Implementation Status And Existing Problems Of Single Disease Payment Based On Clinical Pathway In A Tertiary Hospital

BackgroundChoosing a reasonable payment method for health services is an important means for the government,healthcare institutions,and medical insurance institutions to control the excessive growth of healthcare expenses.The reform of payment methods for health services has been the focus of attention in the process of health reforms and development in worldwide.Among the various attempts to reform payment methods made by many countries,DRGs is the most successful.DRGs were first proposed by experts and scholars in the United States.After more than 30 years of development,DRGs have comprehensively taken into consideration on the interests of patients,healthcare institutions,and governments,which have shown great advantages in controlling the excessive growth of medical expenses.According to the experience in the United States,the United Kingdom,Germany,Australia,Japan,South Korea and other countries have successively carried out DRGs and achieved great results.The experience in the implementation of DRGs has a strong reference for China’s case-by-case payment methods.However,due to limited conditions,various areas in China tend to adopt simpler single-disease payment methods to pay for common and frequently-occurring diseases.In some areas,medical institutions have adjusted the combination of single-disease payment methods and other payment methods according to the own characteristics,which has achieved remarkable results including the control of expenses,strengthening of healthcare standards and improvement of service quality.However,there are also some problems in the actual implementation process,such as low disease coverage,unscientific pricing methods,and lack of monitoring and evaluation system.AimThrough research on the status of implementation of the single-disease payment method in a top-level hospital in Shandong Province,analyzing the existing problems and risk factors,and exploring the impact on the operation of the hospital,to summarizing the experiences for standardizing the implementation of single-disease payment methods.MethodThis research collected the basic and expense information of ordinary inpatients in a 3rd hospital of Shandong Province from 2015 to 2017,demographic data,total hospital expenses,and various diagnostic and treatment costs for inpatients with single disease from the medical insurance institution,and correlated policy.Through analyzing the status and problems of implementation of single-disease payment method in the hospital,include the rate and constituent ratio of inpatients’ quantity and cost,different medical insurance types,professional single disease patients’ entry rate,etc(The rate of admission is the proportion of the single disease patients who paid according to the disease),statistical test of the each cost of patients with single disease,find problems in single disease payment,and provide suggestions for standardizing single-disease payment for clinical pathways.ResultsThere is a significant increase in the number of single-disease cases.The total number of single-disease treatment categories has significantly increased from 120 in 2015 to 141 in 2017.The single-species inpatient’s expenses have been on the rise,rising from 4.47%in 2015 to 7.03%in the first half of 2017,which represents a significant increase in the proportion of common inpatient expenses.The number of single-species of inpatients has been on a rising trend,rising from 1.93%in to 3.18%in January-June 2017.The proportion of single-disease patients in intervention department and general surgery department has exceeded 50%of the total.The enrollment rate of single-disease patients showed an upward trend during the first half of 2015-2017 The enrollment rate of municipal employees’ medical insurance and provincial direct insurance policy-type has increased in three years.The enrollment rates of single-disease patients in orthopedics,hematology,neurosurgery,interventional,laparoscopic,general and other department were higher than thoracic,and urologic department.The existing problems and risk factors in the single-disease payment process of the hospital:serious disease,poor prognosis,and the single-disease involved in the important organs of the human body.These single disease types with low enrollment rates are mainly concentrated in cardiac surgery,thoracic surgery,urology,and general surgery departments,but only the overall enrollment rate for thoracic surgery and urology is low.The research found that the excess of single-species costs is the main reason for the large number of patients with single-species diseases to withdraw from the disease.The low enrollment rate for some diseases is due to the low standard setting for single disease,which does not meet the actual conditions of the hospital and it is difficult to accept the actual implementation of the hospital.Further investigation found that the enrollment rate of single disease was affected by the patient’s condition and subjective choice.Finally,there is a lack of supervision of the implementation of the single disease in the hospital clinical department.Conclusion and SuggestionsWith the increase in the number of single-disease types,the number and cost of patients continues to increase.And there is a problem of low enrollment rates for single-disease inpatients in single-disease payouts.The complexity of the patient’s condition,formulation of the single disease quota standard and effective supervision system are the cause of the excess cost of the single-disease patient,further affecting the enrollment rate of the single-disease patient.We propose a number of policy recommendations:(1)establish a corresponding single disease quality control and evaluation system to ensure that each link of costs,quality and other in line with the standard of clinical path.(2)The calculation of the single disease rate needs to be in line with the economic development level of the local hospital.Scientific pricing is used for the diagnosis,treatment,examination,and other joints of the single disease.The development of the clinical pathway is more reasonable.(3)Establish a single-disease management information system to open the information on payment criteria and clinical pathways and obtain timely feedback to facilitate further improvement of management methods.(4)Establish a real-time monitoring and early-warning system for single-disease payment methods to ensure that single-species costs are controlled within a reasonable range and reduce the patient’s medical burden and hospital’s financial pressure.