Medical insurance big data will accelerate the integration and control of fees

According to the public data, as of October 22, Hu Jinglin, director of the state health insurance bureau, and Chen Jinfu, deputy director, successively investigated Shanghai Pharmaceutical centralized bidding and purchasing Affairs Management Institute and Ping'an medical insurance technology based on medical insurance informatization and intelligent medical insurance services Health point learned during the first national health insurance summit that the integration of big data of national health insurance is accelerating In this way, the regulatory capacity of medical insurance will be improved, but at the same time, the construction of national medical insurance information platform is a very difficult work This work not only affects the drug bidding and purchase in the pharmaceutical industry, the calculation of the volume and price of medical insurance access, but also affects the medical insurance intelligent fee control business undertaken by commercial insurance companies and big data companies On July 24, the newly established state medical insurance bureau held the kick-off meeting of medical insurance informatization work this year On August 24, Hu Jinglin, director of the medical insurance bureau, presided over the Expert Symposium on medical insurance informatization business standards He stressed that the establishment of unified business standards is a prerequisite for the construction of unified medical insurance information system On October 22, Chen Jinfu, deputy director general, led a team to Ping An medical insurance technology to investigate commercial health insurance and intelligent medical insurance services The primary task of the informatization construction of the state medical insurance bureau is to unify the business standards of medical insurance Experts in data technology standards, intelligent fee control, hospital informatization and other fields told the health point that in the process of breaking the "data island" of medical insurance supervision, the supervision ability of the medical insurance department will be greatly improved, but only when the big data of medical treatment, medicine and medical insurance are connected can the huge dividend of data be released The national health insurance bureau is faced with the difficulty of data exchange among "data island" departments and enterprises, so it has to provide financial insurance project As early as August 2002, China listed social security information system as one of the 12 key projects of e-government construction, and "financial security project" was launched in an all-round way At present, the human resources and social security departments above prefecture level in China have generally established data centers, and most regions have realized the centralized and unified management of business data at the municipal level The three-level network of the Ministry, the province and the city has been further connected, basically covering all kinds of public employment service institutions and social insurance agencies, and extended to most streets, communities, towns, designated medical institutions and retail pharmacies, initially forming an information network framework Zhang Jie, former deputy director of the technical standards Department of the China Medical Insurance Research Association, told the health center that during the period under the jurisdiction of the Ministry of human resources and social security, the national medical insurance information system basically uses the financial insurance engineering platform, with about 200000 designated pharmacies and 130000 designated medical institutions able to interface with the social security information system in the overall planning area Relying on the special network of financial insurance, the information systems of all cities can also upload data to the information center of the Ministry of human resources and social security However, healthcare big data is far from the goal of interconnection Zhang Xiao, a senior engineer in the Information Technology Department of Shenzhen University General Hospital who used to work in the information center of Shenzhen Municipal Bureau of human resources and social security, said that although the "financial insurance project" and the relevant departments have standardized the collection of medical insurance data, the development level varies greatly due to the different establishment time of medical insurance systems in different regions Experts participating in the forum said that due to the localized management of medical insurance, about 400 overall planning areas are built and operated independently Some areas are also divided into employee medical insurance, resident medical insurance, new rural cooperative medical insurance, long-term care insurance and other systems, which are scattered in different departments such as human resources and social security, civil affairs, health planning and so on The fragmentation of information system is serious In addition, the technical barriers brought by information standards, hardware technology, network technology and developers' separatism, so there are data in medical insurance, but there are still obstacles in its application "The codes of disease classification, surgical operation, drugs, consumables, diagnosis and treatment projects in 32 regions of China are not unified," said the relevant experts participating in the above forum The business standard codes are the basis of data docking, while the standards are not unified, resulting in problems such as difficult medical treatment and insurance settlement across provinces and regions Zhang Xiao said that at present, the settlement of medical treatment in different places is basically based on categories, and it is difficult to settle according to the drug name "At present, the data of China's medical industry is not in the informatization stage but in the electronic stage, and the data between different departments and institutions can't be 'exchanged'" The regional head of a medical insurance intelligent fee control system development and service provider told the health point that the unification of standards is still a major difficulty in medical insurance data collection The data of "medical insurance medicine" need to be cleared, which forces rational drug use and fine cost control Experts participating in the forum said that as the insured's agent, the medical insurance department should more reflect the insured's demands, gradually change from a pure payer to a service customization person, and purchase medical services with value for money for the insured The application of medical insurance big data can make the medical insurance management more efficient Although the national collection of medical insurance big data has not been completed at present, the Ministry of human resources and social security has applied it to the existing medical insurance big data when negotiating the access of medical insurance basic drug catalog in 2017 In 2017, the Ministry of human resources and social security of the people's Republic of China negotiated with relevant enterprises, 36 of which were successfully negotiated Compared with the average retail price in 2016, the average decline of negotiated drugs reached 44%, and the highest reached 70% In the process of negotiation with the enterprise, the human resources and social security department has an expected payment standard for medical insurance If the lowest quotation of the enterprise is more than 15% higher than the expected payment standard, the negotiation will be terminated The expected payment standard of medical insurance is based on the combination of pharmacoeconomics and medical insurance data The big data of medical insurance can not only judge the value of drugs "After big data collection, you can magnify some problems like a magnifying glass." The above intelligent medical insurance fee control enterprise said that when we get a prescription, it is difficult to determine the value of the above drugs, but through big data analysis, there is evidence to prove the value of the drugs, to monitor the medical services of medical institutions and medical personnel, and then promote rational use of drugs In addition to the judgment of drug value, the supervision and guidance of big data on medical service behavior also has value For example, experts participating in the above forums said that big data application can supervise and manage medical service behaviors, and force hospitals to use drugs reasonably, save costs and reduce medical expenses through reform of medical insurance payment methods and formulation of payment standards According to the above intelligent medical insurance fee control enterprise, the problems of fund arbitrage and leakage in the operation of medical insurance can be supervised through big data, and the original small problems will be magnified, so as to carry out accurate medical insurance supervision Du Xin, director of Beijing medical insurance affairs management center, once said that due to the different age of patients in different medical institutions, and the difference in the rate of re diagnosis and the proportion of drugs among different age groups, the medical insurance department standardized the data, then compared which medical institution used the medical insurance fund more efficiently, and decided how to pay for the medical insurance In addition, it is very important to master the real trading information of drug market for drug bidding and purchase A pharmaceutical industry person said that at present, most regions in the country adopt the "national lowest price" As an alternative, enterprises may adopt the strategy of placing drugs of different specifications and dosage forms in different regions, but these problems can be solved after data standardization and national platform construction Zhang Jie said that after the standardization and national platform construction, basic problems such as the lack of unified standards and collection of data are expected to be solved, providing the basis for the real realization of "volume for price, volume price linkage" However, in order to realize these applications, we need the prescription data of medical institutions, patient data and so on This person stressed that when the big data of medical treatment, medicine and medical insurance can get through each other, its value can be greatly played Medical insurance big data is also very valuable for commercial insurance According to Zhang Xiao, the current scope of commercial supplementary insurance reimbursement is almost the same as that of medical insurance reimbursement catalog, which has little appeal to the public When commercial insurance companies get medical insurance data, it will help them to carry out actuarial and dislocation development But Zhang also pointed out that although the industry has a great demand for big data of medical insurance, the data can not always lie in the government's database, and should be commercialized through reasonable rules and mechanisms Zhang Jie also said that the ultimate mission of big data is to realize social value Only when data is open, and on the premise of protecting data security, for the use of the whole society, can we maximize the value and provide the most powerful support for social governance of government departments Up to now, except for the social insurance law, there are no special laws and regulations in China's medical insurance management Even among the medical insurance departments at all levels, the rights of big data are not clear Zhang Xiao said that when the national health insurance department collects data, the boundaries of rights, responsibilities and interests among all levels of departments are also vague There are great challenges in data collection and construction of health insurance information system across the country.