How to change the payment method for outpatient services from the post-payment system to the pre-payment system?

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2017《》，，DRG/DIP，
。

 

，《》（《》）20214，，
。

 

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。

 

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Under the circumstances of weak fund-raising ability and limited management level at that time, this arrangement helped to increase the insurance participation rate and promoted the smooth development of the medical insurance system
.
However, with the further development of the economy and society, personal accounts and family accounts cannot effectively play the role of fund coordination and mutual aid, and the drawbacks of a large number of funds have become increasingly apparent.
Even some urban residents' medical insurance does not set up personal accounts at all, and outpatient protection is completely lacking
.

 

During this period, many experts have voiced through the media, claiming that the limited or lack of outpatient coverage has prevented effective treatment of potential serious and chronic diseases, delayed serious illnesses and increased expenses, and even "small illnesses and major treatments" in order to obtain medical insurance hospital reimbursement, which is wasteful.
Medical resources
.
The call for outpatient coordination to establish a reasonable risk-sharing mechanism for outpatient medical expenses is gradually rising
.

 

　　"With the aging of the population and the increase in the incidence of chronic diseases, the burden of outpatient clinics for residents continues to rise, and the importance of guaranteeing and regulating outpatient medical behavior continues to be highlighted
.
" Zheng Jie, deputy director of the Beijing Medical Insurance Center, once pointed out in a seminar.
The service management will effectively reduce the hospitalization rate and reduce the burden on the medical insurance fund
.

 

　　As early as 2009, the Ministry of Human Resources and Social Security put forward the guidance on the overall planning of medical insurance outpatient clinics, and in 2011 clearly put forward the requirements for the universal development of urban residents' medical insurance outpatient clinics across the country
.
Subsequently, most cities have successively carried out pilot projects for the overall planning of urban residents' medical insurance outpatient clinics
.

 

　　Summarize term, patient co-ordinate the pilot are mainly two models: one outpatient serious co-ordination, in the coming few require long-term treatment of chronic or outpatient medical costs can be expensive, but in the outpatient treatment of disease into the pool fund range, which is called " Type of disease" protection
.

 

　　The second is the overall planning of general outpatient clinics, that is, the expenses of some common and frequently-occurring diseases in outpatient clinics are included in the coverage of the overall planning fund
.
This model generally does not define the types of diseases included in the scope of reimbursement, but provides certain protection to the insured residents by formulating low-level "deductible lines" and "capped lines".
This method is again regarded as "expense" protection
.

 

　　"At present, almost all outpatients have been coordinated for major illnesses throughout the country, but only some economically developed areas have implemented general outpatient coordination based on cost-based security
.
" Zhong Jihu, head of the treatment and settlement section of the Yantai Medical Insurance Business Center, told the health community, Yantai At present, the main focus is on disease protection.
The number of major chronic diseases in outpatient clinics has reached 73.
The overall plan for general outpatient clinics for employees has not yet been established
.

 

　　At the same time, most cities that carry out general outpatient coordination have implemented the grassroots first consultation system, that is, the grassroots health institutions are used as designated first consultation service institutions, and the cost of patients who go to non-designated institutions without referral will not be granted by the overall planning fund.
Paid
.

 

　　There are also some cities unable to undertake the task of the first diagnosis due to the need to improve the primary medical system
.
Zhong Jihu said that in the case of insufficient grass-roots technology and low people’s trust, the forced implementation of the primary referral system at the grassroots level will increase the work pressure at the grassroots level on the one hand, and on the other hand the increased referral links will arouse the people’s attention.
Disgust affects the people's sense of gain, and may even delay the optimal treatment period, causing more serious disease burdens and fund expenditures
.

 

　　At present, whether it is the overall planning of major outpatients or general outpatients, the nature of the payment method is still "pay by project
.
" Among them, the general outpatient service is generally based on the project-based payment system under total control; the critical illness outpatient service adopts the project-based settlement method
.

 

　　Some cities adopt two settlement methods for serious diseases included in outpatient clinics.
For example, Huludao City has four types of outpatient serious diseases with higher costs for various types of malignant tumors, rejection treatment after organ transplantation, hemophilia, and uremic dialysis.
, Outpatient clinics are reimbursed according to the hospitalization method (that is, payment by project), and for the 7 types of outpatient diseases with relatively low costs, the single-disease limit settlement is implemented, that is, the maximum limit for each disease type is stipulated.
Participants will be reimbursed on a pro rata basis, and the medical institution will be settled on a real basis.
If the limit is exceeded, the designated institution will be responsible
.
However, this single-disease quota settlement is actually also a project-based payment under total control
.

 

　　Opportunities for outpatient mutual aid policy

 

　　The release of the "Opinions" has brought an opportunity for the further development of outpatient coordination
.

 

　　According to the "Opinions", the content of the reform of mutual aid security for outpatient medical insurance for employees can be summarized as "one decrease, one increase, one build and one adjustment", that is, to reduce the funds allocated to personal accounts and increase the investment of outpatient mutual aid protection; establish general outpatient medical expenses Coordinate the guarantee mechanism and adjust the scope of use of personal accounts
.

 

　　This means that personal account funds decrease and outpatient overall planning funds increase, and outpatient expenses of insured employees will be changed from the risk and self-balancing under the personal account model to overall payment and mutual aid protection
.

 

　　The "Opinions" pointed out that the general outpatient cost overall guarantee mechanism should start with the chronic and special outpatient diseases, such as hypertension and diabetes, which are burdened by the masses, and gradually expand to other diseases with greater cost burden
.
At the same time, it also pointed out that it is necessary to continuously improve the outpatient mutual aid guarantee mechanism, and gradually transition from "disease guarantee" to "cost guarantee"
.

 

　　"Although the document has been released, many places have not yet begun to implement it.
At present, major illness outpatient insurance has been widely implemented throughout the country, that is,'disease protection'.
According to the requirements of the document, it is estimated that in the future, all regions will gradually supplement the'cost guarantee' for general outpatient services.
, To further improve the level of outpatient protection
.
” Zhong Jihu said that the specific reform path must be coordinated and promoted by the higher-level competent department
.

 

　　How to realize the "prepayment system"?

 

　　The release of the "Opinions", especially the reform of personal accounts, also released a large amount of funds for mutual aid protection, and the reform of outpatient payment methods also ushered in new opportunities
.

 

　　The data shows that in 2018, the income of the employee medical insurance personal account was 529.
7 billion yuan.
If the unit payment is transferred to the outpatient pooling, about 250-310 billion yuan of funds can be released from the personal account, which is about equivalent to all the outpatient clinics of public hospitals in the same period.
30%-37% of revenue (about 830 billion yuan)
.

 

　　After the reform of personal accounts, the size of the outpatient co-ordination fund has increased, and it assumes the responsibility of paying the insured staff's outpatient fees.
Accordingly, it has obtained the management authority to guide, standardize and supervise outpatient medical treatment and service behavior, so that it can better play The strategic purchase of medical insurance has transformed outpatient payment from extensive management to fine management, and shifted from passive payment to active purchase
.

 

　　"The behavior of outpatient medical treatment will also change from self-decision-making and free medical treatment to the
insurer 's guidance and orderly medical treatment .
" Chen Dengju , director of the medical insurance department of the First Affiliated Hospital of Heavy Medicine, told the health industry that the ever-increasing level of protection requires more refined management
.

 

　　Among them, the most direct guidance method is the payment method, which directly affects the operational balance of the Outpatient Co-ordination Fund
.
"In this process, the implementation of head-to-head payment (a prepayment system) for the characteristics of various outpatient services is a reform trend of outpatient medical insurance payment methods
.
" Lecturer, School of Politics and Public Administration, China University of Political Science and Law, Tsinghua University Medical Service Governance Liao Cangyi, a postdoctoral fellow at the Research Center, once wrote an article that pointed out
.

 

　　Liao Cangyi further explained that this trend is specifically manifested in the implementation of head-to-head payments for the "general outpatient clinics" on the basis of the total budget for the providers of designated medical treatment at the grassroots level, and the implementation of disease-based demand for chronic and special outpatients (that is, the overall planning of outpatient major diseases).
Head-to-head payment, areas with the foundation of DRG/DIP reform can further promote the outpatient APG (outpatient case grouping) point method or the outpatient head point method
.

 

　　One is that the "general outpatient clinic" implements head-payment by the provider (for medical institutions) for designated medical treatment at the grassroots level.
This model requires that a grassroots first consultation system must be established.
Insured patients do not go through the grassroots first consultation or do not comply with the referral arrangements, and choose high-level ones by themselves For medical institutions, the self-pay ratio can be significantly increased until no compensation is given
.

 

　　Then, based on family doctors signed, according to the number of insurance contract, capitation fee agreed in advance by the health insurance sector standards , the clinic fund residents per capita packaged to primary health care institutions or family doctor team to provide general illnesses by the latter Outpatient services
.

 

　　In the true sense, according to "pay per capita", the medical expenses of the contractor have been determined before the service, and have nothing to do with the actual medical expenses incurred in the subsequent, which stimulates family doctors or primary health institutions to do a good job in health management and improve the health of the insured.
In order to reduce medical insurance expenditures; however, studies have shown that the "per capita settlement" implemented in the actual pilots is actually to calculate the total budget through the number of contracted heads and the fixed number, and the total budget is settled according to the actual amount (or there may be a small amount of rewards) , The overexpenditure is not compensated (or shared).
Therefore, the income of the medical institution within the total budget is still proportional to the amount provided, but there is a rigid (or flexible) constraint on the total budget, so in essence, it still belongs to the project under the total control Payment system
.

 

　　"The current domestic hierarchical diagnosis and treatment situation has not yet been fundamentally improved, so many domestic explorations based on first-level consultations based on head-to-head fees are difficult to make substantial progress
.
" Zhong Jihu said, the smooth operation of the head-to-head system in general outpatient clinics The need for a complete community first diagnosis and referral system is closely related to the construction of domestic hierarchical diagnosis and treatment
.

 

　　The second is the “outpatient serious illness” that implements the demand-side (for the insured or the patient) head payment, which is based on a clear clinical path of diagnosis and treatment and the beneficiary of a fixed population size, and the patient is assigned to a specific disease.
The medical treatment of medical treatment is carried out on an annual headcount, and in the strict sense it should be called payment according to head disease
.

 

　　In this regard, we can learn from the DRG/DIP case grouping ideas and point allocation methods
.
At present, Jinhua City has implemented the outpatient APG point method of payment, that is, based on DRG grouping, the head of the general outpatient clinic and chronic disease outpatient clinics of the contracted personnel is contracted to the medical institution, and the payment is based on the contract fund combined with the APG point method
.
"And based on DIP grouping, the outpatient overall planning service package and the head quota standards for outpatient chronic diseases can be counted, and the outpatient head count method can be implemented
.
" Liao Cangyi wrote
.

 

　　"Similar to the DRG/DIP reform of inpatient services, the medical insurance payment for outpatient services will be more refined in the future, and the essence is to reform from the post-payment system to the pre-payment system
.
" Chen Dengju said.
Exploring payment methods, "The release of outpatient mutual aid documents is only the beginning, and the specific reform of payment methods requires unified arrangements by the state
.
"

　　The medical insurance payment system reform and its established benefit distribution mechanism are important levers for regulating medical service behavior.
The continuous improvement of payment methods is conducive to optimizing resource allocation and improving the efficiency of the medical system
.

 

　　In 2017, the "Guiding Opinions on Further Deepening the Reform of Basic Medical Insurance Payment Methods" was released.
Especially since the establishment of the National Medical Insurance Administration, the DRG/DIP pilot has been rapidly advanced, and the reform of medical insurance payment methods for inpatient medical services has basically taken shape
.

 

　　At the same time, the "Guiding Opinions on Establishing and Improving the Employee Basic Medical Insurance Outpatient Mutual Aid Guarantee Mechanism" (hereinafter referred to as the "Opinions") was formally announced in April 2021, personal accounts were reformed, and the level of outpatient medical protection was further improved
.

 

　　In this case, on the one hand, the possible hospitalization expenses that may occur after the DRG/DIP payment reform is fully implemented are transferred to the outpatient clinic; on the other hand, the implementation of outpatient mutual aid is likely to bring about problems such as rapid growth of outpatient expenses
.

 

　　As a result, it is particularly necessary to simultaneously advance the reform of outpatient medical insurance payment methods and improve the system integration and coordination of the reform
.
So, what is the current outpatient medical insurance payment policy? What impact will the "Opinions" have on outpatient co-ordination after the release? What is the future development trend of outpatient payment?

 

　　"Pay by Project" under Outpatient Coordination

 

　　As we all know, the establishment and development of China's basic medical insurance system began with hospitalization planning (ie, "insurance for hospitalization"), which embodies the functional positioning of medical insurance to "insure serious illness"
.
For outpatient services, either self-management through personal or family accounts and private accumulation, or self-pay
.

 

　　Among them, the urban employee medical insurance adopts the "pooling account" model, the "pooling account" only covers hospitalization and serious illness, and the ordinary outpatient expenses are paid by the "personal account"; the original new rural cooperative medical care adopts the "family account" model.
Guarantee general outpatient services
.

 

　　Under the circumstances of weak fund-raising ability and limited management level at that time, this arrangement helped to increase the insurance participation rate and promoted the smooth development of the medical insurance system
.
However, with the further development of the economy and society, personal accounts and family accounts cannot effectively play the role of fund coordination and mutual aid, and the drawbacks of a large number of funds have become increasingly apparent.
Even some urban residents' medical insurance does not set up personal accounts at all, and outpatient protection is completely lacking
.

 

　　During this period, many experts have voiced through the media, claiming that the limited or lack of outpatient coverage has prevented effective treatment of potential serious and chronic diseases, delayed serious illnesses and increased expenses, and even "small illnesses and major treatments" in order to obtain medical insurance hospital reimbursement, which is wasteful.
Medical resources
.
The call for outpatient coordination to establish a reasonable risk-sharing mechanism for outpatient medical expenses is gradually rising
.

 

　　"With the aging of the population and the increase in the incidence of chronic diseases, the burden of outpatient clinics for residents continues to rise, and the importance of guaranteeing and regulating outpatient medical behavior continues to be highlighted
.
" Zheng Jie, deputy director of the Beijing Medical Insurance Center, once pointed out in a seminar.
The service management will effectively reduce the hospitalization rate and reduce the burden on the medical insurance fund
.

 

　　As early as 2009, the Ministry of Human Resources and Social Security put forward the guidance on the overall planning of medical insurance outpatient clinics, and in 2011 clearly put forward the requirements for the universal development of urban residents' medical insurance outpatient clinics across the country
.
Subsequently, most cities have successively carried out pilot projects for the overall planning of urban residents' medical insurance outpatient clinics
.

 

　　Summarize term, patient co-ordinate the pilot are mainly two models: one outpatient serious co-ordination, in the coming few require long-term treatment of chronic or outpatient medical costs can be expensive, but in the outpatient treatment of disease into the pool fund range, which is called " Type of disease" protection
.

 

　　The second is the overall planning of general outpatient clinics, that is, the expenses of some common and frequently-occurring diseases in outpatient clinics are included in the coverage of the overall planning fund
.
This model generally does not define the types of diseases included in the scope of reimbursement, but provides certain protection to the insured residents by formulating low-level "deductible lines" and "capped lines".
This method is again regarded as "expense" protection
.

 

　　"At present, almost all outpatients have been coordinated for major illnesses throughout the country, but only some economically developed areas have implemented general outpatient coordination based on cost-based security
.
" Zhong Jihu, head of the treatment and settlement section of the Yantai Medical Insurance Business Center, told the health community, Yantai At present, the main focus is on disease protection.
The number of major chronic diseases in outpatient clinics has reached 73.
The overall plan for general outpatient clinics for employees has not yet been established
.

 

　　At the same time, most cities that carry out general outpatient coordination have implemented the grassroots first consultation system, that is, the grassroots health institutions are used as designated first consultation service institutions, and the cost of patients who go to non-designated institutions without referral will not be granted by the overall planning fund.
Paid
.

 

　　There are also some cities unable to undertake the task of the first diagnosis due to the need to improve the primary medical system
.
Zhong Jihu said that in the case of insufficient grass-roots technology and low people’s trust, the forced implementation of the primary referral system at the grassroots level will increase the work pressure at the grassroots level on the one hand, and on the other hand the increased referral links will arouse the people’s attention.
Disgust affects the people's sense of gain, and may even delay the optimal treatment period, causing more serious disease burdens and fund expenditures
.

 

　　At present, whether it is the overall planning of major outpatients or general outpatients, the nature of the payment method is still "pay by project
.
" Among them, the general outpatient service is generally based on the project-based payment system under total control; the critical illness outpatient service adopts the project-based settlement method
.

 

　　Some cities adopt two settlement methods for serious diseases included in outpatient clinics.
For example, Huludao City has four types of outpatient serious diseases with higher costs for various types of malignant tumors, rejection treatment after organ transplantation, hemophilia, and uremic dialysis.
, Outpatient clinics are reimbursed according to the hospitalization method (that is, payment by project), and for the 7 types of outpatient diseases with relatively low costs, the single-disease limit settlement is implemented, that is, the maximum limit for each disease type is stipulated.
Participants will be reimbursed on a pro rata basis, and the medical institution will be settled on a real basis.
If the limit is exceeded, the designated institution will be responsible
.
However, this single-disease quota settlement is actually also a project-based payment under total control
.

 

　　Opportunities for outpatient mutual aid policy

 

　　The release of the "Opinions" has brought an opportunity for the further development of outpatient coordination
.

 

　　According to the "Opinions", the content of the reform of mutual aid security for outpatient medical insurance for employees can be summarized as "one decrease, one increase, one build and one adjustment", that is, to reduce the funds allocated to personal accounts and increase the investment of outpatient mutual aid protection; establish general outpatient medical expenses Coordinate the guarantee mechanism and adjust the scope of use of personal accounts
.

 

　　This means that personal account funds decrease and outpatient overall planning funds increase, and outpatient expenses of insured employees will be changed from the risk and self-balancing under the personal account model to overall payment and mutual aid protection
.

 

　　The "Opinions" pointed out that the general outpatient cost overall guarantee mechanism should start with the chronic and special outpatient diseases, such as hypertension and diabetes, which are burdened by the masses, and gradually expand to other diseases with greater cost burden
.
At the same time, it also pointed out that it is necessary to continuously improve the outpatient mutual aid guarantee mechanism, and gradually transition from "disease guarantee" to "cost guarantee"
.

 

　　"Although the document has been released, many places have not yet begun to implement it.
At present, major illness outpatient insurance has been widely implemented throughout the country, that is,'disease protection'.
According to the requirements of the document, it is estimated that in the future, all regions will gradually supplement the'cost guarantee' for general outpatient services.
, To further improve the level of outpatient protection
.
” Zhong Jihu said that the specific reform path must be coordinated and promoted by the higher-level competent department
.

 

　　How to realize the "prepayment system"?

 

　　The release of the "Opinions", especially the reform of personal accounts, also released a large amount of funds for mutual aid protection, and the reform of outpatient payment methods also ushered in new opportunities
.

 

　　The data shows that in 2018, the income of the employee medical insurance personal account was 529.
7 billion yuan.
If the unit payment is transferred to the outpatient pooling, about 250-310 billion yuan of funds can be released from the personal account, which is about equivalent to all the outpatient clinics of public hospitals in the same period.
30%-37% of revenue (about 830 billion yuan)
.

 

　　After the reform of personal accounts, the size of the outpatient co-ordination fund has increased, and it assumes the responsibility of paying the insured staff's outpatient fees.
Accordingly, it has obtained the management authority to guide, standardize and supervise outpatient medical treatment and service behavior, so that it can better play The strategic purchase of medical insurance has transformed outpatient payment from extensive management to fine management, and shifted from passive payment to active purchase
.

 

　　"The behavior of outpatient medical treatment will also change from self-decision-making and free medical treatment to the
insurer 's guidance and orderly medical treatment .
" Chen Dengju , director of the medical insurance department of the First Affiliated Hospital of Heavy Medicine, told the health industry that the ever-increasing level of protection requires more refined management
.

 

　　Among them, the most direct guidance method is the payment method, which directly affects the operational balance of the Outpatient Co-ordination Fund
.
"In this process, the implementation of head-to-head payment (a prepayment system) for the characteristics of various outpatient services is a reform trend of outpatient medical insurance payment methods
.
" Lecturer, School of Politics and Public Administration, China University of Political Science and Law, Tsinghua University Medical Service Governance Liao Cangyi, a postdoctoral fellow at the Research Center, once wrote an article that pointed out
.

 

　　Liao Cangyi further explained that this trend is specifically manifested in the implementation of head-to-head payments for the "general outpatient clinics" on the basis of the total budget for the providers of designated medical treatment at the grassroots level, and the implementation of disease-based demand for chronic and special outpatients (that is, the overall planning of outpatient major diseases).
Head-to-head payment, areas with the foundation of DRG/DIP reform can further promote the outpatient APG (outpatient case grouping) point method or the outpatient head point method
.

 

　　One is that the "general outpatient clinic" implements head-payment by the provider (for medical institutions) for designated medical treatment at the grassroots level.
This model requires that a grassroots first consultation system must be established.
Insured patients do not go through the grassroots first consultation or do not comply with the referral arrangements, and choose high-level ones by themselves For medical institutions, the self-pay ratio can be significantly increased until no compensation is given
.

 

　　Then, based on family doctors signed, according to the number of insurance contract, capitation fee agreed in advance by the health insurance sector standards , the clinic fund residents per capita packaged to primary health care institutions or family doctor team to provide general illnesses by the latter Outpatient services
.

 

　　In the true sense, according to "pay per capita", the medical expenses of the contractor have been determined before the service, and have nothing to do with the actual medical expenses incurred in the subsequent, which stimulates family doctors or primary health institutions to do a good job in health management and improve the health of the insured.
In order to reduce medical insurance expenditures; however, studies have shown that the "per capita settlement" implemented in the actual pilots is actually to calculate the total budget through the number of contracted heads and the fixed number, and the total budget is settled according to the actual amount (or there may be a small amount of rewards) , The overexpenditure is not compensated (or shared).
Therefore, the income of the medical institution within the total budget is still proportional to the amount provided, but there is a rigid (or flexible) constraint on the total budget, so in essence, it still belongs to the project under the total control Payment system
.

 

　　"The current domestic hierarchical diagnosis and treatment situation has not yet been fundamentally improved, so many domestic explorations based on first-level consultations based on head-to-head fees are difficult to make substantial progress
.
" Zhong Jihu said, the smooth operation of the head-to-head system in general outpatient clinics The need for a complete community first diagnosis and referral system is closely related to the construction of domestic hierarchical diagnosis and treatment
.

 

　　The second is the “outpatient serious illness” that implements the demand-side (for the insured or the patient) head payment, which is based on a clear clinical path of diagnosis and treatment and the beneficiary of a fixed population size, and the patient is assigned to a specific disease.
The medical treatment of medical treatment is carried out on an annual headcount, and in the strict sense it should be called payment according to head disease
.

 

　　In this regard, we can learn from the DRG/DIP case grouping ideas and point allocation methods
.
At present, Jinhua City has implemented the outpatient APG point method of payment, that is, based on DRG grouping, the head of the general outpatient clinic and chronic disease outpatient clinics of the contracted personnel is contracted to the medical institution, and the payment is based on the contract fund combined with the APG point method
.
"And based on DIP grouping, the outpatient overall planning service package and the head quota standards for outpatient chronic diseases can be counted, and the outpatient head count method can be implemented
.
" Liao Cangyi wrote
.

 

　　"Similar to the DRG/DIP reform of inpatient services, the medical insurance payment for outpatient services will be more refined in the future, and the essence is to reform from the post-payment system to the pre-payment system
.
" Chen Dengju said.
Exploring payment methods, "The release of outpatient mutual aid documents is only the beginning, and the specific reform of payment methods requires unified arrangements by the state
.
"