Second, the main contents of the "Implementation Opinions" put forward specific measures to establish and improve the outpatient economic security mechanism in our province from six aspects. (a) the establishment of employee medical insurance general outpatient co-ordination system. On the basis of doing a good job in medical security for chronic diseases and special diseases such as hypertension and diabetes, the general outpatient expenses of frequently-occurring diseases and common diseases will be included in the payment scope of the employee medical insurance pooling fund. The general outpatient service covers all the insured personnel of employee medical insurance as a whole. Qifubiaozhun is set on a per-time basis. In principle, every time it does not exceed 50 yuan, designated medical institutions at the grass-roots level do not set qifubiaozhun. The maximum annual payment limit for on-the-job workers' general outpatient service is about 1.500 yuan, and the maximum annual payment limit for retirees is about 2000 yuan. The annual maximum payment limit of general outpatient co-ordination is not included in the employee medical insurance co-ordination fund The general outpatient medical expenses above Qifubiaozhun and below the maximum payment limit shall be paid by the employee medical insurance pooling fund in proportion, and the payment ratio for medical treatment in tertiary designated medical institutions shall be not less than 50%, that in secondary and below designated medical institutions shall be not less than 55%, and that for retirees shall be higher than that of on-the-job employees 10 percentage point; After the insured signed the family doctor contract, the proportion of general outpatient medical expenses paid in the contracted primary medical institutions increased by 5 percentage points on the above basis. The specific standards are determined by the overall planning areas according to the affordability of the medical insurance fund. (2) Improve the method of personal account calculation and payment. The basic medical insurance premiums paid by individual employees are included in individual accounts, and the basic medical insurance premiums paid by units are all included in the overall fund; Retirees' personal accounts are included in the monthly quota of the overall fund, and the amount included is determined by the overall planning areas according to about 2% of the monthly average level of the basic pension in the previous year. After adjusting the overall fund and personal account structure, the increased overall fund is mainly used for outpatient economic security and improving the outpatient treatment of insured persons. The adjustment of employee medical insurance personal account will be implemented simultaneously with the overall planning of general outpatient service. (3) Standardizing the scope of use of personal accounts. Personal account funds are mainly used to pay out-of-pocket expenses of insured persons within the policy scope of designated medical institutions. It can be used to pay the medical expenses incurred by the insured and their spouses, parents and children in designated medical institutions, as well as the expenses incurred by individuals in purchasing drugs, medical devices and medical consumables in designated retail pharmacies. Can be used for spouses, parents, children to participate in the basic medical insurance for urban and rural residents or I participate in large medical expenses subsidies for employees and other personal contributions. It shall not be used for public health expenses, physical fitness or health care consumption and other expenses that are not covered by the basic medical insurance. (4) Strengthen policy coordination. Gradually improve the policies and measures for the protection of chronic diseases and special diseases in outpatient clinics, formulate the catalogue of chronic diseases and special diseases in outpatient clinics in the province, and unify the standards for the identification of diseases. According to the affordability of the medical insurance fund, the overall planning area can gradually expand the scope of outpatient chronic diseases and special diseases paid by the overall planning fund. While implementing the general outpatient co-ordination system of medical insurance for employees, it is necessary to strengthen the connection with the hospitalization expenses payment policy, appropriately adjust the hospitalization Qifubiaozhun of medical insurance for employees in combination with the annual maximum payment limit of outpatient co-ordination, and appropriately widen the gap between hospitalization Qifubiaozhun of different levels of medical institutions. Simultaneously improve the outpatient co-ordination of basic medical insurance for urban and rural residents, and gradually improve the level of protection. (5) Improve the payment mechanism suitable for outpatient service. Primary medical services are paid per head, and the combination of payment per head and chronic disease management is actively explored; Pay for special outpatient diseases that meet the requirements, such as day surgery and dominant diseases of traditional Chinese medicine, according to the disease type or the relevant groups of disease diagnosis; For outpatient expenses that are not suitable for package payment, they can be paid by project. (6) Strengthen supervision and management. Establish and improve the supervision and management mechanism suitable for outpatient economic security, guide the rational use of medical resources, ensure the stable operation of medical insurance funds, and give full play to the security function. Establish a dynamic management mechanism for the whole process of personal accounts, and strengthen the audit of the use and settlement of personal accounts. Strengthen the supervision of medical behavior and medical expenses to ensure the safe, efficient and rational use of funds.
Three. Safeguard measures: Establishing and perfecting the economic security mechanism for medical insurance outpatient service for employees is an important content of deepening the reform of medical insurance system, and an effective way to enhance the security function of medical insurance fund, improve the efficiency of fund use and realize a fairer and more sustainable system. Involving the vital interests of the majority of insured persons, it needs the coordinated promotion of medical insurance, finance, health, human resources and social security, provinces and cities. The implementation opinions put forward specific safeguard measures from three aspects to ensure that the first is to introduce the plan in time. All overall planning areas should further clarify and refine the policy provisions in light of the actual situation, and issue implementation rules before the end of April 2022, and fully implement them before the end of June 2022. It is necessary to strengthen the policy convergence before and after the reform, improve the family doctor contract service and hospital prescription management, and improve the overall security function and the efficiency of reform system integration. The second is to strengthen departmental cooperation. All relevant departments should cooperate closely to form a joint force, do a good job in strengthening the management of fund use, improving the payment method of outpatient security, and standardizing the diagnosis and treatment behavior of designated medical institutions to ensure the orderly progress of reform. The third is to create a good atmosphere. All co-ordination areas should accurately interpret the policy, vigorously publicize the important role of establishing and improving the economic security mechanism of medical insurance outpatient service in reducing the burden of medical expenses of insured persons and promoting a fairer and more sustainable system, as well as the significance of establishing * * * medical insurance to help each other, and create a good public opinion atmosphere.