6 innovation 4 focus points, to create a credit management-based health insurance fund supervision of the new pattern

In order to further study and carry out the spirit of the CPC Central Committee and the State Council's Opinions on Deepening the Reform of the Medical Security System (the Opinions), and to establish a well-effective and efficient payment mechanism for medical insurance, commissioned by the State Health Insurance Administration, China Medical Insurance Magazine held a series of seminars on the focus issues of higher social concern and wider impact in the Opinions.
The fourth seminar on the theme of "accelerating the construction of the medical security credit system", at which the Deputy Secretary-General of the Shanghai Medical Insurance Association, Yu Yi expounded how to strengthen the management of the medical insurance fund from two aspects: exploring the new model and mechanism of medical insurance credit management and the countermeasures to improve the credit management of medical insurance.
1. The construction of a new pattern of supervision of medical insurance funds is an innovative move The General Office of the State Council", "Guidance on promoting the reform of the regulatory system of medical security funds", proposes to form a comprehensive regulatory pattern based on the rule of law, credit management, multi-form inspection, big data supervision, party leadership, government supervision, social supervision, industry self-discipline and personal trustworthiness.
this is the most complete interpretation of the supervision model of the health insurance fund, but also the comprehensive innovation of the regulatory system mechanism of the health insurance fund.
health insurance fund management has always been the top priority of medical insurance management, related to the correct use of health insurance funds and balance of income and expenditure, but also related to the high quality and sustainable development of the health insurance system.
health insurance fund supervision is also difficult in health insurance management, not only there are many institutional and institutional obstacles, the existing capacity is often difficult to cope with a wide range of regulatory burden.
After the establishment of the National Health Insurance Administration, in view of the severe supervision situation of the health insurance fund, conscientiously implement the Party and the state on the fight against fraud and fraud and maintain the spirit of fund security, take a series of strong measures such as intelligent monitoring, departmental linkage, flight inspection, social publicity, and so on, to form an unprecedented situation of strict management of the health insurance fund and achieved remarkable results, thus laying a solid foundation for the construction of a new pattern of supervision of the health insurance fund.
the introduction of credit management mechanism into the supervision of medical insurance funds is undoubtedly a bright spot in the new pattern of medical insurance fund supervision.
It changes the limitations of relying mainly on the unilateral supervision and single punishment means of the medical insurance sector, strengthens the self-discipline and self-restraint of the credit subjects such as medical institutions and medical personnel through the joint incentive and joint disciplinary measures of the medical insurance credit system, thus establishing the safety net of the supervision of the health insurance fund in a wider field, and also helps to promote the modernization of the health insurance governance system and governance capacity.
second, explore the new model and new mechanism of medical insurance credit management Since May 2019, when the National Health Insurance Administration launched a pilot project on the construction of the medical insurance fund supervision credit system nationwide, the pilot areas have based on local, focused on innovation, grasped the internal laws of credit management, actively explored new ideas, new ways and methods of innovative medical insurance credit management, demonstrated "six innovations", and opened up a way for the construction of the medical insurance credit system and created experience.
1. Innovative credit management system, comprehensively standardize the credit management of medical insurance.
The pilot areas have generally formulated medical insurance credit management measures, clarified the information collection, credit evaluation, credit publicity, objection application, credit repair, trustworthiness incentives and failure of trust and other major matters, and for different credit subjects, formed a series of supporting systems.
2. Innovative credit evaluation index system, comprehensive reflection of the main credit status.
credit evaluation index is the core of the whole medical insurance credit management system.
the pilot areas have formulated corresponding credit evaluation indicators for different credit subjects.
Combined with medical insurance administrative law enforcement, protocol management, anti-fraud insurance, intelligent monitoring and payment method reform, pay attention to the actual role and operability of each indicator, widely solicit opinions and repeated adjustments, carry out large samples and multiple rounds of simulation operation to ensure that credit indicators are objective and realistic and feasible.
3. Innovative credit evaluation index application, clear and implement reward and punishment measures.
and punishment mechanism of trustworthiness and trustworthiness is the core mechanism of the operation of social credit system.
Incentives for medical institutions in the pilot areas include general control indicators, fund allocation and annual assessment, reducing the frequency of daily supervision, and disciplinary measures include reducing the total control indicators, limiting the scope of disease settlement, and increasing the intensity and intensity of daily inspections.
incentives for retail pharmacies include the implementation of "green channels", "lack of acceptance" and the reduction of the frequency of daily supervision, and disciplinary measures, including increased inspection and intensity.
, the corresponding incentives and punishments have been formulated for physicians, pharmacists and insured persons.
4. Innovative credit management system, to achieve a full range of efficient management of the whole process.
Pilot areas simultaneously promote the construction of credit management system, through bidding to identify third-party professional institutions, make full use of modern information technology, innovative medical insurance credit management model, establish and improve the basic functions of credit information collection, information sharing, credit evaluation, red and blacklist, joint rewards and punishments, credit repair and other basic functions of the health insurance credit management system.
5. Innovation introduces industry self-discipline and creates a common governance pattern.
Pilot areas have made some attempts in the area of industry self-discipline, mainly in the form of fixed-point pharmaceutical institutions, physician pharmacists and other credit subjects signed a commitment letter, but also some areas have tried to form relevant trade associations, the formulation of industry norms and self-discipline conventions, to carry out industry self-discipline commitment work.
6. Innovative credit management mechanism to meet the requirements of credit management.
is to establish an information security mechanism, do a good job in information collection, flow, use and other aspects of data security management, and effectively protect the information security and rights and interests of credit subjects.
is to establish a credit repair system.
can be repaired, make a list of repairable items, and repair their credit according to the law.
is to create a culture of integrity atmosphere.
through the media publicity, publicity, education and training, widely publicize credit management knowledge.
In just over a year, medical insurance credit management from scratch, credit subject has been partially covered to fixed-point pharmaceutical institutions, physicians and pharmacists, insured units and insured persons, pharmaceutical production and circulation enterprises and operating institutions, medical insurance fund supervision credit system basically took shape, administrative law enforcement, protocol management and credit management "Tweally" supervision model began to play a role.
3. Countermeasures to further improve the credit management of medical insurance Although the pilot areas have achieved initial results through active exploration, but from the current analysis of the construction of the medical insurance credit system, the basis is still relatively weak, more exploratory components, many difficult problems, and the formation of a replicable, replicable advanced experience of medical insurance credit management is still some distance.
further improve the credit management of medical insurance, mainly from the following aspects of efforts.
1. To further grasp the relevant policies of credit management.
years, while advocating the construction of good faith, the state has placed great emphasis on compliance with the law.
The relevant documents of the State Council shall be based on laws, regulations, standards and covenants, strictly regulate the scope of credit information collection, sharing and disclosure in accordance with existing laws, regulations or the decisions and orders of the State Council, strictly regulate the identification of serious breach of trust lists, the punishment of breach of trust and the restoration of credit;
, we must pay full attention to the system construction of medical insurance credit management, overcome blindness and randomness, and effectively manage according to the law.
2. Further improve the closed-loop management of the credit system.
analysis of the existing situation in the pilot areas, there are problems of lack of management elements to varying degrees.
form a more complete credit management link, first, credit information, including credit information catalog, records, sharing, collection and classification management, etc. ;
, credit evaluation and red blacklist, should be two different credit management methods, the red blacklist system has strict policy requirements.
3. Further strengthen information sharing and sectoral linkages.
construction of social credit system requires the establishment of cross-regional, cross-sectoral and cross-disciplinary mechanisms to promote the disclosure and sharing of credit information.
health insurance credit management must focus on the establishment of cross-sectoral information sharing and joint rewards and punishments.
so-called "a loss of trust, everywhere limited", unilateral incentives and punishment measures are often limited means, insufficient strength.
Pilot areas, some are linked with the health care sector, combining the credit evaluation of medical insurance with the ratings of medical institutions and the promotion of medical personnel;
4. To further integrate the way health insurance funds are regulated.
credit management becomes the basis of fund supervision, social supervision, industry self-discipline, personal trustworthiness and how to fulfill, are related to the construction of a new pattern of all-round fund supervision.
based on credit management, the key lies in promoting the self-discipline and self-restraint of credit subjects through joint incentive and disciplinary mechanism, and forming a new situation of supervision of medical insurance funds that promote good faith and punish bad faith.
As far as "two pilots and one demonstration" is concerned, credit management must be combined with regulatory innovation and intelligent monitoring, and in terms of fund supervision, credit management must be combined with administrative law enforcement and protocol management, so as to play the role of collaborative management, mechanism integration and complementary advantages, and truly realize the new pattern of all-round fund supervision.