About health insurance research report can be divided into three parts to describe, the first can describe the main content of the research, the second can describe the research of what problems exist, the third can describe the improvement of these problems on the recommendations.
About medical insurance research report a
In recent years, in Baoshan municipal party committee, under the strong leadership of the municipal government, the city health insurance agency in the management of the designated medical institutions to take a series of effective measures to resolve the outstanding contradictions and problems, and has achieved remarkable results. However, the medical and health system reform, "difficult to see a doctor" "expensive to see a doctor" has not been fundamentally resolved. Recently, the city of medical insurance fund allocation on the medical institutions to treat patients of the impact of research, now the relevant situation is reported as follows:
A research situation and problems
Through the research, the city did not find due to the allocation of the amount handed down to the fixed-point medical institutions and the fixed-point medical institutions of the gap between the expectations of the medical institutions, leading to the fixed-point medical institutions to "medical insurance fund run out". The medical insurance fund is exhausted" as the reason for shirking the phenomenon of patients. The phenomenon of allowing insured patients to purchase medicines outside the hospital at their own expense during hospitalization exists in some medical institutions, but it is not prominent.
For example, in early June 2017, retired cadre Yun Mou went to Baoshan City Medical Insurance Center to reflect the situation that he was asked to purchase *** counting 12,162 yuan of special materials at his own expense during his hospitalization in the city's No. 2 People's Hospital from October 29, 2016 to November 9, 2016, during the hospitalization in the outpatient clinic of the hospital. Baoshan City Health Insurance Center conducted on-site investigations of the issue on June 9 and June 14, 2017 based on this lead. The patient's medical records, examination and treatment situation materials were extracted on site, and interviews were conducted with healthcare personnel. According to the investigation and verification, Yun was indeed asked to purchase medical materials at his own expense at the outpatient clinic during his hospitalization, which shifted 6,394 yuan of material costs that should have been paid by the health insurance fund to the patient's own burden. In this regard, Baoshan City Health Insurance Center of the city's second people's hospital to order the hospital to immediately stop violations, strengthen the health insurance policy and the "service agreement" learning, requiring effective improvement of the level of health insurance management services; at the same time require the hospital to re-settlement of self-purchased material costs, return the patient's out-of-pocket expenses of 5,434.90 yuan; and in accordance with the "service agreement" of the hospital to the hospital deducted from the hospital's settlement costs 24324.00 yuan of punishment.
Second, the causes of the problem
The city's health insurance payment method reform work from 2005 in accordance with the requirements of the country, the province began to pilot to promote the city has formed for different medical services characteristics, to carry out a multi-compound health insurance payment method system. According to the budget situation at the beginning of the year, the hospitalization medical services are mainly carried out on a per-bed-day payment, per-patient payment, per-project payment and DRGs payment of multi-compound payment methods. After years of practice, it has been proved that the multi-compound medical insurance payment method under total prepayment is effective in controlling the unreasonable growth of medical fees, rationally allocating medical resources, and safeguarding the interests of insured persons. However, due to the medical institutions on the allocation of indicators within the hospital was approved by the layers to the departments, doctors, some medical staff on the average of the indicators of the concept of the wrong understanding of the case limit, resulting in the occurrence of the insured patients in the hospitalization period should be paid for by the medical insurance fund was arranged for outpatient out-of-pocket expenses for the purchase of the phenomenon occurs.
Third, the measures taken
In response to the above situation, the city's medical insurance agencies to take the following measures to prevent the occurrence of related problems:
1, strengthen budget management, scientific and reasonable indicators. Medical insurance adopts the revenue and expenditure management mode of "determining expenditures by revenue", and the targets are formulated with the fund's collection, with reference to the level of socio-economic development, and scientifically approved according to the costs of the designated medical institutions in the past three years. After approval, the approved medical institutions are incorporated into the service agreement for management to ensure the operability of the service agreement.
2, in order to prevent the fixed-point medical institutions to refuse to accept, shirking patients, reduce the service or lower the standard of service, or will not meet the criteria for discharge of the insured person for discharge, through the agreement management, specifically for this situation to deal with the development of methods. At the same time, health insurance operators use the intelligent audit system and daily supervision and inspection of designated medical institutions to detect problems in a timely manner and effectively curb the occurrence of out-of-hospital drug purchases during hospitalization.
3, in view of the uncertainty of the occurrence of disease and to prevent the problems caused by the deviation of the approved index, the city introduced a reasonable sharing mechanism of the cost of over-indexing, to relieve the medical institutions of the worries. 2016, according to the end of the year of the fixed-point medical institutions of the results of the liquidation of the sub-period of the integrated payment of the amount of the fixed-point medical institutions exceeding the amount of less than 10% of the over-indexing integrated cost of the full amount of the medical insurance fund to bear; the sub-period of the For those designated medical institutions whose average payment amount exceeds 20% or less, the medical insurance fund shall bear 90% of the exceeding standardized costs, and the medical institutions shall bear 10%; for those designated medical institutions whose average payment amount exceeds 30% or less, the medical insurance fund shall bear 85% of the exceeding standardized costs, and the medical institutions shall bear 15%; and for those designated medical institutions whose average payment amount exceeds 50% or less, the exceeding standardized costs shall be borne 80% by the medical insurance fund, and 80% by the medical institutions; and the medical institutions shall bear 15% by the medical institutions. The medical insurance fund will bear 80% and the medical institutions will bear 20%; for the fixed-point medical institutions whose average payment amount exceeds 50%, the medical insurance fund will bear 70% and the medical institutions will bear 30% of the exceeding standardized costs.
Four, suggestions
Based on the irregularities that exist in the designated medical institutions, it is recommended that the first health care, social security and other relevant departments to form a synergy, in particular, the health care sector to strengthen the management of medical institutions, increase the supervision and inspection of medical behavior, unreasonable behavior to give the appropriate penalties, and to be notified, and to play a practical role in "investigating and punishing a. Educating a piece of" role, Education of a piece of the role; Second, increase financial input, enrich the health insurance fund; Third, strengthen the guidance of the medical behavior of participants, the implementation of hierarchical diagnosis and treatment measures; Fourth, to strengthen the grass-roots level, especially the township-level medical institutions capacity building, to provide convenient and accessible medical services for the grassroots. (Lin Min)
Research Report on Medical Insurance II
Class: Labor and Social Security, Department of EthnologyResearch Report on Rural Cooperative Medical Security System
Practice Topic: Research Report on Rural Cooperative Medical Security SystemTime: December 4, 2014Location: Gaoshaozaitang, Wanzhou District, ___ City Square
Abstract: The medical insurance system aims to improve the current situation of rural medical care, improve the health of farmers, the construction of the rural cooperative medical system to farmers to bring tangible benefits is obvious, especially the new rural cooperative medical care in the majority of rural areas of the attempts as well as the great results it has achieved. This is an important part of China's economic construction must be faced, but the situation of expensive and difficult to see a doctor did not go completely with it, and the defects of the health insurance system and the implementation of the process of the problem is increasingly exposed through the investigation found that the current rural medical security deficiencies, put forward relevant recommendations to make it increasingly perfect, service to the people. Keywords: rural; health insurance; problems; suggestions China is a large agricultural country, the agricultural population accounts for more than 60% of the national population, but the rural economic development is backward, the rural social security lagging behind, which seriously impedes the development of China's economy, and jeopardizes the social stability. Rural medical insurance has broken through the dead corner of rural social security is also a new dawn of rural social security. However, rural medical insurance is in the early stage of development, problems arise, will inevitably hinder its development process. The purpose of this paper is to explore the reasons for its emergence, put forward proposals to solve the problem so that it is more perfect, service to the people, and promote China's economic development better and faster. First, the emergence and development of China's rural cooperative medical system
Theoretically, the rural cooperative medical system, mainly relying on the strength of the community residents, in accordance with the principle of "risk sharing, mutual ****ji" in the community within the scope of the multi-faceted fund-raising, used to pay for the medical care of the insured person and his family, preventive health care, health care and other service costs of a comprehensive health care system, and so on. It is a comprehensive health care measure that covers the costs of medical, preventive and health care services for the insured and their families. Cooperative medical care in rural China has its own developmental footprint and is an inevitable choice under China's special national conditions. The World Health Organization (WHO) said in a report that "the reference to primary health care workers is largely inspired by China. The Chinese have developed a successful primary health care system in rural areas, which account for 80% of the population, to provide people with low-cost, appropriate health care technology services to meet the basic health needs of the majority of the population, a model that is well suited to the needs of developing countries." The development of China's rural cooperative medical system is as follows: 1. The emergence of the cooperative medical system The cooperative medical system in China's rural areas can be traced back to the period of the War of Resistance Against Japanese Aggression, when medicine and health care were organized in the form of "cooperatives", which was actually a kind of sprouting of the rural medical security system. In the early years of the founding of the PRC, due to limited resources, the principle of welfare provision was chosen to differentiate between urban and rural areas, so that the vast majority of rural peasants were basically outside of the national social welfare system, and those who lacked medical care took the form of spontaneous mutual aid to solve their medical problems. The formal emergence of the cooperative medical care system with mutual assistance nature in rural areas of China was at the climax stage of rural cooperativization in 1955. In some places such as Shanxi and Henan, health care stations organized by rural production cooperatives appeared, adopting the method of combining the "health care fee" contributed by the members of the community and the subsidies from the production cooperative public welfare fund, with the masses pooling their money to cooperate in medical treatment and practicing mutual assistance.In early 1955, the first medical health care station was set up in China in Mishan Township, Gaoping County, Shanxi Province, realizing the goal of providing medical care to farmers. In early 1955, Mishan Township in Gaoping County, Shanxi Province, set up China's first medical care station, realizing the farmers' wish for "early prevention of disease, paper making, labor and money saving, convenience and reliability".12. Popularization and development of the cooperative medical system In February 1960, the central government recognized the cooperative medical system as a form of medical care and forwarded the Ministry of Health's "Report on the On-Site Meeting on Rural Health Work," which made the system a collective medical care system.2 On May 18, 1960, the Health Daily recognized this approach to a collective medical care system in its editorial, "Actively Implementing the Basic Health Care System," which was a good example of how a collective medical care system could help to promote rural health. approach to the health care system, which played a role in promoting the development of the nation's rural cooperative medical care system, which by this time had reached 40 percent of the nation's agricultural production brigades organizing cooperative medical care systems. "The emerging rural cooperative health care system was vigorously promoted. According to the World Bank (1996), the cost of cooperative health care at that time was only about 20 percent of the national health costs, yet it initially solved the health care problems of the rural population, which accounted for 80 percent of the population at that time. By 1976, about 90% of the administrative villages in rural areas nationwide had implemented the cooperative medical care system.3. Decline of the Cooperative Medical Care System
In the late 1970s, due to the implementation of the economic reform in the rural areas, which was mainly based on the household contract responsibility system, and the establishment of the two-tier management system combining the unification of production and division of labor, the original "one big, two communal" and "team-based" systems of management were adopted, and the "one big, two communal" and the "team-based" systems were adopted. " "team-based" form of social organization disintegrated, the rural cooperative medical care also followed a substantial decline in 1989 statistics show that the administrative villages that continue to adhere to the cooperative medical care accounted for only 5% of the country.3
Two, the current situation of rural medical insurance and the problems that exist
( I) The current situation of rural medical insurance
1. Low level of protection in rural areasChina's agricultural population accounts for 63.91% of the country's total population, while only 12 out of 100 people in rural areas enjoy commercial or socially co-ordinated medical insurance to varying degrees, and in large and medium-sized cities the figure is 54.From the social security reform formally implemented in 1999, 108,950,000 people have benefited from the program so far, of which Nearly 65 percent are urban enterprise workers and retirees, while the rate of social security enjoyed by peasants is extremely low, with less than 20 percent of them covered by socially-coordinated major medical insurance, which has the largest coverage of any kind of commercial and social insurance. Moreover, 79% of farmers in rural areas pay for their own medical care, and the level of protection is low. China's social security only in the city is not enough, so that the majority of farmers enjoy social security is one of the important links in China's economic construction.
2. Insufficient investment in rural areas, the gap between urban and rural areas is large For many years, we have followed the idea of tilting to the city in economic and social development, and for a long time China's urban and rural health resource allocation is imbalanced, accounting for 70% of the country's rural population, but only 30% of the health resources. Rural health insurance is seriously underfunded. With the reform of rural taxes and fees, local finances are tight, and many villages have very little left in their collective economies; subsidies to rural health institutions have been reduced, and rural health resources will become even more scarce.
3. "Poverty due to illness" is a serious phenomenon at present, in China's vast rural areas, the supply of medical services gradually market-oriented, self-funded health care system is still dominant, the cost of medical services in rural areas continue to rise, "poverty due to illness", It is no longer an accident that "it is difficult to seek medical treatment because of illness" in rural areas, and farmers are concerned about access to medical care. In recent years, the cost of medical care for farmers has risen faster than the increase in their average real incomes. Many farmers are no longer able to afford the increasing costs of medical care, creating a general situation of "delaying minor illnesses and resisting major ones". The contradictions in rural health care in China are prominent, and the rural health insurance system must be reformed; otherwise, rural health care, such as family planning, infectious diseases and the management and control of epidemics, will face serious challenges. A large number of theoretical research and practical experience shows that the establishment of a new cooperative medical insurance system in rural areas is imperative.
4. The new rural cooperative medical system has great defects
First of all, the lack of incentives for farmers to participate in the insurance enthusiasm is not high, because the new rural cooperative medical system is to coordinate the purpose of the major diseases, mainly to solve the farmers of the burden of the medical treatment of major diseases. And suffering from a major illness has a chance, therefore, farmers will be reluctant to insurance premiums to participate in the coordination because of the small chance of suffering from a major illness. Second, there are loopholes in management and insufficient funding, and some practices have emerged in individual localities that violate the central government's policy on the new rural cooperative medical care system and the guiding principles of the pilot program. In addition, inter-regional differences have been neglected, resulting in the inability to meet the problems of different levels of farmers' health insurance.
(2) China's rural medical insurance problems
New rural cooperative medical system of the legal system is lagging behind 80% of China's population live in rural areas, China's stability depends first of all on the stability of this 80%. The city is beautiful, without the stable foundation of the countryside is not possible. 2014 October promulgated the implementation of the Central Committee, the State Council "on further strengthening the work of rural health decision" also clearly pointed out that: "Rural health work is the focus of China's health work, related to the protection of rural productivity, revitalization of the rural economy, maintenance of rural social development and stability of the overall situation, to improve the overall situation of the whole nation, to improve the health of the people. It is also of great significance in improving the quality of the entire nation."
On medical insurance research report III
Director, deputy directors, members:
According to the municipal people's Congress Standing Committee's 2017 work points and sub-monthly arrangements, on May 10, Hong Xiubo, deputy director of the Standing Committee of the Municipal People's Congress, led some of the municipal people's Congress Standing Committee constituents, members of the Legal Affairs Committee on the city's The operation of the medical insurance fund was investigated, field inspection of the city hospital, the city medical insurance bureau, listened to the city human resources and social security bureau on the operation of the city's medical insurance fund report and held talks and exchanges, the relevant information is reported as follows:
I, the basic situation
The city's basic medical insurance protection system consists of the basic medical insurance for urban workers (hereinafter referred to as employee medical insurance), the original Urban residents' basic medical insurance (hereinafter referred to as the former residents' medical insurance) and the former new rural cooperative medical care (hereinafter referred to as the former New Rural Cooperative Medical Care) three parts.
(I) Employee medical insurance. The city's participation of 81,500 people, the participation rate of 96.47%. 2016 fund income of 239,639,700 yuan, the fund expenditure of 144,637,800 yuan, the fund balance of 95,001,900 yuan for the current period, the cumulative balance of 308,082,000 yuan, the fund can be guaranteed by the cumulative balance of the number of months is 19 months.
(ii) Original residents' medical insurance. The city's participation of 120,900 people, the participation rate of 100%. 2016 fund income of 62,593,300 yuan, the fund expenditure of 54,896,300 yuan, the fund current balance of 7,697,000 yuan, the cumulative balance of 148,848,800 yuan, the accumulated balance of the fund can be guaranteed for a number of months of 22 months.
(C) the former New Agriculture Cooperative. The city's participation of 707,800 people, the participation rate of 100%. 2016 fund income of 382,204,400 yuan, fund expenditure of 362,343,200 yuan, the fund current balance of 2,932,500 yuan, the cumulative balance of 117,599,400 yuan.
The main practices
Since the implementation of the basic medical insurance system reform in my city, the Municipal Human Resources and Social Security Bureau of the health insurance fund strictly implement the "two lines of income and expenditure" and the special funds, special accounts, special financial management system, to take the separation of income and expenditure, management and use of separate, money and accounts, and the use of the allocation of separation of the operating mechanism, standardize and The financial management model has been improved to ensure the safe and smooth operation of the fund.
(1) Strengthening the supervision of the fund to ensure the safe operation of the fund. First, the implementation of the fund level settlement, reduce the fund income and expenditure link; strengthen the statement early warning analysis, strengthen the fund operation control, effectively prevent and resolve the fund operation risk. The second is to revise and improve the medical insurance audit and settlement management system and other rules and regulations, sorting out and standardizing the declaration and review process of various approval matters. It has also implemented the working mechanism of "vertical responsibility and horizontal supervision", and established an internal control system with clear division of authority and responsibility from income to expenditure, and from supervisors to staff.
(2) Deepening the reform of medical insurance and solving the problems of fund operation. First, the fund management model of "single disease quota settlement under total control" was created, changing "fuzzy" management to "actuarial" management, further improving the city's medical insurance fund settlement management. The fund settlement management of the city has been further improved. Secondly, a standardized, real-time and secure medical insurance information system has been established, realizing real-time transmission of medical insurance business data. At the same time, the city has signed an agreement with 78 designated medical institutions in the province on instant settlement of medical treatment in other places, and has implemented the "five-working-day settlement system" to simplify the process of transferring patients to hospitals (clinics) and emergency treatment, and to solve the problem of "advancing a lot of money and reimbursing the complicated reimbursement" for medical treatment in other places. The problem of "advancing more, reimbursement is complicated" has been solved.
(3) Strict institutional management, standardize the services of fixed-point institutions. Adopt the management mode of signing "agreement" with the designated medical institutions every year, and implement the quantitative assessment of the percentage system. At the same time, strictly hold the "three passes", to strengthen the management of hospitalization behavior, that is, to put the hospitalized patients off, to put an end to impostor hospitalization; to put a good hospitalized diseases off, the strict implementation of a single disease quota settlement management standards; to put a good "three directories" implementation of the pass, focusing on the audit The implementation of designated medical institutions, effectively avoiding the loss of health insurance funds. In recent years, *** investigated and dealt with designated retail pharmacies placed sales of daily necessities 56, designated medical institutions, large prescriptions, indiscriminate inspection, abusive charges 124, decomposition of hospitalization, hospitalization 38, to recover the loss of health insurance fund more than 300 million yuan.
(4) establish a long-term mechanism to combat health insurance fraud. First, all chronic disease outpatient designated pharmacies in the city installed a video monitoring system, real-time view of their drug placement and sales. Second, the establishment of a long-term mechanism to prevent and control, where the designated medical institutions found to have disciplinary violations, depending on the severity of the situation to be punished, all the confiscated income into the health insurance fund. Third, in the city's designated medical institutions and designated retail pharmacies set up a special report and complaint phone and mailbox, the masses reflect the case of clues, to do piece by piece investigation, real-name reports 100% feedback. Fourth, on-line medical service behavior online monitoring system, to further regulate the medical insurance medical service behavior, to achieve the violation of medical behavior beforehand to remind, in the event of caution and after the validation of the function, to ensure the safe and effective operation of the fund. 2016, *** investigated and dealt with 13 fixed-point medical institutions and 52 fixed-point retail pharmacy there are violations of discipline and violation of law, involving an amount of 1,369,600 yuan, the amount of violations of discipline and violation of law has been completely recovered to the medical insurance fund.
(E) pay close attention to team building, improve management service level. First, the implementation of the "study hall" and "study test" system, take the leadership of the management to lead the study, each section to take turns to learn a variety of forms, to enhance the overall quality of all cadres and workers in the political and business. The second is the full implementation of the first-responsibility system, time-bound completion system, accountability system and "window star" evaluation activities to further improve and enhance the work style, service awareness and efficiency. Third, the establishment of a special hotline and public opinion box, announced the supervision phone, accept social supervision, and constantly improve the level of service, to ensure that the work of medical insurance scientific, standardized and orderly.
Three, there are problems and difficulties
(a) the fund expansion and collection difficulties. First, non-public economic organizations are mostly small and micro enterprises, the number of employees, short-term employment, mobility, labor relations are not standardized, the expansion of operational difficulties. Secondly, some of the enterprises are in recession and suffer from serious losses, and there is a phenomenon of non-payment of fees. Third, some units and employees are not strong awareness of insurance, the legal representative of the excessive pursuit of self-interest, for employees to participate in the insurance and contribute to the enthusiasm is not high.
(ii) difficult to control medical costs outside the city. The city's hospitalization costs of designated medical institutions within the city to take "total control of the single disease quota settlement" management mode, while the provincial designated medical institutions hospitalization cost settlement is still to take "according to the actual settlement" management mode, coupled with the lack of effective control and supervision of the means, resulting in out-of-city hospitalization medical costs. This, coupled with the lack of effective regulation and supervision, has led to a year-on-year increase in hospitalization medical expenses outside the city limits, and an increase in the risk of fund operation year after year.
(3) Medical insurance contribution policy needs to be improved. Flexibly employed people need to pay 1,782 yuan per person per year health insurance premiums, urban and rural residents only need to pay 120 yuan per person per year, a difference of nearly fifteen times the individual contribution standard, resulting in the participation of employees in the employee health insurance of flexibly employed people continue to urban and rural residents to health insurance, resulting in the number of employees in the health insurance continues to decline, the fund's risk-resistant ability to continue to weaken.
(4) Serious shortage of working funds. First, the personnel and daily office expenses are insufficient. The staff will increase to 74 after the integration of the former Health Insurance Bureau and the former New Agricultural Cooperative, and there is a serious shortage of personnel funds and daily office funds in 2017. Second, the health insurance network renovation and maintenance costs are insufficient. In accordance with the requirements of the provincial government, the city needs to carry out the integration of urban and rural residents of basic medical insurance information management system, transformation of foreign medical network settlement platform, the establishment of a four-level management service information system covering the city, town, township, village, the financial has been included in the budget funding and the required cost is far from the distance.
Four, comments and suggestions
(a) further enhance the ideological understanding, strengthen the implementation of the responsibility. Medical insurance is an important part of the social security system, is the people's concern, the focus of social concern, the relevant departments to further raise awareness, to be people-centered, in order to the people as the starting point, to strengthen the responsibility, pay close attention to the implementation, to ensure the safe and effective operation of the medical insurance fund.
(ii) further establish and improve the mechanism to strengthen the fund supervision. According to the medical insurance policy and the actual work, improve the work system, standardize procedures, improve efficiency and quality of service; strengthen the supervision and inspection of designated hospitals and designated pharmacies, timely detection of problems, eliminate loopholes; increase the law and crack down on criminal acts of arbitrage and fraudulent funds, to ensure that the fund is safe and efficient operation.
(3) further strengthen the collection measures to expand the fund collection surface. To establish the human resources and social departments to take the lead, the relevant departments to collaborate with the whole society *** with the participation of the overall linkage of the work mechanism, to promote the expansion of medical insurance collection work to the depth of the expansion. To innovate publicity ideas and methods, increase publicity efforts to improve the general public's awareness of health insurance-related laws and regulations and policies, to accelerate the extension of urban health insurance to non-public economic organizations and various types of employment, to achieve the insurance should be insured.
(4) further improve the medical insurance policy, improve the level of medical protection. According to the actual situation of medical insurance work in the municipal area, the medical insurance levy standards, medical reimbursement scope and standards should be reasonably adjusted in due course. To explore the realization of urban workers' medical insurance, urban and rural residents' medical insurance, major medical insurance and medical assistance policy "seamless convergence", improve the medical insurance policy system, improve the level of medical security.
(E) further strengthen the team building, enhance the level of management services. To speed up the construction of medical insurance information system project, comprehensively improve the level of medical insurance information management. To speed up the construction of the agency, work funds into the financial budget at this level, complete the medical insurance agency staffing, and at the same time to continuously improve the staff's sense of responsibility and level of work, to enhance the level of management services.
The above is what I shared today, I hope it can help you.