Zhejiang province issued the Opinions on Promoting the Reform of the Payment Method of Provincial Basic Medical Insurance for County Medical Community, taking the lead in comprehensively launching the reform of the payment method of provincial medical community, and becoming the first province in China to promote the drGs-based payment method for inpatients.

Reporter | a static collation

Edit | zhang jing

Zhejiang province recently issued the Opinions on promoting the reform of the payment Method of basic Medical Insurance for all counties and counties (hereinafter referred to as the Opinions).

The Opinions require that Zhejiang comprehensively implement total budget management throughout the province. For in-patient medical services, payment is mainly based on DRGs points; For long-term and chronic hospital medical services, we will gradually introduce pay-per-bed per day; For outpatient medical services, we will explore the combination of family doctor contracted services and implement the per-head payment. Zhejiang will become the first province in China to introduce drGs-based payment for hospital admissions across the province.

Reform of the basic

At present, 70 counties (cities and districts) in Zhejiang province have carried out comprehensive reform, with 208 county-level hospitals and 1,063 health centers forming 161 medical institutions.

The reform target

In principle, the annual growth rate of medical insurance fund expenditure should not exceed 10%. By 2022, the rate of primary medical treatment should be above 65%, and that of county medical treatment should be above 90%.

The reform of medical insurance payment method in Zhejiang province mainly focuses on four key policies

1. Comprehensive implementation of total budget management

Total budget management is mainly to form a constraint incentive mechanism. Decided to collect on the concrete practice in accordance with the "branch, balance of payments, somewhat balance" principle, more than a year results of medical insurance fund balance of payments statements, considering the economic growth level, next year income budget, major policy adjustment and factors such as medical service quantity, quality, ability, each plan as a whole area health care department under the State Council in conjunction with the health, the financial department and the medical body led by the hospital, etc., through negotiation, determine the next annual total amount of medical insurance fund budget, control the medical insurance fund expenditure in total "cage", the annual increase in medical insurance fund spending control within 10%.

2. Focus on DRGs point payment

It is mainly to stimulate the endogenous power of the medical community and doctors to control the medical cost. DRGs points method refers to the health department according to disease type, severity, treatment and other factors, the disease is divided into several groups (group Jin Huashe 634), according to the historical data set points in each group, every hospital treatment of a patient to get the corresponding points, the medical insurance fund annual budget spending divided by the area as a whole all the hospital total points, calculate the value of each point, and then work out the cost of every hospital take-home (that is, the "medical insurance fixed point, hospitals earn workpoint").

DRGs standards are formulated by the provincial level, DRGs points are calculated by the prefectural level, and DRGs point values are determined by the overall planning area. Through the establishment of this mechanism, hospitals are encouraged to see more doctors and use more cost-effective drugs and materials, reduce unnecessary examinations, save medical costs, increase hospital revenue, and encourage hospitals and doctors to become the "double gatekeepers" of people's health and medical insurance funds.

DRGs has been a relatively mature payment method in foreign countries, but it is only carried out in sporadic regions in China. Zhejiang is the first province to promote DRGs at the provincial level in China.

3. Explore outpatient medical services in combination with family doctors' contract and pay per head to support the promotion of graded diagnosis and treatment.

The practice of paying per head in outpatient clinics means that the per head fee is allocated to the medical community according to the corresponding population in a certain area. Among them, those who sign a contract with family doctors are given priority, which not only facilitates people to seek medical treatment, but also achieves the goal of curing diseases with the lowest medical expenditure. At the same time, we will reasonably coordinate the reimbursement rates of medical institutions of different levels within and outside the region, and guide insured people to seek medical treatment at the grass-roots level in accordance with regulations.

4. Coordinated promotion of "Three Medical Linkage"

The aim is to increase people's sense of gain and security. The reform of payment mode is to adjust the medical service behavior of doctors through the system design, so that the insured people will not be affected. The Opinions fully released the dividend of institutional reform, further strengthened departmental cooperation, established supporting mechanisms, and implemented hierarchical medical treatment, so that the people can have good medical resources at home, realize the nearby medical treatment, and give preferential medical insurance policies to the patients who receive primary treatment at the grass-roots level and two-way referral.

The target of this reform is the hospitals and pharmacies in the whole province, including the medical community.

"Opinions" does not restrict the broad masses of insured people, their sense of access to medical treatment will not be affected, or as before, pay-per-project, can freely choose medical treatment.

In the long run, the reform will stimulate the internal impetus for hospitals and doctors to control medical costs, and people will spend the least money to see a doctor better at home and enjoy more reform dividends.

The reform of medical insurance payment method is an important tool to promote graded diagnosis and treatment.

The measures to promote graded diagnosis and treatment in the Opinions can be summarized as "four ones" :

A platform

County comprehensive medical reform platform

County medical community is a comprehensive "platform" to promote hierarchical diagnosis and treatment. The Opinions made an "article" on the platform of the county medical community for graded diagnosis and treatment, strengthened the efforts of the medical insurance payment side and service supply side in the same direction, and worked hard to achieve the goal of graded diagnosis and treatment with 65% of the patients at the grass-roots level and 90% at the county level by 2022.

A set of payment methods

The multi-component payment system under the total budget management

The biggest difference between the Opinions and the previous one is that the county medical community as a whole is the designated institution of medical insurance and the budget unit of medical insurance fund;

We will reform the multiple and complex medical insurance payment methods under the budget management of the total medical insurance community, and implement the mechanism of "retaining the balance of medical insurance funds while sharing the excess expenditure" for the total medical insurance funds.

The former solved the problem of hierarchical diagnosis and treatment between county-level hospitals and basic medical and health institutions, and became a family from two families. The latter solves the benefit mechanism of "releasing" the dividend of two-way referral reform, that is, the medical community can obtain the reform dividend from guiding "reasonable diagnosis and treatment" and reducing the total amount of regional medical insurance.

A range of medical reimbursement policies

Differentiated reimbursement rates for medical expenses

Three measures are proposed:

The reimbursement ratio of medical institutions of different grades (including member units of the medical community) within and outside the region should be reasonably drawn up, and the difference of reimbursement ratio between adjacent grades should not be less than 10% in principle.

Ginseng protect personnel to did not press classification diagnosis and treatment, go to what medical establishment sees a doctor outside as a whole area by oneself, should raise individual from pay scale, in principle not under 10%.

To be in hospital in the body that realizes basic-level first examine, two-way refer to be in hospital ginseng protect personnel, regard be in hospital once, no longer double computation rises to pay a line, rises to pay a line to press standard of higher grade medical establishment to decide.

A management approach

Catalogue of graded diagnosis and treatment and measures for the management of two-way referral

The Opinions proposed to study the directory of diagnosis and treatment of diseases at the county and township levels and the management of two-way referral, so as to guide patients to seek medical treatment rationally.