A brief reflection on improving the total control of medical insurance payment
Abstract The total control of the basic medical insurance payment is one of the commonly used means to inhibit the unreasonable growth of medical costs, at present, most of the regions in China to take the total expenditure of the fund according to the budget according to a certain rule at the beginning of the period of the decomposition of the total control of the fixed-point medical institutions, but the implementation process has some negative impact and problems. At present, most regions in China adopt the total control method that the total expenditure of the fund according to the budget is decomposed to the fixed-point medical institutions at the beginning of the period according to certain rules, but some negative impacts and problems have appeared in the process of implementation. This paper compares and analyzes these two typical total control methods, and proposes a way to improve the total control of medical insurance payment.
Keywords medical insurance; total control; improve; thinking
The total control of basic medical insurance payment (hereinafter referred to as the total control) is one of the commonly used means to control the excessive growth of medical costs in many countries around the world, and it can effectively inhibit the rapid growth of medical costs of medical service providers through the implementation of the budgetary management of medical insurance funds, and determining the expenditure based on the income. It effectively restrains the impulse of medical service providers to rapidly increase medical expenses by implementing budget management for the medical insurance fund and determining expenditures based on revenues, so as to realize the smooth and sustainable operation of the medical insurance fund. In recent years, with the initial formation of China's universal medical insurance system, the coverage of the population continues to expand, the level of protection has been steadily increased, the establishment and improvement of the protection mechanism for major diseases and the successive introduction of convenient measures such as direct settlement and cross-district medical treatment, the demand for medical treatment by the people has been released at a relatively fast pace, with a substantial increase in the number of medical visits and a rapid rise in medical costs. In order to ensure the stable and sustainable development of medical insurance, the Ministry of Human Resources and Social Security, the Ministry of Finance and the Ministry of Health issued the Opinions on Carrying Out Total Control of Basic Medical Insurance Payments, deepening the reform of medical insurance payment methods nationwide, carrying out total control work, and controlling the excessively rapid and unreasonable growth of medical costs. However, in recent years, from some areas (such as Baoding, Hebei, etc.) to try to implement the total amount of control, some medical institutions to avoid overspending, with various reasons to shirk the medical insurance patients, and some even simply refused to accept the medical insurance patients; and some medical institutions in order to increase the cost of the budget amount of the following year, for some patients with minor illnesses are also required to be hospitalized or its prescription, and then stealthy arbitrage of the medical insurance fund and so on some discordant note. Discordant notes. The first step in the process is to make sure that you are able to get the best out of your system, and that you are able to get the best out of your system.
First, the connotation of the total control of the basic medical insurance payment
The total control of the basic medical insurance payment refers to the medical insurance organization according to the budget of the medical insurance fund income and expenditure, through consultation with the designated medical institutions to determine the total amount of medical expenses incurred by the insured person within a period of time should be paid for by the basic medical insurance fund and to adopt corresponding settlement methods and incentives. It is the act and process of adopting corresponding settlement methods and incentive and constraint control measures to control the unreasonable or excessive growth of medical costs, improve the performance of medical insurance, and safeguard the rights and interests of insured patients.
Broadly speaking, the total control of medical insurance payment includes the control of the total amount of medical expenses that should be paid by the basic medical insurance fund incurred by the insured in the designated medical institutions and the insured in the non-designated medical institutions (referring to the medical treatment in other places outside the place of insurance); narrowly speaking, the total control only refers to the control of the total amount of medical expenses of the basic medical insurance organization on the designated medical institutions. The total control in the practice of medical insurance management mainly refers to the total control in the narrow sense.
The total control of the basic medical insurance payment is not for the insured patients incurred in the payment settlement of medical service costs, but in the insured patients according to the medical insurance policy to pay the corresponding medical service costs of the medical insurance fixed-point medical institutions in the consultation and negotiation on the basis of the expenditure budget to the corresponding range of control of medical services. The basic medical insurance payment total control contains several meanings:
First, according to the medical insurance fund income and expenditure budget to determine the control target. On the basis of the income and expenditure budget of the basic medical insurance fund, the expenditure budget is prepared scientifically by taking into account the actual payment situation of the medical insurance fund of the coordinated region in recent years, and combining the factors of economic development, the number of insured persons, the age structure and changes in the spectrum of diseases, as well as the policy adjustments and the treatment level, etc. The expenditure budget is prepared in a scientific manner. After consultation with the designated medical institutions and comprehensive consideration of various types of expenditure risks, the annual total control target of the medical insurance fund to pay to the medical institutions is determined.
The second is to produce the corresponding incentive constraints. Total control to effectively play the role of controlling medical costs, standardize the behavior of medical institutions, the key is to establish a scientific incentive constraints mechanism, so that the medical institutions really become the total control of the management and the responsibility of the bearer, in order to fully mobilize the medical institutions to control the medical costs of the enthusiasm and initiative.
Third, the purpose of total control is to enhance the performance of basic medical insurance protection. Through the total control to promote rational diagnosis and treatment of medical institutions, self-management and cost control, to better protect the basic medical rights and interests of insured persons, control the personal burden of insured persons. There should be corresponding measures to prevent some medical institutions in order to avoid overspending or obtain the balance and shirking refused to accept patients, lower service standards, false reporting of the volume of services and other supporting measures and assessment means, and constantly improve the scientific health insurance payment method, improve fund performance and management efficiency.
Two typical modes of total control of basic medical insurance payments
At present, many of China's health insurance co-ordination areas have implemented total control of medical insurance payments, and there are two main ways to carry out total control of the more typical practices around the world: one is to decompose the total amount of the fund's expenditures according to the budget at the beginning of the period according to certain rules to the designated medical institutions, and the other is to decompose the total amount of the fund's expenditures according to the budget according to certain rules. The other is to settle the bill according to the budgeted total fund expenditure according to the value of the disease type by period.
( i) The total budgeted fund expenditure is broken down to the sentinel medical institutions at the beginning of the period according to certain rules.
Shanghai, Hangzhou City, Zhejiang Province, Baoding City, Hebei Province, and most other regions have adopted the practice of budgeting the total amount of fund expenditure according to certain rules broken down to the fixed-point medical institutions, more typical and the implementation of the earliest is the Shanghai Municipality.
1. Fund budget.
At the end of each year, by the health insurance agency in accordance with the principle of income to determine expenditure, set aside the necessary risk reserves and other funds, to the actual income of the health insurance fund plus the next year, the health insurance fund income is expected to increase the next year to formulate the annual budget of the health insurance fund. On the basis of the next year's health insurance fund budget, in accordance with the health insurance fund to pay for the project, the total hospital budget control indicators, submitted for approval after the implementation.
2. Negotiation to determine the total budget control indicators for each hospital. In the public annual fund revenue and expenditure budget and hospital budget total control indicators, the city's hospital budget total control indicators and the actual implementation of the basis, through the hospitals recommended by the representatives (to participate in the consultation of the hospital representatives elected), the synthesis of different hospitals and the situation of independent consultation ("three rounds of consultation") Determine the total hospital budget target (hospital consultation is based mainly on the cost of each hospital in recent years).
3. Monthly disbursement and suspension of disbursement. The year-end assessment is due to strengthen management, control unreasonable cost expenditure and lead to the actual declared costs lower than the amount of prepaid part of the hospital retained.
4. Mid-year adjustment of the total budget control index. The health insurance agency organizes the district and county health insurance departments and hospitals to adjust the annual budget indicators of each hospital in the middle of the year to cope with possible changes in circumstances affecting the budget indicators.
5. Year-end assessment share. At the end of each year, the municipal health insurance department based on the views of hospital representatives to draw up the budget management year-end liquidation program, for the whole year the actual declared costs do not exceed the annual budget indicators of the hospital, in principle, the year-end assessment is not deducted, not shared. For the whole year the actual declared costs exceeded the annual budget target of the hospital, in the hospital diagnosis and treatment behavior norms, medical cost reasonableness, etc. on the basis of the assessment, and taking into account the health insurance fund and the hospital affordability, by the health insurance fund and the hospital on the excess budget part of the proportion of the reasonable share.
6. Practices in other cities. Compared with Shanghai, the difference between the total control of other regions is mainly on the determination of the hospitals quota, not like Shanghai through the form of negotiation, but according to the previous year's medical expenses incurred by the medical institutions to determine the total amount of the budget (the vast majority of cities to take this approach). For example, in Baoding City, Hebei Province, the total income of the previous natural year is taken as the base, 10% of the risk transfer fund is set aside, another 10% is set aside as the fund for transferring to other places, reimbursement from other places and reimbursement for outpatient chronic diseases, and the rest is the total amount of prepayment. The total prepayment amount is multiplied by the hospital's weight [based on the hospital's 'proportion' of the previous three years' coordinated payment (80%), inpatient hospitalization costs (6.67%), number of beds (6.67%), and number of enrolled health care providers (6.67%)], and then is used as the hospital's annual prepayment target. The hospital's annual prepayment target will be redistributed to each month. When the hospital incurs coordinated expenses equal to or less than the prepayment target in a month, the Pooled Fund will settle the bill accordingly, and the balance of the target will be transferred to the next month's prepayment target; and when the hospital incurs coordinated expenses greater than the prepayment target in a month, the Pooled Fund will settle the bill according to the prepayment target of that month. At the end of the year, there is a balance of prepaid indicators, and more than 80% of the assessment indicators of the hospital, 50% of the balance of funds as a hospital development fund to reward the hospital; more than the prepaid indicators of the hospital, in line with the health insurance provisions of the reasonable overexpenditures in excess of the annual prepaid indicators of less than 10% of the portion of the hospital and the integrated fund were borne by the hospital and the respective 50%; exceeding 10% (including 10%) more than the portion borne by the hospital.
Another example is Hangzhou, Zhejiang Province, the total amount of hospitals to determine is based on the previous year's medical expenses of medical institutions and the adjustment factor (adjustment factor based on the previous year's medical expenses and changes in the level of economic and social development of the city and other factors to determine the total amount of the proposed budget program for the current year, after consulting with the relevant medical institutions to be issued. On the basis of the total budget at the beginning of the year, the medical insurance agency will break down the budget to the hospitals on a monthly basis. If the monthly cost is below the budget, it will be pre-drawn in accordance with the regulations based on the actual cost; if it exceeds the monthly budget, it will be pre-drawn in accordance with the regulations based on the budgeted amount. At the end of the year, the annual costs are liquidated, and for hospitals whose total actual costs are lower than the budget, the savings are shared between the hospitals and the health insurance fund***; for hospitals whose total actual costs exceed the budget, the overspending is shared between the hospitals and the health insurance fund. During the period, the health insurance agency based on the hospital's service volume can be adjusted to the budget, service incremental part of the cost of additional budget.
( Secondly, according to the budget of the total fund expenditure on the settlement of the value of the disease
Huai'an City, Jiangsu Province, Zhongshan City, Guangdong Province, Nanchang City, Jiangxi Province, Wuhu City, Anhui Province, etc., the implementation of the "revenue to determine the expenditure, the total amount of control, the implementation of the disease on a monthly basis, the value of settlement" payment. In addition to the above, the company has also introduced a new product called the "Purely Purely Purely Purely Purely", which is a new product called "Purely Purely Purely Purely Purely Purely".
1. Screening of diseases. In accordance with the "International Classification of Diseases" (ICD-10) extensive investigation of the actual occurrence of the designated hospitals in the past three years, the actual number of cases per year in the number of more than 10 cases of disease singled out as a common disease to be categorized, summarized, screened out to cover the city's number of cases more than 90% of the different departments of the disease 892 types.
2. Determine the score. All patients discharged in the last three years of the disease and cost data (including non-employee health insurance patients) are categorized and summarized, according to the different treatment requirements of each type of disease and cost of the historical average, to each type of disease to determine the initial score, after the experts corrected and comprehensive feedback from hospitals to determine the score of each type of disease (big diseases and serious illnesses). "The score for each disease type is determined after expert correction and feedback from each hospital (high score for major diseases and low score for minor diseases). According to the relationship between the average cost ratio of each type of disease in different levels of hospitals to determine the level of the hospital coefficient (i.e., the conversion factor when calculating the score), the hospitals settlement according to the corresponding level coefficients to determine the settlement of the score (three, two, one hospital level coefficients for 1.0, 0.85, 0.6, respectively).
3. Total budget. At the beginning of each year, the total amount of the integrated fund available for distribution for the year is measured based on factors such as the number of participants and the contribution base, and with reference to the use of funds in previous years. After withdrawing 5% of the comprehensive adjustment fund (for year-end final transfers), then 15% of the total amount withdrawn for outpatient specific items, outbound transfer personnel medical expenses, and the remaining 70% as the total amount of inpatient medical expenses of the designated hospitals can be allocated to the distribution of the month
4. Prepaid expenses. At the beginning of the year, based on the actual cost incurred by the designated hospitals in the previous year, combined with the grades assessed by the hierarchical management of medical institutions, the working capital was prepaid in accordance with the proportion of 8-12%.
5. Monthly settlement. Taking the sum of the points of the monthly discharged insured patients' diseases in each designated hospital (after converting the points according to the corresponding grade coefficients), the specific price of the points of the month is calculated, and the medical insurance fees are settled separately according to the cumulative points of the discharged patients in each hospital.
6. Budget adjustment. Every year in July, according to the adjustment of the contribution base, participation in the expansion of the distribution of the integrated fund for re-estimation and adjustment, so that the monthly distribution of the fund and the actual fund revenue and expenditure more in line with.
7. Year-end accounts. At the end of the year, according to the actual income of the integrated fund and the outpatient specific projects, stationed outside the country and the transfer of personnel in the medical cost of overspending or surplus, the hospitals throughout the year, admitted to the critical cases, long-term inpatient as well as the use of special materials, and combined with the implementation of the agreement, and the final account of the hospitals with the designated.
8. In the specific settlement process also take corresponding supporting mechanism. For the condition is significantly special, the treatment is particularly complex and so on, according to the discharge of the first diagnosis determined by the score deviation is obvious, the organization of the hospital representatives and experts *** with the deliberation, to determine a reasonable score. Secondly, the mechanism of collegial deliberation for critical cases. For cases of the same type of disease with critical conditions, higher treatment costs, and larger differences in settlement according to the score, the appropriate score will be re-determined by the experts before the year-end final accounts are finalized. Third, the compensation mechanism for long-term hospitalized patients. Long-term hospitalized mental patients and other cases are evaluated by experts to confirm a reasonable subsidy standard at the time of final accounts. Fourth, the mechanism of deferred payment for special materials. For cardiovascular stents, cardiac pacemakers, orthopedic special materials and other medical materials with high costs, which are easy to abuse and difficult to control, a unified study will be conducted to solve the problem according to the fund balance at the end of the year, so as to make the use of special materials match the needs of the disease. Fifth, the score against the integrity of the mechanism. The disease points against the situation into the fixed-point agreement for day-to-day management, the "diagnosis of upgrading" and "high set of points" and so on in the settlement of the corresponding punitive measures.
( The two total control methods of analysis and comparison
From the part of the coordinated regional implementation of the total control of the basic medical insurance payment, the total control of the medical insurance payment of the amount of medical service institutions have a high degree of control over the amount of services and costs, is the most reliable and most effective way to control the cost of medical care, the most effective way to control the cost of medical care. It is the most reliable and effective way of controlling medical costs, and also an easy-to-operate way of controlling fees. Although there are some differences in the specific implementation scope and settlement methods, they have all achieved the effect of controlling the growth rate of medical insurance expenditure, standardizing the behavior of hospital medical services, reducing the excessive consumption of medical expenses, and rationalizing the use of health resources.
Compared with the two total control methods mentioned above, the first control method is relatively simple to operate, and has been adopted by more coordinating regions and more common in the management practice. However, there are:
First, it is more difficult to determine a scientific and reasonable total control amount for each specific designated medical institution. Due to the ever-changing medical technology and the introduction and use of frequently updated drugs and medical equipment, the convenience and accessibility of medical services so that insured patients are free to choose their own medical care (medical care disorder), etc., it is difficult for the medical insurance department to accurately predict the number of consultations and treatments in each medical institution, and it is also difficult to determine a reasonable quota for the medical institutions. If the budget is high, it will lead to unreasonable growth in medical supply; if the budget is insufficient, it will affect the motivation of the designated hospitals and the interests of the insured patients.
Second, the way the quota is determined at the beginning of the period is not conducive to competition among medical institutions, and also affects the enthusiasm of the hospitals to provide medical services and the potential motivation to develop new technologies. Once the total amount of indicators is determined, medical service providers will not compete for the market by way of competition. Instead, the indicators will be set too tightly, affecting their service attitude and quality of service, and the use of high and new technologies will be restricted, which will not be conducive to the improvement of the level of medical technology, and the result will be that the motivation of medical institutions will be depressed and the pace of technological development will be limited.
Thirdly, medical service providers may blindly economize on costs, suppressing the reasonable medical needs of the demand side. The medical service provider may cut services artificially to save costs, shirk patients, artificially delay medical treatment and other phenomena, resulting in the insured not being able to enjoy the basic medical protection they deserve, the rights and interests of the insured are damaged, and the reasonable needs of the demand side can not be satisfied, resulting in the contradiction between the supply and demand sides. Some hospitals, taking into account the assessment of hospitalization trips and sub-average costs by the medical insurance administration department, have broken down their services, restricted their services, shifted the responsibility to the seriously ill, etc. (limiting the amount of prescription, increasing the number of outpatient visits, and shirking the responsibility of patients with high costs of medical treatment, etc.), or shifted the burden of costs to the insured persons (requiring the patients to pay for the costs out of their own pockets). In the internal management of the hospital, the hospital simply breaks down the total amount to the department, and turns the original calculation of the law of large numbers, "average cost", "average hospitalization days" and so on into a mandatory implementation of the standard, so that the legitimate interests of the insured person is infringed upon.
The second way of total control and decomposition of the quota, compared with the following characteristics:
First, the total amount of indicators to coordinate the regional control is relatively scientific and reasonable. How to make scientific and reasonable distribution among hospitals under a certain total amount is the focus and difficulty in the process of implementing total control. In the case of the settlement of disease points, the total amount of the budget can be allocated, the beginning of the period is not in the distribution of the designated medical institutions, the insured persons in the designated hospitals present the relationship between this and that, which breaks the distribution pattern of the first control mode, creating a fair competition atmosphere.
Second, the medical service behavior is incentive constraints. The disease score is based on the relationship between the cost of treatment of different diseases, according to the diagnosis of the value of the settlement, reflecting the principle of "the same disease, the same cost". When there is a difference between reasonable treatment and over-treatment among medical institutions (or diagnostic and treatment groups), reasonable treatment can be allocated relatively more than the actual cost; while over-treatment can only be allocated relatively less than the actual cost, reflecting the incentives for reasonable treatment and constraints on over-treatment.
Third, the establishment of special medical service behavior of the special negotiation mechanism. Due to the complexity and uncertainty of disease treatment, there will be some cases of the same disease in critical condition, the treatment cost is obviously higher special circumstances, in the settlement of the case if you can not provide the channel of evacuation, even if the hospital from the point of view of treating the sick to save the lives of the necessary treatment, but also on the payment system to produce dissatisfaction and resistance. To address this situation, through the monthly organization of experts, special cases, annual deliberations on critical cases and other mechanisms to be resolved, not only to alleviate the concerns of the doctors to treat patients with acute and critical illnesses, but also to effectively resolve the shirking of the patient and decomposition of hospitalization and other behaviors occur.
Three measures to improve the total control of basic medical insurance payments
Through the analysis and comparison of the above two typical total control methods, it can be seen that the total control of basic medical insurance payments are in accordance with the principle of "to determine expenditures based on revenues, balance of income and expenditures, and a slight surplus. Through the analysis and comparison of the two typical ways of total control, it can be seen that the total control of basic medical insurance payment is in accordance with the principle of "to determine expenditures according to income, balance of income and expenditure, with a slight surplus" to determine the total amount of fund that can be allocated in the coordinated area, and the difference lies in how to decompose the total amount of the budget to the medical institutions. In the first of these ways, the total amount of fund available for distribution in the coordinated area is determined after the total amount of the fund is determined, and the quota target for the current year for each sentinel medical institution is determined through a certain form of negotiation or according to the corresponding targets and parameters of the previous year, and is drawn up and paid out at the time of the monthly settlement based on the assessment of the different situations; the second way is to allocate the budgeted amount of fund based on the number of discharges from the various hospitals and the types of illnesses in the respective hospitals each month. In the co-ordinated areas adopting the first approach, regardless of the changes in the number of patients discharged from various hospitals each month, there are just so many quotas, and hospitals usually follow the practice of the medical insurance departments to further implement the total budget targets to departments, and in some departments, to doctors, and even impose restrictions on the unit price of prescriptions. This produces in the integrated regional level in accordance with the principle of the "law of large numbers" has a high degree of reasonableness, but specifically in the distribution to each smaller localization, the reasonableness tends to be reduced. In particular, when simply adopting the average distribution method, its rationality will be even lower. The fixed-point hospitals are bound to produce phenomena such as weakening competition, restricting medical care, and cost shifting, which have a considerable degree of negative impact on the reform of the health insurance payment system. The second way is based on the proportionate relationship between the medical costs of treating different diseases suffered by discharged patients. To each hospitalized disease to give the corresponding score, in order to objectively reflect the medical cost of high and low and how much the situation, according to the composition of the monthly discharged disease and the number of discharges of each type of disease to calculate the total score to score to represent the amount of services of the hospital and as a reimbursement basis for the settlement of costs. Since there is no quota limit for each hospital and corresponding department, there is no reason for shirking patients and other reasons for restricting medical care, and because of the mechanism of special cases and special negotiation, there is also a channel to solve the problem of patients with high medical costs. Moreover, the score does not directly represent the "cost", but is only the "weight" used for weighted distribution, and the unit price of the score each month changes dynamically with the number of patients discharged from the hospital and the severity of the disease, thus eliminating the direct correspondence between the type of disease and the cost, and not only effectively controlling the total amount, but also when the patient is discharged from the hospital, the unit price of the score changes dynamically with the number of patients discharged from the hospital. This eliminates the direct correspondence between disease types and costs, which not only effectively controls the total amount, but also makes it easier to form a cost-sharing mechanism when the total amount is insufficient.
The medical insurance agency should strengthen communication, consultation and negotiation with the designated hospitals on the total amount of control, and improve the initiative of the designated hospitals to implement the total amount of payment. Through communication and negotiation, it is conducive to fixed-point hospitals to fully accept the management requirements of the total amount of payment to stimulate their internal management initiative; it is conducive to reflect the fixed-point hospitals budget index allocation process of fairness, scientific and end-of-year assessment of the liquidation of the reasonableness; it helps to realize the effect of the participants, the health insurance agency, fixed-point hospitals, "three wins". Consultation and negotiation should follow the principles of openness, fairness and impartiality, and the annual budget of the income and expenditure of the medical insurance fund and the total payment program should be disclosed to the designated hospitals, and their opinions should be fully solicited. Through consultation and negotiation with the designated hospitals, the cost standards, service content, assessment indicators and other standards are reasonably determined.
( Second) Scientific design to determine the parameter indicators of the hospital quota, and increase the magnitude of reasonable adjustments in the settlement.
To ensure that medical institutions in the implementation of medical services can be in the implementation of the basic medical insurance policy, to protect the rights and interests of participants, must have a reliable and true basis for the settlement of costs, change the current existence of some areas of the rough way of management for the refinement of the management, the implementation of flexible payment. To promote the disease value settlement method in areas with conditions, the total amount of control to control the focus from the specific decomposition of the quota to the medical institutions to change to the total amount of distribution according to the medical institutions in a certain period of time to provide medical services, in order to achieve the quota of the designated institutions of the scientific and reasonable; temporarily do not have the conditions, to determine the total amount of medical institutions, should be left with enough leeway, a better way to do a good job of adjusting the system of indicators. Specific parameter indicators should include: the total amount of fund expenditures, the number and age structure of the insured and the level of cost expenditures of different categories and levels of medical institutions, as well as the quality of service, quantity requirements.
( II) Strengthen incentives and constraints to guide orderly competition.
Total control to effectively play the role of controlling medical costs, standardize the behavior of medical institutions, the key is to establish a scientific incentive constraint mechanism. Because the key point of medical cost control is the hospital self-management, through the full introduction of the competition mechanism, so that the medical institutions really become the total control of the management and responsibility of the bearer, in order to effectively form a mechanism of incentives and constraints, to create a rational treatment, rational use of drugs, "merit merit" of the atmosphere. It is necessary to reasonably determine the proportion of the medical insurance fund and the designated medical institutions to share the surplus funds and the overspent medical costs, in order to fully mobilize the enthusiasm and initiative of the medical institutions to control the medical costs. At the same time, a positive incentive mechanism should be established to fully mobilize doctors to take the initiative to participate in cost control, and strive to seek "the same disease, the same fee", so that the interests of health insurance, hospitals, doctors and patients tend to converge.
( 4) Sound supervision and management to provide quality services.
Sound supervision and management services is the key link to standardize medical behavior. For the total control of the quality of medical services, the number of problems that may arise, can not only through the aftermath of the audit cost expenditure to prevent, must be in the determination of the total budget on the development of a set of medical services to achieve the quality of the number of guaranteed indicators, so that through the review of these services to ensure that the indicators and rewards and penalties to realize the system measures to prevent the health care institutions in order to reduce medical costs to reduce the necessary medical services, damage to the participants in the insurance The system prevents medical institutions from reducing essential medical services in order to lower medical costs, to the detriment of the rights and interests of insured persons in obtaining basic medical insurance. Specific measures include: establishing and improving standards and management norms for doctors' medical service behavior, scientifically determining monitoring indicators (such as average cost per visit, follow-up rate, hospitalization rate, headcount ratio, out-of-pocket co-payment by insured persons, referral and transfer rate, surgery rate, elective surgery rate, and proportion of critically ill patients, etc.), improving the medical insurance information system, perfecting the evaluation method, and encouraging the society to participate in monitoring through multiple channels and in multiple directions. At the same time, the fixed-point institutions, insured patients to strengthen services, and strive to meet their reasonable requirements, in particular, open channels of appeal, properly handle the exception of disputes, to be based on the day-to-day management of the problems identified and the reasonable demands of doctors and patients, the establishment of a long-term, sustainable regulation mechanism, supporting mechanisms, etc., so that the settlement model is more reasonable and improved.
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