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Diagnosis-Related Groups in the System of Compulsory Health Insurance. Possibilities of Payment for Medical Care of Patients, who Need Administration of Genetically Engineered Biological Drugs

Issue № 23 | 2016 (1)

Abstract

Since 2012, a unified method of payment for medical care in hospital settings according to diagnosis-related groups (DRG) is being introduced within the framework of compulsory health insurance (CHI) in Russia. In 2012-2015, the model of DRG was annually revised. Old groups were divided and new groups formed, cost coefficients changed and new ways or regional adaptation of the federal model were proposed, such as adjustment coefficients, new subgroups within standard DRGs etc.
These changes involved many diseases including rheumatoid arthritis, juvenile rheumatoid arthritis, ankylosing spondylitis, Crohn’s disease, ulcerative colitis, and psoriasis. The effective treatment in certain groups of patients requires genetically engineered biological drugs (adalimumab, infliximab, etanercept, certolizumab pegol etc.) For example, the federal model of DRG for 2016 includes DRG no. 295 «Treatment with the use of genetically engineered biological drugs in absence of effective background therapy» for 24h hospital (weight coefficient = 5,35), and DRG no. 109 «Treatment with the use of genetically engineered biological drugs» for day hospital (weight coefficient = 9,74). Cost coefficients introduced for these DRGs enable to provide appropriate drug therapy for the respective groups of patients in both 24 h and day hospital.
Due to objective reasons, some regions have not yet introduced the new (fourth) model of DRG developed in 2015, and continue to pay for medical care according to previous models. These models do not stipulate the use of genetically engineered biological drugs (GEBD) in separate DRGs, while low cost coefficients for diseases that require GEBDs make prescription of these drugs difficult. It seems that such regions should consider distinguishing subgroups with higher cost coefficients within standard DRGs for the cases of GEBD prescription.

Keywords

diagnosis-related groups (DRG), cost coefficients (CC), genetically engineered biological drugs.

For citations

Sura M.V. Diagnosis-Related Groups in the System of Compulsory Health Insurance. Possibilities of Payment for Medical Care of Patients, who Need Administration of Genetically Engineered Biological Drugs. Medical Technologies. Assessment and Choice. 2016; 1(23): 24–34.

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