Research On The Reform Of DRG Medical Insurance Payment Method

Basic medical insurance system is one of the most important part of China’s social security.Through development and evolution,the current urban employee basic medical insurance and urban and rural residents medical insurance two basic medical insurance categories are formed.China’s basic medical insurance system is gradually established and improved,medical insurance management and service level is gradually improved,but under various factors,China’s medical and health costs continue to grow at a high level,and the imbalance of medical insurance fund is severe.As the national medical insurance has entered the stage of high-quality development,higher standards and requirements have been put forward for the management and use efficiency of medical insurance funds.The payment mode of medical insurance is based on the flow of medical insurance fees among the insured persons,medical insurance institutions and medical and pharmaceutical institutions,and connects each subject of medical and health service market by economic means.The difference of payment method will have different chain effects on each subject.Scientific medical insurance payment system can not only guarantee the security of medical insurance fund,improve the efficiency of fund use and strategic purchasing ability.It can also play an important leverage role in regulating medical service behavior and guiding the allocation of medical resources.The key role of the payment method of medical insurance in the reform of the medical and health system and the "linkage of the three medicine" has been paid more attention.Pilot reforms of different medical insurance payment methods have been carried out in many places in China.Based on a series of pilot experiences,the state proposed to construct a compound medical insurance payment method based on payment by disease.After the establishment of the State Medical Insurance Administration,the Sinicization process and standardization construction of DRGs by diagnosis were accelerated,and the reform action plan was formulated.It is required to extend the reform of DRG/DIP payment method to all medical insurance fund pooling areas.DRG payment method is a refined payment management tool,which can motivate medical institutions to control costs and improve efficiency,realize efficient management of quality payment of medical insurance fund,and realize the insured masses to obtain high-quality medical services.Whether the reform of DRG payment method can achieve the expected effect and purpose of the reform and achieve multi-benefit depends on the specific promotion of the local grassroots.J City has always attached great importance to the reform of the medical and health system.It is in the forefront of S province in the construction of the basic medical and health system,the improvement of the public health service system,the promotion of hierarchical diagnosis and treatment,the construction of medical association,and the cancellation of the mark-on of drug consumables.But similarly,J City is also faced with the development dilemma of the increase of medical and health costs and the imbalance of the medical insurance fund.Exploring and implementing a scientific and reasonable medical insurance payment method is an inevitable demand for breaking through the reform bottleneck and development dilemma.In May 2019,J City was identified as one of the pilot cities of DRG medical insurance payment method reform in S province.After preliminary preparation,the first batch of pilot hospitals started simulation operation in2020.Now the third batch of pilot reform has been launched.But in the reform process,inevitably encountered many problems and constraints,this paper through policy analysis,site visits,statistical data analysis and other ways,from the perspective of the medical and health service market players,found the main parties in the reform of the problems,such as weak linkage between departments,medical insurance supervision methods do not match,data quality needs to be improved,professional organization absence,etc,and carry out attribution analysis around the problem,and then put forward relevant countermeasures and suggestions for the phenomenon,in order to further improve the relevant mechanism of local promotion of DRG medical insurance payment method reform,help the high-quality development of medical and health service system,and through this study to provide a certain degree of experience for other regions to carry out DRG medical insurance payment method reform.