2024-08-07
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On December 27, 2022, in Beijing, the screen in the emergency hall displayed information on hierarchical diagnosis and treatment. The hospital carried out diagnosis and treatment according to the severity of the patient's condition. Yi Haifei | China News Service | Visual China
"Is it difficult for patients with rare diseases to be hospitalized? Are patients with rare diseases naturally a 'low-score' group?" On the first weekend of August 2024, the National Healthcare Security Administration held three consecutive meetings to interpret the Medical Insurance DRG/DIP2.0. At the meeting, Wang Guodong, deputy director of the Medical Insurance Center of the National Healthcare Security Administration, raised this "common" issue.
DRG groups patients with similar resource consumption and clinical processes and pays by disease group. DIP is the total budget of the regional point method and payment by disease score. The payment standard includes the score multiplied by the point value. In short, different diseases and treatment methods will correspond to different "scores". The lower the score, the less settlement the medical institution will receive, and the higher the score, the more settlement the medical institution will receive.
As of now, more than 90% of the coordinated areas in the country are already using DRG or DIP payment, 190 coordinated regions have implemented DRG payment, and 192 coordinated regions have implemented DIP payment.
For special patients with rare diseases, the treatment is complex, the cycle is long, and the cost is high. Whether treatment may be hindered has become one of the focus issues.
The person who answered this question is Wang Ru, Director of the Medical Insurance Office of Peking University People's Hospital.immunityTo give an example of defects, the diagnosis and treatment of these two types of rare disease patients are long-term. The former may need hospitalization as the condition changes, and the latter requires long-term infusion of immunoglobulin. Severe cases may require hematopoietic stem cell transplantation, and may face a "low score" situation.
"We must make good use of existing policies such as special cases and special outpatient diseases to reduce the impact of medical insurance payment limits and alleviate the pressure on clinicians and patients," said Wang Ru.
On July 23, 2024, the National Healthcare Security Administration issued the "Disease Group (DRG) Payment Grouping Scheme Version 2.0" and the "Disease Indicator Value (DIP) Payment Disease Database Version 2.0" (hereinafter referred to as Version 2.0). Version 2.0 is an improvement on the original basis of the two plans, and will be used uniformly across the country from 2025.
At the aforementioned interpretation meeting, Huang Xinyu, director of the Medical Services Management Department of the National Medical Insurance Administration, described the relationship between medical care and medical insurance as "two-way travel". Medical insurance provides a relatively stable source of funding for medical care, and every penny of the medical insurance fund will be used in designated medical institutions and designated retail pharmacies. The purpose of the reform of the medical insurance payment method is to make the use of medical insurance funds more efficient and bring more benefits to the insured.
After being "named", Li Bo, a patient with primary immunodeficiency (PID), was quite excited. He immediately edited the meeting clips and shared them in the patient group. The special case single discussion mechanism is a medical insurance topic that many patients are concerned about, and it is directly related to the settlement of each treatment fee.
"For cases that are not suitable for payment according to DRG/DIP standards due to long hospitalization time, high medical expenses, use of new drugs and new technologies, complex and critical illnesses, or multidisciplinary joint diagnosis and treatment, medical institutions can independently apply for special cases for single negotiation. In principle, the number of special cases for single negotiation shall be within 5% of the total DRG discharge cases or 5‰ of the total DIP discharge cases." The National Healthcare Security Administration pointed out when releasing version 2.0.
However, Li Bo is worried that according to version 2.0, the number of special cases is limited, and it is not a one-time application that will solve the problem once and for all. Instead, each patient needs to apply for it every time they are hospitalized. Considering that there are also special patients in other clinics such as the ICU, PID patients may not get a turn.
Similar to PID, patients with the rare disease Fabry also need regular infusions of drugs. Some patients have difficulty taking adequate medication due to low DRG/DIP scores, because if they take adequate medication, the medical institution will lose money. On August 4, a representative of the Fabry patient organization told the Southern Weekend reporter that they have been guiding patients from all over the country to communicate with local medical insurance bureaus to see if they can solve the problem of medication difficulties through special cases and individual discussions. "At present, the situation in provincial-level hospitals is relatively good for the time being, and basic medication can be guaranteed."
On August 3, Wang Guodong disclosed at the National Health Insurance Administration version 2.0 interpretation meeting that the special case discussion mechanism has been in place since the pilot in 2019, and more than 90% of the pooling areas have it, but the actual reporting varies greatly from place to place, and some medical institutions or doctors do not have a deep understanding of it. "Although there is a set upper limit, some places only use less than 1%."
After the application for special case discussion, it must be reviewed. Wang Guodong used Tianjin, which implements both DRG and DIP, as an example: In 2023, Tianjin applied for 62,000 DRG special case discussions, accounting for 5.86%, and 57,000 cases were approved, with a pass rate of nearly 92%; in 2023, 2,935 DIP special case discussions were applied for, accounting for 1.95‰, and the review pass rate was 99%.
"This prescribed ratio can generally meet the needs of medical institutions, making the majority of medical institutions willing to accept and treat complex and critical cases," said Wang Guodong.
In addition to patients with rare diseases, many psychiatric, rehabilitation, and palliative care patients suffer from pain, have complex conditions, and require long-term hospitalization. They also face the difficulty of how to group and pay for medical insurance.
Bai Yujie, deputy director of the Beijing Medical Insurance Bureau and an expert in the DRG Technical Guidance Group, introduced that the core of DRG grouping is based on case combinations, using big data research methods, while integrating disease diagnosis and treatment methods, including individual characteristics such as patient age and number of hospital stays, combined with clinical data demonstration and statistical analysis of costs.
"Therefore, the use of (DRG) groups is mainly suitable for patients who need medium- and short-term emergency treatment. Patients like psychiatric and rehabilitation patients basically need long-term hospitalization, and DRG is not appropriate as a means of payment." Bai Yujie suggested that local governments should explore a fixed-rate payment method based on bed days for chronic disease patients like mental illness and rehabilitation who need long-term hospitalization based on actual conditions.
Wang Guodong also said that in reality, psychiatric and rehabilitation patients in various places are indeed paid according to a fixed rate per bed day, which is also a medical insurance payment method.
In terms of outpatient services, some places have also listed some diseases as outpatient chronic diseases or outpatient special diseases, which can be protected by referring to the regulations on hospitalization benefits in the coordinated areas. For example, the first batch of outpatient special diseases announced by Zhejiang Province include severe mental disorders,UremiaDialysis, also including rare diseases such as hemophilia, the remaining personal expenses after medical insurance reimbursement are included in the payment scope of major disease insurance.
Li Bo told the Southern Weekend reporter that currently some PID patients in Henan can enjoy special outpatient disease treatment, but the situation varies from place to place, and it is difficult for ordinary rare disease patients to promote the medical insurance special and chronic disease policies on their own.
After the implementation of the DRG/DIP payment method of medical insurance, some people have questioned whether doctors need to "hold a stethoscope in one hand and a calculator in the other hand". Will the reform really affect the hospital's admission of patients with critical and difficult diseases?
Yuan Xiangdong, deputy director of Guangdong Provincial People's Hospital, shook his head, saying that this was a misunderstanding of the medical insurance payment policy. DRG/DIP pays for different diseases under the control of the total budget. Generally speaking, the more complex the disease and the more difficult it is to treat, the higher the weight and score allocated.
Take aortic dissection as an example. This is a serious cardiovascular emergency that can be life-threatening if not treated in time. Yuan Xiangdong introduced that according to Guangzhou's disease-based payment method (DIP), different treatment methods correspond to different medical insurance payment amounts: conservative medical treatment is 8,700 yuan per case; aortic intrasaccular dilatation repair for type B aortic dissection costs about 67,500 yuan per case; partial aortic resection and artificial vascular replacement costs about 290,000 yuan per case.
Yuan Xiangdong recalled that if the payment method of total amount + average number of times was followed before the reform, the aortic dissection quota of their hospital was 26,000 yuan per case, and the hospital would lose 50,000 to 70,000 yuan per patient on average, lacking reasonable segmentation and incentives. Now, Guangdong Provincial People's Hospital has completed about 70% of aortic dissection surgeries in Guangzhou, with a very high cure rate.
Before going to Beijing to attend the conference, Yuan Xiangdong also found out that there was an elderly patient with aortic dissection in their hospital.anemiaDue to the underlying diseases such as heart disease, the entire operation cost about 450,000 yuan, far exceeding the aforementioned amount. Therefore, this case was treated as a special case and settled on a project basis.
"We don't use medicines that shouldn't be used, and we don't do examinations that shouldn't be done. We use the freed-up surplus funds to make structural adjustments to support the development of our disciplines, major and difficult diseases, and new technologies." Yuan Xiangdong said that after precise management, the hospital's proportion of level 4 surgeries and minimally invasive surgeries has both increased, and patients' illness course has also been shortened.
Ying Yazhen, deputy director of the National Medical Insurance Research Institute of Capital Medical University, emphasized at the third interpretation meeting that medical insurance payment is facing multiple challenges, and it is necessary to guide medical institutions to diagnose and treat more scientifically and rationally to achieve a win-win result.
Southern Weekend reporter Huang Sizhuo
Editor: Cao Haidong
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