A new exploration of health care reform! Central media briefing on-demand settlement system.

Medicine Network September 11 - Recently, one of the most closely watched topics in the medical community is health insurance flight examination.
why does the medical community pay the most attention to flight tests? Because almost every place, without exception, there is a "serious" problem, moving millions and tens of millions.
with the strict local fee control measures introduced before, resulting in primary medical institutions almost no longer dare to see a doctor.
obviously this is not a normal phenomenon.
's the problem? In the old Xu's opinion, it is still the scourge of the health insurance payment system.
is unique, september 4, Xinhua Daily Telegraph published an article is worthy of industry thinking.
article is entitled "The exploration of health care reform triggered by a fraud case", which is about the South Bank District of Chongqing.
's going on in Southbank? In 2018, the South Bank District Commission for Discipline Inspection confirmed that between January 2013 and July 2018, Wen Wei, then a member of the Party Committee of the South Bank District Human Resources and Social Security Bureau and head of the South Bank District Social Security Bureau, took advantage of his position to receive cash from four hospitals, including the University Hospital, and Zhang's cash totalling 1.279 million yuan.
the convenience given by WenXuan and others, the university hospital defrauded the medical insurance fund of 14.29 million yuan by illegally soliciting patients, providing false medical records, and tampering with information data.
, Wen was dropped and sentenced, and in addition to those responsible for the hospitals involved, 133 Party members and cadres and public officials were investigated and punished.
the case can be investigated, but its exposed health insurance fund supervision and other deep-seated problems more worthy of reflection, alert! In 2019, Chongqing City in deepening the development of case warning education to start the "case reform governance, case reform supervision, case reform system, case reform style" pilot work, the Wenxuan case has become "case four reform" and in-depth analysis of the field of health insurance system problems target.
WenWenWenWenYi case to give two warnings: (1) responsible for the supervision of the health insurance fund related industry departments are one, separate, information sharing is not enough to fully reflect the overall supervision efficiency, so that some hospitals can through systematic fraud to evade block-type supervision.
(2) there are obvious disadvantages to the advance payment of total health insurance.
total advance must first determine a total annual total, a hospital can report a year how much health insurance funds, by the Health Insurance Bureau when the budget to determine.
this aspect has resulted in some hospitals not enough health insurance funds, some hospitals are not used up, on the other hand, the health care sector is too powerful, leaving room for rent-seeking power.
According to the monitoring recommendations, the South Bank District began two major changes, one is led by the District Health Insurance Bureau to build an intelligent medical insurance audit system, the other is to change the total allocation system to an on-demand settlement system, through the medical insurance intelligent monitoring and auditing system approved the actual costs of settlement, hospital services, good efficacy, high technology, more patients, access to health insurance funds naturally, not only eliminate the corrupt space, but also play a positive incentive role for hospitals.
practice has also shown that this health care reform is achieving remarkable results.
in just one year, the already strained SouthBank District Health Insurance Fund not only ensured full access to health care last year, but also had a balance of 160 million yuan at the end of the year, accumulating more experience for the nation's health care reform.
should I prepay from total to on-demand settlement? Although China's basic medical insurance has been implemented for many years, in the payment of health insurance, there have been a lot of unremitting exploration.
as the highest decision-making level, there are two of the most important and authoritative documents on the reform of the health care payment system.
is the guidance issued by the General Office of the State Council in June 2017 on further deepening the reform of the payment methods for basic medical insurance (State Office Issued No. 55 of 2017).
guidance points out that China's medical insurance to implement a multi-composite medical insurance payment method.
reform of the classification of medical insurance payment methods in view of the characteristics of different medical services.
For inpatient medical services, mainly by disease, according to disease diagnosis-related groups, long-term, chronic inpatient medical services can be paid by bed, for primary medical services, pay by head, actively explore the combination of pay-per-head and chronic disease management, and for complex cases and outpatient fees that are not suitable for packaging and payment, can be paid by project.
to explore payment methods that meet the characteristics of Chinese medicine services and encourage the provision and use of appropriate Chinese medicine services.
guidance, strengthen the budget management of the health insurance fund.
, in accordance with the principle of collecting expenditure, balance of income and expenditure, and slightly balance, scientifically prepare and strictly implement the budget of the health insurance fund.
the overall areas should improve the total control method in combination with the budget management of the medical insurance fund, and improve the scientific and reasonableness of the total control index.
improve the appraisal and evaluation system and dynamic adjustment mechanism that are suitable for the total amount control, and the reasonable increase in the workload of the medical institutions with the over-total control indicators may be compensated according to the agreement according to the appraisal situation, so as to ensure the normal operation of the medical institutions.
improve the consultation mechanism between medical insurance agencies and medical institutions, and promote collective consultation among medical institutions.
control indicators shall be appropriately tilted towards primary health care institutions, children's medical institutions, etc., and the formulation process shall be made public to medical institutions, relevant departments and society in accordance with the provisions. The
guidance proposes to establish and improve the mechanism of open and equal negotiation and consultation between medical insurance agencies and medical institutions, the incentive and risk-sharing mechanism of "residual retention and reasonable overspend sharing", to improve the enthusiasm of medical institutions to self-management, and to promote the transformation of medical institutions from scale expansion to intension development.
Please note that the difference between "total control" and "total advance" is "total control", which controls only a "number" and "total advance" pays a large amount of "money".
document is the opinion of the State Council of the CPC Central Committee on deepening the reform of the health care system in March 2020.
has pointed to continued efforts to reform medicare payments.
improve the total budget method of the medical insurance fund, improve the mechanism of consultation and negotiation between the medical security agencies and medical institutions, promote collective consultation among medical institutions, scientifically formulate the total budget, and link it with the quality of medical care and the performance appraisal results of the agreement.
vigorously promote the application of big data, the implementation of a multi-composite medical insurance payment method based on disease-based payment, the promotion of disease diagnosis-related group payment, medical rehabilitation, chronic mental illness and other long-term hospitalization pay by bed day, outpatient special chronic diseases pay by head.
to explore the separation of medical services from medicines.
to adapt to the development and innovation of medical service model, improve the payment method and settlement management mechanism of medical insurance fund.
To explore the implementation of total payments to close-knit medical complexes, strengthen supervision and assessment, balance retention, reasonable overspend sharing, conditional areas may advance part of the medical insurance funds to medical institutions in accordance with the agreement, to ease the pressure on the operation of their funds.
the document also provides only a "total budget" and does not specify a "total advance", but a "total payment" for the close-knit health-care complex.
why is the nation's top brass generally cautious about "total advances" for health care funding? Because there are so many drawbacks to the total up-payments that have been explored over the years.
, the total is hard to determine.
can not effectively consider the development of medical institutions and new business development, and the health care sector in determining the total amount is difficult to avoid "profit transmission" and corruption.
Second, the implementation of the total advance payment, the health insurance bureau is easy, can pick a pick, regardless of regard, can be lazy, but the hospital will turn away from receiving major diseases, especially at the end of the year after the cost of medical insurance exceeded the refusal of medical insurance patients, not only harm the interests of insured patients, in the long run, but also harm the interests of the hospital, not conducive to the development and progress of the hospital, hospital quality, technical level is difficult to improve.
South Bank District to change the "total advance" to "on-demand settlement"? South Bank District said that "on-demand settlement" is for the total amount of prepaid disadvantages, in strict implementation of real-time supervision of information, in accordance with the actual cost of medical services in a way of settlement, here "needs", is the clinical norms of the actual needs of diagnosis and treatment.
With their term "on-demand settlement" is "through the medical insurance intelligent monitoring and audit system approved the actual costs to be settled", the result is that the hospital service is good, good efficacy, high technology, more patients received, access to health insurance funds naturally more, not only eliminate the corrupt space, but also played a positive incentive role for the hospital.
Chongqing South Bank District health insurance payment implementation of the "on-demand settlement system", it seems to be an "innovation", in fact, is also a kind of "return", this "return" is to respect the law of medical care, but also the result of medical insurance, medical care, medicine linkage, the reason for the "Xinhua News Agency" affirmation, should also be to the ongoing vigorous reform of the health insurance payment system a warning.
you remind me of? Remind us that reform is not a toss-up, reform cannot go against common sense, reform is not to push everything back.
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