■ Diabetic patients independently choose health authorities, which are responsible for educating and guiding diabetic patients to strengthen self-management and providing standardized diabetes health management services for diabetic patients.
■ At present, 543 medical institutions in the city have been declared as the competent department of diabetes health, and promised to provide diabetes health management services including disease monitoring, complication screening, therapeutic drugs and referral for diabetic patients by themselves or in cooperation with other medical institutions.
■ Since the implementation of 1 in June, nearly 30,000 diabetic patients in our city have independently chosen the health authorities, which has run smoothly and received good response.
The scope of reimbursement is not limited by the scope of special payment.
The policy is clear. After choosing the competent health department, diabetic patients receive diabetes diagnosis and treatment in the competent health department and its cooperative medical institutions, and the scope of reimbursement is not limited by the payment scope of diabetes projects in our city. By the competent department of health and its cooperative medical institutions, according to the actual situation of diabetic patients, choose appropriate medical services within the scope of payment of basic medical insurance in our city, and formulate standardized treatment and medication plans for diabetes and its complications. The medical expenses incurred shall be reimbursed by medical insurance according to the treatment standard for diabetic patients. Diabetes patients who have not yet selected the competent health department can still continue to see a doctor in the designated medical institutions, and the medical expenses for diabetes diagnosis and treatment will be reimbursed in strict accordance with the payment scope of diabetes projects in our city.
Seven questions and answers to frequently asked questions 1. Which insured patients can choose the health authorities for diabetes?
Answer: All insured patients who enjoy the medical insurance benefits for urban workers and residents and are recognized as diabetic patients in this city can choose one of the published "Tianjin Diabetes Health Authorities" as their own health authorities, except those who have gone through the settlement procedures for medical treatment across provinces and different places.
Second, how do diabetics go through the registration procedures selected by the health authorities?
Answer: Patients with diabetes go to the health authorities to be transferred with social security cards or medical insurance electronic cards, and go through the registration procedures for transferring the health authorities under the guidance of the staff of the health authorities. After handling the selected registration procedures, it will take effect on the following natural month 1 day, and the registration period is long-term.
3. How do diabetics go through the formalities for changing the registration of health authorities?
A: After choosing a health authority, diabetics can change health authorities according to their own wishes. With social security card or medical insurance electronic certificate, diabetic patients will go to the next selected health administrative department and go through the registration formalities for the change of health administrative department under the guidance of the staff. After going through the registration formalities, it will take effect on the following natural month 1 day, and the registration period is long.
4. How to link the per capita payment of diabetic patients in the early stage with the responsibility system of health supervisors?
A: Before June, 2022 1, all the medical institutions in our city that participated in the pay-per-head treatment of diabetes have been turned into the competent department of diabetes health. If the diabetic patient has previously signed a contract with the designated medical institution of medical insurance to participate in the per capita payment for diabetic patients, and still has a continuing relationship with the contracted medical institution, the original contracted medical institution will be directly transferred to the health authorities of its own choice after June 1 day, 2022, which will be effective for a long time.
5. What are the changes in medical reimbursement for diabetic patients after they choose the competent health department?
A: The policy is clear. After the selection of the health authorities, the management restrictions on the reimbursement scope of diabetic patients and the number of hospitals will be relaxed to a certain extent, and the medical security treatment standards related to diabetic patients will not be affected.
The first is about the scope of medical insurance reimbursement. After choosing the competent health department, diabetic patients receive diabetes treatment in the competent health department and its cooperative medical institutions, and the scope of medical insurance reimbursement is not limited by the payment scope of diabetes care projects in our city. By the competent department of health and its cooperative medical institutions, according to the actual situation of diabetic patients, choose appropriate medical services within the scope of payment of basic medical insurance in our city, and formulate standardized treatment and medication plans for diabetes and its complications. The medical expenses incurred shall be reimbursed by medical insurance according to the treatment standard for diabetic patients.
The second is about the scope of hospitals. According to the current regulations of our city, diabetic patients can choose no more than three medical institutions as medical institutions with specific points for diabetes. After choosing the competent health department, diabetic patients will implement "1+N treatment mode" according to the regulations. The health authorities can refer diabetic patients to a number of designated medical institutions for medical reimbursement according to their actual needs, regardless of the number of tertiary hospitals.
The third is about medical insurance reimbursement. According to the Notice, the medical insurance treatment standards for diabetic patients (including the minimum payment standard, the proportion of medical insurance reimbursement, the maximum payment limit, etc.). ) will not be affected before and after being elected as the competent health department.
Six, diabetes patients selected health authorities, how to accept health management services and medical reimbursement in the health authorities?
A: After selecting the health authorities, diabetic patients should receive diabetes health management services including disease monitoring, complication screening, treatment and medication in the selected health authorities or cooperative medical institutions referred by them. The medical expenses incurred will be reimbursed by medical insurance according to the treatment standard of diabetic patients. After selecting the competent health department, diabetic patients who have not been referred by the competent health department to other designated medical institutions for diagnosis and treatment of diabetes are not included in the payment scope of diabetic patients.
It should be noted that the reimbursement of diabetic patients for hospitalization, general outpatient (emergency) diagnosis or other outpatient specific diseases is still implemented according to the current regulations, and there is no need to choose to seek medical treatment in the competent department of diabetes health, nor to be referred by the competent department of health.
Seven, diabetes patients in the health authorities for diabetes diagnosis and treatment, how to carry out personal settlement?
A: In principle, the medical expenses incurred by diabetic patients in the health authorities and their cooperative medical institutions are directly settled through the Internet. In case of special reasons such as network failure, medical institutions can adopt the method of delaying credit card settlement; Medical expenses incurred due to diabetes are reimbursed according to diabetes treatment standards and are not limited by the scope of diabetes payment.
Designated retail pharmacies provide home delivery or physical store dispensing services for diabetic patients according to the electronic outsourcing prescriptions issued by the health authorities and their cooperative medical institutions, and the medical expenses incurred are reimbursed according to the treatment standards of the designated medical institutions that prescribe. The drug distribution expenses incurred by designated medical institutions or retail pharmacies are subject to market-adjusted prices and are not included in the scope of medical insurance fund payment.
List of diabetes health authorities
(As of July 2022 12)
Health management of specific diseases in diabetes clinics in Tianjin
(First Edition) I. Group Management
(1) Selection criteria: Diabetic patients have chosen the health authorities, understand the health management plan of the health authorities, and are willing to cooperate with regular follow-up.
(2) Admission examination: After newly enrolled diabetic patients, the health authorities will conduct a new admission examination, including medical history, physical examination and laboratory examination. Among them, diabetic patients admitted by other health authorities within 3 months can be directly included in the follow-up management without repeated admission examination.
1. Medical record
2. Physical examination
Routine physical examination: blood pressure, heart rate, height, weight, waist circumference, hip circumference, body mass index, waist-hip ratio, etc.
Complications screening: fundus examination, foot examination, pathological examination of lower limbs, neuropathy examination, etc.
3. Laboratory inspection
If abnormalities are found in physical examination and laboratory examination, ultrasound examination, ambulatory blood pressure monitoring and neuroelectrophysiological examination can be further done according to the guidelines.
(3) Treatment and management plan:
1. Control target blood sugar (fasting, 2 hours after meals), glycosylated hemoglobin, blood pressure, total cholesterol, high-density lipoprotein cholesterol, triglyceride, low-density lipoprotein cholesterol, body mass index (short-and long-term weight loss targets for overweight or obese patients), etc.
2. Drug use plan hypoglycemic drugs, drugs with acute complications and drugs with chronic complications;
3. Lifestyle interventions such as exercise, diet, smoking cessation and alcohol restriction, diabetes education, diabetes self-monitoring and management.
4. Mental health assessment 2. Follow-up management
(1) Follow-up inspection: Follow-up management inspection items mainly include physical examination and laboratory inspection. , mainly focusing on the monitoring of process indicators.
1. Physical examination Routine physical examination: blood pressure, heart rate, weight, waist circumference, hip circumference, body mass index, waist-hip ratio, skin of lower limbs and feet, etc.
Follow-up of patients with complications: those with retinopathy should have fundus examination; Patients with diabetic foot should have a foot examination.
2. Laboratory inspection
If abnormalities are found in physical examination and laboratory examination, ultrasound examination, ambulatory blood pressure monitoring and neuroelectrophysiological examination can be further done according to the guidelines.
(2) Follow-up frequency: The diabetic patients with stable condition start from 3 months after entering the group, with an interval of about 3 months each time; Follow-up of patients with unstable condition.
(3) Evaluation and adjustment of treatment and management plan: According to the follow-up inspection, evaluate and adjust the treatment and management plan.
Three. Annual review (1) Annual review: Annual review includes physical examination and laboratory examination. , mainly focusing on the annual review of physical and chemical indicators.
1. Physical examination Routine physical examination: blood pressure, heart rate, height, weight, waist circumference, hip circumference, body mass index, waist-hip ratio, etc.
Complications screening: fundus examination, foot examination, pathological examination of lower limbs, neuropathy examination, etc.
2. Laboratory inspection
If abnormalities are found in physical examination and laboratory examination, ultrasound examination, ambulatory blood pressure monitoring and neuroelectrophysiological examination can be further done according to the guidelines.
(2) Time and frequency: 1 annual inspection every year. The interval between the annual inspection and the last follow-up management is about 3 months, and the cumulative number of group inspection and follow-up management has reached more than 3 times.
(3) Evaluation and adjustment of treatment management plan: According to the annual inspection, the next treatment management plan is evaluated and determined.