5 comprehensive means to improve the regulatory system system to strengthen the supervision of health insurance funds.

Text . . . Wang Zongfan in China's medical security system reform and construction process for more than 20 years, the fund supervision is relatively weak.
poor supervision has become one of the important reasons for the widespread abuse of medical services and even fraud and insurance.
the establishment of the State Medical Security Administration in 2018, the special fund supervision department has been set up, the relevant fund supervision system has been promoted, the supervision and inspection efforts are much deeper than in the past, the means of supervision are also constantly innovative, the fund supervision work has been greatly strengthened, and the results achieved are also obvious to all.
the "Guidance on Promoting the Reform of the Regulatory System of the Medical Security Fund" issued by the General Office of the State Council recently, can be said to be a major policy breakthrough in improving and perfecting the supervision system of the medical insurance fund on the basis of summarizing the practical experience and exploration of the supervision of the medical insurance fund over the course of more than 20 years of medical insurance reform and development, especially in recent years.
. First, in the Opinions on Deepening the Reform of the Medical Security System published in early March, the supervision of the medical insurance fund was listed as one of the four main links of medical security system treatment, financing, payment and fund supervision for the first time, and the supervision of the fund has become one of the six key tasks of deepening the reform of the medical insurance system, highlighting the important position of fund supervision in the steady operation of the medical security system.
the "guidance" issued this time is not only the real need to strengthen the supervision of the medical security fund, but also the concrete implementation of the task of deepening the reform of the medical security system reform.
the author believes that the "guidance" will be 2025 reform objectives as "basically built medical insurance fund supervision system", but also intended to complete the 2025 deepening of the reform of the medical security system in the field of fund supervision reform tasks, so as to complement the medical security system in the fund supervision of this short board, to achieve the overall medical security system in 2025 basic mature set development goals.
from the framework structure of the Guidance, the Guidance puts forward the main objectives of the reform of the fund supervision system, clarifies the regulatory responsibilities of the various regulatory bodies, especially the governments that play a leading role, and puts forward the main tasks of the reform and construction of the supervision system in six aspects, such as supervision and inspection, intelligent monitoring, reporting reward, credit management, comprehensive supervision and social supervision.
the Guidance also proposed to form a comprehensive regulatory structure based on the rule of law, credit management, multi-form inspection, big data supervision, party committee leadership, government supervision, social supervision, industry self-discipline, personal trustworthiness, and build a full-extent, full-process fund security prevention and control mechanism.
from these statements can be seen that the introduction and gradual implementation of the Guidance marks China's entry into a comprehensive construction of the health insurance fund supervision system, promote the medical insurance fund all-round, all-round, all-process supervision of the new era.
, the medical security department to assume the main responsibility of the fund supervision Although, the supervision of the medical insurance fund is a full range of supervision, the Party committee, the government (including medical insurance and other related departments), the social, pharmaceutical industry, medical institutions, individuals have their own responsibilities or responsibilities, fund supervision needs to weave a network, form a joint force, but the competent departments of medical security should play a central role in the entire fund supervision system.
the Guidance, the supervision of health insurance funds adheres to the government-led, while clarifying the role of the lead of the government-led chinese medical security authorities.
first of all, the fund supervision is the scope of responsibility of the medical insurance department, the medical insurance department should bear the main responsibility of maintaining the security of the fund, the responsibility.
the competent department of medical insurance is not only the main drafter of the text of the fund supervision and regulation and the most important promoter of the construction of the rule of law, but also directly assumes the supervision and inspection and administrative law enforcement responsibilities related to the medical service behavior and medical expenses paid by the medical insurance;
second, the health insurance sector also plays an important coordinating and guiding role in multi-sector coordination and supervision of the fund in the field of social co-management.
health care department is the coordinator, organizer, industry self-discipline and self-management guide and promoter of joint supervision.
, the medical insurance department must keep its responsibilities, fulfill the role of the main responsible person of fund supervision, strengthen the administrative supervision of the department, promote the organization to strengthen and improve the agreement management and fund audit, and coordinate the joint action of other relevant departments, guide and motivate the public to actively participate in the law, complete the effective execution of illegal crimes, and strive to build a new comprehensive supervision pattern led by the government and involving all parties.
, to promote the reform of fund supervision and governance, to promote social co-governance Although the supervision of the health insurance fund is led by the government, but the government administration, operating institutions are limited in strength, professional capacity is not enough, fund supervision can not rely solely on the government, but also need the active participation of social forces, multi-party coordination, in order to form an all-round and strict and powerful new mechanism of fund supervision.
multi-participation and social governance is the established direction of the governance reform and modernization of our government, and it is also the development trend of the reform of medical insurance governance and the reform of the fund supervision mechanism.
the Guidance, on the one hand, it proposes to strengthen the capacity-building of the medical insurance sector's own fund supervision and inspection, establish and improve the fund supervision and enforcement system, strengthen the strength of personnel, on the other hand, it also explicitly calls for the active introduction of information technology service institutions, accounting firms, commercial insurance institutions and other third-party social forces to participate in fund supervision, in order to enhance the professionalism, precision and efficiency of supervision.
it should be noted that the Guidance further states that the introduction of pay-per-service performance in the purchase of fund regulatory services provided by third-party social forces is a major breakthrough in the reform of the fund's regulatory mechanism.
active and professional fund supervision services can reduce fund waste, improve the efficiency of fund use, through the fight against fraud and insurance can directly recover fund losses, strict and powerful fund supervision can produce huge economic benefits.
therefore, through the necessary incentives, the implementation of the fund-based regulatory performance to pay the relevant management services costs (relatively small input), to stimulate the regulatory power and energy of social forces, the output of higher efficiency of the use of funds (greater returns), is very worthwhile, but also very "cost-effective".
in addition, the author believes that the medical insurance operators should also explore the introduction of a certain level of fund management performance-linked incentive mechanism, to stimulate the operating institutions to strengthen the agreement management, fund audit enthusiasm, initiative.
the establishment of economic incentive mechanism is fully in line with the basic direction of reform and innovation of medical insurance public management services in deepening the reform of medical security system, and we should promote the governance reform which will help to improve management performance.
as to how to measure the performance of regulatory services, how to relate the payment of management service fees to performance, performance payment of the source of funds, it is necessary to explore through practice and further government decision-making and even modify the relevant laws to complete step by step.
. To clarify the relationship between the administration and operation of medical insurance, and give full play to the role of management in the past quite a long time, China's professional medical insurance administrative supervision is basically missing, for this reason the medical insurance operators have to assume a certain administrative supervision responsibility.
with the establishment of the administrative supervision department of medical insurance and the gradual establishment of the administrative law enforcement system, it is really necessary to deal with the problem of medical insurance administration and management responsibilities unclear.
the "guidance" requirements, straighten out the relationship between the administrative supervision of medical insurance and the management of the operating agreement, and clarify the administrative supervision and the responsibility boundary of the audit.
although the same medical insurance department, have the responsibility of regulating medical services, but the administrative and administrative functions are different, the content and mode of supervision are also different, it is necessary to clarify the regulatory responsibility boundary between the two sides.
administrative departments and law enforcement agencies rely on administrative coercive means, administrative supervision and inspection, investigation and punishment of violations and law enforcement penalties according to clear legal liabilities, while the operating agencies implement agreement management, mainly by means of economic means (purchase services and expense payment), the use of negotiations to sign agreements, the use of relatively flexible such as interviews, warnings, fee refusal, assessment and settlement linked, mid-term (end) agreements and other means to restrain and guide medical services.
medical services professional, there are serious information asymmetry, unreasonable, and even some illegal medical service behavior is not easy to identify, and some unreasonable, non-compliance and the system environment distorted profound background, and not suitable for the simple disposal through tough administrative punishment.
, in addition to a few serious violations of the law, the vast majority of medical services are more suitable for negotiation and more flexible and delicate way of management, and not suitable for administrative and judicial means to regulate.
therefore, we should strengthen the capacity-building of the medical insurance operators, strengthen and optimize the management of agreements, comprehensively promote the reform of payment methods, and give full play to the important role of management in guiding and regulating medical service behavior and improving the efficiency of the use of medical insurance funds.
V. To establish supervision on a solid foundation of self-management through administrative means to investigate and deal with illegal acts in the medical service process, to combat fraud and insurance, of course, can reduce the loss of funds, is conducive to maintaining fund security, but better improve the efficiency of the use of the fund requires the occurrence of illegal acts, medical service behavior generally standardized, reasonable and efficient, which needs to promote and guide the self-management and self-restraint of medical service providers through the relevant institutional arrangements.
if the investigation and punishment of illegal acts, to combat fraud and insurance is the cure, to promote the supervision of the object of self-management, self-restraint is the way to cure.
to this end, the Guidance emphasizes that fund supervision is led by the government, but also the industry self-discipline, personal trustworthiness in the important position.
the "Guidance" requirements, promote self-regulation of the pharmaceutical industry to guide the self-management of pharmaceutical institutions, establish a credit management system, through joint trustworthiness incentives and breach of trust joint punishment, to promote the norms of behavior and self-restraint of pharmaceutical institutions and individuals, through the consultation and negotiation of institutions and agreement management, to promote the medical institutions and medical personnel self-restraint and actively regulate service behavior, actively control costs.
, in the process of the construction of the system of medical insurance fund supervision, we should actively guide and promote the self-management and self-restraint of the providers of medical services.
the more the provider of medical services attaches importance to self-management and self-restraint, the less administrative supervision and even judicial disposition will be used.
, of course, achieving more reliance on self-management and restraint, less use of administrative and judicial regulation is not overnight, but a long process of systemic reform is needed, and there is a long way to go.
for a long time, in the field of drug services price distortion, behavior misconduct, imbalance in the allocation of resources, rigid distribution mechanism and other issues have not fundamentally changed, the economic means of the management of the agreement of the medical insurance organizations and the reform of payment methods are still difficult to give full play to the role of effective incentives and restraints, strengthen the administrative supervision of medical insurance funds, investigate and punish violations of the law, and combat fraud and insurance, is still the top priority of the current health insurance fund supervision.
original title: improve the regulatory system system and strengthen the supervision of health insurance funds.