Labor and Social Security Bureau of medical insurance work report

Second, the main practice

Medical insurance belongs to the social insurance, so it is different from commercial insurance. In order to make this work involving a wide range of strong policy can be carried out smoothly and steadily, the city in October XX set up a special working body, work to strengthen the fund collection, strengthen the fund management, improve the quality of service as a means to ensure that the fund collection is strong, the use of the appropriate and safe operation.

(a) Strengthen the fund collection, to ensure that should be insured as much as possible, should be collected as much as possible.

In July XX, the municipal people's government formulated and issued a trial approach to urban workers' medical insurance and the implementation of the rules, a clear scope of medical insurance, in accordance with the principle of territorial management, requiring all employers in the city to participate in the medical insurance. From the overall situation since its implementation, it has basically realized that all units should be insured according to the document. Fund collection is mainly by the insured unit in accordance with the "Interim Regulations on the Collection of Social Insurance Premiums", entrusted to the insured unit account bank withholding, or directly to the medical insurance agency to pay, through strong supervision and timely reminder, the collection rate has been at a high level.

1, the strict implementation of the target assessment. In recent years, the government every year will be health insurance work on the important agenda, from the policy to support, work on the guidance, the ideology of the "medicine" on the same level of importance as the "food" position. The first is to adhere to the target responsibility management unswervingly. In the elaboration of specific implementation programs and assessment methods, to determine the work objectives, decomposition of work tasks, signed the work on the basis of responsibility, the establishment of a "hand" to grasp, grasp "a hand" of the work mechanism, will be included in the municipal units and township streets The main content of the performance appraisal of the leadership team. Business training, business work conference and promotion work conference were held several times to analyze the situation, study the problems and point out the solutions and measures. Secondly, industry and commerce, taxation, labor security and other departments have increased joint law enforcement efforts, unified understanding of the expansion of work, coordination, the formation of synergies, the reluctance to participate in the enterprise to increase administrative intervention, ordered to participate in the insurance, while in the evaluation of the first, the creation of excellence, tax incentives, and other aspects of the direct linkage. Units that have not completed the task to implement a veto. Due to the clear target responsibility, measures in place, each year exceeded the target task issued by the higher level.

2, effectively strengthen the policy publicity. Medical insurance work in the city started relatively late, in order to create a good atmosphere of public opinion, so that the policy is widely popular, the city from four aspects to strengthen the policy publicity. First, in the television station opened a propaganda column, the medical insurance policy for a period of two months of a series of publicity reports; second is the combination of labor security rights enforcement actively carry out "publicity week", "publicity month" and other activities to focus on publicity, the cumulative distribution of various types of publicity materials more than 18,000 copies; third, to effectively strengthen the policy publicity. Publicity materials of more than 18,000 copies; third is to make full use of meetings, briefings, seminars, reception, street consultation and other ways to the insured to focus on publicity; fourth is to organize designated hospitals, designated pharmacies, on the street to set up publicity counters, bulletin boards, distribution of information, free clinic and other forms of publicity to the public for a wide range of publicity.

3, constantly increasing the collection. "To determine the expenditure, a little savings; last month in advance, the next month to pay" is the operating principle of the health insurance fund, if the fund can not be fully collected in a timely manner in place to ensure that the payment will become an empty word. For medical insurance contributions, the state to implement mandatory collection methods. The city has also established a government-led, the National People's Congress supervised, departmental cooperation of the three-tier linkage fund collection mechanism. Do not start the medical insurance of the financial allocation of units, the implementation of the accounting center does not reimburse medical expenses, the unit does not withhold contributions to the unit's main person in charge of the prescribed penalties, the money does not pay and arrears of serious units, once the investigation is confirmed, the financial sector will only be sent to 80% of the salary, deduct 20% of the salary used to make up for the payment of insurance premiums. For other enterprises and institutions, the departments of industry and commerce, taxation and public security are required to check proof of payment of insurance premiums during the annual inspection of the relevant licenses; the audit department carries out special audits on key non-paying units, and the banks give priority to the withholding of insurance premiums, and so on. At the same time, in order to solve the problem of enterprise insurance and fund collection, the city health insurance agency in-depth enterprise, through dialogue with the person in charge of the enterprise, preaching policies and laws and regulations, so that enterprises realize that participation in the long-term interests of the development of enterprises, thus enhancing the initiative to participate in the insurance.

(2) Strengthen the supervision of the fund, to ensure that the real thing to do, the good thing to do.

For the participants to provide services to the designated medical service organizations, is the link between the participants and the insurance authority, but also the insurance fund outflow channel and the valve of the balance of the insurance fund, therefore, the "two" management is also the work of the medical insurance agency's 'focus and difficulty. At present, the city has 8 hospitals and 24 designated pharmacies to obtain the qualification of designated. In order to ensure that medical insurance in accordance with the policy implementation in place, the city health insurance agency specifically equipped with two medical professionals and technicians, specifically responsible for the designated hospitals, designated pharmacies to carry out inspections, and focus on the management of the insurance agency.

1, strict "three passes" to strengthen the management of designated hospitals. In the process of fund use, the funds paid to the designated hospitals account for the vast majority of the total amount of funds paid, therefore, the supervision of the designated hospitals is naturally the top priority of the regulatory work. The city's main practice is to supervise the whole process, put a good three passes.

First, the good hospitalized patients off, to prevent fraudulent hospitalization. On the one hand, in the designated medical institutions to promote the trial of basic medical insurance diagnosis and treatment routines, timely sampling of hospitalization records, outpatient prescriptions, invoices, purchase of drug details, etc., to strengthen the hospitalization of light disease, hospitalization, excessive inspection, unreasonable treatment and illegal use of medication and other phenomena of the management of the strength. On the other hand, the hospitalization of the insured, the city health insurance agency explicitly requires the designated hospital health insurance section, the nurse station staff, the patient hospitalization verification, such as the discovery of the phenomenon of impostor hospitalization, must be reported in a timely manner, otherwise the hospital will be heavily fined until the cancellation of its designated qualifications. So far, no impostor hospitalization has been found, and no complaints have been received.

Secondly, the hospitalization of diseases to prevent the loss of funds. The city's health insurance agency strictly enforces the "Zhuzhou City, the basic medical insurance hospitalization catalog," and requires the designated hospitals to hold the initial examination, to ensure that the fund is properly used without loss. Through the audit, so far, *** there are 31 cases of medical insurance hospitalized patients, does not belong to the medical insurance agency to pay the scope of medical expenses, to prevent the fund from undue loss. Such as February 27, XX, the water company female employees Zhang, in the company on the zero shift accidentally fell, immediately felt abdominal, right chest and right shoulder pain, family members will be carried home after vomiting, and then sent to Xiangdong Hospital outpatient clinic, outpatient to "abdominal trauma" admitted to the hospital, hospitalized in the next day after the CT examination of the upper abdomen, was diagnosed with Hepatic contusion and closed abdominal injury. This is an obvious workplace accident, and the unit did not carry out workplace injury insurance, the health insurance agency immediately made the decision not to reimburse the health insurance costs.

Third, the "three directories" implementation of good, strict prevention of fund waste. The three directories of the designated hospitals, the implementation of the city health insurance agencies to take the form of regular or irregular key audit, two full-time medical review staff, every day to go into the hospital to check once. The content of the audit is mainly whether there is a small disease, hospitalization; whether the implementation of the one-day list system; whether the doctor's use of drugs to follow the principle of safety, economy and effectiveness, whether the patient is discharged from the hospital with the drug exceeds the standard; whether the doctor is to put the special inspection, special treatment and referral to the hospital for initial examination. In addition to direct questioning of patients or their families, on-site inspections, checking the medical records on the shelf, access to archived medical records, the audit also makes full use of the network system of inpatient medical costs for timely, dynamic monitoring, strict audit. Over the past three years *** audit more than 5,000 times, *** refused to pay unreasonable costs of 450,000 yuan. April XX, in a surprise audit of Chinese hospitals, found that unreasonable costs (including the use of drugs is unreasonable, diagnosis, inspection, etc. without a doctor's note) more than 40,000 yuan, and immediately refused to pay. In addition, this year also organized the City Health Insurance Bureau, the Finance Bureau and the Health Bureau and other departments, each month to the designated hospitals to conduct a centralized audit to protect the health insurance fund reasonable and normal expenditure.

2, adhere to the "three in place", to strengthen the management of designated pharmacies.

The management of health insurance designated pharmacies, the city introduced a green card access, yellow card constraints, red card exit management mechanism, from the approval, management, assessment and other aspects of the implementation of the full range of review and supervision, received a better result.

First, adhere to the approval in place, the strict implementation of the access system. In full consideration of the rational layout, quality of service, service level and other factors and on the basis of total control, the implementation of a strict market competition access system, by the municipal health insurance agency in conjunction with the financial, industrial and commercial, health, drug supervision, price, quality supervision and other departments to carry out a comprehensive review, to determine the designated units. At the same time to liberalize the threshold of competition in the designated pharmacies, so that private affordable pharmacies among the scope of the designated, at present, the city's 24 designated pharmacies to obtain the qualification of the unit has a private pharmacy 22. The participation of private affordable pharmacies, not only reduces the price of drugs, saving the health insurance fund, but also reduces the burden of insured patients, but also effectively combat the unhealthy trend of the pharmaceutical industry.

Second, adhere to the management in place, strictly regulate the sale of drugs. The health insurance agency from strengthening the management of health insurance designated service organizations to start, the designated pharmacy indicators management requirements, requirements must be strictly enforced "designated pharmacy standardized management standards" and "basic medical insurance drug directory" two normative documents, 24 designated pharmacies have established a sound drug quality assurance system, the basic medical insurance directory drugs equipped with the rate of more than 80%, the sale of prescription drugs Basically, they dispense medicines in strict accordance with the procedures of reviewing, formulating and rechecking, thus well controlling the personal burden rate of insured persons. Through the inspection, so far, the designated pharmacies operating procedures standardized, the quality of service continues to improve, but also did not find the phenomenon of drugs for goods, drugs for drugs.

Third, adhere to the assessment in place, the strict implementation of target management. In line with the principle of rationality and operability, the city in the beginning of the start of the health insurance has formulated the "designated pharmacy target assessment rules", the management responsibilities, drug quality, sales service and other aspects of the corresponding requirements. Over the past few years, we have ensured the realization of the management objectives by establishing an assessment mechanism combining daily inspections and special assessments and implementing an annual qualification review system. Daily inspection mainly starts from checking the prescriptions of pharmacies, focusing on the rational use of medicines, rational sale of medicines and reasonable charges, and focusing on the quality of medicines, whether the licensed pharmacists are on duty, whether the prescriptions are kept in stubs and the service attitude, etc.; the special assessment mainly consists of routine inspections at the end of each quarter to regulate the price of medicines and the reasonableness of operation, and to conduct a comprehensive assessment on the level of service and the quality of service, and the result is linked with the year-end assessment The results are linked to the year-end assessment, as an important basis for whether or not to renew the agreement.

3, highlighting the "three", to strengthen the management of the staff.

Cultivate a strong political, high quality, hard style of the team is to strengthen the effectiveness of the health insurance agency construction requirements, but also to continue to promote the development of the cause of health insurance, to ensure that the fund management standardization of the prerequisites and fundamental guarantee. In order to improve the quality of the team and work efficiency, the city health insurance institutions to create "three excellent service window" as a carrier, to implement the "three" as a breakthrough in the majority of staff to carry out the political situation, collective honor, tree overall image activities, to guide them through the good Power off, interest off, honor off, and constantly improve the overall quality of staff and service level.

Institutionalization of work, so that there are rules to follow. In recent years, the medical insurance agency has introduced and implemented an internal control system. The internal control system includes a performance appraisal system, unit job responsibility system, health insurance audit and settlement management system, accountability system, health insurance approval management system, as well as designated hospitals, designated pharmacies, special clinics, referrals and transfers to hospitals, off-site choice of medicine, special inspection and special treatment of the examination and approval of the management system, health insurance procedures and other thirteen items. Through the establishment of sound rules and regulations, standardize business processes, strengthen the power constraints, to ensure that the work of the rules and regulations, steady progress.

Openness and acceptance of public supervision. In the process of work, the agency will be all the policies and regulations and procedures published on the wall, greatly facilitating the majority of participants, but also conducive to the general public and participants in the supervision. It also actively promotes the first-question-responsibility system, which requires all staff members to respond to the inquiries of insured persons with accurate and understandable answers. It has also set up an opinion book and a director's mailbox at the workstations, actively adopting useful suggestions, sincerely accepting supervision, and improving work in a timely manner. In last year's year-end social satisfaction assessment, the labor security work of the public satisfaction rate ranked first in the city.

Service humanization, improve the level of service. The daily work of medical insurance is mainly for the service of the participants, the agency always adhere to the "all for the sake of the participants" concept of work, to provide quality service throughout the work, and constantly improve the service attitude, advocate service with a smile, the use of civilized terminology, to be courteous to others, and carry out the creation of the three excellent civilized service demonstration window activities and the "a member of the party, a flag". "A party member, a flag" activities, to achieve the participants as the center, with high standards of efficiency and a full range of quality services as the core, and ultimately to achieve the participants, participating units and social satisfaction in three aspects. xx, including medical insurance insurance insurance service window, was named the province's "three-excellent service demonstration window. The company has been recognized as one of the best in the world in the field of insurance services.

(C) to strengthen the policy in place to ensure that the policy is honored, treatment implementation.

In order to effectively reduce the personal burden of hospitalization, improve the treatment of insured persons, the city has repeatedly adjusted the health insurance policy, improve the reimbursement rate, XX year issued the "lilao word [XX] 02" document, reduce the hospitalization of the starting standard fee, improve the payment standard of the bed fee; followed by the successive issuance of the "lilao word [XX] 37," the "lilao word [XX] 12", "lilao word [XX]", "lilao word [XX]", "lilao word [XX]", "lilao word [XX]", "lilao word [XX]" and "lilao word [XX]". No. 12", "lilao social word [XX] No. 5" and "lilao social word [XX] No. 19" four documents, one is the special outpatient clinic of the starting line to be lowered; the second is the introduction of a single disease to implement the cost of the settlement of the lump sum, has been more than 160 people to benefit from; the third is to reduce the hospitalization of the starting standard and out-of-city referral to hospitals, out-of-town choice of first out-of-pocket expenses; fourth is to increase the special outpatient clinic, hospitalization reimbursement ratio. The maximum payment limit of the basic medical insurance fund was raised from 25,000 yuan to 60,000 yuan, and the reimbursement rate for in-service and retired persons above the 10,000 yuan threshold was set at 95 per cent. Through these policy adjustments, the overall hospitalization reimbursement rate reached 73% (the higher the cost the more benefit).

In order to reflect the people-oriented, caring for the participants of the purpose, really make the fund play its due role, the city health insurance agencies also carefully review the insured hospitalized objects should enjoy the cost of payment, effectively preventing errors and omissions. xx February 17, Shi Ting Township, United School teacher Guo Mou fell between the board ladder in their own home, resulting in a fracture of the left femur, was sent to Xiangdong Hospital hospitalization, the family with relevant documents to the hospital. When the hospital's medical insurance section entered the microcomputer, the hospital advised that the fracture caused by trauma generally does not belong to the scope of reimbursement of medical insurance, such as caused by the disease, need to be confirmed by the medical insurance agency. After receiving the report of the medical insurance section, the agency medical review staff access to the patient's hospitalization medical records and questioning the patient, found that there was vertigo, insomnia, anemia symptoms, the morning of March 30 (when the patient has been discharged), the medical review staff and law enforcement brigade personnel went to the United Schools, the school to investigate the verification to determine that there is no third-party liability, in accordance with the relevant documents, to be reimbursed to the decision to make a strong defense of the legitimate rights and interests of the insured.

Three problems and future intentions

The reform of the medical insurance system has entered a new period, the goal of the reform is also clearer: First, to reflect social equity, so that more people can participate in the insurance and enjoy the corresponding protection; second, to make the system run more robust and sustainable development; third, to make the insurance Socialized management service system can be continuously improved; Fourth, to make the system more open and compatible. The city's medical insurance work in the full recognition of the achievements at the same time, but also facing four major outstanding contradictions.

First, the traditional industry is not good constraints on the expansion of insurance. The city's ceramics and artillery two traditional industries are labor-intensive industries, technology content is not high, and labor costs are relatively high, the vast majority of enterprises have relatively small profit margins, if all the mandatory inclusion of insurance in accordance with the policy will inevitably cause great pressure on the enterprise, part of the enterprise may not be able to withstand the face of the normal functioning of the enterprise. If you can't effectively change this situation, the insurance expansion will be very difficult to cross this threshold, at least it will cause the expansion of the pace of slowing down.

Secondly, the lack of financial resources limits the implementation of the policy. According to Zhuzhou Municipal Government [XX] No. 82 document "Zhuzhou City, the State Civil Servant Medical Benefits Interim Provisions", the city in the implementation of basic health insurance at the same time, the establishment of civil servants to establish medical subsidies and the implementation of the five-year transitional health insurance personal account subsidies, the two funds municipal finances each year, the need to arrange a budget of 17.6 million yuan -19.9 million yuan (5% -7% of the average human) Subsidies, each year to lay a month of personal account funds 1000 yuan / person). However, due to the limited financial resources of the city, the budget did not make arrangements, therefore, the city civil servants are not enjoying the above two subsidies. In order to solve the restructuring of the basic medical insurance, the city has formulated the restructuring of the staff of the enterprise medical co-ordination approach (for trial implementation) draft, the preliminary estimate of this piece of financial and to inject funds of about 7 million yuan a year. At the same time, the Ministry of Labor and Social Security has long been proposed to include urban residents in the scope of health insurance, many counties and cities in the province has begun to implement the city, once the implementation of the city, the most critical is still the ability to achieve the full amount of financial resources in place.

Third, the infrastructure configuration is not fully bound to the management in place. The city's health insurance agency personnel strength is thin, only eight people, in Zhuzhou City, five counties and cities, the number of people is the least. And to undertake heavy operational work, which involves tens of millions of dollars in funds, the insured population of more than 50,000 data, every month to cope with the settlement of hundreds of people, but also to the hospital settlement audit, collection of funds, almost every staff member has to undertake a number of jobs. If the urban residents' medical insurance is carried out, tens of thousands to hundreds of thousands of people will participate in the insurance, and its workload can be imagined. In particular, the work injury insurance work, the face of the city's nearly 1,000 enterprises, hundreds of thousands of insured persons, and the lack of essential transportation and other tools, such as once an accident occurs at work must be rushed to the scene in a timely manner, so the implementation of a separate work injury insurance, the establishment of specialized agencies to increase staffing has been imperative, without delay.

Fourth, the lack of medical system weakened the role of play. Medical institutions, public welfare functions diluted, serious behavior, profit-oriented, "expensive" as high prices, as expensive as school, year after year, year after year. Designated hospitals, designated pharmacies often from their own economic interests, in the medical examination, medication, fees, there are a lot of irregularities, drug prices are still high, the unhealthy trend has not been corrected in a timely manner, which greatly increased the cost of medical care. For example, the purchase price of ceftriaxone sodium injection is 5.7 yuan per bottle, and the sale price is as high as 38.1 yuan per bottle, and the difference between purchase and sale rate is 568%. Insured workers also hope that medical expenses less out-of-pocket, more reimbursement. Several factors **** the same role, leading to excessive growth in medical costs, the health insurance fund burden, invariably weakened the role of the fund reasonable and efficient play.

The task of medical insurance is glorious and arduous, in order to strive to achieve the city's health insurance system of sound operation and sustainable development, the future will have to further clarify the ideas, improve policies, strengthen leadership, strengthen measures, and strive to achieve new and greater achievements.

Labor Security Bureau of medical insurance work report Part 2

In recent years, my county urban workers, urban residents of the medical insurance development faster, running well, but there are some problems:

A problem

1, the implementation of the health care system is not strict, the designated medical institutions of the health care services are not standardized behavior. Part of the designated medical institutions driven by economic interests, encouragement or acquiescence of the medical fee income and department, medical staff of the economic interests of the direct link, resulting in medical staff to reduce the admission standard. At the same time, there are cases of medical expansive consumption, such as the excessive use of various means of examination, expensive drugs and medical materials, and the phenomenon of randomly prescribing medicines and examinations that are not related to the condition.

2. The level of information management is low, and the management and supervision of the designated hospitals by the organizers lacks strength. Although some designated hospitals have invested in medical insurance computer information network management, the construction of real-time information uploading system is still unsatisfactory; affected by the current objective conditions, the cost of violation is low, and it is difficult to enforce the punishment of hospitals or doctors who violate the law, and the punishment is not as effective as it should be.

3, the designated medical institutions, although the establishment of the medical insurance office or a person responsible for medical insurance business, but most of the medical insurance office functions are limited to the settlement of business transactions with the medical insurance agency, failed to effectively play the role of training, coordination, supervision and management.

Two measures

First, enhance internal control

1, the unit of internal organizations to set up a reasonable position, clear job responsibilities, the establishment of the post between the supervision and control mechanism, to strengthen the fund collection, payment, allocation, storage and expenditure of the main links of the supervision and control. In accordance with the division of labor of unit leaders and business section functions, in accordance with the principle of "who is in charge of who is responsible", the implementation of accountability system.

2, the strict implementation of the "two-line management" system, resolutely implement the "special funds, dedicated, special account management", standardize the operation of the fund.

Secondly, strengthen the external supervision

1, online monitoring and control. Medical supervision unit of the hospital, pharmacy settlement, through the online audit. Once a problem is found, the uploaded data is immediately returned and re-accounted for.

2, on-site supervision and control. Regular or unscheduled unannounced inspections of the designated medical institutions, found hanging beds and other irregularities, immediately verified and dealt with.

3. Case access control. Organize a special person to carry out no less than 10% random inspection of the medical records of the designated hospitals every month, and find out the problematic medical records, and deal with them in accordance with the relevant regulations.

4, agreement control. Through the signing of the "fixed-point institution fixed-point service agreement" with the fixed-point medical institutions and pharmacies to regulate the service behavior of the fixed-point medical institutions and pharmacies. For violation of the agreement management provisions, give the appropriate treatment.

5, the establishment of departmental joint mechanism. Give full play to the discipline inspection and supervision, health, human resources, drug supervision, finance, audit, the news media and other departments of the functional role of the cadres assessment and appointment, salary performance linkage, title evaluation and recruitment of the initiative, *** with the same efforts to promote the health care system, the benign operation of the mechanism.