This paper systematically summarizes the reform and experience of high-value innovative medical technology payment under the MS-DRG payment system in the United States. It specifically summarizes its long-term payment mechanism for high-value innovative medical technology and new technology additional payment, abnormal value payment and co-payment policies under the short-term payment mechanism. It is expected to provide a reference for China to explore and establish an incentive mechanism that takes into account medical advancement and the rational application and promotion of high-value innovative medical technologies while promoting the reform of medical insurance payment methods and the scientific use of medical expenses.
Key words
United States /
package payment /
high-value innovative medical technology /
short-term payment mechanism /
long-term payment mechanism
{{custom_sec.title}}
{{custom_sec.title}}
{{custom_sec.content}}
References
1 [[1] Bhattachary J, Hyde T, Tu P. 健康经济学[M]. 桂林: 广西师范大学, 2019: 361-388.
[2] Medpac. Hospital acute inpatient services payment system[EB/OL].2021[2021-12-02]. https://www.medpac.gov/wp-content/uploads/2021/11/medpac_payment_basics_21_hospital_final_sec.pdf.
[3] Simcha BR, Brian DG, Deborah LR.Diagnosis-related Groups and Hospital Inpatient Federal Reimbursement[J]. RadioGraphics, 2015, 36(6): 1825-1834.
[4] CMS. Application for New Medical Services and Technologies Seeking to Quality for Add-On Payments Under the Hospital Inpatient Prospective Payment System for Federal Fiscal Year2023[EB/OL]. 2021[2021-12-02]. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/newtech.
[5] CMS. Example of How to Submit and Case Weight for Cost Criterion[EB/OL].2021[2021-1202]. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/newtech.
[6] CMS. MS-DRG Classification and Software[EB/OL].2021-11-17[2021-12-02]. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software.
[7] Medicare Part A&B, Nursing Facilities. Fiscal Year (FY) 2022 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) Rates Final Rule[EB/OL]. 2021-08-02[2021-12-2]. https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2022-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-0.
[8] CMS HHS. Medicare Program; Change in Methodology for Determining Payment for Extraordinarily High-Cost Cases (Cost Outlier) Under the Acute Care Hospital Inpatient and Long Term Care Hospital Prospective Payment Systems[EB/OL].2003-6-9[2021-12-02]. https://www.federalregister.gov/documents/2003/06/09/03-14492/medicare-program-change-in-methodology-for-determining-payment-for-extraordinarily-high-cost-cases.
[9] Maccariella-Hafey P. New Technology Add-on Payments (NTAP) for FY2021-Part 4[EB/OL]. 2020-10-28[2020-12-6]. https://www.hiacode.com/education/new-technology-add-on-payments-ntap-2021/.
[10] CMS. Outlier Payment[EB/OL].2021-12-01[2021-12-06]. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/outlier.
[11] CMS, HHS.Medicare Program; Medicare Program; Change in Methodology for Determining Payment for Extraordinarily High-Cost Cases (Cost Outlier) Under the Acute Care Hospital Inpatient and Long-Term Care Hospital Prospective Payment System[J]. Federal Register, 2003, 68(110): 34494-34515.
[12] CMS HHS. Medicare Program; Explanation of FY2004 Outlier Fixed Loss Threshold as Required by Court Rulings[EB/OL]. 2016-01-22[2016-1-22]. https://www.govinfo.gov/content/pkg/FR-2016-01-22/pdf/2016-01309.pdf.
[13] Busse R, Geissler A, Quentin W, et al.Diagnose-Related Groups in Europe: Moving Towards Transparency, efficiency and quality in hospitals[M]. Germany: Open University Press and WHO Regional Office for Europe, 2011: 131-147.
[14] CMS. Design and development of Diagnosis Related Group (DRG)[EB/OL].2020[2021-12-06]. https://www.cms.gov/icd10m/version37-fullcode-cms/fullcode_cms/Design_and_development_of_the_Diagnosis_Related_Group_(DRGs).pdf.