Medical insurance doctor is a new identity established on the basis of practicing doctors to standardize doctors' practice behavior. Generally speaking, it refers to a medical practitioner who meets the national qualification requirements, has been trained and assessed by the medical insurance management institution, signed a service agreement with the medical insurance department, and can provide medical services for the insured. The medical insurance doctor system refers to the definition of the concept of medical insurance doctors in its jurisdiction and the provisions on the medical insurance prescription behavior of medical insurance doctors. It is an industry procedure and code of conduct that medical insurance doctors should abide by. From "practicing doctor" to "medical insurance doctor" is a further standardization of doctors' qualifications and practice behavior, which shows that doctors are not only the gatekeepers of people's health, but also the gatekeepers of people's medical insurance funds.
Medical insurance physician system is the inevitable product and development trend of medical insurance fund supervision.
At present, most insurance companies in China manage medical insurance funds by setting up designated medical institutions and pharmacies, but the problems are becoming more and more obvious. On the one hand, it is a common phenomenon that designated medical institutions are "easy to get in but difficult to get out". In areas where medical resources are scarce, the only designated medical institution naturally forms a monopoly position. Once the medical insurance designated qualification is revoked due to the supervision and use of medical insurance funds, it will affect not only medical institutions but also local patients. On the other hand, it is unreasonable to punish the whole medical institution because of individual doctors' medical insurance violations. Today, with the gradual liberalization of doctors' multi-point practice policy, doctors have more choices and outlets, and their violations in medical institutions will not affect their entire career. In the past, the rough management of designated medical institutions could not completely prevent the moral hazard caused by doctors' personal behavior.
Since 2009, the basic medical insurance for urban residents has been fully promoted, and the population covered by medical insurance has been expanding. By the end of 20021,the participation rate of basic medical insurance in China reached 96.6%, but the number of medical insurance supervisors was relatively limited. In view of the diversity of clinical diseases, the illegal behaviors of designated medical institutions emerge one after another for different reasons, which leads to the difficulty of medical insurance supervision and the sharp increase of pressure, making the establishment of medical insurance doctor system an inevitable product and development trend of medical insurance supervision. By extending medical insurance supervision from medical institutions to individual doctors, the doctor's diagnosis and treatment behavior is directly linked to medical insurance, and the responsibility of "gatekeeper" of medical insurance fund is implemented to realize the rational use of medical insurance fund.
Establishing the system of medical insurance doctors is the key to the "three-medical linkage"
Since the implementation of a new round of medical and health system reform in 2009, China has continuously explored and improved the system of medical insurance, medical care, medicine and "three-medicine linkage". In March 2022, Premier Li Keqiang put forward the tasks of the government in 2022, demanding to improve the medical and health service capacity, deepen the reform of medical insurance payment methods, and strengthen the supervision of medical insurance funds; Improve the direct settlement method for cross-provincial medical treatment in different places, and realize the basic unification of the scope of medical insurance drugs nationwide; Adhere to prevention, strengthen health education and health management, and further promote the Healthy China Action. At every stage of reform, medical insurance, medical care, medicine and other systems are complementary, and the "three-medical linkage" promotes the improvement of medical and health service capacity.
Introducing the medical insurance doctor system is the key to realize the linkage of medical insurance, medical care and medicine with the "small incision" of medical insurance doctors. In the process of a series of system reforms, doctors are the core, the executors of the system and the providers of medical services. Through the "pen" in the doctor's hand, not only the diagnosis and treatment means and medication plan are finally determined, but also the effective expenditure and use of the medical insurance fund are determined. The establishment of the medical insurance doctor system has shifted the barrier of medical insurance fund supervision to doctors. Through training and assessment of doctors on relevant medical insurance policies, signing a service agreement, guiding doctors to consciously abide by medical insurance regulations, further standardizing diagnosis and treatment behavior and medication prescriptions, realizing the purchase of medical insurance funds, and making medical insurance doctors become the link between the three hospitals.
The medical insurance physician system is an important supplement to the new Physician Law.
Article 29 of the People's Republic of China (PRC) Physician Law, which came into effect in March 2022, stipulates that doctors should adhere to the principles of safe, effective, economical and reasonable drug use, and follow the guiding principles of clinical application, clinical diagnosis and treatment guidelines and drug instructions. This is a new regulation compared with the Law of People's Republic of China (PRC) on Medical Practitioners, which puts forward clear requirements for standardizing doctors' medication.
In addition, the new "Physician Law" affirms the policy of doctors practicing more and encourages doctors to provide services to medical and health institutions below the county level on a regular basis, which may increase the difficulty of supervising doctors' medical insurance violations to some extent. The medical insurance doctor system emphasizes real-time monitoring of information system, irregular spot checks and intelligent analysis of big data, and detects non-compliant medical prescriptions one by one, which is of great significance for standardizing doctors' drug use behavior and ensuring the safety of medical insurance funds. Therefore, the medical insurance physician system can be an important supplement to the new "Physician Law", which is helpful to standardize doctors' behavior and medical insurance supervision. To create conditions for active promotion, medical institutions should make great efforts to strengthen hospital medical insurance.