1. The window service of medical insurance handling work plays a huge role. 1. Serving the 1.3 billion insured people, China has built the world's largest social medical security network, basically realizing that legal personnel should cover all the insurance. Since 212, the number of people participating in basic medical insurance in China has remained above 1.3 billion, the coverage rate has remained above 95%, and the number of people issuing social security cards has reached 972 million. Among them, the number of urban basic medical insurance participants was 743.92 million at the end of 216, an increase of 27.51 million compared with 536.41 million in 212, and more than twice that before the medical reform (28). The number of employees participating in the basic medical insurance was 295.32 million, and the number of urban residents participating in the basic medical insurance was 448.6 million. In 215, it was 376.89 million. 2. Managing more than 3, "two-fixed" institutions agreement management has become the basic way of medical insurance management. In 215, there were 132,2 designated medical institutions for urban basic medical insurance nationwide, an increase of more than 6, compared with before the reform, and 215,7 designated retail pharmacies, an increase of 14, compared with before the medical reform. In the same year, the number of people enjoying basic medical insurance in cities and towns exceeded 2.2 billion, and in 212, the number of people seeking medical insurance was 1.47 billion. 3. What services are provided? Responsible for the collection, payment and operation management of the basic medical insurance fund; Relevant policy consultation, insurance registration, fee collection, etc.; Responsible for signing agreements, business guidance, service supervision and assessment with designated medical institutions and retail pharmacies; Responsible for the settlement and payment of basic medical insurance premiums; Responsible for the preparation of the budget and final accounts of the basic medical insurance fund.

second, the dilemma of medical insurance handling reform. under the background that universal medical insurance has been realized and the reform of medical and health system has been deepened, the medical insurance handling management service system is facing new requirements and challenges in all aspects. The ability of medical insurance agencies is stretched to meet these new challenges. Especially under the management system of public participation and relative administration, on the one hand, the management of medical insurance agencies and medical institutions lacks the basic platform for consultation and negotiation; On the other hand, there is a lack of effective economic incentives in internal management, and the vitality of agencies and managers is limited. There are many bad reviews on medical insurance management in society: insufficient service ability, busy, chaotic and soft, low enthusiasm and efficiency, many loopholes in fund supervision, frequent insurance fraud and so on. In fact, the medical insurance managers are really wronged. The current medical insurance agency was born out of the old staff or the management organization of public medical care, and it did not get an increase in human, financial and material resources with the development of medical insurance system and the increase of coverage population. The proportion of medical insurance handling personnel and insured personnel and the level of handling funds are far lower than those of similar foreign institutions. With the realization of universal health insurance and the further deepening of the reform of medical and health system, the responsibility of medical insurance has gradually shifted from the previous simple fee collection and payment of cashier to the new role of service purchaser, which requires such contents as drug price negotiation, medical insurance physician management, outpatient chronic disease management and so on. At the same time, the medical reform requires medical insurance to play a fundamental role in it, such as the reform of payment methods, the signing service of family doctors, the construction of medical associations, and health poverty alleviation, all of which require the support and implementation of medical insurance agencies. With the increasing complexity and increment of medical insurance management tasks, the whole medical insurance management service is busy, chaotic and soft due to the insufficient investment in handling resources (human, financial and material), the administrative management caused by the institutional nature of participating in public management, and the ensuing problems such as insufficient institutional vitality and insufficient handling capacity. First, with the increase and increasing complexity of business scale, the number and difficulty of transactions handled by medical insurance agencies are increasing, showing an endless state of busyness. Second, the medical insurance agency, as the institution that finally implements the relevant policies on medical service purchase, is controlled by many departments, and there are too many clues. Third, compared with foreign agencies, China's medical insurance agencies have some problems, such as low status, limited management means, insufficient management ability and poor management effect. According to the metaphor of an expert image, the current medical insurance handling business is similar to being in the state of 1 jars and 7 covers, and the jars are still being added at present, so there is a hurry and lack of follow-up management ability. Some local agencies have reported that their own agencies have not increased their establishment for more than ten years, but their work has doubled, and they believe that this situation is very common in agencies all over the country. Although some personnel have been saved through management optimization and service innovation, the operation of the agency is still in a state of barely maintaining, and it is difficult to effectively improve its ability and arrange employees for further study.

third, it is suggested that some experts believe that there are three ways out: first, hand it over to commercial insurance to do medical insurance handling services. The reason for this formulation is that it is generally believed that in a perfect and fair competitive market environment, the commercial operation and enterprise management mode are the most efficient. There are three problems in this road: first, our medical service market is monopolized by public hospitals, and public hospitals are still administrative management systems. Commercial insurance may supervise strong public hospitals with weak social forces, and the effect may be even worse. Second, the people in China have a weak sense of identity with commercial insurance, and the government departments are the most trusted. This should be an indisputable fact. Third, although commercial insurance has been involved in a lot, it has not seen the so-called advantages of commercial insurance. But at least this is a direction. Maybe when the east wind comes and everything is ready, we can sail and sail. Second, transform yourself. At present, the medical insurance agency is more like a government department than a socialized management organization. Some experts believe that this mode of participation in public administration has seriously balanced the service ability and competitiveness of medical insurance agencies. We can consider changing our functions, becoming a truly independent legal entity, giving corresponding human rights and financial rights, and implementing socialized management services. Only in this way can we employ people and encourage them flexibly, release the competitive vitality and adapt to the development needs of the market economy. The third way is the nature of immovable property rights, and the maximum tactical measures may produce miracles: first, promote legislation so that the handling agency can act according to law. Now the cost of defrauding insurance and violating the regulations on the use of medical insurance funds is too low, just like touching porcelain. Many times it is not impossible to find out, but what should I do after finding out? Call the police for insurance fraud? The public security requires the whole chain of evidence, and there is no legal basis for the punishment of fraudulent insurance fraud at present. Deduction or cancellation of the agreement for the two institutions that violate the rules? In reality, we have to face great risks and pressures (acquaintance society, administrative level, personal risk). If we ignore these punishments, will the law not blame the public after the storm? Will the government make peace? Who is the last back-pot man? In the face of a group of insurance fraudsters who are in their seventies and eighties, they may fall to the ground ..... Therefore, the long-term mechanism is to speed up the legislative process and provide clear, firm and smooth support for the handling work at the legal level. The second is to improve policies, standards and agreements so that managers can act according to the rules. The supervision of medical insurance fund needs perfect and clear policies and technical standards as the basis. It is said that people over-treat, but what are the authoritative technical standards and policy basis? It is only reasonable and well-founded to carry out the work. In addition, standardizing medical service behavior should also play the role of the linkage of the three hospitals, so that hospitals can realize the importance of compliance, and reasonable and compliant access to economic benefits is the long-term development path. In the management of the agreement between the two institutions, the responsibility for regulating medical service behavior can be clearly defined to the medical institutions. As long as the irregular and unreasonable medical service behavior causes the loss of medical insurance funds, who should bear the responsibility and then act according to law. The third is to promote information construction and big data application, so that managers can speak with data. Raise the construction of medical insurance information system to a strategic level, establish a unified national social security management service platform, vigorously promote the application of medical insurance big data, and improve the level of intelligent monitoring. Try to change the management of medical insurance from window service to platform service. Just like WeChat and Alipay, services are integrated into life, and there is no trace everywhere (WeChat sealed your number, who are you looking for? )。 Today, with the rapid development of internet plus, big data and artificial intelligence, the construction of medical insurance informatization is promising! The fourth is to strengthen the capacity building of medical insurance management, so that it can win respect with professionalism. It is essential for medical insurance managers to build their own abilities, which determines the competitiveness of medical insurance handling services in the future market. Only when one's own ability is excellent will it not be replaced by a "third party". We can work hard on talent recruitment and business training, and support corresponding incentive mechanisms to avoid letting horses run and not grazing. The fifth is to borrow the power of the "third party" to make the handling work more competitive. We can consider entrusting part of the work to a third party, giving full play to its flexible mechanism and completing the work that is not easy and convenient for government departments to complete. We can consider letting medical institutions supervise each other. After finding out the violation, the supervisor can transfer the corresponding medical insurance quota of the supervised party. You can consider giving full play to the enthusiasm of the insured and reporting prizes. Of course, these are just immature ideas and need to be further explored. Some experts have put forward deeper thinking that this reform involves not only medical services, but also the handling service market. It is necessary to consider the future reform direction, and it is suggested that the future reform idea should be a highly socialized and market-oriented system, in which multiple payers, socialized handling and management are separated, and the medical service market reform is in place and the competitive medical service market is combined; Or choose the mode of single payer, financial management, administrative handling and public and administrative management of medical service market. Of course, many experts believe that the latter model is essentially a publicly-funded medical model that has been proved to have failed before, and it does not conform to the development trend of the national social medical security system and is a retrogression. As we all know, no matter which road is easy, the reform is bound to be full of pain. When there is no quiet time, someone must carry a heavy load. Determination is the most important thing. If we want to achieve the same reform results as Nirvana, we must face challenges, gnaw hard bones and innovate ourselves. Medical insurance handling work may only suffer from the pain of rebirth, in order to achieve a qualitative leap.