Currently, health insurance is facing multiple challenges such as increasing pressure on fund balance, frequent medical service violations, and outdated traditional experience decision-making methods, etc. From the perspective of informationization, the human resources and social welfare departments have promoted universal insurance registration, intelligent monitoring of health insurance, payment reform and mobile payment exploration, and actively carried out the health insurance big data application. However, in the process of application, it still faces problems such as data quality needs to be improved, data application is not yet sufficient, and the security system needs to be improved. To continue to deepen the application of health insurance big data, the next step should focus on four aspects: first, converge and improve the health insurance big data; second, accelerate the construction of big data platform; third, continue to help the development of health insurance business; fourth, build data security system.
Currently, under the combined effect of the gradual improvement of the universal health insurance system, the aging trend of the population, the rapid release of medical demand, and the rising medical costs, medical insurance is facing the pressure of increasing fund balance, the frequent occurrence of medical service violations, and the backwardness of the traditional empirical decision-making methods, etc. How to make full use of the big data, "Internet +How to make full use of big data, "Internet" and other information means to further support the sustainable development of medical insurance in the new situation, to realize universal health insurance, safe health insurance, scientific health insurance and convenient health insurance, and to comprehensively improve the quality of health insurance, is an important issue in front of us.
The current dilemma facing the management of medical insurance
1 Increasing pressure on the balance of medical insurance fund
With the improvement of the living standard, the insured people pay more attention to their health, and the medical demand is rising, at the same time, the universal medical insurance is shifted from the system of full coverage to the full coverage of the personnel, and the scale of the expenditure of the basic medical insurance is then growing rapidly. These factors have brought greater pressure on the balance of the health insurance fund.In 2016, the number of participants in the basic medical insurance managed by the social security department was 744 million, and the fund expenditure was 1076.7 billion yuan. Participants enjoyed medical insurance treatment for 2.5 billion times. Considering the current situation of economic downturn and population aging, the pressure on the balance of income and expenditure of the medical insurance fund will be even greater in the future.
2Medical service violations are frequent
China's medical insurance treatment expenditures are growing at a high rate, not only because of the normal factors such as the policy of benefiting the people's livelihood, the aging of the population, the advancement of medical technology, and the rise of medical costs, but also because of the irrational factors such as large prescriptions, indiscriminate inspections, and false invoices.2016 Audit Commission's special audit of the medical insurance fund showed that some medical service organizations and individuals had been able to obtain medical treatment through false medical treatment, decomposition of hospitalization, and false foreign invoice. , disaggregated hospitalization, false off-site invoices, and other means of siphoning off more than 200 million yuan from the medical insurance fund. In the face of such a scale of expenditure, the traditional means of supervision of medical insurance, such as manual audit, random audit and fixed rule audit, are difficult to comprehensively cover the increasingly complex scenarios of the use of the medical insurance fund, and it is difficult to effectively identify the increasingly hidden violations of medical services.
3Traditional empirical decision-making methods are outdated
In the past, the formulation of health insurance policies and the evaluation of their efficiency often relied on business knowledge and work experience. With the rapid growth of the number of participants, the complexity of medical behavior changes, health insurance operators generally tight hand, the traditional experience of decision-making increasingly unable to meet the needs of business development, in the current rapid development of information technology, medical data continue to accumulate on the basis of making full use of advanced technological means, in-depth exploration of the advantages of massive data resources, through the system of operation simulation, policy efficiency assessment, financial stress test, etc., to assist in achieving efficient decision-making, scientific and technological development.
Application of medical insurance big data
Social insurance informatization has been adhering to the principle of national unified planning and construction for many years, and along with the upgrading of the level of integration, it has promoted the upward centralization of data and the downward extension of services, and gradually laid a solid data foundation. Utilizing the large-scale medical insurance data, the human resources and social security departments have actively promoted a number of applications to curb irregularities, assist in scientific decision-making, and protect fund security.
1Promoting the universal insurance plan and realizing universal healthcare coverage
The "Recommendations of the Central Committee of the People's Republic of China on the Formulation of the Thirteenth Five-Year Plan for National Economic and Social Development", which was adopted at the Fifth Plenary Session of the 18th CPC Central Committee, explicitly proposes to "implement the universal insurance plan and basically realize full coverage of statutory personnel".2017 , the Ministry of Human Resources and Social Welfare accelerated the construction of the universal insurance registration system, docking between ministries and provinces, and data reporting, etc., and has now basically formed a universal insurance registration database at the ministry and provincial levels, which supports the mapping of legally uninsured persons, helps the universal insurance plan, and realizes full coverage of all who should be insured. By the end of 2017, provinces*** had reported 3.042 billion pieces of information on people's participation in insurance, including medical insurance, providing strong data support for the next step of participation and expansion.
2Implementation of Intelligent Monitoring of Medical Insurance to Create Safe Medical Insurance
In 2012, the Ministry of Human Resources and Social Security organized the construction of the Intelligent Monitoring System of Medical Insurance, which designed more than 500 monitoring rules for different business processes such as outpatient and inpatient care, and monitored common irregularities in medical service behaviors such as frequent medical treatment, disaggregated inpatient hospitalization, excessive costs, large prescriptions, and an abnormal proportion of medicines, etc., and the targets of monitoring cover medical In 2014, on the basis of the previous work, the Ministry of Human Resources and Social Security issued the Opinions on Further Strengthening the Supervision of Medical Services in Basic Medical Insurance (No. 54 of the Ministry of Human Resources and Social Security [2014]), which clarified the supervision channels, responsibilities of all parties, and procedures for dealing with the problems, etc. In recent years, the intelligent monitoring of medical insurance has been carried out. In recent years, the number of co-ordination areas carrying out intelligent monitoring of medical insurance has been increasing, and now more than 90% of the co-ordination areas nationwide have fully carried out intelligent monitoring. Through the deterrent effect of automatic monitoring in all scenes, links and time, a large number of potential illegal and irregular behaviors have been curbed, and the rights and interests of the insured and the safety of the health insurance fund have been safeguarded.
3Promoting Payment Method Reform, Promoting Scientific Health Insurance
In recent years, based on the health insurance data accumulated over the past years, the human resources and social security departments have carried out extensive work on optimizing the payment method, and actively promoted the exploration of the composite health insurance payment method.In 2017, the General Office of the State Council issued the "Guiding Opinions on Further Deepening the Reform of the Payment Methods of Basic Health Insurance" (Guo Ban Fa [ No. 55, 2017), which put forward clear requirements for the reform objectives. At present, the vast majority of regions have carried out total amount control, and analyzing the historical data of medical insurance is the main basis for the medical insurance department to negotiate with medical institutions to set the total amount. In addition, some regions have made full use of health insurance data during the exploration of payment methods such as single disease types and DRGs. For example, Shenyang City began exploring DRGs payment in 2015, applying local health insurance payment data to optimize DRGs grouping. Shanghai has strengthened the application of mathematical models in health insurance budgeting, and simultaneously promoted payment by disease type.
4Exploring mobile payment for health insurance and guiding convenient health insurance
The "Internet + Human Resources and Social Security" 2020 Action Plan (No. 105 of the Ministry of Human Resources and Social Security [2016]) puts forward the action theme of "payment and settlement," calling for the construction of a platform for payment and settlement of human resources and social security, and the expansion of a platform for payment and settlement. Human resources and social security payment and settlement platform, expand the social security card online payment and settlement mode. After nineteen years of construction and development, the social security card has laid a profound foundation for online application, with functions such as identity credentials, information records, self-service inquiries, medical settlements, payment and entitlement, and financial payments, and has become an electronic credential for cardholders to conveniently and quickly enjoy the rights and interests of human resources and social security as well as other governmental public **** services. According to the spirit of the document, combined with the "Internet +" requirements, actively explore and practice health insurance mobile payment, such as Hangzhou, Wuhan, Shenzhen, Kunming and other places where the insured can complete the outpatient expenses through cell phone health insurance payment, to ease the pressure of queuing at the window; Shenyang, Tianjin, Jiaxing, Zhuhai and other places where the insured can purchase medicines online, through the cell phone or mobile POS card to complete the health insurance payment. In Shenyang, Tianjin, Jiaxing, Zhuhai and other places, the insured can purchase medicines online and complete the payment of medical insurance through mobile phones or mobile POS cards, improving the user experience.
Challenges in the application of big data in health insurance
1 Data quality needs to be improved
One is incomplete data. At the local level, the health insurance data managed by the social insurance information system is mainly concentrated in the basic data of insurance participation and settlement, and the data of medical instructions, medical records, medicine purchase and sale, inspection and test reports in the process of medical behavior are not comprehensively collected, and the data of service feedback, treatment effect, and the unstructured data such as logs, videos, files, and so on, are generally missing, which restricts the application of intelligent monitoring of the medical insurance and the reform of the payment method. This restricts the in-depth development of applications such as intelligent monitoring of health insurance and payment method reform, and makes it difficult to support the development of accurate services for insured persons. At the ministerial level, since 2009, when health insurance network monitoring indicators were reported, localities have reported data to the Ministry of Human Resources and Social Security on a monthly basis, and the health insurance mainly includes basic information such as participation in the insurance, entitlement to treatment, and designated medical institutions, with a lack of detailed information on the business.
The second is the lack of timeliness of the data. The health insurance network monitoring data is reported on a monthly basis, which supports a number of system applications such as ministerial fund supervision, macro decision-making, and social insurance participation and treatment comparison query. However, the timeliness of the data updated on a monthly basis is difficult to meet the needs of new businesses such as national integration and real-time monitoring of key operations.
Thirdly, the data accuracy is not high. From the point of view of ministerial networking and monitoring data, although the scale of data and the coverage of the population are growing rapidly, there are still inconsistencies in the basic information of each type of insurance and business, business status information, and the use of some of the codes is not standardized and regulated, and there are even a lot of errors or invalid information, which has a greater impact on in-depth analysis of the data and its wide application.
2 Data application is not yet sufficient
One is the lack of awareness of data application. In recent years, the social sector has gradually recognized the enormous value of data, and actively carry out data application, but compared to the social sector management of big data, has developed the data is just the tip of the iceberg, massive data is still "sleeping", sleeping data in the problems continue to accumulate, in turn, affecting the application of data to carry out the work. After all, only continuous application, in order to fundamentally promote the quality of data.
The second is the "problem data" is not enough attention. The obvious anomalies in the data are partly the result of poor data quality and partly the result of objective business problems that lead to data errors. In the process of data application, the first thing that is often done is to screen out the abnormal data, which in fact also screens out the possible problems and risks. In the era of big data, it is even more important to cultivate the awareness of paying attention to abnormal data, and to be good at discovering problems and preventing risks, so as to gradually reduce "problem data" and improve data quality.
Thirdly, the application of cross-business data is insufficient. At present, the development and application of data, mostly focused on a single business segment, the application of cross-business linkage is insufficient, such as social security and employment data related to analysis, medical information and the survival status of the combination of judgment. Only when data is truly integrated can it stimulate new ideas and create new value.
3Security system still needs to be sound
In 2014, the Ministry of Human Resources and Social Security successively issued the Specification for the Security Management of the Application System of the Human Resources and Social Security Data Center (for Trial Implementation) (No. 47 of the Office of Human Resources and Social Security [2014]) and the Specification for the Security Management of the Database of the Human Resources and Social Security Data Center (for Trial Implementation) (No. 48 of the Office of Human Resources and Social Security [2014]) to regulate the application system and database of the human resources and social security data center at a specific operational level and at a specific operational level. specific operational level to the application system and database security put forward normative requirements. However, the data chain becomes longer, the data scale grows, the data sources are diverse, and the data mobility is enhanced in the big data environment, which makes it more difficult to protect the data security, the risk of personal information leakage intensifies, and the traditional security control measures are challenged.
Direction of development of health insurance big data
1 Convergence and improvement of health insurance big data
One is to consolidate basic information. Coordinate the construction of the universal insurance registration database and the basic information database of card holders, improve the basic information database of ministerial personnel and units, accurately grasp the basic situation of service recipients, and further play the role of the basic information database of the human society to realize the role of a number of one source and "one person, one card".
The second is the integration of information resources. From the data reporting timeliness, optimize the networking monitoring data reporting mechanism, adjusted from monthly reporting to daily real-time updates; from the data reporting granularity, expand the reporting indicators, supplement the detailed business data. In terms of data collection sources, the use of the Internet, mobile terminals and other channels to increase the sources of information collection, supplementing the results of medical services, quality, satisfaction and other types of data, and at the same time to promote data *** enjoyment with the Medical Insurance Bureau, the Health Commission and other departments, to achieve data integration.
Third, improve data quality. Continuously improve the quality of data, on the one hand, do a good job with the population database and other external data comparison, approved data resources. On the other hand, gradually investigate the causes of data anomalies, the possible existence of invalid data, further analysis and comparison, and found that the problem of timely supervision and rectification.
2 Accelerate the construction of big data platform
To realize the efficient and intensive management of medical insurance big data, the construction of big data platform is imperative. The report of the 19th CPC National Congress proposed to "establish a national unified social insurance public **** service platform", the connotation of which is to use the "Internet +", big data and other information technology means to provide the masses with no geographical mobility boundaries, no barriers to the convergence of the system, the rights and interests of the insurance information more open and transparent, more convenient, more convenient, more convenient and more convenient. The meaning is to use "Internet+", big data and other informatization means to provide people with social insurance public **** services without geographical mobility boundaries, without barriers to system convergence, with more open and transparent information on participation rights and interests, with more convenient and efficient social security services, and with organic convergence in the integration of service matters. Efficient external services require a strong data support capability of the underlying big data platform, therefore, the construction of a reliable and safe social security big data management platform adapted to the business of social security, collaboration, supervision, decision-making, and service, as the basis for big data generation, aggregation, analysis and application, to realize unified standards and control of the data, to enhance the efficiency of the management services, and to provide data support services for the upper-level applications is the key task at present.
3Continuing to help the development of health insurance business
The fundamental starting point and foothold of the application of big data is to promote the development of the business, improve the management efficiency, and realize scientific decision-making, precise supervision, and people-oriented services. Specific applications, such as: giving full play to the advantages of big data clustering, decision trees and other algorithms to support the design, measurement and evaluation of payment standards for single diseases and DRGs, and to promote the in-depth development of the reform of multi-dimensional and composite health insurance payment methods; improving drug data and unified standards, and exploring the development of drug payment standards by drawing on the advanced experience of various regions; utilizing big data technology to analyze and predict the operation of the fund, and to improve the financing and treatment mechanism; deepening the application of intelligent monitoring system for health insurance; and improving the management of health insurance. ; deepening the application of intelligent monitoring system for health insurance, exploring the use of artificial intelligence, graph computation and other cutting-edge technologies to improve monitoring accuracy and realize more intelligent monitoring; promoting the research and application of electronic social security card, providing services such as online expense settlement and mobile payment for health insurance, and creating an online application service system; and providing health management services such as accurate recommendation for insured people by using big data recommendation model.
4 Constructing a data security system
The practice of data application in the big data environment has put forward higher requirements for data security and personal privacy protection. It is necessary to effectively establish the awareness of data security, realize the full life cycle management of data, and ensure data security, integrity and consistency.
One is to establish a data management mechanism, including information resource catalog, data hierarchical classification management, data security management system, data **** enjoyment and open process, etc., to ensure that the management process is standardized, and that the rights and responsibilities are clearly defined;
The second is to strengthen the infrastructure security, enable electronic seals, data encryption, biometric identification and other security technology means, to provide a basic guarantee for data security;
Third, to ensure the security of personal information, the provision of services to obtain personal authorization, to protect personal privacy.