Comprehensive promotion of disease-based fees, more severe price war may be coming.

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Recently, the National Development and Reform Commission website issued the "Notice on Promoting the Work of Charging by Disease". The "Notice" was jointly issued by the National Development and Reform Commission, the Health and Family Planning Commission, and the Ministry of Human Resources and Social Security to deploy all localities to comprehensively promote the reform of charging by disease. The "Notice" requires that the pilot areas for the comprehensive reform of urban public hospitals should not be less than 100 diseases before the end of 2017.

The issuance of the "Notice" may force hospital managers at all levels to actively implement fee control and effectively curb the growth of medical expenses. (Please refer to the link for the progress of pilot areas that have implemented charging by disease type)

Medical services are charged by disease means that medical institutions charge patients in the process of providing medical services, based on the type of disease. The charging standard includes the expenses of diagnosis, treatment, operation, anesthesia, nursing, beds, drugs and medical consumables from the time of diagnosis and admission to the standard treatment and discharge according to the type of disease. In principle, hospitals are not allowed to charge additional fees according to the disease type. The purpose of this reform is to promote medical institutions to establish a reasonable cost restraint mechanism, standardize clinical diagnosis and treatment behavior, guide medical staff to actively control medical expenses, and reduce the burden of patients and social medical expenses. This is also to promote the reform of medical service pricing mechanism and establish various forms. An important part of the coexistence of pricing methods.

Under the current project charging model, due to the high professional threshold of medical services, information asymmetry is caused. The doctor has the final say on what items and treatments the patient wants to see, which can easily lead to excessive medical treatment. However, paying according to the type of disease is like a "buffet", with a fixed amount of "meal expenses". Naturally, hospitals and doctors will not send too many "dishes" to patients ". It can be seen that paying by disease is one of the best ways to get rid of the "cancer" of public hospitals, or it can force hospitals and doctors to return to normal from the distorted state of excessive diagnosis and treatment in the past.

For pharmaceutical industry enterprises, the basis of payment by disease is still the clinical pathway, and it is the key to enter the clinical pathway and be selected by the hospital. In addition, the payment by disease is based on the calculation scheme of the total cost package system, which means that consumables and drugs will become the cost of the hospital instead of income, which will lead the hospital to choose drugs with higher cost performance. Exclusive product enterprises focus on the collection of evidence on the clinical value of drugs, and many production enterprises will face increasingly severe price wars.

320 Disease Catalogue Released

At least 100 pilot areas will be implemented by the end of the year.

The ''Notice'' requires that on the basis of the previous reform pilots, all localities should further expand the number of diseases charged by disease type, reasonably determine the specific diseases, and focus on promoting the treatment of common diseases and frequently-occurring diseases with standardized clinical pathways and clear treatment effects. The work of charging by disease type encourages day surgery to be included in the scope of charging by disease type. The "Notice" published a catalog of 320 diseases including breast cancer, cervical cancer, kidney cancer, rectal cancer, cataract, and leukemia, for all localities to choose when charging according to disease. Public hospitals at the second level and above in all localities should select a certain number of diseases to charge according to the types of diseases, and no less than 100 diseases will be charged according to the types of diseases before the end of 2017 in the pilot areas for comprehensive reform of urban public hospitals. All localities should promptly formulate implementation rules for promoting fees based on diseases, and announce them to the public and organize their implementation before the end of June this year.

Maximum price management

Gradually establish a dynamic adjustment mechanism for charging standards

The "Notice" clarified that all localities must formulate charging standards for various diseases in accordance with the principle of "incentives and constraints", implement maximum price management in principle, and gradually establish a dynamic adjustment mechanism for charging standards. The charge according to disease type includes all the expenses of diagnosis and treatment during the hospitalization period. That is, the expenses of diagnosis, treatment, operation, anesthesia, examination, nursing, beds, drugs, medical materials and so on during the whole process shall not be charged to the patient in addition to the expenses of disease type, the cost of examination after admission shall not be transferred to outpatient fees. The specific standards should be based on the reasonable cost of medical services, reflect the value of medical technology and medical personnel services, and be approved with reference to the actual costs incurred in the past.

Communication and coordination of various departments

Simultaneous determination of medical insurance payment standards for corresponding diseases

In fact, in recent years, many pilot areas have begun to try to charge according to the type of disease. However, due to the lack of medical insurance payment methods, some county-level hospitals can no longer support it after two years of trial. Some experts said that the "one price" charge must have a medical insurance supporting policy.

The ''Notice'' issued today also specifically pointed out that local price, health and family planning, human resources and social security departments must strengthen communication and coordination, do a good job in supporting the connection of relevant policies for the reform of payment by disease, and give full play to the synergy of payment by disease. Form a policy synergy. When formulating and publishing the charging standards by disease type, the medical insurance payment standards for the corresponding diseases should be determined simultaneously. It is necessary to establish a system of rewards and punishments for medical institutions based on disease charges, incorporate disease-based charges into the performance appraisal system of public medical institutions, strengthen supervision, evaluation, incentives and constraints, and mobilize the enthusiasm and initiative of medical institutions to implement disease-based charges.

News Link

Current progress in promoting payment by disease in various regions


Recently, Tianjin issued the "Notice on Carrying out the Pilot Work of Basic Medical Insurance Payment and Charge by Disease", and decided to carry out the first batch of pilot reforms of payment and charge by disease in the three-level medical insurance designated hospitals that implement public hospital reforms.

The first batch of pilot reforms by disease type covers 110 common diseases such as senile cataracts, coronary artery bypass grafting, hydrocele, ovarian cysts, nodular goiter, acute appendicitis, and lumbar disc herniation, including surgical diseases 46, 22 cardiac diseases, 17 orthopedic diseases, 17 gynecological diseases, and 8 ophthalmic diseases. The pilot hospitals cover all the three-level medical insurance designated hospitals that implement the reform of public hospitals.

After the medical insurance is paid according to the type of disease, the medical expenses incurred by the patient in the process of diagnosis and treatment of the disease, including the expenses of drugs and materials purchased by the medical institution or recommend the patient, will no longer be charged one by one according to the price of the service item, but will be settled according to the prescribed disease cost standard. The cost standard of the disease is based on the clinical path and historical data of the disease, and is determined on the basis of hospital declaration, scientific calculation, and expert argumentation. The charging and payment standards are consistent, and are not higher than the historical average level of the city's tertiary hospitals. Except for bed fees that exceed the basic medical insurance payment standard, hospitals are not allowed to charge patients in addition to the disease fee standard.

After the implementation of payment by disease type, the medical insurance settlement shall be implemented in accordance with the "Tianjin Basic Medical Insurance Payment Management Measures" issued by the Municipal Human Resources and Social Security Bureau and the Municipal Health and Family Planning Commission. The personal burden of the cost of the disease shall be calculated on the basis of the lower value of the actual medical expenses and the standard of payment of the disease, and shall be calculated in accordance with the relevant provisions of the city's medical insurance hospitalization reimbursement. The difference between the personal burden and the standard payment of the disease is paid by the medical insurance fund.

In the process of diagnosis and treatment of diseases, if the medical service items used by the hospital for patients exceed the scope of medical insurance reimbursement, they shall be included in the scope of medical insurance payment and settlement according to the provisions, and no additional charges shall be charged in the form of patients' own expenses.

For cases that are included in the payment by disease type, due to complications, complications, or variations in the patient's severe condition, special physique, etc., the actual medical expenses obviously exceed the disease type cost standard, the medical insurance fund will compensate the hospital according to regulations, and the insured Patients no longer pay extra.


Recently, Anhui Province issued the "Guiding Opinions on Promoting the Reform of Fees by Disease", which will be implemented from January 1, 2017.

Reform to implement the "first pilot, after the push". Before April 30, 2017, 10 cities including Suzhou, Huaibei, Wuhu, Huainan, Chuzhou, Bengbu, Xuancheng, Anqing, Lu'an, and Chizhou carried out 9 categories and 21 types of acute appendicitis and inguinal hernia in public hospitals above the second level. Disease pilot work. Before the end of 2017, 16 cities will implement no less than 50 fees based on disease types in public hospitals above the second level. The specific diseases can be selected within the range of 104 diseases announced by the state, or they can be determined by themselves according to local conditions.

All cases received by public hospitals above the second level and included in the national clinical pathway management shall be charged according to the type of disease. Among them, the inclusion of diseases in clinical pathway management should reach more than 50%, and the completion rate should reach 70%. Cases that do not enter or withdraw from clinical pathway management are still charged according to the project. Charges according to disease types are managed at the provincial and municipal levels. The provincial and municipal price authorities, in conjunction with the health and family planning, human resources and social security departments at the same level, respectively announce the disease types and fees charged by provincial public hospitals and city and county-level public hospitals. standard.

All cities are required to combine actual conditions, to reflect the principle of medical technology and the value of medical staff's labor services, to compensate for the reasonable cost of medical services, to refer to the average cost of each disease in the first three years of the hospital, to scientifically calculate according to the clinical pathway, and to deduct the expenses incurred outside the clinical pathway., Formulate the standard of charging by disease type, and make dynamic adjustments to gradually improve. The charging standards of the same disease in different grades of hospitals should maintain a reasonable price difference.

All diseases included in the pilot program of charging by disease type are included in the basic medical insurance (new rural cooperative medical system) to pay by disease type, and the charging standard of disease type is taken as the fixed standard of basic medical insurance (new rural cooperative medical system) to pay by disease type. The basic medical insurance management departments at the provincial, municipal and county levels respectively stipulate the standards for public hospitals at the same level to pay according to the disease type charging fund and individual payment.


The Zhejiang Provincial Department of Human Resources and Social Security has decided to select some common hospitalized diseases with mature clinical diagnosis and treatment plans and a large number of actual visits, and has launched a pilot reform of the payment method by disease before the end of 2016.

The ''Notice on Carrying out the Pilot Reform of Basic Medical Insurance Payment Methods by Disease, ''issued by the Zhejiang Provincial Department of Human Resources and Social Security, pointed out that according to the disease payment standard, according to the standardized diagnosis and treatment plan of medical institutions, historical operating data, etc., combined with the adjustment of medical service prices, On the basis of scientific calculation and expert argumentation, it is determined by the medical insurance department and medical institutions after negotiation and consultation.

It is understood that the Zhejiang Provincial Department of Human Resources and Social Security has compiled a total of 118 reference catalogues, including thyroid cancer, lumbar disc herniation, gastric cancer, and planned cesarean section. On the basis of extensive consultation with medical institutions, all localities are required to steadily expand the scope of pilot diseases and incorporate them into mature ones.

The medical insurance payment standard for diseases includes medical expenses such as drug fees, examination fees, nursing fees, treatment fees, operation fees, material fees, bed fees (except those exceeding the medical insurance standard) and other medical expenses involved in the first hospitalization or day ward diagnosis and treatment of the disease, as well as the consultation expenses in and out of the hospital, and the expenses of drugs and materials required or recommended by medical institutions. The same level of medical institutions for the same disease to implement a unified payment standard.

In the settlement method, the settlement of the cost of the pilot disease shall be jointly borne by the medical insurance fund and the insured. According to the regulations, the medical expenses for diseases that should be paid by the insured person shall be settled by the patient and the medical institution when discharged from the hospital; the difference between the disease payment standard and the individual payment shall be made up by the medical insurance fund according to the regulations. For cases where the actual medical expenses obviously exceed the payment standard due to complications, complications or the patient's serious condition, special constitution and other reasons, you can apply to withdraw from the payment according to the type of disease and still pay according to the original settlement method. Health insurance agencies should focus on strengthening the post-audit of exit cases.


In accordance with the requirements of the division of key tasks in the comprehensive reform of public hospitals in Shandong Province, in the first half of 2016, public medical institutions fully implemented the reform of the first batch of charging methods for dominant diseases of traditional Chinese medicine. Public Chinese medicine hospitals should give full play to the advantages of Chinese medicine, take active actions, and take the lead in carrying out reforms. By the end of June 2016, each public Chinese medicine hospital will have at least one disease to implement the reform of charging methods. At the same time, other qualified medical institutions are encouraged to carry out reform work.

In accordance with the requirements, the relevant medical institutions, in the light of their own reality, establish various supporting measures for the reform of the charging method according to the type of disease, take the initiative to fulfill the obligation of notification, sign a written agreement, and properly implement the responsibilities and obligations of both doctors and patients; it is necessary to establish a charging publicity system, and publicize the names, charging standards, reimbursement standards and other matters according to the type of disease in a prominent position, and accept social supervision.


In 2016, the Department of Human Resources and Social Security of Jiangsu Province required all localities to generally carry out day surgery based on the previous pilot projects. The province has recommend 20 common surgeries. Patients can be discharged within 24 hours after check-in, and at least 80% of medical insurance reimbursement can be achieved.

In addition to the recommend diseases in the province, Jiangsu also encourages all localities to combine local conditions to select diseases that have established clinical pathways or diagnosis and treatment specifications, relatively few complications and comorbidities, mature diagnosis and treatment technology, controllable medical quality, and guaranteed medical safety. Actively carry out day surgery to collect and pay according to the type of disease, and further expand the number of diseases. Changzhou, Xuzhou and other places have expanded a certain number of diseases.

It is reported that the cost standard for day surgery diseases includes all the expenses incurred in the whole process from outpatient service to discharge after standardized diagnosis and treatment, such as preoperative examination, surgery, drugs, anesthesia, nursing and postoperative follow-up, which are no longer charged by item, that is, "package price"


In 2016, Jiangxi Province launched a pilot program for day surgery based on disease types. 26 diseases including thrombotic external hemorrhoids, colorectal polyps, and senile cataracts were included in the scope of day surgery based on disease types. This means that patients with these 26 diseases can not only complete surgery and discharge within one day, but also achieve up to 85% of medical insurance reimbursement.

Day surgery is a new medical model of "short, flat and fast", which can speed up the turnover of hospital beds, shorten the number of hospital days, give as many hospital beds as possible to difficult and severe patients, and achieve the maximum utilization efficiency of hospital bed resources. In order to promote the implementation of day surgery, the pilot project of paying by disease type in Jiangxi Province will package the cost of the whole treatment process and give fixed payment, which will help to further alleviate the problem of "expensive medical treatment.

In order to implement a disease-based payment system for day surgery, some details need to be improved. For example, reasonable pricing should be established. The determined price should not only protect the interests of patients, but also reflect the labor value of medical institutions; for example, it is necessary to strengthen supervision to prevent Doctors pass on medical expenses by allowing insured patients to purchase drugs. In this way, more patients can benefit from the system.


In October 2016, multiple departments in Guangdong Province jointly formulated the "Implementation Plan on Controlling the Unreasonable Growth of Medical Expenses in Public Hospitals."

The plan is clear that at least 100 diseases will be paid by disease by the end of 2016. First of all, we must standardize the medical service process. It is necessary to improve the rate of first diagnosis, timely report rate of examination and three-day operation rate of admission. By improving the level of medical technology, optimizing the diagnosis and treatment process, and carrying out day surgery, the average length of stay was shortened. At the same time, it is necessary to implement the diagnosis and treatment standards for primary lung cancer, breast cancer, liver cancer and other malignant tumors issued by the National Health and Family Planning Commission, and further expand the coverage of clinical pathway management (clinical pathway refers to the establishment of a set of standardized treatment models and treatments for a certain disease), specialties and diseases, and promote standardized diagnosis and treatment of major diseases such as tumors.

The plan is particularly clear, it is strictly forbidden to set income-generating targets for medical staff, and the personal salary of medical staff shall not be linked to the hospital's business income such as drugs, consumables, inspection and treatment of large-scale medical equipment. Standardize the inspection management, and issue inspection items according to the actual needs of the patient's condition. If the diagnosis can be made clearly through the inspection with lower cost, the patient shall not be induced to perform other similar inspection items. Not necessary for disease diagnosis and treatment, inspection shall not be repeated. At the same time, it is necessary to strictly crack down on "large-scale examination and disorderly examination" and improve the positive rate of large-scale imaging equipment examination. The positive rate of large-scale X-ray machine examination in tertiary hospitals is not less than 70%, and the positive rate of CT and MRI examination is not less than 70%.