2020 Medical Insurance Statistics Bulletin released!

Medical Network News, June 11, 2020 National Medical Security Development Statistical Bulletin (hereinafter referred to as the "Communiqué") was officially announced on June 8
.
This is the third time that the National Medical Insurance Administration has issued a statistical bulletin on the development of the national medical security industry after its establishment, and it is also the final report after the release of the medical security statistical bulletin on March 8
.

 

So what kind of response does the "Communiqué" give to the following four general concerns of medical institutions? Here I will discuss with you
.

 

30 cities carry out DRG payment pilot

 

71 cities carry out DIP payment pilot

 

In June 2017, the General Office of the State Council issued the "Guiding Opinions on Further Deepening the Reform of Basic Medical Insurance Payment Methods" (Guobanfa [2017] No.
55), calling for the full implementation of a multivariate compound medical insurance payment based on disease-based payment Way
.

 

The proposed goal is: by 2020, the reform of medical insurance payment methods will cover all medical institutions and medical services, and multiple and compound medical insurance payment methods adapted to different diseases and different service characteristics will be widely implemented nationwide, and the proportion of payment by item will be significantly reduced
.

 

In December 2018, the National Medical Insurance Administration issued a document to start reporting by disease diagnosis-related group (DRG) pilot cities.
In May 2019, it was determined to launch DRG pilots in 30 coordinated areas
.
The pilot cities and provinces are required to under the unified leadership of the national DRG payment pilot working group, follow the three-step idea of ​​"top-level design, simulation testing, and actual payment", through the deep participation of DRGs payment pilot cities, and jointly determine the pilot plan.
Explore the path of advancement, formulate and improve a nationally unified DRGs payment policy, process, and technical standards and specifications, and form pilot results that can be used for reference, replication, and promotion, to ensure simulation operation in 2020, and actual payment in 2021
.

 

On October 19, 2020, the National Medical Insurance Administration issued a pilot work plan for the total budget of the regional point method and the payment by disease point (DIP) (Medical Insurance Office [2020] No.
45), requiring all localities to complete the pilot before October 20 City declaration
.
On November 4th, the National Medical Insurance Administration determined to carry out pilot projects of total budget of regional points method and payment by disease scores in 71 areas under overall planning
.

 

Therefore, the "Communiqué" has clearly and continuously promoted the reform of payment methods.
The DRG-paying national pilot work has been carried out in 30 cities.
All 30 pilot cities have passed the evaluation and assessment before the simulation operation and entered the simulation operation stage; regional points have been developed in 71 cities The total law budget and DIP payment pilot work
.

 

Medical insurance fund supervision is on the track of legalization

 

Medical insurance supervision is what everyone feels most in recent years
.

 

Since March 2018, the central and national institutional reform plans were passed, and since the establishment of the National Medical Insurance Bureau, the fight against fraudulent insurance has set off a new upsurge
.

 

On September 13, 2018, the National Medical Insurance Administration, the Health Commission, the Ministry of Public Security, and the Food and Drug Administration jointly held a video conference on the national special action against fraudulent insurance, which kicked off the first wave of the National Medical Insurance Administration led by the National Medical Insurance Administration since its establishment.
Cracking down on fraud and security operations
.

 

　　On November 28, 2018, the Office of the National Medical Security Administration issued a notice on strengthening the management of medical insurance agreements to ensure the safety of funds (Medical Insurance Office Fa [2018] No.
21)
.
The notice pointed out that the medical security management departments at all levels must fully understand the important role of agreement management, strictly check and strengthen supervision in all links such as fixed-point application, agreement implementation, fee review, evaluation and assessment, and maintain the behavior of defrauding medical insurance funds in violation of the agreement.
High pressure and heavy blows
.
The notice stated that all designated medical institutions and designated retail pharmacies that breached the contract would "dissolve the service agreement" and that they would not be allowed to apply for designated medical insurance within 3 years
.

 

　　On February 26, 2019, the National Medical Security Administration issued a notice on the supervision of medical security funds in 2019 (Yibaofa [2019] No.
14)
.
The notice requires that the crackdown be increased to consolidate the high pressure situation
.

 

　　At the beginning of 2020, the fourth plenary meeting of the Central Commission for Discipline Inspection was held
.
At the meeting, the country’s top leaders rarely and explicitly stated that it is necessary to resolutely investigate and deal with collusion between internal and external medical institutions, and establish and strengthen a long-term monitoring mechanism
.

 

　　On June 10, 2020, the National Medical Insurance Administration and the National Health Commission jointly issued a notice on the special management of the standardized use of medical insurance funds by medical insurance designated medical institutions (Medical Insurance Letter [2020] No.
9)
.
The notice pointed out that it is necessary to strengthen policy guidance and joint departmental law enforcement, severely combat fraud and insurance fraud with a zero-tolerance attitude, and standardize the diagnosis and treatment services and charging behavior of designated medical institutions
.

 

　　On July 10, 2020, the General Office of the State Council issued the Guiding Opinions on Promoting the Reform of the Medical Security Fund Supervision System (Guobanfa [2020] No.
20)
.

 

　　2020 December 18, Taihe County of Anhui Province for the part designated medical institutions induced hospitalization, false hospitalization and other issues, the Office of the National Health and Social Security Bureau, the National Health health under Commission General Office issued regarding the development of special projects designated medical institutions "look back" Notice (Medical Insurance Office Fa [2020] No.
58)
.

 

　　The "Communiqué" reported this work in the section "Supervision of Medical Security Funds"
.
The “Communiqué” pointed out: In the whole year, medical insurance departments at all levels inspected 627,000 designated medical institutions and investigated and dealt with 401,000 medical institutions that violated laws, regulations, and contracts.
Among them, 6,008 medical insurance agreements were cancelled, 5457 were administrative penalties, and 286 were transferred to judicial organs; 26,100 people insured who violated laws and regulations were handled, of which 3,162 were suspended for settlement and 2,062 were transferred to judicial organs; a total of 22.
31 billion yuan was recovered in the whole year
.

 

　　The National Medical Insurance Bureau organized a total of 61 unannounced inspection teams to conduct on-site inspections in various provinces across the country.
The unannounced inspection teams inspected 91 designated medical institutions (including integrated medical care institutions), 56 medical insurance agencies, and undertook medical insurance for urban and rural residents and serious illnesses.
Forty commercial insurance companies insured have found a total of 540 million yuan in funds suspected of violating laws and regulations
.

 

　　This information tells us that the use of medical insurance funds is still very irregular, and "medical institutions in violation of laws and regulations" account for more than 60%.
It is expected that all insurance-related institutions will use medical insurance funds in compliance with the law
.

 

　　This year’s crackdown on fraud and insurance has clearly stated that the focus of the crackdown is three fakes, namely "fake patients", "fake medical conditions" and "fake bills
.
"

 

　　Particularly worthy of attention is that on February 19, 2021, the State Council issued the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" and decided to implement it from May 1, 2021
.
This is the legalization of medical insurance fund supervision
.

 

　　Is the payment ratio of hospitals at all levels high or low?

 

　　The "Communiqué" shows that the hospitalization expenses fund within the scope of the employee medical insurance policy pays 85.
2%
.
The hospitalization expenses fund payment within the policy scope of secondary and lower-level medical institutions was 86.
9% and 88.
7%, respectively, which were 2.
6 and 4.
4 percentage points higher than those of tertiary medical institutions
.

 

　　In 2019, the National Medical Insurance Bureau bulletin showed that the hospitalization expense fund within the scope of the employee medical insurance policy paid 85.
8%, the actual hospitalization expense fund paid 75.
6%, and the personal burden was 24.
4%
.
The hospitalization expenses fund payment within the policy scope of secondary and lower-level medical institutions was 87.
2% and 89.
3%, respectively, which were 2.
2 and 4.
3 percentage points higher than those of tertiary medical institutions
.

 

　　Based on this, the "Communiqué" concluded that the hospital reimbursement level remained stable
.

 

　　The "Communiqué" shows that the hospitalization expense fund within the scope of the residents' medical insurance policy pays 70.
0%, an increase of 1.
2% over the previous year
.
According to the level of medical institutions, the hospitalization expense fund payment within the policy scope is: 65.
1% for the third level, 73.
0% for the second level, and 79.
8% for the first level and below
.
Among them, 74.
6% of the funds paid within the policy scope of secondary medical institutions and below are 9.
5 percentage points higher than that of tertiary medical institutions
.

 

　　To understand this communiqué, one must first understand a concept, that is, "hospital expenses within the scope of the medical insurance policy"
.
To clarify this concept, the premise is to figure out what out-of-pocket expenses are? What is self-care expenses? What is out-of-pocket expenses? The so-called out-of-pocket expenses refer to the medical expenses that are borne by the individual in proportion to the basic medical insurance provisions, the first out-of-pocket expenses of the transferred hospitalization individual, the hospitalization threshold, and the prescribed (special) disease threshold
.

 

　　The so-called self-care expenses refer to the basic medical insurance catalog for the category B items, category B drugs, etc.
, which need to be paid by the individual first
.
The so-called out-of-pocket expenses refer to the project expenses that are not included in the scope of basic medical insurance and are entirely borne by the insured person
.
The so-called "hospital expenses within the scope of the medical insurance policy" refers to the expenses that can be included in the scope of the medical insurance policy to be reimbursed in accordance with the prescribed proportion in addition to the above three types of expenses
.

 

　　Speaking of this, you may understand why the “hospital expenditure fund payment ratio within the scope of the medical insurance policy” mentioned by the medical insurance is usually not a small gap with the actual reimbursement ratio we feel, mainly because we are in the process of hospitalization.
There are always part of the expenses that are out-of-pocket, self-care expenses, and self-paid expenses, which must be paid or not included in the “medical insurance policy”
.

 

　　Another issue worth noting is that the gap in the reimbursement ratio of hospitals at all levels is actually not large.
This shows that the medical insurance policy is actually not effective enough to induce patients to stay at the grassroots level.
Determined by the medical service capacity of the grassroots)
.

 

　　Judging from the actual situation of the tightening of medical insurance policies and strict management of medical insurance in some places, the actual out-of-pocket ratio of patients may increase significantly
.

 

　　Has the hospital's drug use increased or decreased after the purchase?

 

Everyone knows that the price of medicines has dropped drastically 　　after mass purchase and negotiation
.
However, whether the burden on patients has been reduced or not is directly related to the average cost of medicines in hospitals and outpatients
.
Unfortunately, the "Communiqué" does not contain this type of information
.

 

　　However, the "Communiqué" has four sets of information: First, the number of hospitalizations has decreased: 50 million employees were hospitalized, a decrease of 12.
3% from the previous year; the hospitalization rate of residents covered by medical insurance was 15.
1%, a decrease of 1.
5% from the previous year
.

 

　　Second, the average hospitalization expenses per time continued to increase
.
In 2020, the average hospitalization cost per medical insurance for employees nationwide was 12,657 yuan, an increase of 6.
5% over the previous year
.
The average hospitalization expenses of urban and rural residents were 7,546 yuan per time, an increase of 7.
1% over the previous year
.

 

　　Among them, the average hospitalization expenses in tertiary, secondary, primary and lower medical institutions were 13,533 yuan, 6464 yuan, and 3237 yuan, respectively, an increase of 9.
6%, 6.
4%, and -1.
3% over the previous year
.

 

　　Third, after the 2020 National Medical Insurance Drug List was adjusted, a total of 119 new drugs were added to the list, and 29 drugs in the original list were removed from the list
.

 

　　Fourth, in 2020, the total amount of online procurement orders nationwide through the provincial centralized drug procurement platform is 931.
2 billion yuan, a decrease of 60.
1 billion yuan from 2019
.

 

　　From the side, after the adjustment of the medical insurance catalog, the catalog increased, which greatly restricted the grassroots (first-level and lower medical institutions), and reduced the hospitalization of mild patients (of course, the impact of the epidemic is also on the one hand), so it shows: the number of hospitalizations decreased, The situation in which costs increase and the medical insurance catalogue increases, but the total amount of drug purchases declines
.
In the years when the prices of medical services were basically not adjusted, it showed that the use of drugs in second- and third-level hospitals did not significantly decrease
.

　　Medical Network News, June 11, 2020 National Medical Security Development Statistical Bulletin (hereinafter referred to as the "Communiqué") was officially announced on June 8
.
This is the third time that the National Medical Insurance Administration has issued a statistical bulletin on the development of the national medical security industry after its establishment, and it is also the final report after the release of the medical security statistical bulletin on March 8
.

 

　　So what kind of response does the "Communiqué" give to the following four general concerns of medical institutions? Here I will discuss with you
.

 

　　30 cities carry out DRG payment pilot

 

　　71 cities carry out DIP payment pilot

 

　　In June 2017, the General Office of the State Council issued the "Guiding Opinions on Further Deepening the Reform of Basic Medical Insurance Payment Methods" (Guobanfa [2017] No.
55), calling for the full implementation of a multivariate compound medical insurance payment based on disease-based payment Way
.

 

　　The proposed goal is: by 2020, the reform of medical insurance payment methods will cover all medical institutions and medical services, and multiple and compound medical insurance payment methods adapted to different diseases and different service characteristics will be widely implemented nationwide, and the proportion of payment by item will be significantly reduced
.

 

　　In December 2018, the National Medical Insurance Administration issued a document to start reporting by disease diagnosis-related group (DRG) pilot cities.
In May 2019, it was determined to launch DRG pilots in 30 coordinated areas
.
The pilot cities and provinces are required to under the unified leadership of the national DRG payment pilot working group, follow the three-step idea of ​​"top-level design, simulation testing, and actual payment", through the deep participation of DRGs payment pilot cities, and jointly determine the pilot plan.
Explore the path of advancement, formulate and improve a nationally unified DRGs payment policy, process, and technical standards and specifications, and form pilot results that can be used for reference, replication, and promotion, to ensure simulation operation in 2020, and actual payment in 2021
.

 

　　On October 19, 2020, the National Medical Insurance Administration issued a pilot work plan for the total budget of the regional point method and the payment by disease point (DIP) (Medical Insurance Office [2020] No.
45), requiring all localities to complete the pilot before October 20 City declaration
.
On November 4th, the National Medical Insurance Administration determined to carry out pilot projects of total budget of regional points method and payment by disease scores in 71 areas under overall planning
.

 

　　Therefore, the "Communiqué" has clearly and continuously promoted the reform of payment methods.
The DRG-paying national pilot work has been carried out in 30 cities.
All 30 pilot cities have passed the evaluation and assessment before the simulation operation and entered the simulation operation stage; regional points have been developed in 71 cities The total law budget and DIP payment pilot work
.

 

　　Medical insurance fund supervision is on the track of legalization

 

　　Medical insurance supervision is what everyone feels most in recent years
.

 

　　Since March 2018, the central and national institutional reform plans were passed, and since the establishment of the National Medical Insurance Bureau, the fight against fraudulent insurance has set off a new upsurge
.

 

　　On September 13, 2018, the National Medical Insurance Administration, the Health Commission, the Ministry of Public Security, and the Food and Drug Administration jointly held a video conference on the national special action against fraudulent insurance, which kicked off the first wave of the National Medical Insurance Administration led by the National Medical Insurance Administration since its establishment.
Cracking down on fraud and security operations
.

 

　　On November 28, 2018, the Office of the National Medical Security Administration issued a notice on strengthening the management of medical insurance agreements to ensure the safety of funds (Medical Insurance Office Fa [2018] No.
21)
.
The notice pointed out that the medical security management departments at all levels must fully understand the important role of agreement management, strictly check and strengthen supervision in all links such as fixed-point application, agreement implementation, fee review, evaluation and assessment, and maintain the behavior of defrauding medical insurance funds in violation of the agreement.
High pressure and heavy blows
.
The notice stated that all designated medical institutions and designated retail pharmacies that breached the contract would "dissolve the service agreement" and that they would not be allowed to apply for designated medical insurance within 3 years
.

 

　　On February 26, 2019, the National Medical Security Administration issued a notice on the supervision of medical security funds in 2019 (Yibaofa [2019] No.
14)
.
The notice requires that the crackdown be increased to consolidate the high pressure situation
.

 

　　At the beginning of 2020, the fourth plenary meeting of the Central Commission for Discipline Inspection was held
.
At the meeting, the country’s top leaders rarely and explicitly stated that it is necessary to resolutely investigate and deal with collusion between internal and external medical institutions, and establish and strengthen a long-term monitoring mechanism
.

 

　　On June 10, 2020, the National Medical Insurance Administration and the National Health Commission jointly issued a notice on the special management of the standardized use of medical insurance funds by medical insurance designated medical institutions (Medical Insurance Letter [2020] No.
9)
.
The notice pointed out that it is necessary to strengthen policy guidance and joint departmental law enforcement, severely combat fraud and insurance fraud with a zero-tolerance attitude, and standardize the diagnosis and treatment services and charging behavior of designated medical institutions
.

 

　　On July 10, 2020, the General Office of the State Council issued the Guiding Opinions on Promoting the Reform of the Medical Security Fund Supervision System (Guobanfa [2020] No.
20)
.

 

　　2020 December 18, Taihe County of Anhui Province for the part designated medical institutions induced hospitalization, false hospitalization and other issues, the Office of the National Health and Social Security Bureau, the National Health health under Commission General Office issued regarding the development of special projects designated medical institutions "look back" Notice (Medical Insurance Office Fa [2020] No.
58)
.

 

　　The "Communiqué" reported this work in the section "Supervision of Medical Security Funds"
.
The “Communiqué” pointed out: In the whole year, medical insurance departments at all levels inspected 627,000 designated medical institutions and investigated and dealt with 401,000 medical institutions that violated laws, regulations, and contracts.
Among them, 6,008 medical insurance agreements were cancelled, 5457 were administrative penalties, and 286 were transferred to judicial organs; 26,100 people insured who violated laws and regulations were handled, of which 3,162 were suspended for settlement and 2,062 were transferred to judicial organs; a total of 22.
31 billion yuan was recovered in the whole year
.

 

　　The National Medical Insurance Bureau organized a total of 61 unannounced inspection teams to conduct on-site inspections in various provinces across the country.
The unannounced inspection teams inspected 91 designated medical institutions (including integrated medical care institutions), 56 medical insurance agencies, and undertook medical insurance for urban and rural residents and serious illnesses.
Forty commercial insurance companies insured have found a total of 540 million yuan in funds suspected of violating laws and regulations
.

 

　　This information tells us that the use of medical insurance funds is still very irregular, and "medical institutions in violation of laws and regulations" account for more than 60%.
It is expected that all insurance-related institutions will use medical insurance funds in compliance with the law
.

 

　　This year’s crackdown on fraud and insurance has clearly stated that the focus of the crackdown is three fakes, namely "fake patients", "fake medical conditions" and "fake bills
.
"

 

　　Particularly worthy of attention is that on February 19, 2021, the State Council issued the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" and decided to implement it from May 1, 2021
.
This is the legalization of medical insurance fund supervision
.

 

　　Is the payment ratio of hospitals at all levels high or low?

 

　　The "Communiqué" shows that the hospitalization expenses fund within the scope of the employee medical insurance policy pays 85.
2%
.
The hospitalization expenses fund payment within the policy scope of secondary and lower-level medical institutions was 86.
9% and 88.
7%, respectively, which were 2.
6 and 4.
4 percentage points higher than those of tertiary medical institutions
.

 

　　In 2019, the National Medical Insurance Bureau bulletin showed that the hospitalization expense fund within the scope of the employee medical insurance policy paid 85.
8%, the actual hospitalization expense fund paid 75.
6%, and the personal burden was 24.
4%
.
The hospitalization expenses fund payment within the policy scope of secondary and lower-level medical institutions was 87.
2% and 89.
3%, respectively, which were 2.
2 and 4.
3 percentage points higher than those of tertiary medical institutions
.

 

　　Based on this, the "Communiqué" concluded that the hospital reimbursement level remained stable
.

 

　　The "Communiqué" shows that the hospitalization expense fund within the scope of the residents' medical insurance policy pays 70.
0%, an increase of 1.
2% over the previous year
.
According to the level of medical institutions, the hospitalization expense fund payment within the policy scope is: 65.
1% for the third level, 73.
0% for the second level, and 79.
8% for the first level and below
.
Among them, 74.
6% of the funds paid within the policy scope of secondary medical institutions and below are 9.
5 percentage points higher than that of tertiary medical institutions
.

 

　　To understand this communiqué, one must first understand a concept, that is, "hospital expenses within the scope of the medical insurance policy"
.
To clarify this concept, the premise is to figure out what out-of-pocket expenses are? What is self-care expenses? What is out-of-pocket expenses? The so-called out-of-pocket expenses refer to the medical expenses that are borne by the individual in proportion to the basic medical insurance provisions, the first out-of-pocket expenses of the transferred hospitalization individual, the hospitalization threshold, and the prescribed (special) disease threshold
.

 

　　The so-called self-care expenses refer to the basic medical insurance catalog for the category B items, category B drugs, etc.
, which need to be paid by the individual first
.
The so-called out-of-pocket expenses refer to the project expenses that are not included in the scope of basic medical insurance and are entirely borne by the insured person
.
The so-called "hospital expenses within the scope of the medical insurance policy" refers to the expenses that can be included in the scope of the medical insurance policy to be reimbursed in accordance with the prescribed proportion in addition to the above three types of expenses
.

 

　　Speaking of this, you may understand why the “hospital expenditure fund payment ratio within the scope of the medical insurance policy” mentioned by the medical insurance is usually not a small gap with the actual reimbursement ratio we feel, mainly because we are in the process of hospitalization.
There are always part of the expenses that are out-of-pocket, self-care expenses, and self-paid expenses, which must be paid or not included in the “medical insurance policy”
.

 

　　Another issue worth noting is that the gap in the reimbursement ratio of hospitals at all levels is actually not large.
This shows that the medical insurance policy is actually not effective enough to induce patients to stay at the grassroots level.
Determined by the medical service capacity of the grassroots)
.

 

　　Judging from the actual situation of the tightening of medical insurance policies and strict management of medical insurance in some places, the actual out-of-pocket ratio of patients may increase significantly
.

 

　　Has the hospital's drug use increased or decreased after the purchase?

 

Everyone knows that the price of medicines has dropped drastically 　　after mass purchase and negotiation
.
However, whether the burden on patients has been reduced or not is directly related to the average cost of medicines in hospitals and outpatients
.
Unfortunately, the "Communiqué" does not contain this type of information
.

 

　　However, the "Communiqué" has four sets of information: First, the number of hospitalizations has decreased: 50 million employees were hospitalized, a decrease of 12.
3% from the previous year; the hospitalization rate of residents covered by medical insurance was 15.
1%, a decrease of 1.
5% from the previous year
.

 

　　Second, the average hospitalization expenses per time continued to increase
.
In 2020, the average hospitalization cost per medical insurance for employees nationwide was 12,657 yuan, an increase of 6.
5% over the previous year
.
The average hospitalization expenses of urban and rural residents were 7,546 yuan per time, an increase of 7.
1% over the previous year
.

 

　　Among them, the average hospitalization expenses in tertiary, secondary, primary and lower medical institutions were 13,533 yuan, 6464 yuan, and 3237 yuan, respectively, an increase of 9.
6%, 6.
4%, and -1.
3% over the previous year
.

 

　　Third, after the 2020 National Medical Insurance Drug List was adjusted, a total of 119 new drugs were added to the list, and 29 drugs in the original list were removed from the list
.

 

　　Fourth, in 2020, the total amount of online procurement orders nationwide through the provincial centralized drug procurement platform is 931.
2 billion yuan, a decrease of 60.
1 billion yuan from 2019
.

 

　　From the side, after the adjustment of the medical insurance catalog, the catalog increased, which greatly restricted the grassroots (first-level and lower medical institutions), and reduced the hospitalization of mild patients (of course, the impact of the epidemic is also on the one hand), so it shows: the number of hospitalizations decreased, The situation in which costs increase and the medical insurance catalogue increases, but the total amount of drug purchases declines
.
In the years when the prices of medical services were basically not adjusted, it showed that the use of drugs in second- and third-level hospitals did not significantly decrease
.