Expert interpretation: The reform and innovation of the regulatory system of the health insurance fund.

Text . . . Wang Zhen's recent "Guidance on Promoting the Reform of the Regulatory System of the Medical Security Fund" (hereinafter referred to as "Guidance") has had a great impact on the industry and society, and has aroused concern from all sides.
this should be based on two big backgrounds: First, in the past many years in the use of China's health care fund in the process of fraud, abuse and waste, such as the use of more serious problems, the use of funds is not efficient, this need not be said, "guidance" also has a clear statement on this; The supervision has made great efforts, whether it is "flight inspection", or daily spot checks, inspection, found a large number of illegal problems, whether on the provider of medical services, or pharmaceutical enterprises have produced a greater shock and impact, health insurance supervision "long teeth, with means."
in these two backgrounds, the issuance of the State Office's "guidance" can be said to be the right time, for the establishment of a normal health insurance fund supervision system laid the foundation.
the Guidance proposes to build a whole-wide, all-process fund security prevention and control mechanism, the tentacles of supervision throughout all aspects of the health insurance fund, the integration of government, industry, social and other relevant areas of the regulatory forces.
this is also the reform and innovation of the fund's regulatory system and mechanism.
is first and foremost government regulation.
here to point out that the supervision of the health care fund is not a matter of the health care bureau, which is related to the medical security related to the industry, the field is more related, but also with China's regulatory power scattered in different departments.
such as the medical service supply institutions and personnel medical and therapeutic activities compliance of the industry supervision, mainly the health administrative departments, drug quality, safety, practice pharmacist behavior supervision is mainly responsible for the drug regulatory departments, the medical and health industry price sourly responsible for the market supervision department, involving criminal cases also need the involvement of public security departments.
health care department to assume these regulatory responsibilities is neither realistic nor possible.
this requires the construction of inter-departmental linkage mechanisms to improve regulatory efficiency and regulatory capacity.
some regions have made exploration and practice in this regard, such as the establishment of a joint mechanism of the supervision of health insurance funds, the introduction of health insurance supervision of the department coordination norms.
is the introduction of information technology service institutions, accounting firms, commercial insurance institutions and other third-party forces to participate in the supervision of health insurance funds.
this is also one of the main contents of the "professional" regulatory system proposed in the Guidance.
"professional people do professional work", the introduction of third-party professional institutions is an important way to improve the supervision capacity of health insurance funds.
In addition, the introduction of third parties can strengthen regulatory power and enhance regulatory capacity under existing constraints.
of course, more important is to introduce third-party participation in supervision is also an important way to build a "co-construction and common governance sharing" governance pattern, is to improve the level of health care governance.
from a regulatory point of view, the introduction of third parties also allows the Government to be more flexible and flexible in its handling of the matter. third,
, strengthen self-discipline in the industry and introduce social supervision.
in the process of constructing the regulatory system, the supervision of the health insurance fund as the purchaser of the service belongs to the "second-party supervision", that is, the supervision of the direct counterparty.
, there is a process of self-restraint and self-regulation.
self-restraint and self-regulation need some incentive mechanism to play a role.
the premise of this incentive is to "vote with your feet" in the market, and if it can't be very self-restraint of its opportunism, then the buyer (the consumer) can choose another person.
to do "vote with your feet", requiring the supply side to have "stability" and "transparency" in the long term.
these two mechanisms are the integrity mechanism and the other is the mandatory information disclosure mechanism.
the Guidance put forward the construction of the integrity system of medical service supply institutions, and the establishment of "integrity files" for each fixed-point institution of the agreement, so as to restrain the "stability" of the behavior of the fixed-point institutions of the agreement;
fourth, make full use of big data and establish an intelligent regulatory system.
China's medical insurance fund supervision for a long time stay in the "manual operation" era, manual audit, manual inspection, which is not the rapid growth of medical insurance business.
of course there are various reasons behind this, but the medical insurance informationization and standardization construction lag is one of the main reasons.
after the establishment of the National Health Insurance Bureau, the medical insurance informationization, standardization construction as the main grasping hand of the construction of the medical insurance system, has made significant progress, the standardization of various medical insurance business has been established, the national unified information system has gradually been built.
this provides the conditions for an intelligent health care regulatory system.
The Guidance emphasizes the need to increase the application of data, establish and improve the monitoring system of medical insurance function, so that the supervision of the medical insurance fund to engage in post-check examination and gradually towards strengthening the supervision before and during the event.
this "guidance" can be said to be a "milestone" in the construction of China's medical insurance fund supervision system, is the construction of normal fund supervision system stepping stone.
it not only provides a basis for improving the supervision level and ability of medical insurance fund, but also has a great impact on the provider of medical services and pharmaceutical suppliers, which is an important measure to reconstruct the ecology of the industry.
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