Second, the basic principle is to protect the basics. Adhere to the fixed income and expenditure, balance income and expenditure, and have a slight surplus, to ensure the basic medical needs of the insured, promote the rational use of medical and health resources, and control the excessive growth of medical expenses.
The second is scientific and reasonable. The total control target should be based on the historical cost data of designated medical institutions and the budget of medical insurance fund, taking into account the rising medical expenses and changes in funds and medical services, and be scientifically calculated and reasonably determined.
The third is openness and transparency. The total amount control management procedures shall be open and transparent, and the total amount control management shall be notified to the society regularly. Establish a consultation mechanism between medical insurance agencies and designated medical institutions, and give play to the role of medical personnel and industry associations in management.
The fourth is incentive and constraint. Establish a reasonable and appropriate incentive and restraint mechanism of "surplus retention and overspending sharing" to improve the enthusiasm and initiative of designated medical institutions to strengthen management, control costs and improve quality.
The fifth is to strengthen management. Strengthen departmental cooperation, use comprehensive means, play the role of medical insurance monitoring, and ensure that the level of medical services is not reduced and the quality is guaranteed before and after the implementation of total control.
Third, the main content
(1) Strengthen and improve fund budget management. Improve the basic medical insurance fund revenue and expenditure budget management system, on the basis of carefully compiling the basic medical insurance income budget, further strengthen the expenditure budget, combine the fund budget management with the expense settlement management, and strengthen the budget implementation. According to the actual payment of the local medical insurance fund in recent years, the overall planning area should scientifically prepare the annual fund expenditure budget in combination with factors such as the number of participants, age structure and disease spectrum changes, policy adjustment and treatment level. To achieve municipal overall planning, it is necessary to establish a municipal fund budget management system and refine the fund budget according to the hierarchical management authority of the municipal, district (county) medical insurance agencies.
(2) Reasonably determine the overall regional total control target. The overall planning area should be based on the principle of fixed income and expenditure, balance of payments and slight balance, and prepare the annual fund budget of basic medical insurance. After deducting the one-time premium paid by the insured units and individuals, coordinating the medical expenses outside the region, the expenses of retirees for medical treatment and designated retail pharmacies, and considering all kinds of expenditure risks, the annual total control target paid by the regional medical insurance fund to designated medical institutions should be determined by comprehensively considering factors such as the price level and the medical consumption level of the insured. While implementing total control, we should protect the basic rights and interests of the insured and control the personal burden of the insured.
(3) Refine the total control index. On the basis of the service provision and actual medical expenses of designated medical institutions in the past three years, according to the different levels, categories, designated service scope, effective service volume and the first referral task undertaken by designated medical institutions, it will be further refined and implemented in designated medical institutions, and differentiated management will be implemented for outpatient and inpatient expenses. According to the differential payment policy of basic medical insurance for different types and levels of designated medical institutions, it is inclined to the grassroots level, so that the indicators of designated primary medical and health institutions occupy a reasonable proportion, so as to adapt to the construction of graded medical service system and the establishment of two-way referral system between primary medical and health institutions and hospitals, and support the formation of a reasonable and orderly medical treatment pattern.
(4) Pay attention to communication and consultation. Overall planning areas should follow the principle of openness and transparency, formulate procedures and measures for the implementation of total control, and announce them to the public. Establish an effective consultation mechanism between medical insurance agencies and designated medical institutions, and solicit opinions from designated medical institutions, relevant industry associations and representatives of insured persons when decomposing regional total control targets. Conditional areas can divide the designated medical institutions into several groups according to grades and categories, and negotiate between groups and within groups through the way of designated medical institutions sending representatives or giving play to the role of industry associations, determine the specific total control indicators of each designated medical institution, and promote fair competition of designated medical institutions.
(5) Establish an incentive and restraint mechanism. In accordance with the principle of "surplus retention and cost overruns sharing", the basic medical insurance fund and designated medical institutions are reasonably determined to share the surplus funds and cost overruns, and the enthusiasm of designated medical institutions to control medical expenses is fully mobilized. On the basis of ensuring the quantity, quality and safety of medical care and strengthening the assessment, a mechanism is gradually formed in which the cost overruns are reasonably shared by designated medical institutions and the surplus funds are reasonably retained by designated medical institutions. Medical institutions that exceed the total index should analyze the reasons, improve management, and put forward rectification opinions in a targeted manner. Medical insurance agencies may, according to the implementation of the fund budget, compensate the designated medical institutions for the reasonable cost overruns caused by the substantial increase in the number of insured persons seeking medical treatment. The medical insurance agency shall negotiate with the designated medical institutions about the specific situation, and make it clear in the designated service agreement.
(six) into the fixed-point service agreement. It is necessary to incorporate the content of total control management into the fixed-point service agreement, and adjust and improve the content of the agreement according to the requirements of total control management. According to the possible situation after the total amount control, the average cost, follow-up rate, hospitalization rate, head-to-head ratio, burden level of the insured, referral rate, operation rate, elective operation rate, proportion of severe patients, etc. It should be gradually incorporated into the assessment index system of fixed-point service agreements and strengthen management.
(7) Improve the management of expense settlement. Overall regional medical insurance agencies should combine the total control indicators with specific payment methods and standards, reasonably reserve a certain proportion of quality margin and year-end liquidation funds, decompose the total control indicators into each settlement cycle (in principle, on a monthly basis), and settle in full and on time according to the fixed-point service agreement to ensure the normal operation of medical services in designated medical institutions. For the medical expenses that do not exceed the total control index during the settlement period of designated medical institutions, the medical insurance agency shall timely and fully allocate them as agreed; Medical expenses exceeding the total control index can be suspended and reviewed at the end of the year. If the medical insurance agency fails to settle the medical expenses in full and on time as agreed, the administrative department of the regional government should strengthen supervision and order rectification, and those who violate the law and discipline should be dealt with according to law.
Medical insurance agencies can set up working capital according to a certain proportion of the total control index, and allocate it to designated medical institutions according to the agreement, so as to alleviate the pressure of their capital operation. Medical insurance agencies and designated medical institutions shall establish a regular information communication mechanism to announce the dynamic situation of medical expenses to the society. In the process of reform, the effective workload or cost composition of medical institutions has changed greatly, and the medical insurance agencies in the overall planning area can adjust the total control index of designated medical institutions in the middle of the year according to the actual situation.
(8) Strengthen the supervision of medical services. Coordinate regional health, human resources and social security departments to strengthen the supervision of medical behavior of designated medical institutions in view of the possible behaviors such as refusing patients, lowering service standards and falsely reporting service volume after the implementation of total control. Designated medical institutions that do not meet the requirements in terms of the quantity or quality of medical services shall appropriately deduct the quality deposit as agreed. It is necessary to improve the medical insurance information system, unblock the channels for reporting complaints, clarify the monitoring indicators, and strengthen the prevention of key risks. It is necessary to establish a departmental linkage mechanism and strengthen the investigation and punishment of breach of contract and illegal medical treatment.
(9) Promoting the reform of payment methods. At the same time, it is necessary to actively promote the reform of paying by head and disease. It is necessary to choose a payment method that matches the current situation of local medical insurance and health management according to local conditions, continuously improve the scientificity of medical insurance payment methods, and improve fund performance and management efficiency.
Fourth, organize the implementation.
(1) Strengthen organizational leadership. Total control is an important task to deepen the reform of medical insurance system and an important measure to promote the reform of public hospitals. All localities should attach great importance to it, strengthen organization and leadership, and take this work as a key work of medical insurance. All provinces (autonomous regions and municipalities) should strengthen research guidance and make overall arrangements; Overall planning areas should study and formulate specific work plans and seriously organize their implementation.
(2) Do a good job of coordination. Strengthen departmental coordination, clarify departmental responsibilities, and form a joint effort. The financial department shall, jointly with the human resources and social security departments, do a good job in the related work of fully implementing the budget management of the basic medical insurance fund, improve the system and method of the budget management of the medical insurance fund, and strengthen the supervision over the budget implementation and expense settlement of the medical insurance agencies. The health department should strengthen the supervision of the behavior of medical institutions and medical personnel, and take the reform of medical insurance payment as an opportunity to explore effective ways to reform public hospitals. It is necessary to strictly control the number and scale of hospitals according to the regional health planning and the establishment planning of medical institutions, and it is strictly forbidden for public hospitals to borrow money for construction. It is necessary to adapt to the situation, strengthen the meticulous management of medical services, and promote the full-cost accounting and standardized diagnosis and treatment in hospitals. Various measures should be taken to control medical expenses, guide medical staff to enhance their awareness of cost control and standardize medical service behavior. All regions should establish a coordination mechanism involving human resources, social security, finance, health and other departments, and study and solve major problems involving total control in a timely manner.
(3) Pay attention to the prevention and control of integrity risks. In the process of total control and management, medical insurance agencies in various regions should adhere to the principle of "openness, fairness and justice", strengthen consultation with designated medical institutions, and realize open and transparent procedures. Medical insurance agencies and designated medical institutions shall not engage in "one hospital, one talk" in principle, resolutely put an end to black-box operation, and the total control indicators determined through consultation shall be disclosed to the public in a timely manner. Total control management should take the initiative to accept the supervision of discipline inspection and supervision departments and all sectors of society. Disputes between medical insurance agencies and designated medical institutions in the process of total amount control and management shall be handled in accordance with service agreements and relevant laws and regulations.
(4) Do a good job in policy propaganda. Attach great importance to the importance of propaganda and public opinion work, do a good job in policy propaganda and interpretation, so that the majority of medical personnel and insured people can understand the importance of total control and understand and cooperate with the reform. In case of major issues or problems in the total amount control work, it is necessary to report them in time and properly handle them.
This opinion applies to the basic medical insurance that the Ministry of Human Resources and Social Security is responsible for.
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