Difficult and expensive medical care has always been one of the difficulties in solving livelihood problems. In order to solve this problem, the state has been promoting health insurance reform. Recently, health insurance payment is about to usher in an important reform. So, what are the specific reforms?
Where does the reform of health insurance payment change?
Implementation of multiple composite health insurance payment methods
For inpatient medical services, payment is mainly made according to the type of disease, according to the grouping of disease diagnosis related to the payment of long-term, chronic disease inpatient medical services can be paid by the bed day.
For primary medical services, payment can be made on a per capita basis, and the combination of per capita payment and chronic disease management is being actively explored.
Complicated cases and outpatient costs for which packaged payment is not appropriate can be paid on a project basis.
Exploring payment methods in line with the characteristics of Chinese medicine services, and encouraging the provision and use of appropriate Chinese medicine services.
Focusing on the implementation of per-disease payment
Gradually incorporating day surgery and outpatient treatment of eligible Chinese and Western medicine diseases into the scope of payment for diseases of the medical insurance fund.
Establishing a sound negotiation and consultation mechanism, based on past cost data and the ability of the medical insurance fund to pay, scientifically and reasonably determining the payment standards for Chinese and Western medicine categories on the basis of ensuring therapeutic efficacy, and guiding the use of appropriate technology.
Doing a good job of articulating the policy of charging and paying for each type of disease, and rationally determining the charges and payment standards, which are shared by the medical insurance fund and individuals***.
Carrying out the pilot project of paying according to the diagnosis-related grouping of diseases
Grouping diseases according to the severity of their conditions, the complexity of their treatment methods, and the actual level of resource consumption, etc., and insisting that the grouping be made public, the logic of the grouping be made public, and the base rate be made public.
The diagnosis-related grouping technology can be used as a support for measuring and evaluating the cost and efficacy of medical treatment in medical institutions, strengthening horizontal comparisons between the same disease groups in different medical institutions, and utilizing the results of the evaluations to improve the payment mechanism of medical insurance.
Gradually, the diagnosis-related grouping of diseases will be used for actual payment and the scope of application will be expanded.
Disease diagnosis-related grouping charges and payment standards include all medical costs, including medical insurance funds and individual payments.
Improving payment methods such as capitation and per-bed-day payment
The coordinating regions should clarify the scope of basic medical service packages for capitation, and guarantee the payment of medicines, basic medical service costs and general diagnosis and treatment fees within the medical insurance catalog.
Gradually, starting with chronic diseases such as diabetes, hypertension, chronic renal failure and other chronic diseases with standardized treatment plans and clear assessment indicators, special chronic disease capitation payments will be carried out.
Regions with conditions can explore paying the outpatient fund of contracted residents on a per capita basis to primary healthcare organizations or family doctor teams, and if patients are referred to hospitals, the primary healthcare organizations or family doctor teams will pay a certain amount of referral fees.
For mental illness, hospice care, medical rehabilitation and other diseases that require long-term hospitalization and have a stable average daily cost, a per-bed-day payment method can be adopted, while strengthening the assessment and evaluation of the average number of days of hospitalization, the average daily cost, and the effect of treatment.
Strengthening the supervision of medical behavior by medical insurance
According to the functional positioning and service characteristics of various types of medical institutions at all levels, the scientific and reasonable assessment and evaluation system should be categorized and perfected, and the results of the assessment should be linked to the payment of the medical insurance fund.
The assessment indicators for TCM medical institutions should include the proportion of TCM services provided.
The local health insurance organizations can prepay a part of the health insurance funds to the medical institutions according to the agreement to alleviate the pressure on the operation of their funds.
How to change the health insurance payment reform?
Strengthening the budget management of the health insurance fund
Speeding up the public disclosure of the final accounts of the revenues and expenditures of the health insurance fund.
The reasonable increase in workload of medical institutions exceeding the total control target can be compensated according to the assessment and in accordance with the agreement.
The total control index should be appropriately tilted toward primary medical and healthcare institutions, children's medical institutions, etc., and the process of formulating it should be disclosed to medical institutions, relevant departments and the society in accordance with regulations.
Conditional areas can actively explore the combination of the point method with the total budget management, payment by type of disease, etc., and gradually use the regional (or within a certain range) total control of the health insurance fund instead of the total control of the specific medical institutions.
Improving health insurance payment policies and measures
Strictly regulating the boundaries of responsibility for basic health insurance, basic health insurance focuses on protecting the costs associated with medicines, medical services, and basic service facilities in line with the principles of "clinically necessary, safe and effective, and reasonably priced".
Public **** health costs, sports and fitness or health care consumption not directly related to the treatment of disease, shall not be included in the scope of payment of medical insurance.
Localities should fully consider the payment capacity of the medical insurance fund, the overall affordability of society and the personal burden of the insured, adhere to the principle of basic protection and responsibility sharing, and adjust treatment policies in accordance with the prescribed procedures.
In conjunction with the construction of the hierarchical diagnosis and treatment model and the family doctor contracting service system, the insured should be guided to prioritize the first consultation at the grassroots level, and the starting line can be calculated consecutively for the hospitalized patients referred in accordance with the regulations, so that the fees for the contracted service of the family doctors in accordance with the regulations can be included in the scope of payment of the medical insurance.
Exploring the implementation of total payment of medical insurance for vertical cooperation of medical consortiums and other modes of division of labor, rationally guiding two-way referrals, and giving full play to the role of family doctors as "gatekeepers" in controlling medical insurance fees.
Encouraging designated retail pharmacies to do a good job of guaranteeing the supply of medicines for chronic diseases, patients can freely choose to buy medicines at medical institutions or outside of medical institutions on the basis of prescriptions.
Cooperating to promote the reform of the medical and health system
Promoting the management of clinical pathways, and improving the transparency of diagnostic and treatment behaviors.
Promoting the mutual recognition of medical examination and test results among medical institutions at the same level, and reducing duplicate examinations.
Establishing a mechanism for disclosing information on the efficiency and costs of medical institutions, disclosing costs, patient burden levels and other indicators on a regular basis, accepting social supervision, and providing references for the medical choices of the insured.
Regulating and promoting multi-practice by medical personnel.
In short, this health insurance reform is a favorable policy for the people.