What problems will exist in Sanming’s medical reform “paying by disease” this year?

A few days ago, Sanming City carried out hospitalization expenses in 21 public hospitals at the county level and above in the city, all paid according to the disease type. According to the principle of “fixed amount of overdraft, overspending, and returning to others”, the medical insurance agency paid according to the unified fund and the standard. At a given point, the medical institution will complete the settlement at the end of the year according to the standard of the disease payment quota.

Sanming’s medical insurance is really admirable. Medical insurance payment has always been a difficult problem in medical reform. Various local governments have made many attempts to learn from foreign experience. However, it is still the mainstay of fixed-rate payment. Although the central and provincial and local co-ordinated funds are increasing year by year, the proportion of medical insurance reimbursement has also risen. The amount of personal payment has continued to increase, and there is no obvious sense of gain. Instead, it has a resentment and the incidence of doctor-patient conflicts is rising. Therefore, it is more important to maximize the benefits of the medical insurance fund and increase the amount of medical insurance funds. Therefore, it is paid attention to by local medical insurance according to the disease.

The so-called disease-based payment is to scientifically formulate the fixed payment standard for each disease through a unified disease diagnosis classification. The social security agency pays the hospitalization expenses to the designated medical institutions according to the standard, and makes the medical resource utilization standardization, that is, medical treatment. Institutional resource consumption is directly proportional to the number of inpatients treated, the complexity of the disease, and the intensity of the service. It is characterized by the fact that the income of a medical institution is only related to each case and its diagnosis, and is not related to the actual cost of the medical institution to treat the case. In short, it is to specify how much it costs for a particular disease.

The mother is undoubted, if the payment according to the disease can be carried out according to the design, the medical insurance and the insured will be happy, but there are many obstacles in the actual payment according to the disease. The author conducted an unannounced visit to a county hospital in northern Henan.

First, with a light weight, take high-paying disease funds

For example, the general severe cold is treated as "acute pneumonia", and transient cerebral ischemia is treated as cerebral infarction and cerebral thrombosis, and fraudulently paid for high-value diseases.

Second, let the "improved" patients be discharged in advance

For patients with better treatment, the doctor urged the hospital to be discharged in advance, and allowed 3 days to be re-hospitalized. The same kind of disease was paid twice for the disease.

Third, hospitalization of different diseases of patients with comorbidities

For example, patients with diabetes and hypertension have been treated with “diabetes” and “hypertension” respectively, and medical insurance is paid for two diseases.

Fourth, reduce the hospitalization threshold

Patients who do not meet the hospitalization conditions are hospitalized and spend less, but the number of hospitalizations is large, and the amount of high-single disease is paid.

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