How to build the medical insurance performance evaluation system? 3 key points to teach you to solve difficult problems.

"The Opinions of the Central Committee of the Communist Party of China and the State Council on Deepening the Reform of the Medical Security System" clearly proposes to "implement the performance management of the whole process of the operation of the fund and establish a performance evaluation system for the medical insurance fund," said Dr. Yu Huping, Ph.D. in the direction of medical insurance, and director of the Development Department of the Zhejiang Provincial Medical Security Bureau.
" full implementation of the performance management of medical insurance funds is to promote the health insurance governance system and the modernization of governance capacity of the inherent requirements.
health insurance department should make an objective and fair evaluation of the economy, efficiency and efficiency of medical insurance fund expenditure according to the set performance targets, using scientific and reasonable evaluation indicators, evaluation criteria and evaluation methods.
performance evaluation refers to the use of certain evaluation methods, quantitative indicators and evaluation criteria to assess the level of achievement of performance goals determined by the higher authorities according to their functions, as well as the budget implementation results arranged to achieve this goal.
, performance evaluation is to evaluate the effect of the evaluation object and the established goal.
As for the performance evaluation of medical insurance fund, it refers to the objective and fair evaluation of the economy, efficiency and efficiency of medical insurance fund expenditure by the medical insurance department according to the set performance target, using scientific and reasonable evaluation index, evaluation criteria and evaluation method.
basic definition, medical insurance performance evaluation should include performance goals, performance indicators, evaluation methods and other links.
about the performance target of medical insurance performance management is an important part of the performance management of public finance funds, is a fund expenditure results-oriented budget management model.
the main body of management, after the institutional reform, the State Health Insurance Administration has become the functional department of the national medical insurance business management.
The National Health Insurance Administration has the full process management responsibility of the health insurance fund from collection, expenditure to supervision, and implements the effective management of the health insurance fund on behalf of the state by various means;
From the point of view of fund attribute, the medical insurance fund belongs to the public funds, china from the beginning of the establishment of the medical insurance system, the medical insurance fund account to the financial department management, from 2011 on the national financial system to promote the overall public financial performance management, the financial department in the concept and operation of the health insurance fund into the unified category of public financial fund performance management.
, the medical insurance department to build the medical insurance performance evaluation system, in essence, is also the public financial fund performance management in the field of health insurance specific deepening.
health insurance performance goals can be divided from two dimensions: first, from the scope, can be divided into the overall health insurance expenditure performance goals and health insurance project expenditure performance goals.
The overall expenditure performance target of medical insurance refers to the goal of ensuring the basic medical needs of the insured personnel by arranging the expenditure of the medical insurance fund within the established time span of the national, provincial, municipal and county health insurance co-ordination areas at all levels.
In accordance with the Social Insurance Law of the People's Republic of China (hereinafter referred to as the Social Insurance Law), the overall expenditure performance goal of medical insurance is to achieve "basic, broad coverage, multi-level and sustainable", and in accordance with the Basic Health Care and Health Promotion Law (hereinafter referred to as the Health and Health Promotion Law), the overall expenditure performance target of medical insurance should be to solve the cost of basic medical services.
The performance target of medical insurance project expenditure refers to the fund expenditure target based on specific items such as outpatient, inpatient and chronic disease protection, such as outpatient co-ordination guarantee level, inpatient treatment guarantee level, chronic disease health insurance level, etc., including, of course, the level of protection reached by the major disease negotiation drugs and project expenditure.
is divided into short-term goals and medium- and long-term goals.
-term target refers to the fund expenditure target for a health insurance year, and the medium- and long-term target is the fund expenditure target, which is defined according to the established task of health insurance construction and spans several years.
, some regions have made the internal management of public hospitals and the quality of medical care the most important goal in the management of medical insurance performance.
the author thinks that this kind of treatment is debatable.
the management of public hospitals and the quality of medical care are highly related to the management of medical insurance performance, but they are not the main objectives, mainly based on four: First, the legal basis is different.
health insurance performance management is based on the Social Insurance Law, hospital management and medical quality is based on the Health and Health Promotion Act.
is that the policy basis is different.
health insurance policy aims to improve the efficiency of the use of medical insurance funds and improve the cost-effective use of medical insurance funds, while the medical and health policy focuses on promoting hospitals to regulate diagnosis and treatment, improve the quality of medical services and reduce the risk of medical accidents.
is that the responsibilities are based on different.
the main responsibility of the medical insurance department is to meet the people's multi-level medical security needs, while the main responsibility of the health department is to meet the people's diversified medical service supply.
fourth is the technical basis is different.
the technical means of the medical insurance sector is the payment tool, which achieves the goal of medical insurance management through different combinations of payment tools, and the technical means of the health sector is the technical tool of the health field, such as medical quality evaluation and clinical path specification.
the detailed and quantitative description of the performance indicators of medical insurance is the goal of medical insurance performance.
financial fund performance indicators, health insurance performance indicators should include output indicators and efficiency indicators.
output index is a description of the expected output of the expenditure of the health insurance fund, and is the core index of the performance evaluation of the health insurance, which mainly includes the quantitative index, the quality index and so on.
index includes basic data indicators such as fund balance and number of insured persons, and is the original data index to construct quality index.
Quality index mainly refers to the index that can reflect the quality of the fund expenditure, such as the actual reimbursement rate of outpatients, the actual reimbursement rate of inpatients, etc., in which the actual reimbursement rate of outpatients is the proportion of outpatient expenses of the medical insurance fund and the actual medical expenses of the outpatient clinics of the insured personnel, reflecting the ability of medical insurance to guarantee the outpatient expenses; After the reform of
institutions, the position of the medical insurance system as one of the five public health systems, including the hierarchical diagnosis and treatment system, the modern hospital management system, the universal medical insurance system, the drug supply guarantee system and the comprehensive supervision system, is more prominent, which determines that the quality index of the expenditure of the medical insurance fund should be the actual medical expenses of the insured.
under such policy logic, reasonable medical supply should become the internal goal of medical insurance management, and the medical insurance department needs to assume the responsibility of the affordability of medical treatment for the insured.
Previously, the state stressed that the medical insurance system as one of the five major social security systems, reasonable medical supply is the preconsequetion of medical insurance management, which means that the quality index of medical insurance fund expenditure caliber to the policy scope of medical expenses, policy scope statistics caliber is conducive to promoting the health sector to better strengthen the management of reasonable medical supply, to prevent excessive medical treatment, overdosing, over-examination and other moral risks.
obviously, under the background of "Healthy China" strategy, as one of the five basic medical and health systems, the quality index of medical insurance fund expenditure should emphasize the actual medical expenses.
performance index is a description of the expected benefit effect of health insurance fund expenditure, including satisfaction index, medical reform benefit index and sustainable impact index.
satisfaction indicators.
is the primary indicator of effectiveness.
is the most direct beneficiary of the health insurance system, whether the insured is satisfied with the expenditure of the health insurance fund is an important part of this index.
according to the theory of health economics needs, people's medium- and long-term demand for health care is growing with the economy and medical standards, which means that the positive satisfaction strategy approach risks underestimating the actual satisfaction of basic health care.
In practice, therefore, the subjective evaluation of the current health-care system by poor families with disease-related expenditures can be reflected by setting reverse indicators, such as the index of the suffering of the poor as a whole due to disease and the return to poverty due to illness.
, the real-world satisfaction level with Medicare fund expenditure can be measured by field survey by reference to the medical pain index.
the effectiveness of medical reform.
in China's new medical reform, medical insurance has actually been given the function of maintaining the daily operation of public medical institutions compensation, so it is necessary to evaluate the function of medical insurance compensation for the normal operation of public medical institutions.
In the specific settings, different compensation ratios should be set up according to different levels of public medical institutions, such as primary health care institutions bear the main function of public health, medical insurance compensation ratio should be relatively high;
sustainable impact indicators.
sustainable impact index is mainly used to pre-judge and evaluate the long-term operation and sustainability of medical insurance, including the number of months paid for the accumulated fund balance of medical insurance, the regional co-ordination ability index of medical insurance fund, etc.
In view of the fact that the regional transfer capacity of medical insurance is affected by the combination of various factors such as the overall level of medical insurance, the level of regional fund balance and the level of structure, too much withdrawal of regional transfer reserve will weaken the actual payment capacity of the region under its jurisdiction, and insufficient withdrawal will weaken the regional co-ordination risk co-ordination capacity, the relationship between the total amount of medical insurance transfer reserve and the degree of difference between the regional medical insurance payment capacity should be considered in the future to set up the regional co-ordination capacity index of the health insurance fund.
need to emphasize here, the author does not think it is appropriate to the medical insurance fund illegal funds investigation quota or investigation rate as the evaluation index of medical insurance fund supervision.
both indicators are based on the assumption that the level of safety management of different interregional health insurance funds and the intensity of supervision of health insurance funds are the same, otherwise there is no comparability.
For example, although the amount of funds investigated for non-compliance in a region is low, it may be due to the low level of fund security management in the region and the lower intensity of fund supervision, which does not indicate a higher level of fund performance management in the region.
, medical insurance on-site supervision and flight inspection coverage can be used as the evaluation index of supervision.
the performance evaluation method has become an important part of the performance management of medical insurance after determining the performance goals and performance indicators of medical insurance.
the following four basic principles in the process of evaluating the performance of medical insurance.
principles of scientific norms.
In view of the particularity of medical insurance, performance evaluation management needs to continuously improve the scientific nature of medical insurance performance evaluation through side pilot, side exploration and summary, and finally form a set of standardized operating processes and technical standards.
principle of fairness and openness.
In view of the fact that the health insurance performance evaluation involves medical institutions, retail pharmacies, and will be extended to pharmaceutical enterprises and participating units, the scope of the units involved is large, the health insurance performance evaluation from the beginning of the goal, indicators and standards set to the final results of the application, we must adhere to fairness and openness, and give priority to ensuring that the process is fair.
the principle of classification.
the current medical insurance policy and medical resources in different regions there are large differences, the state in the process of medical insurance performance evaluation should adhere to the unity and differentiation of dialectical unity.
the national level to determine health insurance performance goals and performance indicators, provinces and municipalities can refine their own evaluation methods, evaluation rules, in the implementation of health insurance performance evaluation has a certain degree of flexibility and autonomy.
principles related to performance.
In the process of specific evaluation, we should closely focus on the core of the performance of the use of health insurance funds and the performance of strategic purchase, it is not appropriate to pursue to cover all aspects of health insurance management, and not to try to evaluate the actual effect of health insurance management in various places through the establishment of a unique comprehensive index.
according to index theory, if managers pursue the high degree of unity of index, it is often at the expense of real-world differences, which eventually leads to index distortion, can not objectively reflect the real world.
, under the current complex environment of medical insurance and medical reform, it is far more scientific and reasonable to form a system of medical insurance performance evaluation indicators than to construct the unique index of medical insurance.
evaluation methods, the following five methods could be considered for the specific evaluation of technical tools.
effectiveness analysis method.
in setting the health insurance fund efficiency indicators, it is likely that the designers will use the ratio of fund-raising expenditure to the fund-effectiveness index according to the basic thinking framework of "benefit-cost" in economics.
From a simple financial model, the fund-raising expenditure ratio does have a certain rationality in reflecting the relationship between income and expenditure of the fund, but because people have a strong subjectivity in the evaluation of medical service satisfaction and highly dependent on the medical supply resource endowment, it is difficult to objectively evaluate the health insurance fund expenditure benefits between the different co-ordination areas when the different co-ordination area participants have a large difference in satisfaction with medical feelings and a large difference in the endowment of medical supply resources.
, the effectiveness analysis method needs to be combined with other methods.
results are compared.
can give priority to the comparison of results when evaluating the level of medical security, such as the actual reimbursement ratio for outpatient and inpatient visits, which can be used directly as an evaluation indicator.
after all, for the insured, the personal burden of seeing a doctor is the most intuitive feeling when evaluating the use of health insurance funds.
factor analysis method.
Many problems in the field of medical insurance are caused by a combination of factors, such as serious diseases will bring some insured people a heavier burden of disease, including some areas and areas of the current level of medical insurance reimbursement protection is not high actual situation, but also medical and pharmaceutical new technologies to promote new demand release, as well as the aging of the population leading to elderly diseases and the elderly tumor high factors, more medical institutions profit-based factors leading to excessive medical waste.
circumstances, we should not simply take the reimbursement ratio as the only indicator of the level of protection against serious and extreme diseases, but should take into account various factors before making an evaluation.
the lowest cost method.
Under the premise that the reimbursement of outpatient expenses of urban and rural residents is not less than 50% and the reimbursement of hospital expenses is not less than 75%, the state can indirectly judge the ability of local health insurance departments to improve the accuracy of protection and control the waste of medical insurance by comparing the per capita financing standards.
the lower the per capita funding standard, the more accurate the use of health insurance funds and a higher level of health care performance management, on the premise that the local government spends less on the same level of coverage.
public judgment.
here include Delphi's expert score method and field investigation method.