Outpatient case group payment (ACG)
Through the outpatient case group payment model, outpatient data is collected and processed, and the number of heads for medical treatment and effective heads for medical treatment is determined, the problems of ineffective fund management and difficult to control the growth of expenses under the existing outpatient payment model are solved, effective medical insurance fund management and cost control are achieved, and tiered diagnosis and treatment and the development of grassroots outpatient clinics are promoted.
Patent Information
- Application Number
- CN202510032852.7
- Authority / Receiving Office
- CN · China
- Patent Type
- Applications(China)
- Current Assignee / Owner
- Filing Date
- 2025-01-08
- Publication Date
- 2025-05-09
AI Technical Summary
The existing outpatient payment model is mainly project payment, which leads to the rapid growth of outpatient funds but lacks effective management, making it difficult to control unreasonable growth of expenses.
The Attended Capitation Groups (ACG) model is adopted, and through the data information management module, data calculation module and calculation index module, outpatient diagnosis and treatment data and settlement data are collected and processed, surveyed and evaluated and coded maintenance are carried out, and the number of heads for treatment and effective heads for treatment is determined, so as to realize payment based on heads for treatment.
Effectively manage medical insurance funds, control unreasonable growth of expenses, promote tiered diagnosis and treatment, and support the development of grassroots outpatient clinics.
Smart Images
Figure CN119964748A_ABST
Abstract
Description
Technical Field
[0001] The present invention relates to the field of outpatient technology, and in particular to outpatient case group payment (Attended Capitation Groups, ACG). Background Art
[0002] Outpatient clinics are places within medical institutions where medical staff provide disease consultation, diagnosis, treatment, nursing and rehabilitation services to patients who do not need hospitalization. The main function of outpatient clinics is to provide patients with preliminary diagnosis and treatment. For patients with more serious or urgent conditions, outpatient doctors will refer patients to hospital wards for further treatment.
[0003] In the existing outpatient clinics, outpatient payment is mainly based on project payment. If project payment is adopted, there will be a phenomenon of rapid growth of outpatient funds and lack of effective management. Therefore, the outpatient case group payment (Attended Capitation Groups, ACG) was invented. Summary of the invention
[0004] To solve the above technical problems, according to one aspect of the present invention, the present invention provides the following technical solutions:
[0005] Attended Capitation Groups (ACG), which include:
[0006] Data information management module, used to collect and process the outpatient diagnosis and treatment data and outpatient settlement data of pilot medical institutions;
[0007] The data calculation module is used to conduct a preliminary assessment and coding maintenance on the data collected by the data information management module in order to complete the project classification and online code maintenance and confirmation work in the pilot medical institutions;
[0008] The measurement indicator module is used to calculate the outpatient expenses based on the number of visits in medical insurance designated medical institutions, and to determine the effective number of visits based on the number of visits.
[0009] As a preferred solution of the Attended Capitation Groups (ACG) payment method of the present invention, the data information management module includes:
[0010] The historical data collection module is used to formulate technical indicators for outpatient diagnosis and treatment data collection and outpatient settlement data collection, and to carry out preparations for historical 1-3 years of data cleaning, standardization, coding mapping, and diagnosis and treatment settlement data association;
[0011] The real-time data transmission module is used to transmit the data processed by the historical data collection module in real time. In order to facilitate the implementation of outpatient payment, the outpatient payment data is derived from the medical insurance settlement list.
[0012] As a preferred solution of the Attended Capitation Groups (ACG) payment method of the present invention, the data calculation module includes:
[0013] The basic assessment module is used to conduct a basic assessment of the standardization, completeness and rationality of the outpatient data of the pilot medical institutions, so as to provide necessary guidance and improvement based on the results of the basic assessment when selecting pilot districts and counties and pilot medical institutions;
[0014] The coding maintenance module is used to compare, clean, standardize, supplement and maintain data when pilot medical institutions uniformly use the national codes for disease diagnosis, surgical operations, drugs, medical consumables and medical service items, so as to complete project classification and online code maintenance and confirmation.
[0015] As a preferred solution of the Attended Capitation Groups (ACG) payment method described in the present invention, the measurement indicators include:
[0016] Determine the data scope module, which is used to fully implement the payment of ordinary outpatient expenses on a per-patient basis in designated medical institutions of medical insurance that are included in the payment scope of the outpatient pooling fund;
[0017] The module for determining the number of patients is used to determine the number of patients. The number of patients refers to the number of medical service recipients provided by a medical institution in a settlement period, that is, how many patients have chosen this medical institution for treatment;
[0018] The effective number of patient visits is determined by a module for determining the effective number of patient visits based on the number of visits of the patient visits.
[0019] As a preferred solution for the outpatient case group payment (Attended Capitation Groups, ACG) described in the present invention, the determination method of the effective patient headcount determination module is: due to the large difference in medical resources between different patient heads in general outpatient clinics, the patient heads are classified according to the number of visits of the patient heads, and the patient heads are divided into low-frequency patient heads, normal-frequency patient heads and high-frequency patient heads. The average patient-headcount ratio indicator of medical institutions of the same level can be used to set the low / high-frequency patient head coefficient of each medical institution to adjust the effective patient headcount corresponding to different frequency patient heads, convert the low-frequency patient heads, and compensate for the high-frequency patient heads.
[0020] As a preferred scheme for the outpatient case group payment (Attended Capitation Groups, ACG) described in the present invention, the calculation method of the low-frequency visit heads, normal-frequency visit heads and high-frequency visit heads is as follows: within a natural year, each insured person who reaches the normal frequency of outpatient visits in a designated medical institution is considered as one effective visit head; the average visit head ratio of the same level and type of medical institutions during the same period is used as the benchmark indicator, and the low-frequency visit heads are those lower than 0.5 times the benchmark indicator; the high-frequency visit heads are those higher than 1.5 times the benchmark indicator; the normal frequency visit heads are those higher than 0.5 times, including 0.5 times, and lower than 1.5 times, including 0.5 times, of the benchmark indicator.
[0021] As a preferred scheme for the outpatient case group payment (Attended Capitation Groups, ACG) described in the present invention, the calculation method of the low / high frequency attendance coefficient is: low / high frequency attendance coefficient = average person-to-person ratio of low / high frequency attendances in the medical institution in the current year ÷ average person-to-person ratio of normal frequency attendances in medical institutions of the same type and level in the current year, wherein, person-to-person ratio = number of visits ÷ number of patients.
[0022] As a preferred scheme for the outpatient case group payment (Attended Capitation Groups, ACG) described in the present invention, the calculation method of the effective number of visits is: the effective number of visits of each medical institution = the number of normal frequency visits of the medical institution + the low frequency visit coefficient of the medical institution × the number of low frequency visits + the high frequency visit coefficient of the medical institution × the number of high frequency visits.
[0023] As a preferred scheme for the outpatient case group payment (Attended Capitation Groups, ACG) described in the present invention, the upper limit calculation method of the high-frequency capitation coefficient is: the upper limit of the high-frequency capitation coefficient of each medical institution = the average cost per capita of high-frequency visits of the medical institution at that level ÷ the average cost per capita of normal-frequency visits of the medical institution at that level.
[0024] Compared with existing technologies:
[0025] 1. By coordinating the payment for hospitalization and outpatient care, it can not only effectively close the loop of medical insurance funds, but also effectively control the unreasonable growth of costs;
[0026] 2. By setting relevant coefficients for primary medical institutions or giving policy adjustment tendencies, we can effectively promote tiered diagnosis and treatment and better support the development of primary outpatient clinics. BRIEF DESCRIPTION OF THE DRAWINGS
[0027] Figure 1 It is a schematic diagram of the process of the present invention. DETAILED DESCRIPTION
[0028] In order to make the objectives, technical solutions and advantages of the present invention more clear, the embodiments of the present invention will be further described in detail below with reference to the accompanying drawings.
[0029] The present invention provides Attended Capitation Groups (ACG), please refer to Figure 1 ;
[0030] It includes: a data information management module, which is used to collect and process the outpatient treatment data and outpatient settlement data of the pilot medical institutions; a data calculation module, which is used to conduct a basic assessment and coding maintenance on the data collected by the data information management module in turn, so as to complete the project classification and online code maintenance and confirmation work in the pilot medical institutions; a measurement indicator module, which is used to count the outpatient expenses according to the number of visits in the medical insurance designated medical institutions, and determine the effective number of visits based on the number of visits.
[0031] The data information management module includes: a historical data collection module, which is used to formulate technical indicators for outpatient diagnosis and treatment data collection and outpatient settlement data collection, and to carry out preparatory work for historical 1-3 years of data cleaning, standardization, coding mapping, and diagnosis and treatment settlement data association; a real-time data transmission module, which is used to transmit the data processed by the historical data collection module in real time. In order to facilitate the implementation of outpatient payment, the outpatient payment data is derived from the medical insurance settlement list.
[0032] The data measurement module includes: a survey and assessment module, which is used to conduct a survey and assessment of the standardization, completeness and rationality of the outpatient data of pilot medical institutions, so as to make necessary guidance and improvements based on the survey and assessment results when selecting pilot counties and pilot medical institutions; a coding maintenance module, which is used to compare, clean, standardize, supplement and maintain data when pilot medical institutions uniformly use the national disease diagnosis, surgical operation, drug, medical consumables and medical service item codes, so as to complete project classification and online code maintenance and confirmation.
[0033] The measurement indicators include: a module for determining the data range, which is used to fully implement the payment of ordinary outpatient expenses on a per-visit basis in the designated medical institutions of medical insurance that are included in the payment scope of the outpatient pooling fund; a module for determining the number of visits, which is used to determine the number of visits, where the number of visits refers to the number of medical service recipients provided by a certain medical institution within a settlement period, that is, how many patients have chosen this medical institution for treatment; a module for determining the number of effective visits, which is used to determine the number of effective visits based on the number of visits per visit; among which, the number of visits refers to a person's visit to the same medical institution within one day, which is regarded as one visit, excluding the fees of less than 10 yuan (including 10 yuan) within the scope of the single outpatient settlement policy; in addition, the standard for per capita payment is to reasonably set the proportion of the ordinary outpatient sector in the total fund according to the budget and final accounting method and the actual situation of the ordinary outpatient pooling fund in the previous year, and the total amount of the ordinary outpatient sector fund divided by the total number of effective visits is the per capita payment standard for the current year.
[0034] The determination method of the module for determining the number of effective patient visits is as follows: since there are large differences in medical resources between different patient visits in general outpatient clinics, the patient visits are classified according to the number of visits per patient, and the patient visits are divided into low-frequency patient visits, normal-frequency patient visits and high-frequency patient visits. The average patient-to-patient ratio indicator of medical institutions of the same level can be used to set the low / high-frequency patient visit coefficient of each medical institution to adjust the effective number of patient visits corresponding to different frequency patient visits, convert the low-frequency patient visits, and compensate for the high-frequency patient visits.
[0035] The calculation method for low-frequency visit per capita, normal-frequency visit per capita and high-frequency visit per capita is as follows: within a natural year, each insured person who reaches the normal frequency of outpatient visits in a designated medical institution is considered as one effective visit per capita; the average visit-to-person ratio of the same level and type of medical institutions during the same period is used as the benchmark indicator, and those below 0.5 times the benchmark indicator are low-frequency visit per capita; those above 1.5 times the benchmark indicator are high-frequency visit per capita; those above 0.5 times, including 0.5 times, and below 1.5 times, including 0.5 times, are considered normal frequency per capita.
[0036] The calculation method of the low / high frequency visit headcount coefficient is: Low / high frequency visit headcount coefficient = the average person-to-person ratio of low / high frequency visits in the medical institution in the current year ÷ the average person-to-person ratio of normal frequency visits in medical institutions of the same type and level in the current year, where the person-to-person ratio = number of visits ÷ number of patients.
[0037] The calculation method for the effective number of patients is: the effective number of patients of each medical institution = the normal frequency number of patients of the medical institution + the low frequency visit coefficient of the medical institution × the number of low frequency visits + the high frequency visit coefficient of the medical institution × the number of high frequency visits.
[0038] The calculation method for the upper limit of the high-frequency capitation coefficient is: The upper limit of the high-frequency capitation coefficient of each medical institution = the average cost per capita of high-frequency visits in the medical institution of that level ÷ the average cost per capita of normal-frequency visits in the medical institution of that level.
[0039] When used, the specific steps are as follows:
[0040] Step 1: Formulate technical indicators for outpatient diagnosis and treatment data collection and outpatient settlement data collection through the historical data collection module, and carry out preparations for historical 1-3 years of data cleaning, standardization, coding mapping, and diagnosis and treatment settlement data association. After that, the data processed by the historical data collection module will be transmitted in real time through the real-time data transmission module. In order to facilitate the implementation of outpatient payment, the outpatient payment data is derived from the medical insurance settlement list;
[0041] Step 2: Conduct a survey and assessment of the standardization, completeness and rationality of the outpatient data of the pilot medical institutions through the survey and assessment module, so as to make necessary guidance and improvements based on the survey and assessment results when selecting pilot counties and pilot medical institutions. After that, the coding maintenance module will be used to compare, clean, standardize, supplement and maintain the data when the pilot medical institutions use the national coding for disease diagnosis, surgical operations, drugs, medical consumables and medical service items, so as to complete the project classification and online code maintenance and confirmation work;
[0042] Step 3: Through the data range determination module, the general outpatient expenses are fully implemented on a per-patient basis in the designated medical insurance medical institutions included in the outpatient pooling fund payment scope. Then, the number of per-patients will be determined through the per-patient determination module. The per-patient refers to the number of medical service recipients provided by a medical institution within a settlement period, that is, how many patients have chosen the medical institution for treatment. After that, the effective per-patient determination module will be used to determine the effective per-patient number based on the number of visits of the per-patient.
[0043] Although the present invention has been described above with reference to the embodiments, various modifications may be made thereto and parts thereof may be replaced by equivalents without departing from the scope of the present invention. In particular, as long as there is no structural conflict, the various features in the embodiments disclosed in the present invention may be used in combination with each other in any manner, and the fact that these combinations are not exhaustively described in this specification is only for the sake of omitting space and saving resources. Therefore, the present invention is not limited to the specific embodiments disclosed herein, but includes all technical solutions falling within the scope of the claims.
Claims
1. Attended Capitation Groups (ACG), characterized by: include: Data information management module, used to collect and process the outpatient diagnosis and treatment data and outpatient settlement data of pilot medical institutions; The data calculation module is used to conduct a preliminary assessment and coding maintenance on the data collected by the data information management module in order to complete the project classification and online code maintenance and confirmation work in the pilot medical institutions; The measurement indicator module is used to calculate the outpatient expenses based on the number of visits in medical insurance designated medical institutions, and to determine the effective number of visits based on the number of visits.
2. The Attended Capitation Groups (ACG) according to claim 1, characterized in that: The data information management module includes: The historical data collection module is used to formulate technical indicators for outpatient diagnosis and treatment data collection and outpatient settlement data collection, and to carry out preparations for historical 1-3 years of data cleaning, standardization, coding mapping, and diagnosis and treatment settlement data association; The real-time data transmission module is used to transmit the data processed by the historical data collection module in real time. In order to facilitate the implementation of outpatient payment, the outpatient payment data is derived from the medical insurance settlement list.
3. The Attended Capitation Groups (ACG) according to claim 1, characterized in that: The data calculation module includes: The basic assessment module is used to conduct a basic assessment of the standardization, completeness and rationality of the outpatient data of the pilot medical institutions, so as to provide necessary guidance and improvement based on the results of the basic assessment when selecting pilot districts and counties and pilot medical institutions; The coding maintenance module is used to compare, clean, standardize, supplement and maintain data when pilot medical institutions uniformly use the national codes for disease diagnosis, surgical operations, drugs, medical consumables and medical service items, so as to complete project classification and online code maintenance and confirmation.
4. The Attended Capitation Groups (ACG) according to claim 1, characterized in that: The measurement indicators include: Determine the data scope module, which is used to fully implement the payment of ordinary outpatient expenses on a per-patient basis in designated medical institutions of medical insurance that are included in the payment scope of the outpatient pooling fund; The module for determining the number of patients is used to determine the number of patients. The number of patients refers to the number of medical service recipients provided by a medical institution in a settlement period, that is, how many patients have chosen this medical institution for treatment; The effective number of patient visits is determined by a module for determining the effective number of patient visits based on the number of visits of the patient visits.
5. The Attended Capitation Groups (ACG) according to claim 4, characterized in that: The determination method of the module for determining the number of effective patient visits is as follows: since the medical resources between different patient visits in general outpatient clinics vary greatly, the patient visits are classified according to the number of visits of the patient visits, and the patient visits are divided into low-frequency patient visits, normal-frequency patient visits and high-frequency patient visits. The average patient-to-patient ratio index of medical institutions of the same level can be used to set the low / high-frequency patient visit coefficient of each medical institution to adjust the effective number of patient visits corresponding to different frequency patient visits, convert the low-frequency patient visits, and compensate for the high-frequency patient visits.
6. The Attended Capitation Groups (ACG) according to claim 5, characterized in that: The calculation method of the low-frequency visit head count, normal-frequency visit head count and high-frequency visit head count is as follows: within a natural year, each insured person who visits a designated medical institution outpatient clinic at a normal frequency is considered as one effective visit head count; the average visit head count ratio of the same level and type of medical institutions during the same period is used as the benchmark indicator, and the low-frequency visit head count is lower than 0.5 times of the benchmark indicator; Those who have a frequency of visits that is 1.5 times higher than the benchmark index are considered high-frequency patients; those who have a frequency of visits that is 0.5 times or more higher than the benchmark index and those who have a frequency of visits that is 1.5 times or more lower than the benchmark index are considered normal frequency patients.
7. The Attended Capitation Groups (ACG) according to claim 6, characterized in that: The calculation method of the low / high frequency patient headcount coefficient is: low / high frequency patient headcount coefficient = the average patient headcount ratio of low / high frequency patients in the medical institution in the current year ÷ the average patient headcount ratio of normal frequency patients in the same type and level of medical institutions in the current year, where the patient headcount ratio = number of visits ÷ number of patients.
8. The Attended Capitation Groups (ACG) according to claim 7, characterized in that: The calculation method of the effective number of patients is: the effective number of patients of each medical institution = the number of patients with normal frequency of the medical institution + the low-frequency patient coefficient of the medical institution × the number of low-frequency patients + the high-frequency patient coefficient of the medical institution × the number of high-frequency patients.
9. The Attended Capitation Groups (ACG) according to claim 8, characterized in that: The calculation method for the upper limit of the high-frequency capitation coefficient is: the upper limit of the high-frequency capitation coefficient of each medical institution = the average cost per capita of high-frequency visits in the medical institution of that level ÷ the average cost per capita of normal-frequency visits in the medical institution of that level.