Work implementation plan (for Trial Implementation)
First, the scope of the disease and implementation time
On the basis of consolidating and improving the medical security level of rural children with leukemia and congenital heart disease, all parts of the province should comprehensively push forward the pilot work of improving the medical security level of 20 major diseases such as end-stage renal disease, female breast cancer, cervical cancer, severe psychosis, multidrug-resistant tuberculosis, AIDS opportunistic infection, lung cancer, esophageal cancer, gastric cancer, colon cancer, rectal cancer, chronic myeloid leukemia, acute myocardial infarction, cerebral infarction, hemophilia, type I diabetes, hyperthyroidism and cleft lip and palate.
Second, graded fixed-point treatment
Major diseases are treated according to disease classification.
(a) the principle of graded fixed-point treatment.
End-stage renal disease, female breast cancer, cervical cancer, AIDS opportunistic infection, gastric cancer, colon cancer, rectal cancer, type I diabetes, hyperthyroidism and other diseases should be treated mainly in qualified county-level medical institutions or with the support of provincial and municipal medical institutions.
Acute myocardial infarction, cerebral infarction and other diseases, in principle, relying on county-level medical institutions to do emergency treatment and then transferred to qualified designated hospitals for treatment.
Severe mental illness, multidrug-resistant tuberculosis, lung cancer, esophageal cancer, chronic myeloid leukemia, hemophilia, cleft lip and palate and other diseases are transferred to qualified designated hospitals for treatment after preliminary examination by county-level medical institutions or other professional institutions.
In addition, in areas where conditions permit, patients with AIDS opportunistic infections and severe mental illness can also receive treatment in primary health care institutions.
(2) Provincial designated hospitals for treatment.
(3) City and county hospitals.
Third, the quota (limit) payment standard
Major diseases are paid according to the quota (limit) of single disease. According to the clinical pathway of the Ministry of Health, the diagnosis and treatment norms and the level of medical expenses in our province in recent years, the provincial health department classifies and calculates, and reasonably determines the payment standard of medical expenses quota (limit) for major diseases in designated hospitals at all levels (annex 1). Patients with AIDS opportunistic infection and severe mental illness are hospitalized in primary medical and health institutions, and the fixed (limited) payment standard is formulated by the municipal (state) health department according to the relevant clinical pathway, and the payment standard is lower than that of secondary hospitals.
Patients with two or more major diseases at the same time, the quota (limit) payment standard is superimposed according to the single disease payment standard.
Fourth, the expense reimbursement standard
Patients with major diseases use drugs and diagnosis and treatment items in accordance with the relevant clinical pathway and diagnosis and treatment operation norms, and are not restricted by the list of reimbursement drugs and diagnosis and treatment items of the new rural cooperative medical system in our province. There is no deductible when patients with major diseases pay by disease type.
(1) hospitalization expenses.
If the hospitalization expenses for major diseases are paid in a fixed amount, the designated hospitals can only charge fees according to the fixed payment standard; 70% (tertiary hospitals) or 75% (secondary hospitals) of the fixed expenses shall be borne by the new rural cooperative medical fund, and the rest shall be borne by patients. The implementation of fixed payment, the designated hospital treatment fees shall not exceed the fixed standard, and the insufficient fixed payment standard shall be collected according to the facts; 70% (tertiary hospitals) or 75% (secondary hospitals) of the expenses within the limit shall be borne by the new rural cooperative medical fund, and the rest shall be borne by the patients.
because
(2) outpatient expenses.
The annual outpatient expenses for the treatment of major diseases shall be paid in a fixed amount, and 70% of the outpatient expenses within the fixed standard shall be borne by the new rural cooperative medical fund.
(3) medical assistance.
The medical expenses of patients with major diseases in rural poor families are reimbursed by the new rural cooperative medical system, and then the civil affairs department gives medical assistance according to relevant policies.
V. Treatment, reimbursement and settlement process
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2 patients with major diseases in hospital, according to the disease quota (limit) 30% of the hospitalization expenses in advance. When patients with major diseases are discharged from the hospital, they should settle out-of-pocket expenses according to regulations.
3. Designated treatment hospitals conduct reasonable diagnosis and treatment of patients in strict accordance with the clinical pathways of various diseases. After the treatment, fill in the Registration Form for Designated Diagnosis and Treatment of Major Diseases of New Rural Cooperative Medical System in Sichuan Province and submit it to the Hospital Medical Insurance Office for settlement. The designated hospitals of the new rural cooperative medical system (NCMS) that have carried out immediate settlement report, and the patients will be settled in time when they leave the hospital; For the designated hospitals of the new rural cooperative medical system that have not carried out the immediate report, the medical insurance office of the designated hospitals shall submit the following materials: 1, Registration Form for Designated Diagnosis and Treatment of Major Diseases of the New Rural Cooperative Medical System in Sichuan Province; 2. Discharge summary; 3. Full cost receipt; 4. List of hospitalization expenses; 5, Sichuan Province, the new rural cooperative medical fund disbursement application form (Annex 3), regularly to the patient's overall area of the new rural cooperative medical fund agencies to apply for disbursement of the new rural cooperative medical fund should be fixed (limit) to pay the cost.
4. After receiving the application materials for the settlement of major diseases in designated hospitals, the agency of the new rural cooperative medical system shall complete the audit within 7 working days, and allocate funds to the designated hospitals according to the quota (limit) payment standard of the new rural cooperative medical system fund.
5. Patients with major diseases such as multidrug-resistant tuberculosis, end-stage renal disease, hemophilia, severe mental illness, type I diabetes, hyperthyroidism and chronic myeloid leukemia. Diagnosed by a designated hospital, the medical expenses incurred in outpatient service shall be reimbursed to the new rural cooperative medical system agency on a monthly or quarterly basis according to the relevant policies with the disease diagnosis certificate and medical expense receipt.
Six, organization and management
1. All localities should attach great importance to this work as a major livelihood project for deepening the reform of the medical and health system and seeking welfare for the masses in our province, and earnestly organize its implementation.
2. The Provincial Health Department determines the scope of major diseases, provincial designated hospitals, quota (limit) standards, the payment ratio of the new rural cooperative medical fund, the patient pays the proportion, hospitalization and compensation settlement process; Monitor and regularly evaluate the actual level of medical expenses for major diseases, adjust the quota (limit) standard in time with the major adjustment or change of the actual level of medical expenses for major diseases, the price of high-value consumables and the price standard of medical services, and establish a dynamic adjustment mechanism for the quota (limit) standard; Supervise the service behavior and service quality of patients with major diseases in designated hospitals, supervise, inspect and evaluate the pilot work in the province, summarize and popularize the pilot experience, and coordinate and solve related problems. The competent price departments at all levels shall supervise the implementation of the pilot disease price paid by disease.
Health administrative departments at all levels should strengthen the supervision of designated medical institutions, standardize medical service behavior, ensure the quality of medical service, control the unreasonable increase of medical expenses, and ensure the safe operation of the new rural cooperative medical fund. Found unreasonable charges, decomposition of hospitalization and other irregularities to informed criticism, a deadline for rectification, until the abolition of designated qualifications.
3. Designated treatment hospitals should set up a leading group for medical security of major diseases, headed by the main leaders of the hospital, with the dean in charge as the deputy head, and the heads of various professional departments, medical management, nursing management, medical insurance management, pharmaceutical affairs management and other departments as members. Designated hospitals should formulate standardized diagnosis and treatment plans for the above major diseases, and report them to the health administrative department at the same level for the record within two weeks after being identified as designated hospitals.
4. Designated hospitals should strictly examine and confirm the patient's participation, whether it meets the scope of major diseases. For patients who do not meet the scope of major diseases, it is necessary to make a good policy interpretation. Commitment to treat patients in strict accordance with the norms of diagnosis and treatment, standardize medical service behavior and charging behavior, ensure medical safety and quality, and actively accept supervision. Designated hospitals shall not refuse or shirk critical patients; It is not allowed to upgrade or exchange diseases outside the scope of major diseases for diseases within the scope of major diseases; We have to reasonably reduce the diagnosis and treatment items and services included in the standardized diagnosis and treatment plan for major diseases, which harms the interests of patients; The medical expenses included in the standardized diagnosis and treatment plan for major diseases shall not be excluded from the current hospitalization medical expenses through outsourcing prescriptions, outpatient prescriptions, outpatient inspections, external hospital inspections, hospitalization decomposition, and cost decomposition. Let the patients pay for themselves. All the above violations occurred in designated medical institutions. Once verified, it will be severely dealt with according to the Measures for the Administration of Designated Medical Institutions of New Rural Cooperative Medical System in Sichuan Province.
5. Co-ordinate the regional new rural cooperative medical institutions to widely publicize and inform the participating farmers of the scope of major diseases, designated hospitals, management and compensation policies, actively guide patients with major diseases to designated hospitals, and strictly implement the referral system; Responsible for the audit and settlement of the new rural cooperative medical system (quota) compensation fees for patients with major diseases, simplify relevant procedures, and timely allocate funds to designated hospitals; Responsible for timely reporting on a monthly basis to improve the compensation for major diseases of rural residents.
Annex 1 Sichuan New Rural Cooperative Medical System for End-stage Renal Disease and Other Major Diseases
2. Registration Form of Major Diseases of New Rural Cooperative Medical System in Sichuan Province
3 Sichuan Province, the new rural cooperative medical fund disbursement application form