In the implementation of basic employee health insurance, not only the existence of medical, patients, insurance between the respective interests of the three, but also includes the employer, drug manufacturers and the health insurance department of the interests of the relationship between. If the medical insurance department can coordinate and deal with the relationship between each other, it is of great significance to promote the reform process of medical insurance, standardize the behavior of medical insurance services, and ensure the smooth operation of the medical insurance fund. Now combined with our Taicang medical insurance work practice, to talk about their own experience and explore a few points.
First, strengthen the infrastructure
View medical insurance as a "global world-class" problem is not excessive, and difficult than its management, it is a complex systems engineering. Therefore, to fundamentally solve this problem, infrastructure work is essential.
1, strengthen the construction of professional teams
Without a proficient medical professional team, in the absence of successful experience to draw on the basis of the development of health insurance service behavioral management norms is difficult; not in-depth repeated grass-roots research combined with the actuality, to refine the standardization of health insurance service behavior is also impossible. Therefore, in order to develop a set of effective management measures for medical insurance, it is necessary to establish a proficient medical business, insurance business, administrative management, financial management, information management, and at the same time good at in-depth investigation and research, a strong sense of responsibility of high-quality professional team.
2, strengthen the system
Medical insurance involves a wide range of personnel level, the direct interests of a large impact. As the employer is as little as possible to participate in the insurance or underreporting, underreporting the contribution base; and insured employees are as far as possible should not belong to their own use of the health insurance fund for their own use or used for friends and relatives; fixed-point unit is as far as possible only to pursue the interests of the loss of the health insurance fund; drug production enterprises is to do everything possible to the production of drugs included in the scope of the health insurance; and the health insurance management is faced with the handling of specific business and The medical insurance management department is faced with the test of power and responsibility in the process of handling specific business and strengthening the management and implementation of the above organizations. To deal with this multifaceted relationship rely only on limited management education is obviously can not be completed, and only through a series of practical management system measures and effective management tools to achieve, especially sound management system of the designated units.
3, strengthen the development of health insurance supervision software
At present, most of the medical institutions in the second level hospitals above the installation of the hospital information management system (HIS), but from the point of view of the integrated management of health insurance is not enough, profit-driven so that the fixed-point unit of the emergence of a complex variety of medical services insurance violations (such as: people do not match the card, drugs or health care products, overdose of medication, non-medicare), and so on. (e.g., the use of drugs for drugs or health care products, excessive use of drugs, inclusion of non-medical insurance program costs in the medical insurance settlement, etc.). To curb these violations, it is necessary to develop management software with simple operation and perfect functions for health insurance monitoring to complete, and the better choice is to carry out real-time networking of the designated units and embed the health insurance monitoring system software into the HIS, so that the behavior of the designated units of the various health insurance services is always under the monitoring of the health insurance management department, and it is possible to make the designated units of the health insurance services violations be effectively curbed by strengthening the education and intensifying investigations and penalties. The company's website has been updated with the latest information about the company's services.
The medical insurance according to the drug supervision department of the implementation of the drug retail enterprises "GSP" certification needs, since 2004 on the designated retail pharmacies unified installation of drugs for the "purchase, sale, inventory" management software - "Pharmacist treasure" management software, "Pharmacist treasure", "Pharmacist treasure", "Pharmacist treasure", "Pharmacist treasure", "Pharmacist treasure", "Pharmacist treasure", "Pharmacist treasure". After the "pharmacist treasure", to investigate and deal with the designated retail pharmacy health insurance service behavior has played a unique effect. The health insurance service behavior of designated retail pharmacies has also been effectively regulated.
The second, standardize the behavior of fixed-point units of medical insurance services
In the management of medical insurance, the management of the fixed-point units is the most difficult, but also the core of the "problem", the management of too tight can affect the relationship between the medical, insurance and may affect the quality of medical care to the insured employees, harming the interests of insured employees; management is too loose If the management is too loose, it will cause the loss of the medical insurance fund, which will also jeopardize the interests of the insured workers. Therefore, the medical insurance department is always in a "gap". However, the health insurance reform is a national policy, the trend, so to make the health insurance sector from this "crack" out, I think we should establish mechanisms in the following areas.
1, the fixed-point qualification confirmation mechanism
The fixed-point qualification confirmation of medical institutions and retail pharmacies, the State and the Ministry of Labor and Social Security only made a general provision. The qualifications of the designated qualifications of the various regions are not the same, more in view of the limited capacity of the medical insurance supervision and the use of "tight" policy. But "tight" also has its drawbacks, manifested in the inconvenience of the insured employees of the medical dispensing; is not conducive to fair competition between the industry; due to the relative concentration of interests and easy to change the normal relationship between the medical, insurance; not the qualification of the fixed-point medical institutions and retail drugstores and the health insurance department of the contradiction between the aggravation of the department and so on. The author believes that the qualification of the fixed-point confirmation has not been included in the scope of administrative licensing, then can be considered with the market economy, to fully introduce the competition mechanism, the implementation of the "lenient entry, lenient exit", that is, all in line with the Labor and Social Security Department to set the standard to be admitted, any violation of the provisions of the operation of the health insurance to be withdrawn. However, the exit mechanism should emphasize the combination of "feasibility" and "convertibility". That is, for some of the existence of violations but can not easily "exit" of the designated medical institutions (such as: municipal hospitals, township health centers), can be converted into a way to pursue economic responsibility to be constrained.
The medical insurance in the implementation of the fixed-point qualification "wide in, wide out" system found that many fixed-point units, in the same competitive environment, in order to make the invincible, and more used to improve service attitude, improve service quality, reduce the price of medicines, etc. to attract the insured workers, so that more insured workers to get the benefits.
2, the fixed-point unit of the management mechanism
The fixed-point unit of the service behavior to rely on a practical management system to regulate, in the absence of relevant legal provisions in the country, the regions in the management of the measures are quite perfect, but still not enough. But in practice, due to staffing constraints, irregularities in health insurance, to control the breadth and depth to be difficult, many areas of health insurance management departments have reflected the work of the fixed-point unit of health insurance violations are only "a drop in the ocean", profit-driven is difficult to make the fixed-point unit was investigated and dealt with after the medical insurance Service behavior is consciously regulated. Especially some large-scale and in the geographical spoils of the fixed-point hospitals or health centers is even more difficult, because even if the violations are confirmed and the same implementation of a strict "leniency" mechanism is difficult to be realistic, and from the recovery of funds to start or to make a certain amount of financial penalties is not enough to be able to fundamentally change their attitudes. Therefore, the state should legislate on medical insurance as soon as possible, and set up economic, administrative and criminal responsibility standards for medical insurance violations. The medical insurance management department should be in the implementation of the provisions of the higher authorities under the premise, as far as possible, combined with the actual situation in the region, in the development of the fixed-point unit management system to achieve the class, detailed, quantitative, especially in the "in and out of the system," "management system" "assessment system", "agreement system", "medical quota settlement system", "fund settlement system" and so on. In terms of more efforts, more articles, the establishment of a complete set of medical insurance management system.
3, report the reward and punishment mechanism
To curb the fixed-point units and insured employees more common health insurance violations, only to criticize the education is far from enough, should establish a strong reward and punishment mechanism. Many areas of the country to local laws and regulations or regulations to improve, but most of the performance of the more punitive and less rewarding. Discipline must have a basis, and the source of the basis of most areas of the current only through the health insurance management department of the investigation found that or a few people's reports after the investigation, which is obviously limited, from the high standard standardization of fixed-point units of health care service behavior is also far from enough. In this regard, the author believes that the management of designated units should be taken to government management and socialized management combined, and socialized management should first mobilize the masses **** with the enthusiasm to stop health insurance violations, there should be practical incentives for reporting, incentive funds to be included in the budget, the amount of reward to be sufficient to mobilize the masses to report enthusiasm to set the reward "bottom line! ", do not set the "ceiling line". Because no one can be a few dollars or tens of dollars for the amount of violations to report and get the amount of discount reward. "There will be a brave man in front of the heavy money".
In the disciplinary mechanism, the subject of the violation, the facts, circumstances, amount, intent, etc. should be treated differently, to comply with the people's hearts, to combine the practical, operational, not to engage in "one size fits all".
It should be recognized that there are still many people in our country and civilized awareness of the state of mind is not enough, consciously abide by the social morality of the distance, which leads to frequent violations of health insurance. To change this phenomenon, from the real sense of standardization of health insurance service behavior, in the strengthening of ideological education and quality training on the basis of the development of a set of effective and acceptable to the masses of constraints, and the establishment of incentives and penalties is one of the important means. To establish the "only by the power of society, in order to do a good job in the true sense of the management of medical insurance" of the basic concept.
4, the policy publicity mechanism
The improvement of the various systems for the standardization of health insurance behavior will play a positive role, but the lack of effective publicity to inform the mechanism is often unable to make the policy provisions of the health insurance in practice. In practice, we have found that many of the fixed-point units and insured employees who have committed health insurance violations have been investigated and punished for their violations because they did not understand the health insurance policy or were unable to comprehend the substance of the policy. Our survey of the staff of all designated retail pharmacies in the city found that a small number of pharmacy managers have a vague knowledge and poor understanding of health insurance policies and regulations; nearly half of the staff of pharmacies know very little about the health insurance regulations; most designated pharmacies do not publicize the health insurance documents to their staff after they receive them, and extensive media publicity is equally unlikely to make the insured employees have a full understanding of the regulations of the health insurance management. It is obviously impossible to regulate the behavior of health insurance services in such a situation. Therefore, it is of great significance to strengthen the publicity of medical insurance policy for fixed-point units and insured employees. In this regard, the author believes that the fixed-point unit should be the main object, because the fixed-point unit is the implementation of health insurance services, the main body, but also for the insured workers to publicize the health insurance policy is an important window, only to strengthen the fixed-point unit of the policy propaganda, in order to effectively strengthen the propaganda on the insured workers, and the insured workers must be through the fixed-point unit of the violation of the implementation of the unit can only be implemented with the cooperation. Therefore, a good fixed-point unit of publicity and management is equal to the "source" on the management of health insurance.
In practice, we Taicang medical insurance through the joint health and drug supervision departments, all the designated medical institutions of the health insurance related departments in charge and designated retail pharmacies of all employees to carry out a comprehensive training after the designated units of health insurance service behavior has been unprecedented improvement. For the effective standardization of health insurance service behavior of the fixed-point unit has played a positive role, for the smooth implementation of health insurance audit laid a good foundation.
5, the audit mechanism
Effective management regulations and proactive and extensive publicity, and can not effectively change the fixed-point units and insured employees due to profit-driven violations of health insurance, only to strengthen the effectiveness of the audit and penalties in order to grasp the management of health care in the last link. In this regard, the author believes that we should do a good job in the following areas. First, to enrich the strength of the inspection team, equipped with the necessary equipment; Second, to strengthen the concept of administration in accordance with the law, pay attention to civilized law enforcement, standardized law enforcement procedures, the implementation of the principle of fairness, justice and openness; Third, to improve the overall quality of law enforcement personnel to establish a good social image, clean government; Fourth, to take a flexible and diverse ways of inspection, can be taken in the form of open and secret investigations; Fifth, in the investigation of evidence should be taken from existing Functional gradually transitioned to a combination of functional and social way, because the functional departments of manpower is limited, to give full play to the role of the grass-roots labor security departments, should be within the scope of the law allows to tap into the community useful professionals to assist the medical insurance department to do a good job in the investigation and evidence collection work. Only in this way can we more effectively curb the more common health insurance violations.
Third, to regulate the insured workers medical insurance behavior
The medical insurance department formulated with the interests of the insured workers and regulate the medical insurance behavior of the policy, should be publicized through a variety of media (such as television, radio, newspapers, the network, etc.), as far as possible to achieve should be aware of. In addition to criticizing and educating the insured employees, the insured employees should also be given necessary financial penalties according to the laws and regulations. Because the insured employees and health insurance department does not occur direct economic transactions, the economic accountability is often difficult to implement. The more effective way is as long as the employee to fulfill the obligation to pay contributions can not be suspended to enjoy the right to health insurance treatment, but can be suspended from its health insurance "IC card" settlement function, that is, medical dispensing first by the employee to pay cash, and then to the window of the health insurance settlement, in the settlement process, and then to pursue its financial responsibility until it fulfills the obligation to penalize and then to restore the The "IC card" settlement function of the medical insurance.
(D) standardize the service behavior of the medical insurance departments
Medical insurance in the management of the insurance, fund collection, fixed-point qualification determination, settlement of medical expenses and other aspects of its unique powers, how to grasp the power in the hands of the people to truly do the people, the power to the people is the responsibility of all the staff, the management of labor security should be how to maintain clean and clear political thinking; strengthen the concept of administration according to the law Ideology; strengthen the concept of administration in accordance with the law; establish diligence for the people; cultivate the concept of quality service; strengthen the administrative supervision mechanism is included in the regular ideological education in the important content, we must effectively improve the internal management system, the workflow system, the administrative supervision system and accountability system, and we must adhere to the key departments to focus on the focus, focus on the management, and in particular, we must strengthen the professionalism of the settlement of the report window, the fund levy audit department of the medical insurance Audit and other key departments of the management, in order to put an end to negligence in the work.