The National Medical Insurance Administration CHS-DRG has been piloted in 30 cities and will be extended to the whole country in 2021. In the context of DRG, what challenges and opportunities will the hospital face, and how should it respond? How should hospitals balance medical quality and medical efficiency, and how to make hospital management reforms have a greater driving force? Zhejiang Province, as a pilot area for the DRG pilot, has several years of experience since the pilot. Its exploration in the DRG payment reform pilot may give us some answers.
Leading the trend of the times, Zhejiang Province’s DRG payment reform bravely assumes responsibility and tries first
Although the DRG reform in Zhejiang Province started in 2015, the real payment reform involved still dates back to 2016. In the same year, the medical insurance department in Jinhua City, Zhejiang Province, led the deployment of DRG pilot projects in the local area, and carried out the basic medical insurance “patient group point method” payment trial. Different from the DRG performance appraisal in Zhejiang province at that time, the focus of the DRG pilot in Jinhua City was on the reform of medical insurance payment.
After three years of pilot projects, the growth rate of Jinhua medical insurance fund expenditure has been effectively controlled, the endogenous motivation of medical institutions and doctors to control medical costs has been stimulated, and medical service capabilities have been improved. This has aroused national attention. In 2019, Jinhua was listed by the state as a pilot city for the reform of the DRG payment method for national medical insurance. Subsequently, Quzhou, Taizhou, and Wenzhou also successively carried out DRG payment reforms.
In November 2019, Zhejiang Province issued the “Interim Measures for the Payment of DRGs Points for Hospitalization Expenses of Zhejiang Basic Medical Insurance”, stipulating that from January 1, 2020, the inpatient medical services carried out by designated medical institutions of Zhejiang Basic Medical Insurance shall be uniformly implemented in Under total budget management, payment is based on disease diagnosis related groupings (DRGs) combined with points. At this point, in the tide of DRG payment reform, Zhejiang Province has become a well-deserved pioneer.
The reason why DRG will be promoted rapidly throughout the country is behind the severe situation that my country’s medical insurance fund expenditures remain high. Take Zhejiang Province as an example in the DRG-leading region. In 2019, the income of Zhejiang employee medical insurance fund increased by only 4.2% year-on-year and expenditure increased by 12.3% year-on-year; the income of residents’ medical insurance fund increased by only 4.6% year-on-year, and expenditure increased by 10.3% year-on-year.
The growth rate of medical insurance expenditure is much faster than the growth rate of income, coupled with the accelerated aging of the population, the pressure on medical insurance funds is huge. In 2019, among the 71 employee medical insurance fund coordinating districts in Zhejiang, 15 were in deficit for the current period; among 73 urban and rural residents’ medical insurance fund coordinating districts, the current deficit was as high as 35, and short-term medical insurance fund imbalances have become normal.
In fact, as a place of wealth and prosperity in my country, Zhejiang Province’s medical insurance fund status is already considered a relatively optimistic region in the country. One can imagine the status of medical insurance funds in relatively backward areas. Because of this, my country urgently needs to reform the payment method to improve the performance of the medical insurance fund and realize the stable and sustainable development of the medical insurance fund.
How FiresoonMDT-style system solutions help pioneer hospitals respond to DRG reform
DRG has higher requirements for hospital informatization. The “National Medical Security DRG Grouping and Payment Technical Specifications” clearly stated that of the six conditions that need to be met for the implementation of DRG payment, three are closely related to informatization, that is, the unified basic code, the compliance of medical record quality and the interconnection of information systems. However, informatization with data as the core is precisely the biggest shortcoming for hospitals. The role that medical information companies will play in the DRG payment reform can be imagined.
Among them, Firesoon, which is now extremely active in Zhejiang Province, the DRG pioneer area, must be indispensable. As a local enterprise in Zhejiang, Firesoon, which was established in 2016, has only been five years old. However, its hospital-side DRG products have been unanimously recognized by hospitals. At present, its hospital-side MDT-style system solutions have been implemented in more than 100 hospitals in Zhejiang, Guangdong, Jiangsu, Anhui and other DRG-leading regions.
It is especially worth mentioning that Firesoon has achieved full coverage in various cities in Zhejiang Province. “Everyone who does medical information technology knows that a company that can be built in Zhejiang is definitely not bad, because Zhejiang’s competition is too fierce and the requirements for the company are too high.” Firesoon CEO Zhang Wei firmly believes in Firesoon’s successful practice in Zhejiang It can be replicated and helped tens of thousands of hospitals across the country successfully complete further development under the DRG payment reform.
The MDT (Multidisciplinary Collaboration) system solution is the first concept proposed by Firesoon, and it is also one of the biggest features of its hospital DRG products. Based on the product concept of multi-department collaboration, Firesoon’s MDT-style system solution seamlessly combines in-hospital process management and post-hospital operation analysis, launching DRG grouping, DRG in-hospital management, smart operation analysis, medical insurance settlement management, and medical record home page quality Control and DRG clinical path management six functional modules, which can help hospital leaders, clinical departments, medical record rooms, medical insurance office, financial department, information department and quality control department to coordinate and implement precise policies, so as to achieve a one-stop hospital for refined management Empowerment.
Medical record control system
For the most critical part of the medical record homepage of DRG payment, the FiresoonMDT system solution provides a three-level quality control system for clinicians, medical record departments, and quality control departments. The quality control of the medical record homepage is placed on the doctor’s side to provide the quality of the medical record homepage from the source; and Introducing intelligent algorithms to build a diagnosis and omission recognition model to further improve the accuracy of coding; at the same time, it can also detect in real time and intervene in DRG risk medical records in advance.
After the launch of CHS-DRG, the medical insurance settlement list will replace the previous status of the front page of medical records. Firesoon has also keenly discovered new optimization directions, and will make targeted improvements to the characteristics of the medical insurance settlement list (using the medical insurance version of disease classification and operation codes, highlighting the consumption of medical resources, etc.) in the future to ensure that the hospital is switching to CHS -DRG can be seamlessly connected.
The real-time pre-grouping function can minimize the impact of DRG rules on doctors’ electronic medical record writing habits through rules engine, NLP technology, correlation analysis and other technologies; advance the time for group core information to be perfected during hospitalization. Combined with segmented cost management, the program can also divide the hospitalization process into different stages of diagnosis and treatment; and give the benchmark cost range according to the cost structure to provide doctors with reference.
Intelligent monitoring and early warning can monitor more than 20 DRG operation indicators in real-time, and provide exclusive early warnings based on different roles for abnormal costs, abnormal cases, and cases with high core management indicators, thereby reducing the risk of cost overruns caused by abnormal cases.
Settlement management can check cases with inconsistent grouping before and after the code before settlement, to ensure that the uploaded cases are in compliance. Once there is a need to appeal to the medical insurance, the management tool can provide an automatic appeal collaborative tool to automatically sort out and directly query, assist in the rapid screening and location of abnormal cases, so that multi-departmental online universities can coordinate to handle appeals.
The core of all these functions lies in the algorithm. Zhang Wei believes that this is the area where Firesoon, which started from data, is best at it. “All intelligent judgments are actually algorithms at the bottom, such as medical record quality control, in-hospital prediction, real-time analysis of hospital data, etc. Therefore, our company’s personnel composition and R&D intensity are fundamentally different from those of other companies. Our personnel are almost all data Analysts and algorithm engineers, R&D investment accounts for 70% of the total investment, so as to ensure the goal of’one generation, one R&D, and one pre-research’.”
The automatic encoding of medical records is of great significance to DRG, which can greatly reduce the workload of the encoding process, but this technology is not easy for two reasons. One is that the underlying data in the hospital is too poor, and the medical records written by each doctor are different. Secondly, because of the ever-changing characteristics of Chinese, the difficulty of NLP segmentation is much higher than that of English. Based on the experience in medical BI data center business, Firesoon has a relatively deep accumulation in this area, and is cooperating with experts to develop intelligent algorithms including automatic coding algorithms.
“Although this is what we are doing, we never hype the concepts of artificial intelligence. The medical field still has to work hard for a long time, so we value the actual implementation most. Data must be accurate to help hospitals bring real value. Like. It is easier to see the effect of implementation in the pilot zone in Zhejiang Province that has been implemented for about 3 years. At present, the hospitals we have done, whether in Zhejiang Province or outside the province, can basically guarantee that they will return under the trend of tightening policies. Being able to do it was a loss, but now it is a profit.” As a technical control with a little perfectionism, Zhang Wei believes that the concept is not important. The implementation effect of the landing is what the hospital most urgently needs, and this is precisely because Firesoon is already nearing. A fait accompli that has been repeatedly verified by hundreds of hospitals.
The results are remarkable, and the DRG Pioneer Zone has opened an innovative road for the national DRG reform
The lean management brought by DRG has been visually demonstrated in data comparison. At the 14th Annual Meeting of Directors of Chinese Hospitals held in Xiamen from September 25th to 27th, 2020, leading hospitals in Zhejiang Province and other DRG pioneer areas demonstrated the practical results of the DRG pilot reform. Most of them have already Apply FiresoonMDT system solution.
The Second Affiliated Hospital of Zhejiang University School of Medicine (hereinafter referred to as the “Second Hospital of Zhejiang University”) is the leading hospital in Zhejiang Province. It has always been in the first echelon of the country in terms of service capacity and medical quality. The Second Hospital of Zhejiang University ranks fifth in China in the global top 100 list of the natural index of medical institutions. The number of operations per bed and the total number of operations are leading in the country; among them, the total number of operations and the disease difficulty index (CMI) rank first in Zhejiang Province.
In response to the DRG payment reform, the Second Hospital of Zhejiang University internally proposed the “efficiency medical” reform, promoted the reform through the integration of “pre-hospital-in-hospital-post-hospital”, and introduced FiresoonMDT-style system solutions to help reform. Over the past year, the DRG reform of the Second Hospital of Zhejiang University has achieved remarkable results.
The proportion of pharmaceutical revenue in revenue continued to decline, from 35.07% (2018) to 30.91% (2019). This indicator further dropped to 28.51% from January to August 2020; the proportion of medical service revenue continued to rise, starting from 2018 The 26.89% of the year increased to 29.41%. This has greatly improved the overall structure of medical income. The average length of hospital stay has also been significantly reduced. In 2018, the average hospital stay in the Second Hospital of Zhejiang University was 6.76 days. In 2019, it dropped sharply to 6.09 days. From January to August 2020, it was further shortened to 5.74 days, breaking the 6-day mark.
“The information system is of great help to DRG. It can monitor how the cases are monitored. It can show the situation of the department and why these cases will lose money according to the current DRG payment. The disease is complicated and the hospital stay is long. It is still medicine. Too expensive, or too much for treatment? The DRG information system can be monitored in real time. Through real-time information analysis, it can help us to do a good job in the DRG reform.” Wang Weilin, Dean of the Second Affiliated Hospital of Zhejiang University School of Medicine, expressed his opinion Views on the role of information system in the implementation of DRG reform in hospitals.
Zhejiang Taizhou Enze Medical Center (Group) (hereinafter referred to as “Taizhou Enze Medical Center”) is the leading hospital among prefecture-level hospitals in the country and the pioneer of lean management in domestic hospitals. It has introduced FiresoonMDT system solutions to implement DRG very early Lean management. This makes the medical service capacity of Taizhou Enze Medical Center not inferior to the provincial tertiary hospitals. In the DRG performance appraisal of Zhejiang’s top three hospitals, Taizhou Hospital under Taizhou Enze Medical Center has a CMI value of 0.9992, second only to Zhejiang University Second Hospital and second in Zhejiang Province.
Especially in clinical path management, the DRG information system has helped Taizhou Enze Medical Center a lot. Combining the cost control of DRG grouping by stages and cost structure can realize clinical path cost control; clinical path analysis can analyze path implementation and its impact on DRG cost; clinical path optimization can evaluate whether the path follows the DRG cost control principle and combine it DRG implementation, DRG cost influencing factors optimization path.
“We started to implement the clinical pathway in 2004, and it was also the first batch of clinical pathway laboratories in the original National Health and Family Planning Commission. The development of this pathway is good, and your DRG pilot management will have a grasp. Through the adjustment of the pathway And optimization can know where the cost is. The current Firesoon system integrates the clinical path, and integrates the node management of the clinical path into the cost control. Combining the two, our path optimization has an additional analysis method.” As the first expert to implement lean management in hospitals, Chen Haixiao, director of Taizhou Enze Medical Center, has a deep understanding of the role of clinical pathways.