On the evening of September 1, Qinghai Medical Insurance Bureau issued a notice on the Interim Measures for the Administration of Total Medical Insurance Payments in Qinghai Province, and requested the provincial and municipal (state) health insurance agencies to approve the total amount of medical insurance fund payments for 2020 as soon as possible, in accordance with the Provisions of the Measures.
shall be implemented 30 days after the date of issuance and shall be valid for two years.
, the total payment is mainly to stimulate and guide medical institutions at all levels to further standardize the behavior of medical services, control the unreasonable growth of medical expenses, improve the performance of the use of medical insurance funds.
Under the total amount of medical insurance payment system, through the continuous implementation of special actions to combat fraud and insurance fraud, to further reduce the inflated prices of drugs and medical supplies, reduce the cost of inspection and treatment of large-scale equipment, control the unreasonable increase in secondary medical expenses, gradually raise the price of medical services, promote the integration of medical, medical, medical, hospital-linked reform systems, and promote the coordinated development of high-quality medical security and medical services.
, in the Opinions of the State Council of the CPC Central Committee on Deepening the Reform of the Health Care System issued by the State Council, it was mentioned that the reform of the payment method for medical insurance should continue to be promoted and the total budget method of the medical insurance fund should be improved.
Improve the consultation and negotiation mechanism between medical security agencies and medical institutions, promote collective consultation among medical institutions, scientifically formulate a total budget, link it with the results of performance appraisal of medical quality and agreement performance, and encourage exploration of the implementation of total payments for close medical complexes, strengthen supervision and assessment, balance retention and reasonable overspending sharing.
To collect expenditure, total amount control according to the notice, total payment management, refers to the medical insurance department to the fixed-point medical institutions annual medical insurance fund expenditure, prior approval of a total budget amount, referred to as "total annual payment", year-end liquidation, balance retention, reasonable overspend sharing.
, according to the notice, total payment management adheres to the principle of "receiving expenditure, total amount control, negotiating, incentive constraints, and regulating transparency".
of medical insurance shall be applied to the settlement of hospital medical expenses for urban workers and urban and rural residents.
medical institutions for three consecutive years, the annual hospital medical expenses of more than 300,000 yuan, the total amount of payment management.
at the same time, in order to steadily promote the total amount of medical insurance payment system, reduce the pressure of fixed-point medical institutions to advance funds, medical insurance agencies in the approval of the total annual payment at the same time, should set up a work capital advance system.
based on the average monthly amount of the co-ordination fund allocated by the fixed-point medical institution in the previous year, the medical work capital of one month shall be pre-allocated to the fixed-point medical institution at the beginning of each year and recovered at the end of the year.
addition, in accordance with the principle of "balance of payments, slightly balance", not less than 10% of the income of the health insurance fund for the current year as a risk reserve for unforeseen fund expenditures in the current period.
, funds for general outpatient clinics, outpatient special chronic diseases, special medicines, off-site medical treatment and manual reporting should also be set aside.
it is not difficult to see that the working capital advance system and reserved risk reserves are to ensure the normal cost of hospital expenditure. once the total amount of payments in
has been confirmed, the total amount of annual payments shall not be reasonably determined on the basis of the number of hospitalizations and the expenditure of the medical insurance fund in the last three years of the designated medical institution.
(1) divided into three levels A, three class B, two, one and below the level of medical institutions, according to the general hospital, specialized hospital category, classification to determine the average cost of hospitalization medical insurance payment standards, the same level of similar fixed-point medical institutions approved in accordance with the same standard.
The standard calculation method for medical insurance payment: the standard for the payment of medical insurance for the average number of hospitalizations in fixed-point medical institutions - the total expenditure of the hospital medical insurance fund for the last three years of similar medical institutions of the same class / The total number of hospitalizations in three years (2) the total annual payment is calculated according to the standard of medical insurance payment for the average number of hospitalizations and the total annual payment for the number of hospitalizations in the previous year.
calculation formula: the total annual payment of fixed-point medical institutions is the average medical insurance payment standard for the hospitalization expenses of similar medical institutions of the same class in the last three years× the number of hospitalizations in the medical institution in the previous year.
(3) The total amount of payment approved according to the bed-day payment standard shall be approved for designated medical institutions for the treatment of long-term inpatients such as mental illness and rehabilitation.
Approved× Measures: Bed-day payment standard s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(v) The total payment target shall not be reduced as a result of the decrease in the cost of centralized procurement and use of medicines for the rational use of selected drugs, the performance of procurement contracts, and the completion of centralized procurement and use of medicines by national and provincial organizations.
the cost of negotiating drugs for countries implementing our province's special drug policy is not included in the total control.
(6) Once the total amount of payment of each designated medical institution has been determined, it shall be strictly enforced and shall not be adjusted during the year.
In the annual implementation, in the event of a major adjustment of the medical insurance policy, a major public health emergency, etc., as well as the suspension or dissolution of the medical insurance service agreement, the total fee control target may be approved or reduced as appropriate at the end of the year liquidation.
The more overspends, the more the hospital pays out-of-the-way notice stipulates that, with the total annual payment target, taking into account the increase or decrease in the number of hospital admissions, the average cost of the second time, etc., the actual expenditure of the medical insurance fund in the fixed-point medical institutions during the year shall be liquidated according to the method of "residual retention and reasonable overspend sharing".
year-end liquidation shall be carried out in accordance with the following procedures: (1) approved annual expenditure of the health insurance fund.
the number of new hospitalizations and special medical expenses during the year, and approved the annual expenditure of the health insurance fund.
Approved amount of medical insurance fund expenditure - total annual payment± New (minus) number of hospitalizations (this year's hospitalization compared with the previous year, deduction of special medical expenses) × times the standard payment standard and special medical expenses special medical expenses refers to the single hospitalization medical insurance fund to pay more than 160,000 expenses.
(ii) to implement the policy of "retention of balances and reasonable overspend sharing". If the actual amount of the expenditure of the medical insurance fund in
is less than the actual amount of the annual medical insurance fund, the difference shall be retained as the balance to the medical institutions; if the actual amount is greater than the approved amount of expenditure, the difference shall be regarded as an overspend and shall be borne by the medical insurance fund and the medical institution in a certain proportion.
The proportion of overspending shall be shared by the medical insurance fund and medical institutions according to the ratio of 6:4, and the overspending of 5%-10% (inclusive) shall be shared by the medical insurance fund and medical institutions in the proportion of 5:5, and the overspending of more than 10% shall be borne by the medical institutions.
According to the above rules, the more medical institutions overspend on the approved amount of medical insurance fund expenditure at the beginning of the year, the more out-of-the-way hospitals will pay, and this kind of over-the-top treatment mechanism will force medical institutions to control their expenses.
The use of the medical insurance catalogue and the purchase of medicines are included in the assessment notice and it is also clear that, on the basis of the initial liquidation, the health insurance fund shall be added or deducted on the basis of taking into account such factors as the average cost, the use of the three catalogues of medical insurance and the management of the use of drug recruitment.
1. Compared with the previous year's fixed-point medical institutions, the average cost of hospitalization shall be rewarded by 1 per cent of the total annual payment;
2. Compared with the previous year's fixed-point medical institutions, the actual reporting ratio for hospitalization shall be increased by 1 percentage point and rewarded by 1 per cent of the total annual payment;
3. The use rate of the three catalogues of health insurance has not reached 80%, and for each decrease of 1 percentage point, a deduction of 1 per cent of the total annual payment is made.
4. Medicines (except special controlled drugs of the State, Chinese medicine tablets), medical supplies online procurement rate of less than 100% (except for those not listed in the first six months of use), each decrease of 1 percentage point, according to the total annual payment of 1 per cent deduction. The total amount of liquidation in
, the approved amount of annual medical insurance fund expenditure , the share of the medical insurance fund± , the amount of incentive constraints - the amount of non-compliance expenses due , the total amount of annual liquidation - the amount of turnover allocated at the beginning of the year - the amount allocated in the implementation of the year - the centralized collection of drugs (medical supplies) means that through total control, the medical insurance department also requires medical institutions to meet the corresponding requirements for the use of medical insurance catalogues and the procurement of drugs, otherwise the medical insurance department will also reduce the total amount of annual payments.
medical expenses are abnormal, the provision of early warning or interview notices also provides for the monthly allocation of fund costs.
(1) The funds approved each month shall not exceed the monthly average amount of the total amount paid.
The portion exceeding the monthly average target shall be included in the year-end liquidation; (2) if the medical expenses declared by the designated medical institution are less than the monthly average amount, the funds allocated each month shall be allocated in accordance with the actual occurrence of the declaration; and (3) the funds allocated each month shall be deducted from the non-compliance expenses investigated and dealt with in the current month.
Finally, medical insurance departments at all levels and commercial insurance institutions entrusted with the medical insurance services of urban and rural residents shall complete the year-end liquidation by the end of March of the following year, simultaneously approve the total payment target for the following year (including the turnover), and report it to the Provincial Health Insurance Bureau for the record.
At the same time, it will also strengthen consultation and negotiation with fixed-point medical institutions, communication and coordination, to inform the relevant fixed-point medical institutions of the settlement of medical expenses, if there is an abnormal situation, timely issue the "total payment indicators implementation of early warning notice", if necessary, work interviews.
the reform of the payment method of medical insurance mainly in order to play the role of the purchase of medical insurance strategy, improve the quality of medical services, reduce the burden of health insurance and patients' expenditure.
In the process of promoting the reform of the payment method of medical insurance, the various payment methods of medical insurance, such as total advance payment, pay by disease, pay by bed, pay by person, etc. are all the reform direction of the encouraged payment method of health insurance for different diseases and different patients.
Under the total cost, the hospital will also start to control the total cost, when the hospital treatment, prescription, medication, examination, etc. will also be affected by the linkage, and the purpose of the series of actions is naturally to reduce the cost of the hospital, and strive to obtain the balance of retained medical insurance funds.