按病种付费3.0版将发布 医保医疗协同如何走

Core Insights - The article discusses the ongoing reform of the "Diagnosis-Related Group (DRG)" payment system in China's healthcare, which aims to improve the efficiency of medical insurance fund usage and enhance patient experience [1][4][13] Payment Reform Overview - The traditional payment method was based on "fee-for-service," which incentivized excessive medical practices. The DRG system groups similar cases and sets a unified payment standard based on historical data, promoting rational use of medical insurance funds [1][2] - The DRG payment reform has been implemented since 2019 and is set to evolve with the release of version 3.0 in 2026, aiming for better fund utilization, hospital sustainability, and improved patient satisfaction [1][13] Challenges and Solutions - Issues have arisen during the implementation, such as hospitals limiting patient stays to under 15 days and pushing patients out prematurely to control costs. This has led to concerns about the quality of care for complex cases [2][3] - Experts suggest that hospitals should collaborate with medical insurance departments to avoid cost-cutting measures that compromise patient care. A mechanism for special cases has been established in some regions to address these challenges [3][5] Case Study: Anyang City - Anyang City has implemented a unique approach where cases exceeding 60 days or requiring special treatment are settled separately, allowing hospitals to manage costs without compromising care [4][6] - In 2024, Anyang reported over 13,000 special cases with a total expenditure of 266 million yuan, demonstrating the effectiveness of this model in preventing premature discharges [6][7] Financial Outcomes - The reform has led to a surplus in the medical insurance fund, with Anyang's fund showing a balance after years of deficits. The total expenditure for hospitals has increased, and the average hospitalization cost has decreased significantly [7][9] - The average hospitalization cost in Anyang dropped from over 11,100 yuan in 2020 to 9,780 yuan in 2024, a reduction of 11.99% [9][10] Day Surgery Implementation - The introduction of "day surgery" has accelerated bed turnover and reduced costs, with nearly 60% of tertiary hospitals adopting this practice. Patients can now complete procedures within 24 hours, leading to lower expenses and resource optimization [10][12] - The average hospitalization duration has decreased, and personal out-of-pocket expenses have also declined, indicating a positive trend in patient care and cost management [12][13] Future Directions - The upcoming version 3.0 of the DRG payment system will focus on more refined classifications and regular updates to payment standards, ensuring that the system adapts to changes in medical practices and technologies [13][14] - Enhancing the service capacity of primary healthcare institutions and facilitating cross-province reimbursement for patients are essential steps for future improvements in the healthcare system [14]