What does medical insurance drg payment mean?

DRG payment method is to divide inpatients into a certain number of disease groups according to clinical similarity and resource consumption similarity (that is, according to the severity of patients' diseases, the complexity of treatment methods and the degree of resource consumption), and set the medical expenses standard in advance as a unit.

DRG classification usually includes four levels: one is to classify the diagnosis according to the medical standards of anatomy or etiology; Then it was divided into surgical treatment group and non-surgical treatment group. Under each treatment type, the basic group classification is determined according to the matching between the main diagnosis and the main treatment. Finally, combined with other resource consumption factors, such as other diagnosis, complications, age, nursing level and so on. , a DRG payment group is assigned.

The payment method of DRG is suitable for acute inpatients, not for mental illness, rehabilitation and non-acute chronic diseases. Mainly has the following typical characteristics:

1. Full coverage: The DRG system needs to classify all hospitalized patients and try to include all eligible hospitalized cases in the DRG payment scope.

2. Cost consistency: each DRG group has a weight, which is the relative cost point obtained by comparing the average regional case cost calculated according to the case list and cost data of the sample hospital with all case costs. If the cost of a DRG is exactly equal to the average cost of all cases, the relative weight is set to 1.

3. Dynamic control: By adjusting the payment rate, hospital payment can be flexibly controlled. The adjustment of payment rate is based on the hospital case combination index (CMI), which can effectively reflect the complexity of hospitalized cases and become an indicator of hospital treatment, thus defining different payment rates.

4. Comparability: Because the DRG payment system needs to use the same tools and standards, multiple comparability is achieved.

legal ground

"Regulations of the Office of the State medical insurance bureau on Printing and Distributing Medical Insurance Handling by Groups Related to Disease Diagnosis (DRG) (for Trial Implementation)"

Article 1 DRG payment is an important part of deepening the reform of medical insurance payment methods, aiming at promoting the rational utilization of medical and health resources, fully ensuring the treatment level of insured persons and ensuring the stable and efficient operation of medical insurance funds.

Article 2 Medical insurance agencies (hereinafter referred to as "agencies") should promote the implementation of DRG payment according to the national grouping scheme of DRG community health services, do a good job in agreement management and data collection, strengthen the budget liquidation management of medical insurance funds, establish payment system, incentive and restraint mechanism and inspection and audit mechanism suitable for DRG payment, improve the construction of DRG payment information system, strengthen assessment and improve the medical insurance negotiation mechanism.

Article 3 DRG is applicable to short-term hospitalization services such as basic medical insurance for employees and basic medical insurance for urban and rural residents. Provincial agencies should earnestly implement the guidance and organizational responsibilities, guide the overall planning areas to formulate management procedures for DRG paid handling, and monitor and evaluate the operation of DRG paid handling. If DRG payment has been carried out in the whole province, the provincial agency shall formulate the management rules for DRG payment in this province according to these regulations.