DRG rules on medical service will continue to change form
DRG rules on medical service will continue to change form
On October 23 October 29, the national health care DRG grouping and technical specification for payment after the release, the related rules of DRG pilot finally clear, grouping, weight, rate and payment standards, settlement rules and regulation the five part is the core of the rules.
For the market, a better understanding of the rules and make strategy according to rules is the key.
First of all, the group's main principle is established 376 ADRG (
Group of the model, allow segmentation under ADRG again.
Mainly consider China gap is larger, if directly with national coverage of DRG grouping, may impact on the formation in parts.
Rules for segmentation method to do the detailed provisions, mainly from the variation coefficient, individual characteristics and severity of disease and so on three aspects to consider.
Future provinces on the basis of the DRG grouping and combined with local rates determine the final payment standards will also be different.
But with the core of the benchmark DRG will make their respective deviation not too big.
Along with the advancement of the pilot, according to the result of practice, the segmentation method of DRG might have continued to adjust.
With the implementation of the DRG, grouping mode will promote the hospital make more deal with, so the payer has brought certain test.
Like Germany after the implementation of DRG, the complexity of diagnosis and treatment of patients with clinical PCCL (
On, a huge jump from the FFS to PPS.
Jump is not the main reasons for the hospital treated patients is more complex, but in the original project paid under the premise of health care is a bed, pay, the importance of PCCL is low, especially the secondary diagnosis only as the form of additional treatment fees.
But under the DRG paying, because PCCL as the main indicator of severity complication, hospitals have an incentive to push up the score, in order to improve the cost of the DRG weights, thereby gaining more reimbursement amount.
Secondly, on the adjustment of the weight, is the trend of reform step by step, gradually abnormal patterns of medical services.
The large proportion of the current Chinese medical service medicine supplies, despite the cancellation of drug addition and medicine accounted for the inspection, but drug plus inspection and material costs are still high, especially in recent years, high grade hospital through health material drug sales revenue decline.
Public tertiary hospital from 2013 to 2017 increased health materials of income, up from 11% in 2013 to 14% in 2017, is among the highest in the hospitals at all levels.
Secondary hospital and primary hospital only 7% and 3% respectively.
And tertiary hospitals in medicine than the decline in market environment, health supplies of rising, this prompt tertiary hospitals for more complex treatment, on the one hand, also prompt large hospital in the case of drug income received limit, will turn to other, more can create high income, and health material is one of the important aspects.
Reform in order to reduce the resistance and the weight of the DRG data source mainly by historical data method, rather than the cost of operation method.
Historical data method is based on a certain period of time before,
As a reference for health care and personal at its own cost, without considering the cost is reasonable.
Homework cost method is based on clinical pathway to calculate the cost of each disease group.
Taking historical data method because the prices of Chinese medical service real was down for a long time, resulting in medical service attached to the product for a long time, which ultimately led to the distortion of the medical service price.
Packaged products and services price calculation is to admit that the past medical service value underestimate the problem, not only reduces the resistance of reform also laid the groundwork for future according to the cost of operation.
Historical data method, while helps DRG tool rapid promotion, but product factors gradually stripped out of the medical service is the ultimate goal.
The main way is through the pilot to promote the process of cost weight adjustment, effective implementation in place for a period of time after the final form of medical service health care pay a price.
Weight adjustment methods are divided into three types: the first is how the consumption of resources, based on the medical, nursing, medical, drugs and consumables, to adjust the management of the five categories of actual cost.
The second is to increase the diagnosis and treatment is difficult, high medical risk weights of DRG group.
DRG after implementation, due to the high risk group of larger consume resources, could have on the cost of the hospital, the hospital unluckily things happen from time to tome, for critically ill patients to drive down the low risk group weight as well as the practice of implementation of DRG.
The third is the adjusting for health care goals, from the perspective of guaranteed basic, also is the request to increase the weight of expectations and reduce the weight of low-tech disease.
Again, on the rate calculation is based on the total budget.
DRG after implementation, the hospital in order to control costs, tend to allow the patient to hospital early, resulting in the readmission rate rise, especially in order to meet group cost limit, often let the patient discharged from hospital readmission after, this reduces the DRG effect on charged fees.
And so budget limits the total hospital operating room, due to the caps the total control of the hospital by having the patient repeatedly admitted to hospital for more revenue will only squeeze to other income, do more harm than good.
Moreover, some countries not only implements the total budget for hospital, also implement the total control of some diseases and service, refinement of the total in a certain extent, reduce the weaknesses in the DRG implementation.