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    Home > Active Ingredient News > Drugs Articles > Expert authority of the Ministry of human resources and social security reveals the reform path of medical insurance payment mode

    Expert authority of the Ministry of human resources and social security reveals the reform path of medical insurance payment mode

    • Last Update: 2017-11-30
    • Source: Internet
    • Author: User
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    Source: Xinkangjie 2017-11-30 medical network November 30 news: "before 2014, the growth rate of economic income of China's medical insurance fund was over 25%, but in recent years, the growth rate of national medical insurance fund income continued to be smaller than the growth rate of expenditure The report of the 19th National Congress of the Communist Party of China proposes to abolish the use of medicine to support medical care and establish a comprehensive medical security system In addition, according to the statistics of 2017 policy documents, it is found that "medical insurance" has become the most frequently used word in the first half of the year How will the 19th national congress change China and the pharmaceutical industry? At the 32nd China Pharmaceutical Industry Development Summit Forum, experts from the State Food and Drug Administration and the Ministry of human resources and Social Security jointly interpreted the medical insurance policy and studied and judged the policy trend " In the past five years, the policy of "medical insurance" has been introduced intensively and the industrial pattern has changed the most According to incomplete statistics, 277 policy documents were issued at the national level from January to October 2017, of which 196 were issued by the State Food and drug administration Based on the statistical data of China Pharmaceutical recruitment Union (CAPD), it is found that the top 10 key words of the documents released in the first half of this year include: medical insurance, centralized procurement, drug supervision, development planning, clinical management, flight inspection, two ticket system, hierarchical diagnosis and treatment, drug and service price reform, medical devices and other special work Around the reform of medical payment system, the standard of sending documents is higher and higher In 2011, the Ministry of human resources and social security issued the opinions on further improving the reform of payment methods In 2013, the Ministry of human resources and social security, the Ministry of Finance and the Ministry of Health jointly issued the opinions on controlling the total payment of basic medical insurance In June 2017, the general office of the State Council issued the guiding opinions on further improving the reform of payment methods of basic medical insurance, which made it clear that in 2017, the composite payment method based on disease payment will be realized, and by 2020, the payment by project will be significantly reduced At the same time, this is the first time for the general office of the State Council to issue a separate document on the reform of medical payment mode The importance of the reform of payment system can be seen Since the 13th five year plan, China's economy has entered into a fast-growing shift period, a period of structural adjustment shock, and a period of early policy stimulus At the same time, the growing medical expenses brought by the aging population, the chronic disease and the high-grade development of health technology bring more and more pressure to the medical insurance fund But in fact, many medical institutions waste a lot in the use of drugs According to relevant statistics, due to unreasonable use of drugs, inferior drugs and other factors, the amount of drug-related waste is up to 1 trillion yuan every year Experts from the Ministry of human resources and social security say that the total amount controls not only the cost of excessive growth, but also the cost of waste "The development process of the hospital is still in the stage of squeezing water, which is equivalent to a sponge that absorbs water The Ministry of human resources and social security will gradually increase its force on this sponge." It is understood that at present, the reform of domestic medical payment mode is divided into three levels: first, the macro level, to strengthen the budget management of social insurance funds Second, at the meso level, we should control the total amount of payment to the designated medical structure, and even to the whole overall planning area Third, at the micro level, we will implement a compound payment mode based on disease payment At the macro level, the Ministry of human resources and social security formulates the insurance revenue and expenditure budget, reports it to the State Council together with the Ministry of finance, and the State Council reports it to the two sessions, and implements it after approval, so as to realize the rigid management of revenue and expenditure budget To control the total amount of designated medical institutions or co-ordinated areas is to control fees, not control services This means that, for medical institutions, once the payment standard is established, the hospital should make reasonable diagnosis and treatment according to the standard, and formulate clinical path and clinical guide to regulate medical service behavior At the same time, the clinical pathway and clinical guidelines are used as the basis for the supervision and assessment of medical services "Payment by disease is just a measurement unit that medical insurance pays for hospitals Not every patient has to spend so much money, let alone every patient can only spend so much money." Officials from the human resources and Social Security Bureau stressed that reimbursement can be applied for separately according to the actual condition In addition to pay by disease, pay by disease score is also worthy of attention The core of score based payment lies in the separation of score and value in work and the combination of score and value in settlement In addition, the human resources and Social Security Commissioner also revealed that he would explore capitation in outpatient and primary medical institutions In terms of the standard cycle, the Ministry of human resources and social security said that it would dynamically adjust the payment standard according to the actual situation, and plan to adjust it every two years When we talk about health care, what are we talking about? DRGs? PBM? Now when it comes to health care, DRG and PBM are always indispensable DRGs (diagnosis related groups) are payment systems based on diagnosis related groups (DRGs) DRG mainly includes three aspects: one is grouping, which is based on disease diagnosis and consumption cost, and requires significant differences between different groups; the other is weight, which is determined by group as well as by disease score; the third is to establish the payment standard of basic weight DRGs has two functions, payment settlement and medical service management For example, the cost consumption of different hospitals under the same group and the mortality rate of low-power recombination patients all reflect the difference of service quality of different medical institutions Under the tide of medical reform and "Internet plus", massive new medical services will gradually rise PBM, which integrates insurance consignment, pharmacy management, mail order and recruitment, is one of them PBM (pharmacy benefit management) refers to the organization that provides services and management for drug payers Since the 1960s, PBM in the United States has made great progress 95% of patients have been treated with PBM, accounting for 80% of all prescriptions in the United States There are obvious differences between China's medical market and the United States Fang Zhiwu, chairman of Beijing wanhu good prescription company and the first member of the medical reform expert committee of the State Council, interprets the PBM model of the United States as the linkage of chronic diseases and three medical services in China from the perspective of "system innovation" In fact, from 2007, the intelligent audit and control system of medical insurance began to be developed, and by 2015, PBM was fully piloted in Wuhu City, Anhui Province PBM has successfully started in China, gradually exploring the construction of chronic disease management and drug center supply system Not long ago, the CIRC publicly solicited opinions on the proposed revised health insurance management measures (Draft for comments) This is after the health insurance management measures were promulgated in 2006, 11 years later, the relevant departments started to revise the health insurance regulatory measures again In the draft, health management services and medical insurance cooperation were mentioned for the first time Driven by the combination of multiple insurance and three medical services, the problem of "Pan welfare of social security" is expected to break through Fang Zhiwu predicted that by 2021, when the connection between commercial insurance and social security is completed, commercial insurance will bear 50% of the cost of medical payment and become an important payer.
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