"We have already conducted tests using data from the second half of 2013 and are going through the bidding process." Peng Weizhong, director of the Employee Medical Insurance Fund Management Center in Changzhou City, Jiangsu Province, told the 21st Century Business Herald reporter at the end of May - in accordance with the relevant requirements of the Ministry of Human Resources and Social Security, all regions

The human resources and social security system must carry out the construction of basic medical insurance and medical service monitoring and data mining systems, and the time limit is the end of 2014.

This is another new way for the human resources and social security system to control medical insurance expenses when the reform of medical insurance payment methods is gradually in trouble.

Through embedded monitoring software, real-time monitoring of medical insurance payments is achieved, promoting the rationalization of diagnosis and treatment, and improving the efficiency of fund use.

The construction of this system will not only greatly enhance the management capabilities of the human resources and social security system for medical insurance, but also increase its weight in the battle for the integration of medical insurance management; the accumulation of basic data and the unification of standards contained in it will also provide a solid foundation for future medical insurance.

Lay a good foundation for third-party management.

However, the idea of ??a human and social system still faces strong competition from medical institutions.

If the public medical system, which is generally in a monopoly position, is not reformed, the role that medical insurance can play will be limited.

Technology forced the Ministry of Human Resources and Social Security to plan and build a basic medical insurance and medical service monitoring system, which started in the second half of 2012.

In February of this year, the "Qinling Incident" that broke out in Shanghai demonstrated in a very dramatic way the consequences of the distorted implementation of the total prepayment system: indiscriminate and frequent evasion of the responsibility to critically ill patients.

However, the medical insurance fund is increasingly stretched, making it difficult to control expenses.

According to Peng Weizhong, there are 1.2 million insured persons in Changzhou’s urban employee medical insurance and urban resident medical insurance. The annual contribution to the medical insurance fund is 2.7 billion to 2.8 billion yuan, and the expenditure is 2.5 billion to 2.6 billion yuan, which is very close to the balance point of the year.

In other parts of the country, there have been frequent reports in the past year or two that medical insurance funds have "bottomed out" that year.

In September 2012, the Ministry of Human Resources and Social Security began to deploy relevant work, and in 2013 issued the "Notice on Issuing the Technical Plan for the Construction of a Medical Service Monitoring System" (Human and Social Security Information Letter [2013] No. 26), requiring all localities to start work as soon as possible.

Represented by 17 pilots including Hangzhou, the medical service monitoring system uses professional software for intelligent review, which can not only increase the processing batch size, but also enable real-time review - Shi Xiaoxiang, deputy director of the Social Security Center in Zhenjiang, Jiangsu Province, a national medical insurance pilot city, told 21st Century Business Herald

According to the reporter, medical insurance has not been able to fully implement real-time monitoring before.

The basic medical insurance medical service monitoring system promoted by the Ministry of Human Resources and Social Security will also build a basic information database for medical insurance, covering more than 400 indicators in 10 categories such as drugs, medical institutions, medical personnel, diseases, and medical treatment settlements, providing a basis for the human resources and social security system to monitor medical insurance.

The refined management lays the data foundation.

This system will also directly benefit the critical illness insurance work promoted by the state.

"The design of the critical illness insurance (Hexun Insurance) system requires a very detailed segmented analysis of basic medical insurance data." said Qian Yingqi, director of the Medical Insurance Settlement Center in Taicang City, Jiangsu Province.

In addition to the aforementioned basic information database, another core content of the proposed basic medical insurance medical service monitoring system for gaming medical institutions is a flexibly configurable monitoring rule database.

The Ministry of Human Resources and Social Security requires that a relatively complete library of monitoring rules be compiled by collecting practical experience in medical service monitoring work in various places and management methods of designated institutions.

It is understood that the monitoring rules compiled by the Ministry of Human Resources and Social Security include monitoring of frequent medical treatment, excessive medical expenses, excessive medication, excessive diagnosis and treatment, repeated diagnosis and treatment, irrational use of drugs, unreasonable admission, fake medical treatment, false medical treatment, and decomposed hospitalization.

There are 241 rules and 294 analysis rules.

However, there will be additions and deletions in various places according to local conditions.

For example, the Jiangsu Provincial Human Resources and Social Security System streamlined the relevant rules to 64, and listed in "Other violations" the number of empty registrations, too many cumulative visits by employees of the hospital, and the provision of outpatient serious disease services by doctors with unqualified qualifications, etc.

Very granular monitoring rules.

In addition to the increase or decrease of projects, the system envisioned by the Ministry of Human Resources and Social Security can also achieve flexible definition of monitoring rules and support multiple parameters such as monitoring objects, business scenarios, time periods, thresholds, medical categories, insurance types, hospital levels, disease classifications, etc.

settings to suit actual local conditions.

According to a reporter from the 21st Century Business Herald, some provincial capitals develop rule libraries in a unified manner, while other places decentralize bidding rights to local governments, with government departments responsible for purchasing commercialized embedded monitoring software.

Regardless of the form, the corresponding monitoring rules are regarded as a powerful assistant by the medical insurance managers of the human resources and social security system.

But outsiders' views on this are not unanimous.

"Jiangsu is just a province, and medication habits are different from north to south." The person in charge of the Jiangsu Provincial Pharmaceutical Business Association said that if the rules are not used well, it will either easily cause disputes or increase the manual review workload of the medical insurance center.

People in tertiary hospitals have more reservations about this new system.

"Its biggest deterrent is that some embedded software can directly deduct non-compliant expenses and refuse to pay them, but medical insurance income only accounts for less than half of our hospital's income." A hospital official from a tertiary hospital in Shanghai

explain.