幻灯片 1

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1 国家卫生计生委卫生发展研究中心 China National Health Development Research Center 中国按疾病诊断相关分组收 ( 付 ) 费规范的研制与展望 Development and prospects for pricing and payment regulation on China s diagnosis-related groups (CN-DRG) 于丽华 Yu Lihua 国家卫生计生委卫生发展研究中心 National Health Development Research Center, NHFPC 2015 年 10 月, 巴黎 Oct.2015, Paris

2 内容 Outline 一中国支付制度改革背景介绍 Background of Payment System Reform in China 二中法双方前期在 DRG 领域的合作 China France Previous Cooperation in DRG Development 三中国 DRG 收 ( 付 ) 费系统开发简介 Brief Introduction of CN-DRG Development by CNHDR 四中法未来合作展望 Prospects for Future Cooperation between CNHDRC and French Counterparts

3 一中国支付制度改革背景介绍 Background of Payment System Reform in China

4 当前全国公立医院经济总体运行特点与问题 Characteristics of economic operation of health facilities 1. 由于政府财政对医院 ( 公立医院 ) 补偿不足, 医疗服务的价格低于成本价格, 以药补医成为当前公立医院补偿机制的主要特征 Due to insufficient government subsidy for public hospitals, prices are below cost price for medical procedures and service, the "over-description of drugs compensation for medical costs mechanism becomes the main feature of public hospitals. 2. 我国医院实行按项目付费, 技术劳务价格偏低, 难以调到合理水平医院趋利行为造成大处方大检查较为普遍, 费用控制成为难题 FFS is the major hospital payment method in China, Low prices of health procedures and labor which are hard to redress to reasonable levels. Profit-driven behavior results in abuse of drugs, lab tests and consumables, cost containment is a big challenge. 3. 医疗机构的补偿过多地依靠药品和耗材收入 Health institution reimbursement over-depends on revenues from medicine and consumable materials -- 对现行的医院支付制度进行改革成为当前我国医改的主要任务之一 The provider payment system reform has become one of the main tasks of the current health care reform.

5 我国支付方式改革演进策略 Evolution of payment reform in China 按人头付费 Capitation 按项目付费 FFS 第一阶段 Stage 1 简单单病种付费 Per case for simple illness 按住院单元付费 Per episode 按住院床日付费 Per diem 第二阶段 Stage 2 复杂单病种付费 Per case for complex conditions 按服务项目打包付费 ( 项目规范 ) FFS for bundles services(fee Schedule) 其他付费方式 Other methods DRG 按项目付费 FFS 第三阶段 Stage 3

6 公立医院支付制度改革趋势 Trends of PPM reform in public hospitals 趋势 : 从按项目付费到按人头按病种按床日付费最终发展成为住院支付以 DRG 为主, 按项目按床日和按人头多种支付方式并存的体系 Trend: PPM will be transformed from FFS, capitation, per diem, case payment to mixed payment system dominated by DRG, together with FFS, per diem and capitation. 创建一个具有自主知识产权的中国 DRG 收 ( 付 ) 费体系成为医改重要内容 To develop CN-DRG with our own intellectual property rights has become one of the important part of the current health care reform.

7 法国 DRG 体系 DRG System in France 法国是世界上在全国范围内推行 DRG 支付医疗费用最成功的国家之一 France is one of the most successful counties in DRG payment system. 法国卫生部医疗服务总局是法国推行 DRG 支付医疗费用的领导部门, 该部下属的医院保健信息分局 (ATIH) 是法国负责研究与实施 DRG 的核心研究与管理机构, 在 DRG 定价支付和监管领域有着丰富的经验, 对我国开发 DRG 系统实施监管 ( 含医院质量管理 ) 与评价有着重要的参考价值和借鉴意义 DGOS is the leader department of GHM in France, ATIH is the key research and management institute responsible for the DRG research and implementation, which has rich experiences on DRG pricing, payment and monitoring field and make valuable references for our CN- DRG design,practice, investigate(including hospital quality management) and evaluation.

8 二中法双方前期在 DRG 领域的合作 China France Previous Cooperation in DRGs Development

2010, CNHDRC held DRG Research and Implementation Summit, Félix Faucon from French

9 卫生发展研究中心自 2009 年起与法国卫生部建立了友好合作关系 Since 2009, CHNDRC has set up good relationship with MOH of France 年 6 月, 我方主办的 DRGs 研究与应用高层研讨会上, 法国的米歇尔布莱蜜进行了法国医疗支付制度的改革与实施发言 Jun. 2010, CNHDRC held DRG Research and Implementation Summit, Félix Faucon from French Ministry of Health delivered a speech on French Health Payment System Reform and Implementation.

10 2010 年 11 月, 卫生发展研究中心与法国卫生部医疗服务总局共同签署了关于卫生筹资医院信息系统和卫生政策评估领域的合作谅解备忘录 Nov, 2010, NHDRC signed the MOU of the Cooperation in health care financing,hospital information system and health policy evaluation with MOH of France 双方主要合作领域包括共同开展医院补偿与筹资体系医疗信息分类与编码医院成本核算研究 ; 共同开展卫生领域培训项目, 并交换访问学者和专家 The main area of cooperation includes: research on hospital reimbursement and financing, classification and coding of health information, cost-accounting of hospital as well as training program in health care system and exchange of experts and scholars.

11 2010 年 12 月, 法国卫生部专家到访北京, 与原卫生部财务司及发展中心工作人员共同撰写完成法国医疗卫生体制改革对我国医改的启示, 提交原国家卫生部 Dec. 2010, Experts from French Ministry of Health visited Beijing and worked together with staff from NHFPC and CNHDRC to develop the report on Health system reform in France, experiences and lessons to health reform in China. The report were submitted to NHFPC 2011 年 2 月, 法国专家 Carine Milcent 在中心进行了关于法国 DRGs 及实施的讲座 Feb.2011, French experts Carine Milcent visited CNHDRC and make a lecture on French DRG and Implementation

12 2014 年 9 月, 国家卫生计生委国家发展改革委领导和发展中心研究人员共同赴法国卫生部医院保健信息局及医疗机构参观访问就法国的卫生服务提供体系医疗服务药品耗材定价, 法国 DRG 支付体系的总体情况进行了全面考察 Sep.2014, NHFPC, NDRC and CNHDRC officials and researchers are invited to visit French Ministry of Health, ATHI and French health facilities to fully understand French healthcare providing system, health care services, drug and consumable pricing, and DRG system.

13 2015 年 4 月, 法国卫生部医疗服务总局局长桑德里娜碧叶女士带队来京, 与发展中心开展为期一周的 DRG 技术交流研讨活动 Apr.2015, Sandrine Billet, Director from DGOS took a group of DRG experts to China to conduct one week DRG technical exchange. 中法双方专家持续在 DRG 收 ( 付 ) 费研究领域进行交流和互访, 对制定中国国家 DRG 收 ( 付 ) 费规范具有重要的借鉴意义 China and France continuing conduct exchange activities on DRG field which make great significances on China DRG development.

14 三中国 DRG 收 ( 付 ) 费系统开发简介 Brief Introduction of CN-DRG Development by CNHDRC

15 三中国 DRG 开发简介 Brief Introduction of CN-DRG Development by CNHDRC 2008 年起, 国家卫生计生委财务司委托中心牵头成立全国按疾病诊断相关分组收 ( 付 ) 费规范大型课题组 Commissioned by Dept. of Finance of NHFPC, led by CNHDRC, large research project group of Regulation on pricing and payment of CN-DRG was established in 期望创建一套符合国情全国统一的 DRGs 分组和权重赋值以及与之配套的管理制度的目标, 为公立医院提供适宜的收 ( 付 ) 费方式和制度体系 Aimed to establish unified national DRGs grouping and relative weights in line with national conditions, as well as compatible management and supporting systems, to provide appropriate payment system for public hospitals.

16 由卫生计生委财务司发改委牵头, 是国家收 ( 付 ) 费系列规范之一 Regulation on pricing and payment of CN-DRG was lead by Dept. of Finance of NHFPC and National Development and Reform Commission (NDRC), and it is one of the series regulations on pricing and payment 李斌主任对本项工作的批示 Comments from DG of Dept. of Finance, NHFPC

17 中国 DRG 收 ( 付 ) 费分组的特征 Characteristics of CN-DRG Grouping ( 一 ) 强有力的技术保障 Strong Technical Support 1. 由卫生计生委财务司李斌司长和卫生发展研究中心名誉主任张振忠教授牵头的核心项目专家团队, 共计 21 人 The core project team, is led by Prof. Zhang Zhenzhong, Honorary Director of CNHDRC, and Mr. Li Bin, the DG of Dept. of Finance, NHFPC, consists of 21 core experts. 2. 有来自全国 13 个省市物价和支付卫生的政策专家 13 local pricing and payment experts, as well as health policy experts. 3. 有全国各专业学会主任委员或副主任委员牵头的庞大的临床专家团队, 共有 35 个专业 735 位临床专家 A large team of clinical experts consist of a total of 35 professional specialties and 735 clinical experts, each specialty led by chairman or vice chairman from national professional institutes.

18 国家卫生计生委财务司颁发的临床专家咨询组专家聘书 Letter of appointment for clinical experts as Advisory Group members by Dept. of Finance, NHFPC

19 临床咨询专家地区分布 Regional Distribution of Clinical experts 省份百分比省份序号七大区 Area 统计 No. 序号七大区 Area Province % Province 统计 No. 百分比 % 1 江苏 % 19 宁夏 % 2 安徽 % 20 西北区新疆 % 3 华东区浙江 % 21 North-west 青海 % 4 East China 福建 % 22 China 陕西 % 5 上海 % 23 甘肃 % 6 山东 % 小计 Subtotal % 小计 Subtotal % 24 四川 % 7 广东 % 25 西南区云南 % 华南区 8 广西 % 26 South-west 贵州 % South China 9 海南 % 27 China 西藏 % 小计 Subtotal % 28 重庆 % 10 湖北 % 小计 Subtotal % 华中区 11 湖南 % 29 东北区辽宁 % Central 12 河南 % 30 North-east 吉林 % China 13 江西 % 31 China 黑龙江 % 小计 Subtotal % 小计 Subtotal % 14 北京 % 15 天津 % 华北区 16 河北 % North China 合计 Total % 17 山西 % 18 内蒙 % 小计 Subtotal %

20 4. 有 16 家医院组成的试验基地 : 其中, 中央级 5 家, 省级 4 家, 市级 2 家, 县级 3 家, 部队医院 2 家 16 pilot hospitals at different levels: 5 at the central level, 4 provincial, 2 municipal, 3 county, two military hospitals. 5. 受国家卫生计生委财务司委托, 建立了全国医疗服务价格和成本监测网络, 收集全国各级各类医疗机构数据,2015 年医院数已达到 949 家, 占全国医疗机构的 3.84% Commissioned by the Dept. of Finance, NHFPC, National M&E networks for price and the cost of medical procedures and services were established to gather data in all types of medical facilities at all levels. In 2015, 949 hospitals, accounting for 3.84% of total hospitals in China are involved.

21 ( 二 ) 在 WHO 的 ICD10 疾病分类框架下建立临床疾病诊断一病一码的编码体系, 规范全国分组工具, 全国权威专家进行论证 Establish the diagnosis terminology based on ICD-10 disease classification which was developed by WHO. In the diagnosis terminology, each diagnosis was designated a unique code, it will be used as a unified DRG grouping tool at the domestic level and it was verified by national experts. -- 基于中国临床实际情况, 组织 700 余名临床专家开始创建供一线临床医生使用的符合临床医生逻辑思维用于临床学术交流的全国统一的中英文的临床疾病诊断名称术语集, 并由临床专家对其与进行对接, 经过全国专家论证后推广应用, 并且作为中国 DRG 收 ( 付 ) 费分组的主要工具之一 Based the clinic, NHDRC organized over 700 clinic experts to development the diagnosis terminology with regulated bilingual terminology (in Chinese and English) for clinical practice and clinical communication which are logic clinically. The terminology was mapped into ICD- 10 classification system by experts. After the argumentation by clinical expert, the terminology will be one og the main tools for DRG grouping.

22 ( 三 ) 使用中国自主创新的中国医疗服务操作项目分类编码 : Use Chinese Classification of Health Interventions (CCHI) codes with Chinese characteristics for procedures and fee schedule -- 卫生发展研究中心于 2006 年开始创建具有中国自主知识产权的中国医疗服务操作项目分类与编码 CNHDRC Developed CCHI with our own intellectual property since 该套编码已经被中国卫生信息标准专业委员会立为行业标准, 即将颁布 CCHI will be used as national industrial health standard in the future. -- 将 CCHI 操作编码应用于价格项目收费编码, 收费编码已于 2012 年 5 月由三部委在全国颁布实施, CCHI was used in nation fee schedule which was issued in May 首次创建了国际上操作码与收费码两码合一的应用规则 Initiated the combination of the procedure classification code and charge code into one system

23 ( 四 ) 开发原则 : 结合多国经验, 确定中国 DRG 分组 : 临床相似性为主, 兼顾资源消耗 ( 临床专家法 + 数据分析法 ) Development principles: based on multi-country experiences, CN-DRG groups developed with the priority of clinical similarity, taking into account the resource consumption (Clinical experts analytical method+data analytical method) ( 五 ) 由全国 949 家医院构建了价格和成本监测网络, 在此基础上, 逐步统一和规范中国公立医院成本核算方法, 逐步发展成为中国 DRG 成本监测中心 Based on 949 public hospitals pricing and cost accounting monitoring and supervision network, we will standardizing cost accounting methods in DRG system

24 ( 六 )DRG 覆盖的范围 :Scope of DRG -- 包括县及县以上医疗机构 Including: hospitals at county hospital level and above -- 包括住院治疗 -- 包括日间手术 including acute inpatient care including ambulatory surgery --DRG 顶层设计中包含了符合中国治疗特色的内容, 如中医 DRG contains a top-level design characteristics in line with China's treatment model, e.g., TCM is included -- 不含在门诊治疗的疾病 ( 如齿科 ) Excluding: conditions & diseases treated in outpatient setting (e.g., dentistry)

25 中国 DRG 收 ( 付 ) 费分组的目前完成的情况 Current achievements of CN-DRG grouping 1. 全国按疾病诊断相关分组收 ( 付 ) 费规范产出 Output of Regulation on pricing and payment of CN-DRG 分组标准 grouping standard 分组权重标准 ( 各个 DRG 组的收付费相对点数 );grouping weights standards 基础费率的计算政策说明 policy instruction of base rate 以上三点全国必须统一, 各个省市自治区可以制定不同的费率 ( 具体价格 ) above 3 issues should be natioanl unified,rates (concrete prices) can be set in different provinces, municipalities and autonomous regions 中国疾病诊断规范名称术语集 China Diagnosis terminology

26 2. 完成了 DRG 收 ( 付 ) 费的数据分组 (958 组 ) Completed the grouping part of CN-DRG( 958 groups) -- 选取 839 家年两年病案首页 3400 万条数据, 进行分组 Except for clinical involvement, Grouping was also based on 34 million medical records data from 839 hospitals in the year of 2012 and 基本组 456 组, 细分组 958 组 Defining adjacent groups: 456 groups; groups:958 groups 序号 No. 国家 Country DRGs 基本组数 No. of adjacent groups DRGs 细分组数 No. of final groups 1 美国 USA 澳大利亚 Australia 德国 Germany 法国 France 中国 China

27 3. 目前正在进行临床分组验证 Clinical experts grouping demonstration meetings 儿科专业疾病诊断名称论证会 Pediatrics 骨科专业疾病名称专家论证会 Orthopaedics 神经专业疾病名称专家论证会 Neurology 肾内专业疾病名称专家论证会 Nephrology

28 临床专家分组讨论 clinical group discussions

29 四中法未来合作展望 Prospects for Future Cooperation between CNHDRC and French Counterparts

30 四中法未来合作展望 Prospects for Future Cooperation between CNHDRC and French Counterparts 希望 DRG 研究与支持项目变成一个持久合作项目, 在前期两国部级合作的基础上, 上升到中法国家层面的合作 Hope DRG Project become a long-lasting national-level cooperation projects between the two countries on the basis of pre-ministerial cooperation. 希望得到法国相关机构和专家们一始既往的支持 Hope to get ongoing support from French agencies and experts. DRG 的政策制定推广应用领域制度建设 ( 财务医保质量管理 ) 管理流程师资培训 DRG policy development, roll-up, applications, system construction (financing, health insurance, quality management), management processes, training of trainers. 在实践 DRG 时, 如何确定医疗服务药品和耗材的定价和价格调整机制 When practicing DRG, how to set pricing and price adjustment mechanism of medical procedures and services, drugs and medical devices.

31 预祝会议圆满成功! Wish the conference a complete Success!

National and Provincial Life Tables Derived from China’s 2000 Census Data

National and Provincial Life Tables Derived from China s 2000 Census Data Yong Cai Department of Sociology University of Utah Salt Lake City, UT 84112-0250 yong.cai@soc.utah.edu Feburay 21, 2005 Data available