2024-07-24
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Over the past three years, the wave of DRG/DIP payment method reform has swept across more than 90% of the country's coordinated regions.
This disruptive payment reform affects every clinician. “Holding a scalpel in one hand and a calculator in the other” has become the first experience of almost every clinician when adapting to this reform.
When clinicians first start working with DRG/DIP, they are often trapped by the fact that the DRG/DIP grouping scheme is not scientific enough.
The disease groups of the internal medicine department are complex, and the department is always losing money; the surgical department has many new technologies, but DRG grouping is not included and often cannot be used; the diseases of the hematology department are complex, and the disease grouping is rough, so the performance of the whole hospital is often at the bottom, and the income of doctors has also plummeted... In the past three years, the voices from the clinic often end up with one question: "When can the DRG policy be slightly modified?"
On July 23, the National Healthcare Security Administration held a press conference to introduce the DRG/DIP 2.0 grouping scheme.
"Health News Consulting" noted that compared with the previous version of the grouping scheme, the core grouping (ADRG) of the DRG (version 2.0) grouping scheme was upgraded from 376 groups to 409 groups, and some disease groups in the previous version were optimized and refined; the DIP grouping scheme (version 2.0) includes 9,520 core disease groups, which can cover more than 95% of hospitalized cases.
According to the relevant notice, the coordinated regions that newly implement DRG/DIP payment in 2024 will directly use the 2.0 version of the grouping plan, while the coordinated regions that have already implemented DRG/DIP payment should complete the preparations for switching to the 2.0 version of the grouping before the end of the year and start using the 2.0 version of the grouping plan in 2025.
It is worth noting that the release of the 2.0 grouping plan is also accompanied by an emphasis on a number of supporting policies, including a special case negotiation mechanism, encouraging fund advance payments, and improving the negotiation and consultation mechanism.
Can the optimization and upgrade of this grouping solve the "complaints" of clinical doctors?
According to the Disease Group (DRG) Payment Scheme Version 2.0, some disease groups in the core groups have been refined.
For example, in the previous version of the core grouping, there was only one grouping, "heart transplantation", but in the grouping scheme of version 2.0, "heart transplantation" was divided into two groups, "heart transplantation" and "heart-lung transplantation".
According to the press conference, the DRG 2.0 version of the grouping focused on optimizing and improving 13 disciplines where clinical opinions are relatively concentrated, such as critical care medicine hematology and immunology, tumors, burns, oral and maxillofacial surgery, as well as combined surgery and complex surgery issues.
Before the official release of the 2.0 version of the grouping scheme, many researchers in the medical insurance field told "Health News Consulting" that the new version of the grouping scheme will definitely refine the groupings, because the previous versions 1.0 and 1.1 of the grouping schemes had some problems that were not close enough to the actual clinical situation, so they will be updated based on clinical calls and demands.
In April 2024, the National Health Insurance Administration held five seminars, invited medical institutions to participate, and listened to opinions on DRG/DIP grouping, medical insurance fee settlement, and coordinated reform. These opinions and suggestions also helped to form the 2.0 version of the grouping plan.
A health policy researcher pointed out that based on international experience, the medical insurance department itself will monitor hospitals that implement DRG and observe changes in costs during the implementation of DRG. When the monitoring reaches a certain level, the DRG grouping plan will be adjusted.
Regarding the disadvantages of insufficiently detailed grouping, a former practitioner in the medical information industry in the DRG field once said that, for example, some obstetrics and gynecology hospitals have expressed dissatisfaction with the grouping in the neonatal field.
In the previous version, the number of surgical groups in the neonatal-related grouping was very small, and only three types of surgeries were divided - one cardiovascular-related surgery, one abdominal surgery, and one other surgery.
This results in many complex surgeries (such as neonatal head surgeries, which are both complex and costly) being classified as "other surgeries". The pricing for this group of other surgeries is generally not too high, and the volume of such complex surgeries performed in specialized hospitals is relatively high. This results in these hospitals losing more money the more surgeries they perform.
"Health News Consulting" noticed that in the 2.0 grouping plan, the number of neonatal-related surgery groups increased from 3 to 4, with a new grouping of "complex surgeries other than cardiovascular surgeries for newborns (age <29 days)". This seems to be a response and improvement to the above-mentioned problems. However, the effectiveness of such grouping and whether it can solve the difficulties related to obstetrics and gynecology hospitals still needs to be implemented by local medical insurance bureaus.
A person close to the DRG National Pilot Steering Group said that the 2.0 version of the grouping scheme responded to the clinical call for refinement and optimization of groupings, but it is unrealistic to fully meet all clinical expectations because the essence of DRG is to gradually standardize non-standard things according to standardized rules.
"If we follow clinical thinking, disease groups can be infinitely subdivided, which would lose the original meaning of DRG."
"Health News Consulting" noticed that a detail in the notification related to the 2.0 version of the grouping scheme was subtly different from the notification related to the 1.0 version of the grouping scheme.
The CHS-DRG sub-group is a further refinement of the 376 core groups in the National Medical Insurance DRG (CHS-DRG) Grouping Scheme and is the basic unit of DRG payment. It can be understood as a reference standard for the sub-groups formulated by the state.
In the notification related to the 1.0 version of the grouping scheme, the requirement is that each pilot city should refer to the grouping results of the CHS-DRG grouping to formulate local DRG groupings. In the notification related to the 2.0 version of the grouping scheme, the National Health Insurance Administration requires that the unified planning areas that newly implement DRG/DIP payment in 2024 directly use the 2.0 version of the grouping scheme.
Simply put, in the 1.0 era, the national medical insurance department encouraged local governments to establish DRG subdivision groups that were in line with local characteristics, and the national medical insurance department's subdivision group plan could be used as a reference; but in the 2.0 era, the national medical insurance department encouraged local governments to directly use the formulated subdivision group plan, and the importance of local governments establishing DRG subdivision groups that were in line with local characteristics was relatively reduced.
The relevant notice of the 2.0 version grouping plan pointed out that it is necessary to "improve the standardization and uniformity of payment method reform."
The person close to the DRG National Pilot Guidance Group said that in the 1.0 era, the quantity and quality of medical insurance data were poor, and even the informationization level of many local medical insurance departments and medical institutions was poor. Therefore, it is not possible to force local governments to implement the 1.0 or 1.1 version of the grouping scheme. Instead, local governments should be encouraged to explore grouping schemes that suit their local characteristics according to local conditions.
However, after three years of pilot exploration, the pilot areas have accumulated enough standardized medical insurance data. After big data processing, they can generate a grouping plan that can cover most of the medical institutions in the country. Therefore, in the new stage 2.0, regions are more encouraged to directly use the national grouping plan.
Many medical insurance policy researchers believe that this change also sends a signal that, following this reform path, the country may be able to achieve a unified grouping plan in the future, with no more local differences.
Some health policy researchers have also pointed out that medical treatment in other places was once an area that DRG could not regulate, and it was also an important source of income for many hospitals, but the idea of using DRG to regulate medical treatment in other places is already on the agenda. From 1.0 to 2.0, the differences in DRG groupings between regions have gradually become smaller, which may also be a preparation for DRG regulation of medical treatment in other places.
Whenever talking about DRG reform, "restricting the entry of new technologies into hospitals" is often criticized by hospitals and doctors.
"Because the adjustment cycle of the DRG grouping scheme is generally 2 to 3 years, there are no statistical data on the cost and weight of the use of new technologies two or three years ago (that is, the corresponding scores of DRG disease groups). This has led to limited application of new technologies and prominent contradictions in clinical practice," said an industry expert.
The director of the cardiovascular department of a well-known hospital in Hangzhou told Jianwen Consulting when the DRG reform was just starting that in clinical practice, DRG reform tends to use mature and classic technologies "because grouping lags behind clinical practice."
We can use several specific diseases to more intuitively understand the current gap between new technologies and DRG payments.
For example, atrial fibrillation, a common disease for the director of the cardiovascular department mentioned above, has actually been treated with a safe and effective left atrial appendage closure technique in China in the past decade, which no longer requires lifelong anticoagulation. In a certain city in central China, the average cost of the DRG group for this disease is about 45,000 yuan, but if the left atrial appendage closure technique is used, the actual treatment cost should be around 85,000 yuan. In other words, if the left atrial appendage closure technique is used clinically, the hospital will lose money for every operation performed.
For example, for varicose veins of the lower limbs, the current preferred treatment method is radiofrequency ablation, but this treatment requires catheter consumables, which cost around 9,000 yuan. However, the payment standard for this disease in the local disease group is only around 9,000 yuan, which means that medical insurance payments are only enough to cover the cost of catheter consumables.
"Patients can only undergo traditional high ligation and stripping, which means that medical services have regressed," said the director of vascular surgery at a tertiary hospital.
In the years since the DRG reform was expanded and implemented, medical insurance departments in various places have gradually paid attention to this problem faced by the new technology and have refined local grouping rules several times.
Regarding the left atrial appendage occlusion mentioned above, in 2021, many hospitals in Hangzhou discovered problems with this grouping. The Hangzhou Municipal Medical Insurance Bureau and the Zhejiang Provincial Medical Insurance Bureau reported this problem to the National Medical Insurance Bureau and singled it out as a disease group standard. But some places are not so lucky. In a tertiary hospital in a certain central city mentioned above, its voice is not as strong as that of the hospitals in Hangzhou, and it is unable to persuade the medical insurance department to modify the grouping. It can only set a rule: the cardiology department can only perform one left atrial appendage occlusion per month. Over the course of a year, the hospital only completed surgical treatments for 15 cases.
In the past three years, many places have been exploring other remedial measures besides DRG, including excluded payments, additional compensation points, new technology coefficients, etc. However, after several explorations, the implementation situation does not seem optimistic.
The catalogue of new technologies excluding payments has been delayed in being released, and the additional compensation points for the Da Vinci robot have been declining year by year, and hospitals are still trapped in the DRG restrictions on new technologies.
At the press conference for the 2.0 version of the grouping plan, the National Healthcare Security Administration emphasized the "special case discussion" system many times, directly addressing the restrictions of past DRG/DIP reforms on new technologies and new drugs and devices.
Wang Guodong, deputy director of the National Medical Insurance Administration's Medical Insurance Center, said that the special case single discussion mechanism is an important part of the DRG/DIP payment method reform, and is of great significance for ensuring adequate treatment of complex and critical cases and supporting the rational application of new drugs and technologies. However, due to the short reform period and insufficient policy publicity, some medical institutions and medical personnel do not understand the special case single discussion mechanism, and some do not even know the existence of this mechanism. Therefore, in the relevant notice of the 2.0 version of the grouping plan, the "special case single discussion mechanism" was specifically emphasized.
In the view of the National Healthcare Security Administration, the DRG/DIP reform does not exclude new technologies and new drugs and equipment, but they still need to be used within a reasonable range. As for what is considered "reasonable", it is very dependent on the decision of the local healthcare security bureau.
This year marks the final year of the three-year action plan for medical insurance payment reform. According to the original plan, all coordinated regions across the country will carry out DRG/DIP payment reform.
According to the data, in 2023, more than 90% of the coordinated regions in the country have implemented payment by disease group (DRG) and disease type value (DIP), and 25 provinces and the Xinjiang Production and Construction Corps have achieved full coverage of the coordinated regions.
In the years when DRG/DIP was expanded from a pilot program to a nationwide program, clinicians had to engage in repeated "tug-of-war" when the problems exposed reappeared in hospitals across the country.
Take new technologies for example. Doctors repeatedly apply and try them under the DRG/DIP framework.
However, a scholar who has conducted research in many places across the country told Health News that according to his observation, the success rate of applying for new disease groups in various places is not high. "If you want to apply for a new disease group, the hospital must have the courage to propose it, have the right to influence the medical insurance department, and have enough cases to calculate the weight. It also requires the medical insurance department to have a high level of government affairs and be willing to solve problems for the hospital." With so many conditions added together, it is not easy to add a new disease group.
Special cases have played an important role in many places. An ICU director once said that the hospital gave all the special cases quotas to their department, otherwise their losses would be even greater.
But in reality, more cases are "applications are not approved". Jianwen Consulting has investigated many places and learned that in some areas, the success rate of medical institutions applying for special cases is not high. In some areas where the overall planning funds are relatively tight, some doctors even complain that "special cases" are in name only and have almost never been successful.
A person close to the National Healthcare Security Administration once revealed, "Some medical institutions use the special case discussion mechanism less than 1% of the time." This is because the implementation of the central macro policies and local policies still needs to be coordinated.
Just at this time, the DRG/DIP disease group database 2.0 has arrived. We look forward to the pitfalls encountered in the pilot areas. After the arrival of 2.0, all places will no longer repeat the same mistakes.
However, it needs to be made clear that DRG/DIP disease group 2.0 solves the problem of rationality of grouping. As for the secondary changes brought about by the DRG/DIP reform - such as the depreciation of scores that hospitals are concerned about, the linkage between surplus and bonuses that doctors are concerned about, and the problem of being shirked that patients are concerned about, whether these can be solved remains to be further observed.
A new round of running-in is about to begin.
(Sun Haijiao also contributed to this article.)
Text/ Yan Yucheng, Song Xinze
Editor/ Li Lin
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