This is another new move by the HSS system to control health insurance spending in the context of the health insurance payment method reform that is getting into trouble. The embedded monitoring software enables real-time monitoring of health insurance payments, promotes the rationalization of diagnosis and treatment, and improves the efficiency of fund use.
The construction of this system will not only greatly enhance the ability of the social security system to manage the health insurance, but also increase its weight in the dispute over the integration of health insurance management; the accumulation of basic data and the unification of its standards will also lay a good foundation for the realization of third-party management of the health insurance in the future.
However, the vision of the social system also faces a strong game of medical institutions. Without a reform of the public healthcare system, which is overall a monopoly, the role that health insurance can play will certainly be limited.
Technology pushes management
The Ministry of Human Resources and Social Security's planning to build a monitoring system for basic health insurance medical services began in the second half of 2012. In February of that year, the "Qinling incident" that erupted in Shanghai showed, in a very dramatic way, the perverse effects of the total prepayment system being distorted in its implementation: indiscriminate and frequent shirking of responsibility for seriously ill patients.
But the increasingly stretched health insurance fund, but also makes the control of fees like an arrow on the string. Peng Weizhong introduction, Changzhou City, urban workers health insurance and urban residents health insurance **** there are 1.2 million participants, the health insurance fund annual contribution of 2.7 billion -2.8 billion yuan, the expenditure of 2.5 billion -2.6 billion yuan, very close to the balance of the year. In other parts of the country, in the past year or two, there have been frequent rumors that the health insurance fund that year "through the bottom" of the news.
In September 2012, the Ministry of Human Resources and Social Security began to deploy relevant work, and in 2013 issued a document "on the issuance of medical services monitoring system construction technical program notice" (Human Resources and Social Security Information Letter [2013] No. 26), requiring localities to carry out work as soon as possible.
And to Hangzhou and other 17 pilot as a representative of the medical services monitoring system using professional software intelligent audit, not only to improve the processing batch, but also be able to do real-time audit - the national health insurance pilot city of Jiangsu Zhenjiang social security center deputy director Shi Xiaoxiang told the 21st Century Business Herald reporter, the health insurance has not been able to do real-time monitoring. completely real-time monitoring.
The basic health insurance medical service monitoring system that the Ministry of Human Resources and Social Security is pushing for will also build a basic information base for health insurance, covering more than 400 indicators in 10 categories, such as medicines, medical institutions, medical staff, diseases, and settlement of medical consultations, which will lay the data foundation for the fine management of health insurance by the human resources and social security system.
The system will also directly benefit the work on major disease insurance that the country is pushing. "The design of the major disease insurance (Hexun Assured Insurance) system requires a very fine-grained segmented analysis of the basic health insurance data." Qian Yingqi, director of the health insurance settlement center in Taicang, Jiangsu province, said.
Gaming medical organizations
In addition to the aforementioned basic information database, another core element of the proposed basic health insurance medical service monitoring system is a flexibly configurable monitoring rule base. The Ministry of Human Resources and Social Security requires that a more complete monitoring rule base be compiled through the collection of actual experience in monitoring medical services and the management of fixed-point institutions around the world.
It is understood that the Ministry of Human Resources and Social Security has compiled monitoring rules including 241 monitoring rules and 294 analytical rules for categories such as frequent visits to the doctor, ultra-high costs, excessive use of medication, over-diagnosis and treatment, repeated diagnosis and treatment, unreasonable use of medication, irrational admissions, impersonation of the name of the doctor, false visits to the doctor, and decomposition of hospitalization.
But there will be additions and deletions to this in different places. For example, in Jiangsu Province, the human resources system has streamlined the relevant rules into 64, and in the "other violations" of the number of empty registration, the cumulative number of times the hospital's employees have too many visits, the qualification does not match the physician to provide outpatient services for major diseases, and other very detailed monitoring rules.
In addition to the addition and subtraction of items, the system envisioned by the Ministry of Human Resources and Social Security also enables flexible definition of monitoring rules, supporting the monitoring of objects, business scenarios, time periods, thresholds, medical categories, types of insurance, hospital grades, classification of diseases, and other parameter settings to adapt to the actual situation of each region.
According to a reporter from the 21st Century Business Herald, some provinces will unify the development of the rule base, while others will decentralize the bidding power to the localities, with government departments responsible for purchasing commercially available embedded monitoring software. No matter which form, the corresponding monitoring rules are regarded as a right-hand man by the health insurance operators of the HSS.
But the outside world does not share the same view. "Just one province, Jiangsu, has different medication habits from north to south." A head of the Jiangsu Pharmaceutical Business Association said that poor use of the rules would either easily lead to disputes or increase the manual review workload of the health insurance center.
And people at tertiary hospitals have more reservations about the new system. "Its biggest deterrent is that some embedded software is able to do direct debit non-payment for non-compliant expenses, but health insurance revenue only accounts for less than half of our hospital revenue." A hospital official at a tertiary hospital in Shanghai said.
Hu Suyun, a researcher at the Shanghai Academy of Social Sciences who has long studied health insurance reform, believes that the current game with public hospitals, health insurance does not prevail, which is not only reflected in the source of funding, but also in the disparity of human resources to match, even if there are technological means of monitoring to detect certain problems in a timely manner, but after the discovery of the timely disposal of the methodology, means and power are the current human resources and social services departments can not afford to carry the burden. Therefore, the reform of the payment method should be recognized. Therefore, the payment reform to highlight its role, the need for public hospitals to cooperate with their own reforms, but also the need for the social sector to get out of the current weak supervision and implementation of the predicament, which involves the socialization of health insurance management affairs entrusted to the problem