DIP The payment method has been reformed. Why do fewer projects and less charging lead to "super low" fees? Doing more projects and charging more results in "super high" fees. The hospital will "suffer". The main purpose is to prevent "under-medical treatment" and "over-medical treatment". It poses a great challenge to the hospital's inertial management mechanism of post-payment according to the project, and has higher requirements for the refined management of hospitals.
1. Why do cases with "ultra-low" hospital expenses suffer "losses"
Let's first understand the calculation of DIP disease scores. It is a process of standardizing different discharged cases. The calculated scores can be used to realize the improvement of hospital medical services. Outputs are evaluated and compared and form the basis for payment.
Disease type score = average medical cost of a certain disease combination/average medical cost of all discharged cases
Generally, the historical data of the previous three years are used, and the calculation ratio is 1:2:7.
Ultra-low-cost cases, that is, cases where the cost is lower than 30%-50% of the disease combination payment standard (the standards are not very consistent in various regions). The treatment method is usually to pay according to the actual medical expenses, and the points will be converted according to the actual medical expenses of the case. The calculation formula is:
The score of the case = the actual medical cost of the case / the average medical cost of the disease in the designated medical institution at the same level in the previous year x the standard score of the disease.
If:
The standard score of a certain DIP disease is 120, the predetermined settlement point value is 100 yuan, and the standard fee is 12,000 yuan. The local medical insurance regulations are lower than 50% and recalculate the score. The average score of medical institutions at the same level last year for this disease medical The treatment cost is 11,500 yuan, and the actual cost of this disease is 5,500 yuan. The score of this case is recalculated as:
The score of this case=5500/11500x120=57.39
The actual score and cost of this case=57.39x100=5739 ( Yuan)
If:
The region stipulates that the cost of this case is between 50% and 200% as a normal case. The actual cost of this case is 6500 yuan, then:
The case multiple = 6500/12000 =54.17%
This case is a normal case, the actual point cost is:
The actual point cost of this case=120x100=12000 (yuan)
Why is the DIP payment method designed in this way? The main purpose is to prevent hospitals from excessive pursuit of medical insurance surplus, resulting in "insufficient medical care", and to guide hospitals to provide reasonable treatment through payment and settlement methods.
Look at the hospital income difference in this case: 12000-5739=6261 (yuan)
Based on this, hospitals should pay more attention to ultra-low cost cases. If the proportion of low-cost cases in the hospital is too high, the hospital will definitely "suffer", so the hospital It is necessary to strengthen DIP lean management to "not suffer losses".
2. Why do cases with "super high" hospital expenses suffer "losses" under DIP payment?
Why do hospitals also suffer losses if they charge more?
Cases with extremely high costs, that is, cases where the cost exceeds more than 2 times the disease combination payment standards, need to be recalculated. The actual medical expenses of the case will be converted into points and a certain deduction will be made to arrive at the corresponding payment points.The calculation formula is as follows:
The actual score of the case = [(actual medical cost of the case/average medical cost of the disease in designated medical institutions at the same level in the previous year - multiple standard) + 1] x standard score of the disease
Still analyzing the above cases:
Suppose:
The standard score of a certain DIP disease is 120, the pre-settlement point value is 100 yuan, and the standard fee is 12,000 yuan. The local medical insurance regulations exceed 200% and recalculate the score. The disease last year The average medical cost per time in medical institutions at the same level is 11,500 yuan, and the actual cost of this disease is 28,000 yuan. The score of this case is recalculated as:
The actual score of this case = [(28000/11500-2) + 1] × 120 = 172.17
The actual cost of this case = 172.17x100 = 17217 (yuan)
What is the hospital’s compensation rate for overcharges?
exceeding standard income = 28000-12000 = 16000 (yuan)
exceeding standard income medical insurance settlement compensation = 16000-5217 = 10783 (yuan)
exceeding standard income medical insurance settlement compensation rate = 5217/16000 = 32.61%
Based on this, the hospital should Pay more attention to cases with extremely high costs. If the proportion of high-cost cases in a hospital is too high, the hospital will definitely "suffer". Therefore, the hospital must strengthen DIP lean management to "not suffer".
3. Hospitals can "not suffer losses" by charging reasonably
Facing the reform of DIP payment methods, local DIP payment policies stipulate that there is a special differential settlement for calculating the payment coefficient for the medical insurance utilization rate. The medical insurance utilization rate is too low or the medical insurance utilization rate is too low. If it's too high, you'll get a discount for settlement. How can hospitals charge reasonably so as not to suffer losses? The key is to rationally use medicines, materials, examinations, treatments and careful budgeting to "not suffer losses".
In short, DIP empowers hospitals to run lean operations. It has great lethality to the traditional "do more projects to generate more income" and reduce the single cost "balanced average cost". Hospitals must adhere to a people-oriented and patient-centered approach. At the same time, economic operation management must be carefully considered.
Source: Qin Yongfang Medical and Health Finance Accounting and Economic Research
Image source: Tu Chong Creative
