Registration, examination, and medicine collection are the most familiar processes of going to the hospital. During this process, if you are a medical insurance holder, every expense will be incurred after exceeding the deductible. Part of it is borne by the medical insurance fund. In other words, the medical insurance fund pays a proportion of the money we spend on medical treatment to the hospital. Starting this year, within three years, the medical insurance payment method will undergo comprehensive changes. Recently, the National Medical Insurance Administration issued the "Three-Year Action Plan for DRG/DIP Payment Method Reform" which stipulates that from 2022 to the end of 2024, all coordinating regions across the country will carry out payment based on disease diagnosis related grouping (DRG)/disease type score (DIP) Method reform work, by the end of 2025, the DRG/DIP payment method will cover all qualified medical institutions that provide inpatient services. At first glance, the reform of payment methods is a matter between the medical insurance fund and the hospital, and has little to do with ordinary insured persons. In fact, this reform is not only related to the use of medical insurance funds, but also related to the interests of insured persons. The payment mechanism is the key to improving the efficiency of the use of medical insurance funds. For a long time, my country's traditional medical insurance payment method is to pay by item. According to all the drugs, medical services, and medical consumables used in the diagnosis and treatment process, the amount is settled according to the amount used. The patient and the medical insurance fund They will bear their respective portions based on actual expenses. This medical insurance payment method is relatively easy to implement and is more in line with the actual situation of my country's medical and health system in the past. With the continuous improvement of people's living standards, the rigid demand for medical treatment is gradually released, and the disadvantages of traditional payment methods are becoming more and more obvious: it is easy to breed excessive medical behaviors such as "large prescriptions" and "large examinations". This not only causes a waste of medical resources, but also causes insured persons to spend more and medical insurance funds to spend more. "The Party Central Committee and the State Council attach great importance to the reform of medical insurance payment methods. The "Opinions of the Central Committee of the Communist Party of China and the State Council on Deepening the Reform of the Medical Security System" clarified the four mechanisms of medical insurance benefits, financing, payment, and supervision. The payment mechanism is to improve the use of medical insurance funds "The key mechanism for efficiency." Huang Huabo, director of the Medical Service Management Department of the National Medical Insurance Administration, said that the "14th Five-Year Plan for National Medical Security" clearly requires continuous optimization of the medical insurance payment mechanism. Promoting the reform of medical insurance payment methods is not only a need for high-quality development of medical insurance, but also a need for high-quality development of hospitals. It is also a need for the people to obtain higher-quality medical insurance and pharmaceutical services. In fact, the practical exploration of the reform of medical insurance payment methods has not stopped, and it has gradually developed from the initial single project-based payment to a multi-complex medical insurance payment method. According to different diseases and different medical service characteristics, we will promote the reform of medical insurance payment methods in a classified manner. For inpatient medical services, explore payment by disease type and disease diagnosis-related grouping; explore payment by bed day for long-term and chronic disease inpatient medical services; for primary medical services, actively explore the combination of capitation payment and chronic disease management. With the development of medical technology, the development of clinical pathways, and the requirements for refined management of medical insurance funds, it is imperative to explore and innovate more scientific, refined, and standardized medical insurance payment methods. Disease-based treatment and scientific pricing have forced hospitals to control costs and increase efficiency. The new DRG/DIP payment method is moving from problem solving, starting, and piloting to comprehensive advancement. The so-called DRG payment refers to payment based on disease diagnosis-related groups. That is to say, patients are divided into diagnosis-related groups with similar clinical symptoms and resource consumption based on disease diagnosis, severity of illness, treatment methods and other factors. On this basis, medical insurance will pay according to the corresponding payment standards. DRG payment began in the 1980s. Currently, more than 40 countries have applied it to medical insurance pricing or fund budgets. It is recognized as one of the more advanced and scientific payment methods in the world. After the establishment of the National Medical Insurance Administration, my country's own payment version CHS-DRG was formed based on the integration of major local versions. It has the characteristics of integration and compatibility, the most complete coverage, unified coding, clinical balance, and data guarantee. This also marks the DRG The implementation in our country has moved from decentralization to unity and gradually standardization. The so-called DIP payment means payment based on the disease score. Under the total budget mechanism, the point value is calculated based on the total annual medical insurance payment, the medical insurance payment ratio and the total score of the cases in each medical institution to form a payment standard. Each case in the medical institution is calculated. Implement standardized payments. Compared with traditional payment by project, DRG/DIP payment is a more scientific and sophisticated medical insurance payment model that can help hospitals manage costs while taking into account clinical development. "In the past, when paying according to traditional items, medical insurance paid the hospital according to the reimbursement ratio based on the total amount of each item multiplied by the unit price. The hospital would have the urge to provide more medical items to increase revenue." National Medical Insurance DRG Payment Technology Zheng Jie, leader of the steering group and director of the Beijing Medical Insurance Affairs Management Center, said. He said that after the implementation of DRG, for medical institutions, the era of relying on volume to increase revenue and expand bed size is over, and hospitals will be forced to improve quality, control costs and increase efficiency. On the basis of assessing the service quality of medical institutions, the medical insurance department shall clarify the surplus retention policy and reasonably share overexpenditures. Therefore, medical institutions will pay more attention to cost control of drugs, consumables, etc., reduce the water content in treatment, and implement a more efficient management model. In the process, patients can also avoid unnecessary medical expenses.

The new payment method can achieve mutual benefit among the three parties. According to the ideal model designed by the DRG/DIP payment method reform, the three parties of medical insurance funds, hospitals and patients should achieve a win-win situation. For medical insurance, DRG/DIP payment is more scientific and standardized, and can better optimize medical services. Limited medical insurance funds can be used to purchase higher-quality services for insured persons and improve the efficiency of medical insurance fund use. For hospitals and doctors, the new payment method will encourage them to consciously and proactively standardize medical services, control costs, and reduce waste of resources. On the other hand, it will guide medical institutions to improve their disease diagnosis and treatment capabilities and use high-quality services and technical levels to attract patients to the hospital for medical treatment. For insured patients, after the hospital controls costs, there are fewer corresponding charging items, patients spend less on medical treatment, and their personal burden is reduced. In reality, can the ideal model be realized? Before the new payment method is officially implemented, since 2019, the National Medical Insurance Administration has launched DRG payment pilots in 30 cities and DIP payment pilots in 71 cities. Wuhan, Hubei Province is one of the first batch of DRG pilot cities, and all designated medical institutions at level 2 and above in the city are included in the pilot. From January to October 2021, when the number of case combinations in the city was basically the same, the average cost of hospitalization dropped from 14,992 yuan in January to 13,712 yuan in October, and the average cost per time dropped by 9%. The adjustment of the revenue and expenditure structure of medical institutions has begun to show, and the proportion of common diseases and frequently-occurring diseases has been significantly reduced. The cumulative balance of the employee medical insurance co-ordination fund has turned from negative to positive, reversing the trend of gaps in the current year for seven consecutive years, and the risk of fund expenditure has been initially resolved. In Liupanshui, Guizhou, after the DRG payment reform, the growth rate of total inpatient medical expenses in 2021 will decrease by 2.51% compared with 2019, and the growth rate of hospitalization expenses paid by the city's medical insurance will decrease by 8.87% compared with 2019; at the end of 2021, the average hospitalization expenses for urban and rural residents will decrease from 6725.07 Yuan dropped to 6,385.09 yuan, a year-on-year decrease of 5%; the average hospitalization cost of urban employees dropped from 10,572.79 yuan to 8,342.34 yuan, a year-on-year decrease of 21.09%; the average hospitalization days dropped from 9.99 days to 9.21 days, a year-on-year decrease of 7.8%. Ying Yazhen, deputy director of the National Medical Insurance Research Institute and vice president of the China Medical Insurance Research Association, believes: "The implementation of DRG/DIP payment will effectively change the long-term shortcomings of passive payment of medical insurance, extensive hospital development, and heavy patient burden for medical treatment. It will have a negative impact on the three parties. In short, it is a mutually beneficial and win-win reform.

""People's Daily" (Page 02, February 13, 2022)