Keep the "money bag" health care fund reform started.

Medical Network July 29 , the General Office of the State Council issued "on promoting the reform of the medical security fund regulatory system system guidance " to open the overall reform of China's medical insurance fund, as the people's "medical money", "life-saving money" of the medical security fund (hereinafter referred to as the medical insurance fund), will establish a medical security treatment list management system, clarify the treatment payment boundary, and improve the medical insurance payment and tender procurement price linkage mechanism, strengthen the role of medical insurance on medical care and medicine incentives and constraints.
at the same time, there are industry insiders revealed that the basic drug catalog will usher in adjustment, the base drug will be combined with the long prescription of chronic disease, the establishment of the core drug catalog of the base drug.
the future, with the basic drug band procurement and medical insurance payment standards unified on the agenda, China's pharmaceutical market changes will be further intensified.
to build a whole-wide, all-process medical insurance fund security prevention and control mechanism "Opinion" pointed out that since the establishment of the basic medical security system, the coverage has been expanding, the level of protection has been steadily improved, but by the supervision system is not perfect, the incentive and restraint mechanism is not perfect and other factors, the use of medical insurance funds is not efficient, fraud and insurance problems are frequent, the fund supervision situation is more serious.
therefore, the Opinions propose that we will speed up the reform of the system of supervision of the medical insurance fund, build a comprehensive and all-process fund security prevention and control mechanism, crack down on fraud and insurance fraud, safeguard social equity and justice, continuously improve the people's sense of access, and promote the healthy and sustainable development of China's medical security system. Wang Zhen, a researcher at the Institute of Economics of
the Chinese Academy of Social Sciences and director of the Public Economics Research Office, said that the Opinion proposes to build a whole-wide, all-process fund security prevention and control mechanism, which will extend the tentacles of supervision throughout all aspects of the health insurance fund, and integrate the regulatory forces in all relevant areas of government, industry and society, which is the reform and innovation of the fund's regulatory system and mechanism. Zheng Gongcheng, president of the China Social Security Society in
, said that the medical insurance fund is the people's "medical money" and "life-saving money", must be well-used, to adhere to the rule of law, supervision according to law.
in China's social security system, medical security shoulder the important responsibility of lifting the medical worries of all the people's diseases, directly related to the vital interests of all people.
and the medical insurance fund is the material basis to support the medical security system, its safety determines whether the health insurance system can be healthy and sustainable development, and directly affects the rights and interests of universal medical security can be fully and effectively implemented.
" but we should also see that the current health insurance system system in China has not yet finally matured, stereotyped, the medical insurance in the field of various illegal phenomena are not uncommon, health insurance fund has become some institutions and individuals to eat the 'Dang monk meat'.
" data show that in 2019, the medical insurance departments at all levels inspected a total of 815,000 fixed-point medical institutions, investigated and punished 264,000 medical institutions for illegal and illegal violations, of which 6730 were released from the medical insurance agreement, 6638 administrative penalties were transferred to the judicial organs;
Zheng Gongcheng believes that there are many reasons for the insecurity of the medical insurance fund, the most critical is that the system of supervision of the medical insurance fund is not perfect, coupled with the division of the previous health insurance management system and the lack of effective linkage between medical and medical care, resulting in local problems of the supervision of medical insurance funds occur from time to time.
therefore, the Opinion pointed out that speed up the standardization of medical insurance and information construction, strictly implement the requirements of integrated sharing of government information systems, strengthen the exchange and sharing of information between departments, and avoid duplication of construction.
and establish and improve the intelligent monitoring system of health insurance, and strengthen the application of big data. in view of the characteristics of fraudulent insurance practices, the
has continuously improved the medical knowledge base, such as basic information standards libraries and clinical guidelines, such as drugs, medical treatment projects and medical service facilities, and improved the rules of intelligent monitoring and enhanced intelligent monitoring functions.
to carry out real-time management of the purchase and sale of pharmaceutical and medical supplies.
increase penalties for fraudulent insurance fraud.
comprehensive use of judicial, administrative, agreement and other means to severely punish units and individuals who cheat and defraud.
actively exert the role of joint punishment by the department, and the department of health and health and drug supervision shall, in accordance with the law, impose penalties such as suspension of business and rectification, revocation of qualifications for practice (operation) and restrictions on practice, and enhance the deterrent effect of punishment for designated pharmaceutical institutions that have been verified by the medical security department and have committed fraud and insurance cases that are particularly serious.
to include the list of persons of joint disciplinary action for fraud and insurance fraud, and to implement joint disciplinary measures.
more to increase the fight against medical insurance fraud insurance in April this year, Shanxi Province Medical Insurance Bureau issued a notice, by the end of September the province will be all fixed-point medical institutions to carry out on-site inspection, and carry out special governance focusing on medical insurance agencies and fixed-point medical institutions; On July 8,
, Jiangsu Provincial Health Insurance Bureau and provincial health care committee issued a notice to carry out special actions on the illegal use of medical insurance funds in all medical insurance-targeted medical institutions in the province. The main contents of the
of this governance are the unreasonable charges of fixed-point medical institutions, the problem of serial exchange items (drugs), the problem of irregular diagnosis and treatment, the problem of fictitious services, etc.
covers all medical conduct and medical expenses that have been covered by the Basic Health Insurance Fund since January 1, 2018. On July 14,
, the Health Security Bureau of Xianning City, Hubei Province, held a 2020 "Anti-Fraud Fraud And Guarantee Maintenance Fund Security" warning education interview meeting and the signing of the medical insurance service agreement of fixed-point medical institutions.
meeting focused on the interview of 223 designated medical institutions, each fixed-point public hospital in charge of the director and the head of the medical insurance office, fixed-point private hospitals, outpatient clinics, clinics, fixed-point chain pharmacies, fixed-point single drugstoreprincipal sitcoms, as well as the underwriting commercial insurance company responsible for the person in charge and business manager to participate in the interview.
this interview focuses on the profound grasp of the importance of combating fraudulent insurance, the standard use of medical insurance funds, medical institutions self-examination, strict implementation of the health insurance fund operation and management policy and other content to carry out warning education, urge the two institutions and underwriting commercial insurance companies to standardize service behavior, and effectively protect the vital interests of the vast number of insured people.
also organized to learn the spirit of the relevant national policy documents, the deployment of two institutions self-examination and self-correction work, to inform the fight against fraud and fraud in the special governance action to investigate the typical cases, interpretation and centralized signed a fixed-point medical institutions medical insurance service agreement. The main reason for
to crack down on the high-pressure situation of fraud insurance is that the health insurance funds "run and leak" serious.
data show that as of 2019, China's health insurance fund spending scale reached 2 trillion yuan, and a few years ago in the era of manual audit, there was a local health insurance bureau chief estimated that the "run and leak" proportion of about 10%.
industry insiders said that the cost of fraud insurance, regulatory difficulties, recovery of funds are very limited.
indeed, in recent years, China's drug-free disease, repeated prescription, excessive prescription of drugs and other fraudulent insurance incidents are not uncommon.
January 2019, a media outlet reported that a vice president of Peking University International Hospital had instructed the relevant department doctors to falsely diagnose himself as "dementia" and repeatedly swiped his health insurance card to prescribe the drug.
and someone reported that a deputy physician of the hospital's surgery would increase or decrease the condition based on whether the patient was covered by health insurance.
regulatory upgrading With volume procurement accelerated" Opinion can be said to be a 'milestone' in the construction of China's health insurance fund supervision system.
" Wang Zhen said that the Opinion not only provides a basis for improving the level and capacity of the medical insurance fund supervision, but also has a significant impact on the provider of medical services and pharmaceutical suppliers, which is a major measure to restructure the ecology of the industry.
Wang Zhen admitted that China's health insurance fund supervision for a long time remained in the "manual operation" era, manual audit, manual inspection and the rapid growth of medical insurance business volume is not matched.
Opinions emphasize the need to increase the application of data, establish and improve the monitoring system of medical insurance functions, so that the supervision of the medical insurance fund to engage in post-check examination and approval gradually towards strengthening the supervision before and during the event.
in fact, this clear opinion, will speed up the establishment of provincial and even national centralized and unified intelligent monitoring system, to achieve fund supervision from manual withdrawal audit to big data all-round, full-process, full-link intelligent monitoring transformation.
at the same time, the establishment of a fixed-point medical institutions information reporting system.
establish the medical insurance credit records, credit evaluation system and points management system for medical institutions and insured personnel.
the comprehensive performance evaluation mechanism of innovative fixed-point pharmaceutical institutions, and associate the credit evaluation results with the results of comprehensive performance evaluation with budget management, inspection audit, fixed-point agreement management, etc. At the same time,
, improve the fixed-point pharmaceutical institutions agreement management system, establish and improve the dynamic management and exit mechanism of fixed-point medical institutions.
improve the monitoring mechanism of medical insurance on medical service behavior, extend the supervision object from medical institution to medical personnel, and shift the supervision focus from medical expense control to medical cost and medical service performance double control. Zheng Gongcheng,
, said that to improve the system of supervision of medical insurance funds, we must adhere to the principle of the rule of law. The fraud in the field of
medical insurance and all kinds of acts that harm the security of the medical insurance fund are all illegal and illegal acts that erode the public interest by the interests of small groups and harm the interests of the group with the interests of individuals.
should speed up the pace of the construction of the rule of law in the field of medical security, including the formulation of the Basic Law on Medical Security and the regulation of medical insurance funds as soon as possible, and truly customize the law and supervise according to law. It is necessary to give priority to the formulation of administrative regulations on the supervision of medical insurance funds
, so as to further clarify the administrative system, departmental linkage mechanism, regulatory procedures, legal means, channels of complaints, as well as judicial intervention and social supervision, so as to provide a concrete basis for the overall promotion of the supervision of the medical insurance fund.
in fact, in deepening reform, the Opinion also explicitly deepens the reform of the payment method of health insurance and strengthens the budget management and risk warning of the fund.
establish a list management system for medical security treatment, determine the connotation of basic security, clarify the payment boundary of treatment, and clarify the authority of policy adjustment.
strengthen the incentive and restraint role of medical insurance for medical and pharmaceutical, strengthen the overall regional supervision responsibilities, and optimize the fund supervision work basis.
deepen the supply-side reform of medical services.
speed up the comprehensive reform of public hospitals, establish and improve the modern hospital management system, and standardize the conduct of diagnosis and treatment.
regulate the promotion of appropriate medical technologies around common and health problems.
constantly improve the market-led drug, medical supplies price formation mechanism, improve the medical insurance payment and tender procurement price linkage mechanism.
strengthen the quality supervision and inspection of accounting information in the pharmaceutical industry, and carry out in-depth special treatment of inflated prices of pharmaceutical and high-value medical supplies.
reporter Liang Wei.