Medical network - on February 21, firmly with sharp eyes staring at the doctor, issued a strong warning: you are targeting, illegal drugs, prescription, punish you! And your hospital!
▍ three ministries issued health charged fees, monitoring the violations and medical treatment
On February 20, the ministry of finance website published a notice. By the ministry of finance, people club department, health development planning commission jointly issued "on strengthening the basic medical insurance fund budget management give play to the role of medical insurance fund control of opinions" (hereinafter referred to as opinions), is proposed for the medical insurance fund to implement the whole real-time monitoring:
Focus on drugs, high value medical consumables usage and large medical equipment examination such as the medical behavior tracking monitoring and evaluation, timely find violations, and on the basis of "social insurance law", "professional medical practitioners law" and the "regulations on the administration of medical institutions" and other relevant laws and regulations and fixed-point protocol to the related medical institutions and medical personnel to make corresponding punishment, promote the diagnosis and treatment behavior, prevent the unreasonable medical expenses.
Have company in training medicine said "medicine, the doctor had a box of a box is open out", people laugh at one another, understand the significant meaning. And health insurance fee also clearly understand this fact, so the doctor monitoring, grueling. But, in addition to the punishment, also have motivation.
▍ balance to the hospital, to urge doctors actively control the cost
"Opinion" to establish and improve the "balance retention, reasonable overruns share" incentive constraint mechanism, incentive medical institutions to improve service efficiency and quality. Promote the medical institutions and medical personnel active control cost and expense.
Macro-reforms, capitation payment is carried out, according to the payment methods, such as a bed, pay medical institutions pay standard, actual cost is lower than contract balance part by retention of medical institutions; Of the actual cost more than pay the standard, exceed a share shall be borne by the medical establishment, for the quality of the reasonable cost overruns can be on the basis of negotiations, Shared by medical institutions and medical insurance fund.
Excessive, additional inspection, will be fined! Within the scope of the pay, go easy, save to the hospital! Doctor the prescription pen in hand, under the prize have penalty, play with, can only accept policy already indicate direction - charged fees. In addition, plus has been conducted by doctor salary system reform, the doctor for kickbacks, adventure prescription power, more and more weak.
Health insurance fee, medicine proportion, the control of illegal drug use, the more closed tight, who have been out of the hospital medicines, the market has no time to make, will find a way around the hospital, even if it is temporary.
▍ outside hospital pharmacy into the mainstream, hospitals, drug companies are all happy
Outside the courtyard of the prescription in a strict sense, in a period of time does not exist, and the desire of money, as long as it is hospital prescription't ran out of the hospital. In fact, the current prescription to outside pharmacy, hospital basically is inextricably related and hospitals, more some hospitals simply set up in hospital pharmacy.
To avoid the medicine proportion, avoids the health insurance fee, on the surface even in conformity with the prescription outflow of policy. Such standards in the world, is the hope of his hospital revenue, is also part of the corporate line. In the context of the current, there have been big, in the form of courtyard outside pharmacy, cooperate with the hospital. Despite the custody of suspects, but for more operations, provides a flexible channel.
So much to lose the original market medicines, besides go hospital pharmacy this road, as the doctor liquidity gradually accelerated, perhaps will create more new model. In short, certainly still want to sell, anyway, will not disappear.
Attachment: on strengthening the basic medical insurance fund budget management play a role of medical insurance fund control of opinion
Provinces, autonomous regions and municipalities directly under the central government departments (bureau), human resources and social security department (bureau), health and family planning commission, the ministry of finance in the provinces, autonomous regions and municipalities directly under the financial ombudsman office:
Since its establishment, the basic medical insurance system in China, expanding coverage, the safeguard level gradually improve, in the protection of basic medical needs, ginseng protect personnel to improve the level of public health and other aspects have played an important role, but also facing unreasonable medical expenses increased pressure, fund operation, the risk of long-term unsustainable. Unreasonable growth of medical expenses partly offset by the effect of government spending, increased social and individual responsibility. To strengthen the basic medical insurance fund budget management, control the unreasonable growth of medical treatment charge, easing the burden on individuals, ensure the basic medical insurance system and the foundation of sustainable operation, according to the "budget law", "social insurance law and the relevant provisions of the state council, we put forward the following opinions.
A, strengthen basic medical insurance fund budget management
(a) scientific establishment budget. Decided to accept the region as a whole must be strictly in accordance with the "branch, balance of payments, somewhat balance", the principle of preparation of budget. According to the base (or pay cost standard), contribution rate, as the number of those factors, comprehensive, accurate and complete establishment of basic medical insurance fund revenue budget. Local fiscal departments at all levels must fully arranged in accordance with the relevant provisions of administrative institution to attend insurance of primary medical treatment unit capture to expend expenditure budget; According to not under the provisions of the state standard and the central and local share proportion, full specified amount to arrange the government subsidies for urban and rural residents basic medical insurance expenditure budget. Considering previous fiscal expenditure scale, local medical expenses, medical expenses control target, ginseng protect personnel to enjoy treatment of treatment number, age structure, policy adjustment factors such as formulating annual budget. In principle should not prepare the budget deficit, can not prepare the fund balance calendar year cumulative budget deficit. In addition to the treatment of insurance of primary medical treatment expenses, used to a serious illness insurance, transfer spending, over the higher expenditure, the subsidy spending at a lower level, in principle should not prepare other spending budget. Is really necessary or other spending budget establishment budget to use calendar year the cumulative balance make up for in those days, must be in accordance with the relevant provisions of the social insurance fund, financial system, and make a detail, to the people's government at the same level for examination and approval. Around to do a good job on the basis of the annual budget, according to the state of social insurance fund budget and medium-term fiscal planning specific deployment and arrangement, combined with local medium-term fiscal plan, to do a good job of basic medical insurance fund interim payments is calculated.
(2) full specified amount collection of insurance premiums in accordance with the law. Each area where overall planning is conducted to further enlarge the coverage of basic medical insurance, should ensure that all confirmed. To strengthen and standardize the worker is basic medical treatment insurance premium collection management, make the base check and ratify and daily audit work and so on, to ensure timely collection of the worker is basic medical treatment insurance premium in accordance with the law. According to no less than the standards stipulated by the state in full collection of urban and rural residents basic medical insurance individual pay cost, gradually establish individual pay cost standard of cohesive mechanism with the disposable income of urban and rural residents, increase the share of individual pay cost overall financing steadily. As a whole the area financial sector to the governments at various levels in time as stipulated, arrangement of urban and rural residents insurance of primary medical treatment subsidy funds allocated to the social insurance fund fiscal revenue. Strengthen the supervision and inspection, further improve the levy rates, delay capture, reduction and put an end to violation behavior such as default, ensure that stipulated.
(3) the specification individual account. In order to strengthen the management of employee basic medical insurance personal accounts spending, individual account, in principle, shall not be used for the medical expenses. Gradually optimize TongZhang structure to improve as a whole fund fraternal and ability to pay. Synchronous reform outpatient service fee payment, to carry out the medical cost as a whole, gradually raise the level of outpatient service a serious illness and chronic diseases, security, ensure the ginseng protect personnel to outpatient service safeguard level is not reduced.
(4) improve pay pay policies. Standard treatment of insurance of primary medical treatment with financing level and adapt to the local economic development level. Improve the level of basic medical insurance shall not exceed fund of insurance of primary medical treatment to bear ability. Reasonable on the premise of ensure the fund balance of payments, improve the basic medical insurance reimbursement cap line, the full implementation of urban and rural residents shift and disease medical treatment of a serious illness insurance, earnestly implement the various institutional guarantee responsibility, make policy cohesion, form the system together, steadily improve serious security level, relieve poverty due to illness, Chinese due to illness. Combined with promoting the construction of the grading system, perfect the ginseng protect personnel at different levels of medical institutions for medical treatment differential pay policies, give full play to the policies of pay of insurance of primary medical treatment to the constraint function, promote the orderly flow. Appropriate improve grassroots health institutions policy within the scope of medical expenses, to conform to the provisions of the referral hospitalized patients can continuous computing starting line. Reasonable away at the grass-roots level, county and city hospital reimbursement level gap between, guiding the clinic, ginseng protect patients reduce disorder treatment caused unnecessary spending.
(5) adhere to fund an actuarial balance. Local human resources social security, health, family planning, finance and other departments to carry out long-term actuarial, fund of insurance of primary medical treatment is completed by the end of June each year on year actuarial report. Reference actuarial result, timely complete the region's measures for the implementation of the basic medical insurance, to ensure that the fund actuarial balance.
Second, strict basic medical insurance fund budget implementation
(a) strict budget execution. The basic medical insurance fund budget should strictly in accordance with the procedures prescribed by the approved budget and implementation, shall not be adjusted freely. Orgnaization of agency of insurance of primary medical treatment should be in accordance with the provisions, report the budget implementation. Because of special circumstances need to increase spending in the execution or reduce revenue, fund of insurance of primary medical treatment budget adjustment plans shall be prepared, according to the social insurance fund budget reconciliation execute after approved.
(2) the implementation of real-time monitoring. The region as a whole should be in accordance with the unified state plan and deployment, perfecting the information system of medical treatment insurance, the medical establishment that decide a dot medical costs beforehand prior warning, monitoring and real-time supervisory review of postmortem whole journey. Focus on drugs, high value medical consumables usage and large medical equipment examination such as the medical behavior tracking monitoring and evaluation, timely find violations, and on the basis of "social insurance law", "professional medical practitioners law" and the "regulations on the administration of medical institutions" and other relevant laws and regulations and fixed-point protocol to the related medical institutions and medical personnel to make corresponding punishment, promote the diagnosis and treatment behavior, prevent the unreasonable medical expenses.
(3) related information disclosure. Promote the fund of insurance of primary medical treatment and the budget implementation to the public. Orgnaization of agency of insurance of primary medical treatment to be in accordance with the provisions, ginseng protect personnel to publicly and enjoy treatment of medical treatment insurance policy information, accept the supervision of the society from all walks of life. The medical establishment that decide a dot to balance of the public hospital in time according to the rules, the medicine price, all cases of outpatient and hospitalization expenses, the main diseases are cost information, such as family planning, health human resources social security departments at all levels to the various medical establishment that decide a dot sorting cost indicators, the ranking results released on a regular basis.
Third, implement the basic medical insurance payment reform
(a) comprehensive reform of payment. The region as a whole to combine local reality, based on the total budget, the full implementation of the outpatient capitation payment, according to disease, according to hospital diagnosis related group (DRGs), by combination of a variety of ways, such as bed day paid to adapt to different people, different compound of payment of the characteristics of the disease and medical service, gradually reduce the project payment, payment will cover all medical institutions and medical service reform.
Give full play to the incentive constraints and control the medical expenses of insurance of primary medical treatment is not reasonable growth, promote the medical institutions and medical personnel active control cost and expense, increasing the service efficiency of medical resources and fund, ginseng protect personnel to medical expenses burden from the source. Each as a whole the area to be worked out according to the requirements comprehensively promote the reform of basic medical insurance payment plan, to regularly assess the effect of the payment reform, and improved in time. Provincial human resources department of social security, health, family planning to set up expert database, putted forward reform, strengthen the guidance of the region as a whole.
(2) to establish a quality control mechanism. Perfect service agreement management assessment method and the medical establishment that decide a dot, the comprehensive reform of payment at the same time, to establish and perfect the medical establishment that decide a dot the number and quality of service evaluation mechanism. To adapt to the characteristics of different payment methods, perfecting examination method, and the assessment results and the funds are tied to pay, to avoid medical institutions to control costs, reduce the necessary service or shuffle patients reduce the quality of service.
(3) to establish the incentive constraints mechanism. Establishing and perfecting the "balance retention, reasonable overruns share" incentive constraint mechanism, to stimulate medical institutions to improve service efficiency and quality. Macro-reforms, capitation payment is carried out, according to the payment methods, such as a bed, pay medical institutions pay standard, actual cost is lower than contract balance part by retention of medical institutions; Of the actual cost more than pay the standard, exceed a share shall be borne by the medical establishment, for the quality of the reasonable cost overruns can be on the basis of negotiations, Shared by medical institutions and medical insurance fund.
(4) establish a negotiated settlement mechanism. Social security, health, family planning as a whole the area of human resources, finance and other relevant departments shall guide orgnaization of agency of insurance of primary medical treatment and the medical establishment that decide a dot negotiated settlement mechanism, encourage the ginseng protect personnel to representative to participate in the negotiations consultation process. Payment reform to ensure that the medical insurance fund can withstand overall did not increase, the burden of the masses, medical institutions have motivation. Adhere to the fair, fair and open, to ensure that the medical establishment that decide a dot to participate in payment reform plan formulation and implementation process.
(5) synchronous promotion coordinated reform. In accordance with the unified arrangements of the state council, vigorously promote the health care, medical treatment, medical reform of "3 d" linkage, accelerate the reform of mechanism of system of public hospitals and grassroots medical institutions, medical service price formation mechanism reform, make payment of medical insurance drugs standard, vigorously improve pharmaceutical production circulation order, take comprehensive measures to control unreasonable medical expenses growth.
Fourth, to strengthen the inspection report and organize their implementation
(a) set up a performance evaluation mechanism. Around to strengthen the performance appraisal of orgnaization of agency of insurance of primary medical treatment, such as budgeting, cost control, quality of service into the inspection scope, its focus from audit reimbursement to cost control, strengthen the budget management, improve service quality. As a whole the districts are encouraged to explore the establishment and orgnaization of agency of insurance of primary medical treatment work performance incentive mechanism.
(2) establish praise reporting mechanism. "Much starker choices-and graver consequences-in" period, the ministry of finance, human resources and social security ministry, the national health and family planning commission will jointly to strengthen the budget management, promote the reform of payment, to examine the control unreasonable medical expenses increased, and so on and so forth (see annex) assessment index, reporting to work promoting fast and good effectiveness, province praise, the work progress lag province shall be criticized. Will inform the inspection content into the Treasury in the provinces, autonomous regions and municipalities directly under the financial ombudsman office audit scope.
(3) to do a good job of organizing the implementation. Around to fully understand to strengthen basic medical insurance fund budget management, controlling the unreasonable growth of the importance and urgency of medical expenses, will this work as the future for a period of time to perfect the medical insurance system, deepen the reform of medical health system carry out key tasks. To clear their respective responsibilities, strengthen coordination to cooperate, in a timely manner on the major issues, work force. To strengthen policy and public opinion guidance, proper response to social concern, for the parties understand and support. Provincial public finance, human resources, social security, health, family planning and other departments to strengthen the guidance of the region as a whole, according to the request to the ministry of finance, human resources, social security, national health and family planning commission and other departments to submit the basic medical insurance fund operation and control unreasonable medical expenses growth, etc. This opinion shall enter into force as of January 1, 2017.
The Treasury of human resources social security national health and family planning commission
On December 29, 2016 |
