"It has been tested with the data in the second half of 213, and it is going through the bidding process." Peng Weizhong, director of Changzhou Workers' Medical Insurance Fund Management Center in Jiangsu Province, told the 21st century business herald reporter at the end of May that according to the relevant requirements of the Ministry of Human Resources and Social Security, the basic medical insurance service monitoring and data mining system should be built in all local people's social security systems, and the time limit is the end of 214.
This is another new measure for the people-society system to control the medical insurance expenditure when the reform of medical insurance payment method is getting into trouble. Through embedded monitoring software, the real-time monitoring of medical insurance payment can be realized, which can promote the rationalization of diagnosis and treatment and improve the efficiency of fund use.
The construction of this system will not only greatly enhance the management ability of the human-social system to medical insurance, but also increase its weight in the dispute of merging medical insurance management; The accumulation of basic data and the unification of its standards will also lay a good foundation for the third-party management of medical insurance in the future.
However, the idea of human-social system still faces the strong game of medical institutions. Without the reform of the public medical system, which is in a monopoly position as a whole, the role that medical insurance can play will be limited.
Technology forces management
The Ministry of Human Resources and Social Security planned to build a monitoring system for basic medical insurance services, which began in the second half of 212. In February of this year, the "Qinling Incident" broke out in Shanghai, and in a very dramatic way, it showed the consequences of the distortion of the total prepayment system in the implementation process: the indiscriminate and frequent shirking of critically ill patients.
However, the increasingly tight medical insurance fund makes the cost control imminent. According to Peng Wei, there are 1.2 million participants in medical insurance for urban workers and medical insurance for urban residents in Changzhou, and the annual contribution of medical insurance fund is 2.7 billion-2.8 billion yuan, and the expenditure is 2.5 billion-2.6 billion yuan, which is very close to the balance point of that year. In other parts of the country, in the past year or two, it has been frequently reported that the medical insurance fund "wore out" in that year.
In September p>212, the Ministry of Human Resources and Social Security began to deploy relevant work, and in 213, it issued the Notice on Printing and Distributing the Technical Plan for the Construction of Medical Service Monitoring System (Human Resources and Social Security Information Letter [213] No.26), requesting all localities to start work as soon as possible.
Taking 17 pilot cities such as Hangzhou as the representative, the medical service monitoring system adopts professional software for intelligent audit, which can not only improve the processing batch, but also achieve real-time audit. Shi Xiaoxiang, deputy director of the social security center in Zhenjiang, Jiangsu, a national medical insurance pilot city, told 21st century business herald that medical insurance has not been fully monitored in real time before.
The basic medical insurance service monitoring system promoted by the Ministry of Human Resources and Social Security will also build a basic medical insurance information base, covering more than 4 indicators in 1 categories, such as drugs, medical institutions, medical personnel, diseases and medical treatment settlement, laying a data foundation for the meticulous management of medical insurance by the human resources and social security system.
The system will also directly benefit the serious illness insurance promoted by the state. "The design of the serious illness insurance (Hexun assured insurance) system requires a very detailed segmentation analysis of the data of basic medical insurance." Qian Qiqi, director of the medical insurance settlement center in Taicang City, Jiangsu Province, said.
Game medical institutions
In addition to the aforementioned basic information base, another core content of the proposed basic medical insurance medical service monitoring system is the flexibly configurable monitoring rule base. The Ministry of Human Resources and Social Security requires that a relatively complete monitoring rule base be compiled by collecting the practical experience of medical service monitoring in various places and the management methods of designated institutions.
It is understood that the monitoring rules compiled by the Ministry of Human Resources and Social Security include 241 monitoring rules for frequent medical visits, excessive expenses, excessive medication, excessive diagnosis and treatment, repeated diagnosis and treatment, irrational medication, unreasonable hospitalization, false medical treatment, and broken hospitalization, and 294 analysis rules.
however, there will be additions and deletions in different places according to local conditions. For example, the Jiangsu Provincial People's Social Security System has simplified the relevant rules to 64, and listed the very detailed monitoring rules such as too many empty registration times, too many accumulated visits by employees in our hospital, and unqualified doctors providing outpatient serious illness services.
in addition to the increase or decrease of items, the system envisaged by the Ministry of Human Resources and Social Security can also flexibly define monitoring rules, and support the setting of monitoring objects, business scenarios, time periods, thresholds, medical categories, insurance types, hospital grades, disease classifications and other parameters to adapt to local actual conditions.
According to the reporter from 21st century business herald, some provincial capitals develop the rule base in a unified way, while others delegate the bidding right to local governments, and government departments are responsible for purchasing commercial embedded monitoring software. No matter which form, the corresponding monitoring rules are regarded as the right-hand man by the medical insurance managers in the people's social system.
however, the views of the outside world are not consistent. "As far as Jiangsu Province is concerned, the medication habits are different from north to south." The person in charge of Jiangsu Pharmaceutical Business Association said that if the rules are not used well, it will either easily lead to disputes or increase the workload of manual review of medical insurance centers.
People in the third-class hospitals are more reserved about this new system. "Its biggest deterrent is that some embedded software can directly deduct the non-compliant fees and not pay them, but the medical insurance income only accounts for less than half of our hospital income." A person from a top three hospital in Shanghai said.
Hu Suyun, a researcher at Shanghai Academy of Social Sciences who has been studying the reform of medical insurance for a long time, believes that medical insurance is not dominant in the game with public hospitals at present, which is not only reflected in the source of funds, but also in the disparity in the matching of human resources. Even if there are technical means to monitor and find some problems in time, the methods, means and strength to deal with them in time after discovery are unbearable burdens for the human and social departments at present. Therefore, in order to show its role, the reform of payment methods needs the cooperation of public hospitals themselves, and it also needs the human and social departments to get out of the current predicament of weak supervision and enforcement, which involves the socialized entrustment of medical insurance management affairs. < P > Read more: How to buy insurance, which is better, and teach you to avoid these "pits" of insurance.