hospital, and Foshan Hospital of Traditional Chinese Medicine is even more famous among its peers in traditional Chinese medicine hospitals across the country with orthopedic Chinese medicine
.
In addition, the scale of some town-level hospitals in Foshan Nanhai and Shunde is not small, and the medical resources and revenue can almost be equivalent to some prefecture-level central hospitals
in the central and western regions.
In Guangdong Province, except for the two prefecture-level cities of Foshan and Shanwei, which implement DRG, the remaining 19 cities implement DIP payment
.
Therefore, Foshan's 2022 DRG payment settlement related issues can be regarded as a sample of medical insurance payment reform in a developed prefecture-level city, which is worth paying attention
to.
According to the Notice, Foshan formed the Foshan CHS-DRG Subdivision Group Plan (2022 Edition) in accordance with the norms and requirements of the relevant national DRGs, and on the premise of following the core group of the national ADRG, which is divided into 848 groups
.
DRG counts points separately:
Dual-channel drugs with higher costs and drugs that have a greater impact on the stability of DRG disease group
The Pharmaceutical Cloud Studio noted that Foshan will calculate points separately for drugs and consumables that meet the limited payment scope of medical insurance
.
The drugs are mainly drugs with high costs in the "dual-channel" drug range in Guangdong Province that have a greater impact on the stability of the DRG disease group, and priority is given to drugs related to first aid, rescue, rare diseases and malignant
tumors.
However, it should be reminded that not all dual-channel drugs are included in the DRG's separate calculation of points
.
Up to now, Guangdong Province has included 291 national drugs into the dual-channel management, and only 78 drugs have entered Foshan for separate point counting this time
.
For details, please refer to the following table: Pharmaceutical Cloud Studio combed and found that among the 78 drugs included in the DRG paid separate calculation points, there are adalimumab, bevacizumab, cetuximab and other earliest biological drugs, and there are currently many analogues on the market in China;
There are also PD-1 products, such as Cindilimab from Innovent, teripulimab from Junshi and tislelizumab from BeiGene
.
It is worth noting that last year's rare disease drug Nocinaxen sodium that entered the catalog was also among them, and after haggling through the soul, the drug dropped from the previous treatment cost of 700,000 yuan to about 30,000 yuan, greatly reducing the cost
of patients and medical insurance.
In addition, high-value consumables such as cochlear implants (domestic, imported), intraocular lenses (monofocal, multifocal, continuous visual range) and peritoneal dialysis catheterization are also expensive, affecting the stability of the disease group, and are also included in the scope
of DRG paid for separate calculation points.
High-value drugs and consumables have attracted widespread attention
in the industry in the context of DRG/DIP.
After the innovative drugs enter the catalogue through national talks, the price is still much higher than that of conventional varieties, and if there is no corresponding policy support for hospital access, use and payment settlement, it is difficult to mobilize hospitals to introduce national drugs
.
Although the state has formulated measures such as not occupying the total amount of medical insurance, not assessing the proportion of drugs, and the blessing of the dual-channel policy, the rate of national drugs entering hospitals is still low
.
Under the premise that DRG payment is based on the maximum payment standard of the patient group, high-value drugs and consumables account for a large proportion of the patient group, and it is inevitable to have many concerns during clinical operation
.
This time, Foshan included some drugs and consumables in the way of DRG payment and separate calculation of points, which can be said to reduce some of the pressure on the hospital and reduce great concerns, which provides a solution
for high-value national drugs to enter the hospital to benefit clinics and patients 。
Hospital clinical assessment under DRG payment: annual liquidation reward points
National talks, centralized procurement of drugs, and key monitoring of high-value consumables have paid attention
Foshan City has also made arrangements for the annual liquidation reward points, and the Notice shows:
According to the actual operation of the annual fund, explore the introduction of the allocation and use of drugs for national medical insurance negotiation access, the use of selected drugs in national centralized procurement, the key monitoring of the use of high-value medical consumables, the key monitoring of drug use, the utilization rate of clinical pathways, and the evaluation results of medical insurance pharmaceutical services as the basis for calculating the reward points, and determine them separately before the annual liquidation
.
The above-mentioned national talks, centralized procurement of drugs, the use of high-value consumables and drugs under key monitoring is worthy of enterprise attention, for the assessment of the use of these varieties, if completed, medical institutions will receive annual liquidation incentives, therefore, hospitals have the motivation to strengthen management
according to the assessment requirements.
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