How should we deal with the reform of the payment method of health insurance when it meets the medical association?

As one of the five basic medical and health systems in China, the establishment and perfection of the hierarchical diagnosis and treatment system has attracted much attention.
Medical union" (referred to as "medical union") is a feasible way to help China's graded diagnosis and treatment at this stage, the state has fully launched various forms of medical union construction pilot, with a view to promoting the sinking of medical resources, improve the excessive overdraft of high-quality medical resources, primary medical resources idle problem, so that patients can be orderly consultation, alleviate the "difficult to see a doctor" problem.
since the beginning of 2017 when the state fully launched a pilot of various forms of medical association construction, the construction of medical association has been carried out for nearly four years.
However, from the practice of various places, although various forms of medical association pilot has blossomed everywhere, hundreds of competition, but in fact in the classification of treatment plays a very limited role: large hospitals "siphon" is still continuing, most of the local three-level public hospitals overcrowded, a bed difficult situation has not been effectively alleviated, and even society still has a unclear understanding of the concept of the situation.
, where is the crux of the problem in the construction of china's medical association? What role can health insurance play in stimulating medical associations to optimize the allocation of medical resources? On this issue, "China Medical Insurance" conducted an in-depth interview with Zhao Wei, director of the Health Policy Evaluation and Technical Assessment Research Office of the Health Development Research Center of the National Health and Health Commission.
: Many people know about medical associations, but they don't know the nature and mode of operation of medical associations.
Zhao Wei: "Simply by definition, the medical association usually consists of a third-level hospital, a second-level hospital, and a primary community hospital and a village health room."
to solve the problem of difficult to see a doctor, to achieve the "small illness at the grass-roots level, major illness to the hospital, rehabilitation back to the grass-roots" ideal pattern of medical treatment.
At present, there are four typical models of medical associations being implemented in China: the first is called urban medical groups or close medical associations, mainly covering cities, that is, a third-level hospital as the lead unit, a number of urban secondary hospitals, rehabilitation hospitals, nursing homes and community health service centers, to build a "1 plus X" medical complex.
The second is the county medical community, the main county-level area below, the goal is to achieve "county hospitals as the leader, township hospitals as hubs, village health rooms as the basis" of the county and township integrated management, to play the role of the county hospital's urban-rural ties and county-level leading role.
The third is the cross-regional specialist alliance, which is a horizontal approach to in-work medical resources, mainly to a medical institutions, the same specialized technical strength of other medical institutions, the formation of a number of specialty centers in the region, to enhance the ability to solve major diseases, such as gynecology, pediatrics, oncology and other specialized alliances.
The fourth is the telemedicudist collaboration network, which is established by the lead unit and medical institutions in primary, remote and underdeveloped areas, which is equivalent to using information technology to promote the vertical flow of medical resources and improve the access of high-quality medical resources to a wider range.
Health Insurance: What do you think is the nature of the medical association? Zhao Wei: Discussing the nature of medical associations, we have to think about the original intention of establishing medical associations.
In fact, as I said above, we expect the medical association to become a carrier of graded diagnosis and treatment, to help optimize the allocation of medical resources, and promote the realization of "grassroots first consultation, two-way referral, rapid and slow division, up and down linkage" such a pattern.
to achieve this goal, it is necessary to build the medical association into a community of responsibility, a community of management, a community of services and a community of interests.
I don't think the expression "graded" is appropriate, because the word "graded" leaves us with a concept of superior and lower-level medical institutions.
I think that "collaborative medical treatment" may be more able to express the nature of the medical association, in fact, a medical association between different medical institutions is the "collaboration" relationship, this relationship was established, you can like this outbreak prevention and control of the same sub-grouping area, the implementation of grid collaborative management, the population in a certain area of disease prevention, and even health management to do a good job.
china's medical insurance: Why in some places in practice, the medical association does not seem to play its practical role, the phenomenon of "siphon" in large hospitals is still very obvious? Zhao Wei: That's because we didn't grasp the core "interest" problem of medical association construction.
first of all, there is no good interest link between medical institutions, the core hospital (i.e., the large-scale general medical institutions in the medical union) and member hospitals are not the same community of interests at all.
on the surface everyone in a medical union body, but each other financial independence, assessment independence, health insurance fund management independence, the actual operation or do their own.
in this case, only loose medical associations are formed, and each other is only a form of medical cooperation linked by the complementarity of medical services.
big hospital or only care about their own bigger and stronger, how the grass-roots medical institutions how to operate also has nothing to do with him;
is not doing a good job in the distribution of benefits within medical institutions, medical institutions within the pay distribution system has not eded, and this is the most difficult part of the reform of public hospitals.
If there is no fundamental change in the way doctors obtain benefits, it will be very difficult for doctors, especially those in primary health care institutions, to obtain distributions from the balance, even if the overall health insurance fund balance is realized through the establishment of medical associations, which will greatly weaken the effectiveness of the implementation of medical associations.
Health Insurance: So how can we solve this problem? Zhao Wei: To solve this problem, I think the key is to the government "licensing", through personnel, finance, performance appraisal between the hospital and the primary medical institutions bound together, so that they become a community of interests, and through the establishment of a council and other ways so that all members of the medical association can "build and share", this time the relationship between the hospital and the grass-roots hospital is like "big brother" and "little brother", we have the momentum to do greater together.
that's one side.
on the other hand, it is necessary to formulate a fair and reasonable performance appraisal system through internal management organizations such as the Council, all medical institutions in the medical association should be treated equally and there should be no "discrimination" in the distribution of performance due to different levels of medical institutions, and the participation of primary medical institutions in this process is particularly important, because the primary purpose of the medical association is to give full play to the role of primary medical institutions.
some people will question this kind of medical association experience to the big three A hospital bigger and bigger, then in the future we will pay more attention to play a small third-level hospital, secondary hospital in the role of the hospital complex.
For example, we will focus on promoting the construction of the county medical community, the National Health Care Commission and the National Health Insurance Administration and other three departments have jointly issued in September 2020 "on the issuance of close county medical and health community construction evaluation standards and monitoring indicators system (trial) notice" to jointly promote this work.
And for the city's large, comprehensive triple-A hospitals, will guide them more to the direction of high-level development, scientific research, teaching, research and development, committed to rare diseases, serious diseases and other medically valuable diseases, to solve the problem of medical science.
such hospitals will eventually withdraw from the construction of medical complexes and slowly become regional medical centers, playing a regional radiation role.
also a point, now some people always use information to say things, the low level of information as a medical union can not push an important obstacle.
But I would like to say that the key lies in the government's mechanism-building, the mechanism is open, the concept is consistent, even through a conference call can do this matter of the medical association.
the problem of information technology, slowly through market means can be solved.
: In the process, what should health insurance do to deal with and adjust? Zhao Wei: To form the "close medical association" we expect, it is very important to cooperate with the reform of medical insurance payment methods, not only to prevent the "security risks" of the health insurance fund, but also to focus on optimizing the structure of the use of the fund, improve the efficiency of its use, and give full play to the role of the "strong grass-roots" of the health insurance fund.
There is a concept in the
health care payment method called "packed payment" or "bundled payment" internationally called Bundled Payment, simply that health insurance pays the medical institutions in one lump sum and then pays them themselves, an payment method that originated internationally in order to tie the big hospitals and primary care units together by region.
Practice, it is generally through an institution to coordinate the operation of a regional health insurance fund, according to the number of heads in the region, past health insurance fund expenditure, etc. to measure the total amount of health insurance funds in the region next year, and then the specific fund expenditure is determined by the medical institutions themselves.
they need to use these fixed health insurance balances to complete health management of the population in the region, to be able to solve 90 percent of the diseases except for the most serious diseases.
if managed, the fund has a balance that can be retained as an internal performance allocation;
There is also a theoretical basis behind this payment method, that is, the use of health insurance "economic leverage" to regulate the medical behavior of hospitals and doctors, because a large number of research and basic research, economic leverage on behavior changes not only for the medical industry, but also for all industries are the most effective.
through this packaged payment method, so that hospitals in the medical union to manage patients' limited medical insurance funds, and ultimately the people really benefit.
: So what do you think medicare payment reform needs to focus on? Zhao Wei: Of the four models of medical associations mentioned earlier, the current level of participation of medical insurance in the construction of county medical associations is the highest, and in September last year, the health care committee jointly issued a document on the county medical community evaluation standards and monitoring indicators system, which will be the next step.
I think the most important thing about health care payments is to do two things well: total budget management and performance appraisal.
management of total medical products, the total amount should be scientifically measured for the characteristics of medical associations.
After all, if the medical association can run efficiently, the allocation of medical resources should be able to achieve the effect of "1 plus 1>2", so in theory the overall expenditure of the health insurance fund should also be lower than the individual medical institutions add up, this amount can be adjusted according to the actual operation, and through the "balance retention> incentive mechanism to guide the medical association to maximize reasonable savings of the health insurance fund.
there are also many issues that need further consideration when it it to performing performance appraisals.
first of all, we should identify the means and indicators of performance appraisal, that is, how health insurance will evaluate the performance of the medical association.
I think the "performance" here can be divided into "quantity" and "quality" two aspects: from the "quantity" point of view, the medical association should be able to promise to a certain area of the population's health management and difficult diseases other than 90% of the disease to solve, that is, to have a clear amount of service;
health insurance can combine these data to analyze whether the medical association has played a role in optimizing the allocation of medical resources and improving the efficiency of the use of health insurance funds.
Then there is the application of performance appraisal results, that is, how to achieve performance appraisal results-based health insurance fund payments, such as how much money to set aside for the redistribution of performance appraisal, and so on, such as the distribution ratio between different levels of medical institutions to determine whether the health care sector is required to participate.
The health care sector must assume more important functions in this regard, but how to divide the responsibilities and responsibilities with the health sector, how to achieve information sharing and collaborative governance, these detailed aspects of the problem need to be constantly explored through the pilot to improve, is being piloted in the county medical union construction of the evaluation criteria and monitoring indicators system can be used as a good pilot sample.
now that the NATIONAL Health Insurance Administration has begun to explore the total budget management of the regional points method, I think this direction is very correct.
Next, I hope that local governments should take the initiative to assume responsibility and really integrate medical institutions in a region, if it is difficult to push it all over, you can also start with cardiovascular, diabetes, hypertension and other common diseases on the pilot.
ever, we hope to strengthen the collection, analysis and utilization of data during the pilot process, and now we can only use historical data to do the calculation of the pilot phase, but in the future through the newly generated data to continuously improve the rationality of this payment method.