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    Home > Active Ingredient News > Drugs Articles > "Two pilots and one demonstration", what experience has been accumulated for the supervision of medical insurance funds?

    "Two pilots and one demonstration", what experience has been accumulated for the supervision of medical insurance funds?

    • Last Update: 2021-05-09
    • Source: Internet
    • Author: User
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    In order to accelerate the establishment of a long-term mechanism for the supervision of medical insurance funds, the National Medical Insurance Administration launched a pilot fund supervision method innovation, a fund supervision credit system construction pilot, and medical insurance intelligent monitoring demonstration sites (referred to as "two pilots and one demonstration") in 2019, and actively promoted the formation Advanced experience in medical insurance fund supervision that can be promoted and replicated.

    The launch of the "two demonstrations and one pilot" has aroused strong responses from all walks of life, formed a social consensus on the supervision of medical insurance funds, strengthened the people's confidence in the development of the medical insurance system, and the public support for the construction of a long-term fund supervision mechanism has become more solid.


    With the promulgation of the Regulations on the Supervision and Administration of the Use of Medical Security Funds, the construction of a medical insurance credit system led by laws and regulations, focused on innovation in supervision methods, supported by intelligent monitoring, and centered on praise and trustworthiness and punishment of dishonesty has been deepened.
    , The overall framework of my country's medical insurance fund supervision has basically been established.


    Local experience of "two pilot projects and one demonstration"

    Since the launch of the "Two Pilot Projects and One Demonstration", the establishment of the medical insurance credit system and intelligent monitoring in the pilot areas have been fully implemented.


    The first is to improve relevant laws and regulations, formulate corresponding policies, establish and improve working mechanisms, and continuously improve credit evaluation standards, index systems and methods.


    The second is to build a credit platform and an intelligent monitoring platform on the basis of the original medical insurance informatization and medical institution information platform to smoothly exchange and share data of medical insurance, medical care, medicines, consumables, etc.


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    2.


    Pilot areas implement a medical insurance fund regulatory credit system, focusing on designated medical institutions, medical practitioners, and insured persons.


    For example, Beijing has established a comprehensive evaluation and dynamic adjustment mechanism for designated medical institutions, and quantitatively scores designated medical institutions and medical institutions that apply for new designated medical institutions.


    Shaoxing City implements industry self-discipline in 18 industry associations, including designated hospitals, designated retail pharmacies, and medical insurance physicians, in the form of "General Conference + Branch".


    Based on the results of credit evaluations, Shenzhen conducts hierarchical and classified management of regulatory objects, optimizes "double random" spot checks, and adopts differentiated regulatory measures based on the level of credit ratings.


    3.


    At present, more than 90% of the coordinated areas across the country have carried out intelligent monitoring of medical insurance, and promoted the transformation of medical insurance and medical expenses settlement from partial review to full review, post-correction to pre-remind and in-process supervision, and from administrative control to supervision, management, and supervision.


    Kaifeng City takes the survey of the insured's satisfaction with medical insurance as the focus of the project, and integrates the intelligent monitoring system and biometric technology into the construction of the fund supervision credit system.


    The medical insurance real-time monitoring platform established by Tianjin City has upgraded the previous monitoring by indicators to monitoring by themes.


    Xiamen City has introduced the "face recognition" technology and applied the facial recognition system to effectively identify the identity of doctors and standardize the practice of multiple doctors.


    Contradictions and difficulties faced by "two pilot projects and one demonstration"

    Judging from the effects of the "two pilot projects and one demonstration" in the pilot areas, the results have been remarkable, and they have contributed to maintaining the safety of funds and establishing and improving the long-term mechanism of medical insurance fund supervision.
    But it also found a series of problems and difficulties, including:

    1.
    Relevant policies are not matched, and supervisory force has not yet formed.

    2.
    The standardization and scientific nature of credit evaluation are lacking, and there are even disputes.
    In some regions, the credibility of the medical insurance credit rating, credit (accumulation) points system, and "blacklist" rules are quite controversial.
    The credit evaluation system has not yet shown its effectiveness in promoting the self-discipline of designated medical institutions, physicians and pharmacists, insured persons, and medical insurance agencies.

    3.
    The intelligent information system is still trapped by the obstacles of funds, talents and data exchange and sharing, the quality of data is not high, and the lack of professionals.
    In particular, the medical insurance information system of some underdeveloped areas and remote and backward areas, the HIS system of medical institutions and the network system of designated pharmacies are backward.
    They cannot be connected with the intelligent monitoring system, and it is difficult to realize the intelligent monitoring function.
    In other pilot areas, designated pharmacies and designated clinics have not yet established a computer network information system due to their small scale and financial difficulties.
    The computer network information system in some pilot areas can only meet the needs of medical insurance handling business, and the intelligent analysis and monitoring functions are weak.

    4.
    The indicators are not unified and standardized, and it is difficult to standardize the interface.

    5.
    The lack of management talents and the lack of professionalism of the talent team.

    6.
    The system is not sound and standardization is not enough.
    Enhance the medical insurance intelligent monitoring capabilities and create a more intelligent, efficient and complete monitoring system, which relies on the comprehensive legalization, standardization and standardization of medical insurance from the system, policy, management to review rules, data, and coding.

    Improve the long-term mechanism construction of medical insurance fund supervision

    The promulgation and implementation of "Regulations on the Supervision and Administration of the Use of Medical Security Funds" has created a deterrent to violations of laws and regulations in the field of medical security.
    Untrustworthy behavior is difficult to investigate due to minor or even hidden violations, but the spillover effect of dishonesty behavior is very high.
    It not only makes the untrustworthy behavior of some untrustworthy subjects affect themselves, but also infects and pollutes the operating environment of the entire medical security system, and ultimately pushes up the entire medical security.
    The operating cost of the system.
    If the punishment is insufficient or the investigation is not timely, it may also trigger the effect of "bad money driving out good money".
    Therefore, we should vigorously promote the construction of the medical insurance credit system, make up for the shortcomings of the credit system construction, and escort the high-quality and sustainable development of medical security.
    Unswervingly advancing the "two pilot projects and one demonstration" will have a fundamental, strategic and far-reaching impact on improving the long-term mechanism for the supervision of medical insurance funds with Chinese characteristics.
    To this end, the following suggestions are made.

    1.
    Strengthen government credit construction

    Strengthening the construction of the government credit system, especially the credit construction of government agencies related to medical insurance, is the fundamental prerequisite for the better functioning of the medical insurance credit system.
    The construction of the medical insurance credit system should not only focus on the outside, but should also "knife inward.
    " From the scientific, fairness and rationality of formulating medical insurance policies to the efficient, convenient and safe handling of services, we must win the trust of the people and be fair and just in all aspects.
    This is of great significance for improving the medical insurance governance environment, maintaining the high-quality and sustainable development of medical insurance, reducing the cost of medical insurance governance, and maintaining fund security.

    But at present, in some provinces, there are still “small areas” where the departments directly under the provincial government plan separately or still implement “public medical care.
    ” Units and individuals enjoy far higher benefits than medical insurance without paying.
    In some areas, there are too many medical insurance management links, complicated procedures, and inconvenience for the masses to do things.
    Even medical insurance services are "easy to enter, good-looking, good-sounding, and not doing things".
    The bureaucracy is lazy and negligent.
    This will directly affect the insured's doubts about the fairness of the entire system, which will induce some people to take advantage of loopholes in the system or management, and endanger the safety of the medical insurance fund.

    2.
    Strengthening the credit supervision of fund collection

    The safety supervision of funds currently mostly focuses on the payment link, focusing on "thrift" and ignoring "open source".
    Most of the "two pilots and one demonstration" areas have established a relatively strict protection network in the fund payment link, but insufficient attention is paid to the trustworthiness system of the fund collection link, which has led to some enterprises and individuals failing to abide by integrity, failing to act in accordance with regulations, and concealing less Reporting the base of payment, deliberately or even maliciously underpayment, underpayment, unreasonable interruption of payment, or selective payment has become a major loophole affecting the safety of medical insurance funds.

    Therefore, it is recommended that in the construction of the medical insurance credit system, government credit, enterprise (including medical institutions, commercial insurance institutions, etc.
    ) credit and individual (including family) credit should be promoted simultaneously, and the overall medical insurance behavior including payment behavior and payment behavior should be included.
    This is also an important sign of the maturity of my country's medical insurance credit system.

    3.
    Improve the construction of credit data system

    The medical insurance credit evaluation and intelligent monitoring system are organically combined to form a unified medical insurance data system.
    The basis of the "two pilots and one demonstration" is the medical security data system, which integrates medical security policies and regulations, standard data, handling business data, medical institution service information data, insurance registration change data of insured persons, Payment data and medical treatment enjoyment data, as well as data from third-party medical security related institutions, include both historically accumulated data and real-time dynamic data, both numerical data and image and audio scene behavior, that is, attitude data.

    However, in reality, the quality of data and the consistency of sources are still the biggest hidden dangers in the promotion of "two pilot projects and one demonstration".
    At present, medical insurance-related data scattered in various industries is still in a mutually monopolized and isolated state, and cannot be well aggregated and utilized in medical insurance credit and intelligent monitoring.
    Information among government departments such as medical insurance, public security, health, human resources and social security, taxation, market supervision, etc.
    still cannot be shared in medical insurance.
    The information of medical institutions, commercial insurance and other institutions is not transparent enough, and it is difficult to obtain medical insurance credit system and intelligent monitoring.
    related data.
    For example, the data of some designated medical institutions is transmitted to the medical insurance department after screening and conversion, and the medical insurance department is difficult to collect first-hand information such as doctor workstations, cases, medical orders, and execution.
    The intelligent monitoring knowledge base and rule database established in some regions use policy, regulatory documents, drug labeling application taboos, etc.
    as the basis for intelligent logic judgments, and the diagnosis process and clinical pathways in medical clinical textbooks as compliance or not The basis, leading to "good for not good use", leading to doubts about credit evaluation or intelligent monitoring results.

    To this end, the construction of the medical insurance credit data system should start from the following aspects.
    First, strengthen the construction of medical insurance credit database.
    It is recommended that relevant medical insurance departments use legal documents and other forms to disclose the standards for obtaining credit information to the whole society, and build a medical insurance professional credit investigation and intelligent monitoring database.
    Second, make full use of the integration of blockchain technology and medical insurance credit.
    As an emerging technology, blockchain provides support for the creation of a new "trust" ecosystem for medical insurance, medical services and other related activities.
    Due to the serious fragmentation of data in my country’s medical insurance institutions, medical institutions, insured units, individuals, etc.
    , the use of blockchain technology’s distributed data storage, sharing mechanism, traceability and anti-tampering features will improve the medical insurance fund regulatory database system Very necessary.
    Third, it is recommended that the National Medical Insurance Bureau organize forces to research and develop general tools such as knowledge bases and rule bases in the intelligent monitoring system as soon as possible.
    The medical insurance business data system, structure, and data in the pilot area may be more different, and the information exchange and sharing methods of the medical institutions in the coordination area are also inconsistent.
    The credit models, indicators and intelligent monitoring models developed and established are also different, but the credit system and intelligent The internal mechanism of the logic of medical insurance policies, regulations and rules required for monitoring is the same.
    Therefore, it is necessary to uniformly form the basic knowledge base and rule library required for medical insurance credit and intelligent monitoring for the pilot areas.

    4.
    Implement the "Three Completes" principle of credit system construction and intelligent monitoring

    The "Three Fulls" means the realization of full coverage, full process and full field of the medical insurance credit system and intelligent monitoring.
    Realize that the medical insurance fund supervision object currently covers all designated medical institutions, designated retail pharmacies, medical insurance physicians and pharmacists, insured personnel, pharmaceutical enterprises, and agencies, and extends to medical insurance, medicine, legal persons and other related medical insurance fund management policies, The source of the fund and the subject of the use of the fund should not favor one or the other, and do not avoid the emphasis on the emphasis.
    The medical insurance fund starts from the collection link to the payment link and the management of surplus funds to achieve full-process coverage and form a new regulatory pattern that runs through the entire link of the medical insurance fund collection, use, and management before, during and after the event.
    Give full play to the roles of party committee leadership, government supervision, social supervision, industry self-discipline, and personal trustworthiness to form an all-round three-dimensional supervision pattern.

        



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