The starting line of medical insurance refers to the starting point of medical insurance reimbursement, i.e., more than the amount of the starting line will be reimbursed, the part of the starting line within the personal responsibility, more than the starting line of the cost of the directory according to the provisions of the medical insurance to be reimbursed by the proportion.
The report mainly mentions the following aspects of the work of medical insurance:
I. Promoting the provincial coordination of basic medical insurance
In 2020, the Party Central Committee and the State Council put forward in the "Opinions on Deepening the Reform of the Medical Insurance System", "Explore the promotion of the vertical management of the medical insurance departments below the municipal and prefectural levels. Encourage provinces (autonomous regions and municipalities directly under the central government) that have the conditions to promote provincial-level coordination in accordance with the idea of hierarchical management, responsibility***taking, coordinated transfer, budget assessment".2021, Premier Li Keqiang proposed in the Report made at the Fourth Session of the Thirteenth National People's Congress to "promote the provincial-level coordination of the basic health care insurance In the same year, the "14th Five-Year Plan for Universal Medical Security" further clarified the specific implementation path, namely: "Promote provincial-level coordination in accordance with the direction of policy unification and standardization, fund transfer and balance, improving hierarchical management, strengthening budget assessment, and upgrading management services". co-ordination". This year, Premier Li Keqiang emphasized it again in the Report. It is certain that during the "14th Five-Year Plan" period, the work of "promoting the provincial coordination of basic medical insurance" will be accelerated and substantial progress will be made.
Second, promoting the centralized purchasing of medicines and high-value medical consumables
Since the formation of the National Health Insurance Administration (NHIA), it has *** carried out six batches of centralized purchasing of medicines from state organizations, and purchased 234 kinds of medicines, which accounted for 30% of the total annual purchases of chemicals by public medical institutions, and saved more than RMB 260 billion in cumulative costs according to the amount of the purchases made before the collection. In terms of the centralized procurement of high-value medical consumables, the successful results of the coronary stent have been implemented for one year, and the annual procurement volume of the selected products is 1.69 million, reaching nearly 1.6 times the agreed procurement volume. The average price of artificial joints has been reduced by 82%. The burden of medicines and medical consumables on the people has been significantly reduced, which has been generally praised by all sectors of society and the people.2021 In January 2021, the General Office of the State Council issued the Opinions on Promoting the Standardization and Institutionalization of Centralized Banded Purchasing of Pharmaceuticals (Guo Ban Fa [2021] No. 2); and in April of the same year, with the consent of the State Council, the State Medical Insurance Bureau and other eight departments jointly issued the Opinions on Carrying Out the National Organization of High-value Guiding Opinions on Conducting State-Organized Centralized Banded Purchasing and Use of High-Value Medical Consumables" (MEPF [2021] No. 31), marking that the centralized banded purchasing of medicines and high-value medical consumables has been normalized and institutionalized. This time, the Report again reiterates "promoting the centralized banded procurement of drugs and high-value medical consumables", which not only signals the future development trend of the procurement of drugs and medical consumables, but also implies that the state's affirmation and support for the centralized banded procurement work.
Three, deepen the reform of health insurance payment method
Health insurance payment method is an important part of health insurance management and deepening health reform, is an important lever to regulate the behavior of medical services and guide the allocation of medical resources, and is an inseparable part of the health insurance system.2020, February 2020, the Party Central Committee and the State Council, in the "Opinions on Deepening the Reform of the Medical Security System", requested that "to implement a multi-dimensional and composite health insurance payment method mainly based on payment by disease, and promote payment by disease diagnosis-related grouping, payment by bed day for medical rehabilitation, chronic mental illness and other long-term hospitalization, and payment by headcount for outpatient special chronic diseases". After three years of piloting, by the end of 2021, all of the 30 national pilot cities for payment according to disease diagnosis-related grouping (DRG) and 71 pilot cities for total budgeting and payment according to disease index (DIP) under the regional point method have entered the actual payment stage, and the pilots have achieved obvious results. On this basis, in November 2021, the State Medical Insurance Bureau officially issued the Three-Year Action Plan for the Reform of DRG/DIP Payment Methods (Medical Insurance Fa [2021] No. 48), requiring all localities to comprehensively complete the task of reforming the DRG/DIP payment methods from 2022 to 2024, and by the end of 2025, the DRG/DIP payment methods will cover all eligible medical institutions that carry out inpatient services by the end of 2025, the DRG/DIP payment method will cover all eligible medical institutions that provide inpatient services, and basically realize the full coverage of disease types and medical insurance funds. The Report proposes to "deepen the reform of the health insurance payment method", which means that the horn of deepening the reform of the health insurance payment method is fully blown, and the reform of the health insurance payment method will be further pushed forward to the depth.
Four, strengthen the supervision of medical insurance fund
Medical insurance fund is the people's "medical money" "life-saving money", the Party Central Committee and the State Council clearly pointed out that, "we must always maintain fund Safety as the primary task. To weave tightly and firmly the system of medical insurance fund supervision cage, efforts to promote the reform of the regulatory system, the establishment and improvement of medical insurance credit management system, with zero tolerance attitude to crack down on fraudulent and fraudulent behavior, to ensure that the fund is safe, efficient and reasonable use. Since the establishment of the State Medical Insurance Bureau,*** it has inspected 708,000 medical institutions, dealt with 414,000, recovered more than 23.4 billion yuan in funds, and exposed 70,000 cases. It has organized 30 groups of flying inspections, and actually inspected 68 designated medical institutions and 30 health insurance agencies in 29 provinces, detecting alleged violations of the law amounting to 558 million yuan. The achievements made in fund supervision are evident to all, with the promulgation and implementation of a series of policies and regulations such as the Regulations on the Supervision and Management of the Use of the Medical Insurance Fund, the system and mechanism for supervising the medical insurance fund has become increasingly sound and improved, and the safety of the fund has been further guaranteed by the system. The Report once again reaffirms "strengthening the supervision of the medical insurance fund", meaning that the supervision of the medical insurance fund will continue to be strengthened, and presents a normalized and institutionalized trend.
Fifth, the realization of the basic unity of the scope of the national medical insurance drugs
In the past, the policy stipulates that localities are allowed to make appropriate adjustments within the scope of the National Basic Medical Insurance Class B Drug List according to the local economic level, medical needs and medication habits. With the economic and social development, living in different places, mobile employment gradually become the norm in life, the frequency of the occurrence of medical treatment in different places is more and more frequent, because the problem of unfair treatment caused by the lack of uniformity of the drug catalog in different places is also becoming more and more prominent, and also triggered a series of contradictions. For this reason, since the beginning of 2019, the state has clearly stipulated that "localities should strictly implement the Drug Catalog, and shall not formulate their own catalogs or increase the drugs in the catalogs by means of workarounds, or adjust the limited payment scope of the drugs in the catalogs on their own. For Class B drugs that have been added to the original provincial drug catalog in accordance with the regulations, they should be gradually digested within three years." This time, the "report" proposed "to realize the basic unity of the scope of the national health insurance drugs", can be seen as a re-emphasis of the above policy provisions.
Sixth: Improving the direct settlement of cross-provincial medical expenses
The Party Central Committee and the State Council have long attached great importance to the direct settlement of cross-provincial medical expenses. Since the launch of the direct settlement of hospitalization expenses across provinces in 2016, all coordinated areas have now opened direct settlement of hospitalization and general outpatient expenses across provinces and online filing for cross-provincial cross-district medical treatment. Meanwhile, through continuous optimization of filing management, acceleration of information system construction, strengthening of fund supervision and other aspects of work, the direct settlement of cross-provincial medical treatment for the common people has become more convenient and efficient.2021, the number of fixed-point medical institutions for cross-provincial direct settlement of inpatient expenses was 52,700, and cross-provincial direct settlement of inpatient expenses benefited the public for 4,406,000 hospitalization visits; the network of cross-provincial direct settlement of outpatient expenses has been opened by There are 45,600 fixed-point medical institutions and 82,700 retail pharmacies connected to the network, with a total of 12,514,400 person-times of cross-provincial direct settlement of outpatient expenses. The people's experience of cross-provincial medical treatment continues to improve steadily. The Report proposes "improving the method of direct settlement for cross-provincial cross-district medical treatment", which means that the medical insurance department should further improve the service quality of cross-provincial cross-district medical treatment direct settlement, further reform and optimize the process of filing for cross-district medical treatment and the management system, so as to make the policy more uniform, the process easier, the cross-district medical treatment policy and filing regulations more concise and easy to understand, and the people's experience of cross-district medical treatment continued to be steadily improved. It will make the policy more uniform, the process more simple, the policy and filing regulations for medical treatment in other places more concise and easy to understand, make it more convenient and smooth for the common people to seek medical treatment in other places, continuously improve the rate of direct settlement for medical treatment in other places across provinces, and strive to enhance the experience of the medical insurance service for the common people who seek medical treatment in other places.
Legal Basis
The Proposal of the Central Government of the People's Republic of China on the Formulation of the Fourteenth Five-Year Plan for the Development of the National Economy and Society and the Vision and Goals for the Second_Third Five-Year Plan
12. Developing Strategic Emerging Industries. Accelerate the growth of new-generation information technology, biotechnology, new energy, new materials, high-end equipment, new energy vehicles, green environmental protection, and aerospace and marine equipment industries. Promote the deep integration of the Internet, big data, artificial intelligence and other industries, promote the development of advanced manufacturing clusters, build a number of distinctive, complementary, structurally sound growth engines of strategic emerging industries, and cultivate new technologies, new products, new business forms and new models. Promote the healthy development of platform economy and ****sharing economy. Encourage the merger and reorganization of enterprises, and prevent low-level duplication of construction.
13. Accelerate the development of modern service industry. Promote the productive service industry to specialization and the high-end of the value chain, promote the participation of various types of market players in the supply of services, accelerate the development of research and development design, modern logistics, legal services and other services, promote the deep integration of modern service industry with advanced manufacturing and modern agriculture, and accelerate the digitization of the service industry. Promote the upgrading of the living service industry to high quality and diversification, accelerate the development of health, pension, childcare, culture, tourism, sports, housekeeping, property and other service industries, and strengthen the supply of public welfare and basic service industries. Promote the standardization and branding of the service industry.