The total payment control of basic medical insurance is one of the common means to curb the unreasonable increase of medical expenses. At present, most areas in our country adopt the total amount control method of dividing the total fund expenditure into designated medical institutions according to certain rules at the beginning according to the budget, but there are some negative effects and problems in the implementation process, and the total amount control method of settling the total fund expenditure according to disease points after the trial in some areas has better avoided these problems. Through the comparative analysis of these two typical total amount control methods, this paper puts forward the ways to improve the total amount control of medical insurance payment.

Medical insurance; Total quantity control; Perfect; think

Total payment control of basic medical insurance (hereinafter referred to as total payment control) is one of the common means to control the excessive growth of medical expenses in many countries in the world. Through the budget management of medical insurance fund, the impulse of medical service providers to increase medical expenses quickly can be effectively suppressed, and the stable and continuous operation of medical insurance fund can be realized. In recent years, with the initial formation of China's universal medical insurance system, the coverage population has been expanding, the level of protection has been steadily improved, and the establishment and improvement of the protection mechanism for serious and serious diseases, direct settlement, medical treatment in different places and other convenience measures have been introduced one after another, which has enabled the people's medical needs to be released rapidly, the number of medical visits has increased significantly, and the medical expenses have increased rapidly. In order to ensure the steady and sustainable development of medical insurance, Ministry of Human Resources and Social Security, the Ministry of Finance and the Ministry of Health issued the Opinions on Carrying out Total Payment Control of Basic Medical Insurance, Deepening the Reform of Payment Methods of National Medical Insurance, Carrying out Total Payment Control and Controlling Excessive and Unreasonable Growth of Medical Expenses. However, judging from the trial of total amount control in some areas (such as Baoding, Hebei Province) in recent years, some medical institutions shirk medical insurance patients for various reasons to avoid overspending, and some even simply refuse medical insurance patients; However, in order to increase the next year's budget, some medical institutions also require some mild patients to be hospitalized or give them big prescriptions, and then implicitly take some discordant notes such as medical insurance funds. How to improve the total cost control of medical insurance is a realistic problem to be solved urgently.

First, the connotation of total payment control of basic medical insurance

The total payment control of basic medical insurance refers to the behavior and process that medical insurance institutions determine the total medical expenses that should be paid by the basic medical insurance fund in a period of time through consultation with designated medical institutions according to the income and expenditure budget of the medical insurance fund, and take corresponding settlement methods and incentive and restraint control measures to control unreasonable or excessive growth of medical expenses, improve medical security performance and safeguard the rights and interests of insured patients.

Generalized medical insurance payment control includes controlling the total medical expenses incurred by the insured in designated medical institutions and the insured in non-designated medical institutions (referring to medical treatment in different places other than the insured place) that should be paid by the basic medical insurance fund; In a narrow sense, total control only means that the basic medical insurance institutions control the total medical expenses of designated medical institutions. The total amount control in the practice of medical insurance management mainly refers to the narrow total amount control.

The total payment control of basic medical insurance is not a payment and settlement method for the medical service expenses incurred by the insured patients, but the insured patients pay the corresponding medical service expenses according to the medical insurance policy, and then control the medical service within the corresponding range according to the expenditure budget on the basis of negotiation. The total payment control of basic medical insurance includes several meanings:

First, determine the control target according to the income and expenditure budget of the medical insurance fund. On the basis of the income and expenditure budget of the basic medical insurance fund, the actual payment situation of the regional medical insurance fund in recent years is comprehensively considered, and the expenditure budget is scientifically compiled in combination with factors such as economic development, number of participants, age structure and disease spectrum changes, policy adjustment, and treatment level. After consultation with designated medical institutions and comprehensive consideration of various expenditure risks, the annual total payment control target of medical insurance fund for medical institutions is determined.

The second is to produce corresponding incentive and restraint effects. In order to effectively control medical expenses and standardize the behavior of medical institutions, the key is to establish a scientific incentive and restraint mechanism, so that medical institutions can truly become managers and responsibility bearers of total amount control, thus fully mobilizing the enthusiasm and initiative of medical institutions to control medical expenses.

Third, the purpose of total control is to improve the performance of basic medical insurance. Through total control, medical institutions can be promoted to make rational diagnosis and treatment, carry out self-management and cost control, better protect the basic medical rights and interests of the insured and control their personal burden. Corresponding measures should be taken to prevent some medical institutions from rejecting patients, lowering service standards, falsely reporting service volume and other supporting measures and assessment means in order to avoid overspending or gain surplus, so as to continuously improve the scientificity of medical insurance payment methods and improve fund performance and management efficiency.

Two, the comparison of two typical models of total payment control of basic medical insurance

At present, many medical insurance co-ordination areas in China have implemented the total payment control of medical insurance. There are two typical ways to implement total amount control in various places: one is to decompose the total amount of fund expenditures according to certain rules to designated medical institutions at the beginning of the year, and the other is to settle accounts on schedule according to the total amount of fund expenditures according to disease scores.

(1) At the beginning of the year, the total fund expenditure in the budget will be decomposed into designated medical institutions according to certain rules.

Most areas, such as Shanghai, Hangzhou, Zhejiang, Baoding, Hebei, etc. All of them have adopted the practice of decomposing the total budget fund expenditure into designated medical institutions according to certain rules, of which Shanghai is the most typical and the earliest implementation. The basic process is as follows:

1. Fund budget. At the end of each year, the medical insurance agency shall, according to the actual income of the medical insurance fund in the current year and the expected growth of the income of the medical insurance fund in the next year after retaining the necessary risk reserve and other funds, prepare the budget of the medical insurance fund in the next year according to the principle of fixed income. On the basis of the next year's medical insurance fund budget, according to the situation of the items paid by the medical insurance fund, the hospital's total budget control index is drawn up and implemented after approval.

2. Negotiate and determine the total budget control index of each hospital. On the basis of disclosing the annual fund revenue and expenditure budget, the total hospital budget control index, the total hospital budget control index and the actual implementation, the total hospital budget index is determined through independent consultation ("three rounds of consultation") through the representatives recommended by the hospital (the hospital representatives attending the consultation are elected), combined with the opinions and situations of different hospitals (the basis of hospital consultation is mainly the hospital expenses in recent years).

3. Monthly payment and deferred payment. Medical insurance agencies according to the total annual budget of each hospital control indicators, and according to the month of hospital medical expenses declaration and settlement, the average monthly allocation of funds, the actual cost growth is faster, the higher the proportion of indicators, the month to implement all or part of the suspension of distribution. After the year-end assessment, the part of the actual declared expenses lower than the prepaid amount due to strengthening management and controlling unreasonable expenses shall be retained by the hospital.

4. Adjust the total budget control indicators in the middle of the year. Medical insurance agencies organize district and county medical insurance departments and hospitals to adjust the annual budget indicators of hospitals in the middle of the year to cope with possible changes that affect the budget indicators.

5. Share the year-end assessment. At the end of each year, the municipal medical insurance department shall, according to the opinions of hospital representatives, formulate a budget to manage the year-end liquidation plan. For hospitals whose actual declared expenses do not exceed the annual budget target, the year-end assessment shall not be deducted or apportioned in principle. For hospitals whose annual actual declared expenses exceed the annual budget target, on the basis of evaluating the standardization of hospital diagnosis and treatment behavior and the rationality of medical expenses, taking into account the affordability of the medical insurance fund and the hospital, the medical insurance fund and the hospital will share the over-budget part reasonably in proportion.

6. Practices in other cities. Compared with Shanghai, the difference of total amount control in other regions lies in the determination of hospital quota, which is not in the form of consultation as in Shanghai, but in determining the total budget according to the occurrence of medical expenses in medical institutions in the previous year (most cities adopt this method). For example, Baoding City, Hebei Province set aside 10% of the risk adjustment fund on the basis of the total overall income in the last natural year, and then set aside 10% as the funds for adjustment, off-site reimbursement and outpatient chronic disease reimbursement, and the rest was the total amount pre-allocated. The total amount paid in advance multiplied by the hospital's weight [the' proportion' calculated according to the overall payment (80%), hospitalization expenses (6.67%), number of beds (6.67%), number of registered medical staff (6.67%) and other factors in the previous three years] is taken as the annual prepayment index of this hospital. Redistribute the annual advance payment index of the hospital to each month. When the hospital's overall expenses in the current month are equal to or less than the prepayment index, the overall fund will be settled according to the facts, and the balance index will be transferred to the prepayment index in the next month; When the overall cost of the hospital is greater than the prepayment index of the current month, the overall fund shall be settled according to the prepayment index of the current month. 50% of the balance of funds at the end of the year will be used as the hospital development fund to reward hospitals with prepaid indicators and hospitals that have completed more than 80% of the assessment indicators; Hospitals that exceed the prepayment index meet the requirements of medical insurance, and the part that exceeds the annual prepayment index 10% shall be borne by the hospital and the overall fund respectively; The excess 10% (including 10%) shall be borne by the hospital.

For another example, the total number of hospitals in Hangzhou, Zhejiang Province is based on the final accounts of medical expenses of medical institutions in the previous year and the adjustment coefficient (the adjustment coefficient is determined according to the changes of medical expenses in the previous year and the economic and social development level of this city), and the total budget proposal for that year is put forward, and the opinions of relevant medical institutions are solicited and issued. On the basis of the total budget at the beginning of the year, the medical insurance agencies are decomposed into hospitals on a monthly basis. If the monthly cost is lower than the budget, it shall be accrued according to the actual cost; If it exceeds the monthly budget, it will be planned according to the budget. Annual expenses will be settled at the end of the year. For hospitals whose actual expenses are lower than the budget, the savings will be shared by the hospital and the medical insurance fund. For hospitals whose actual expenses exceed the budget, the overspending will be shared by the hospital and the medical insurance fund. During the period, the medical insurance agency can adjust the budget according to the service volume of the hospital, and the incremental cost of the service will be added to the budget.

(two) according to the total expenditure budget of the fund, according to the disease score settlement.

Huai 'an City, Jiangsu Province, Zhongshan City, Guangdong Province, Nanchang City, Jiangxi Province, Wuhu City, Anhui Province and other places have implemented the payment method of "fixed income, total amount control, and monthly settlement according to diseases". Huai 'an City, Jiangsu Province is the earliest city to implement it. The basic idea is to determine the corresponding score for each disease according to the proportion of different medical expenses required by different diseases, and each designated hospital will settle the expenses according to the budget and the medical insurance fund that can be allocated by the medical insurance agency.

1. Screening for diseases. According to the International Classification of Diseases (ICD- 10), the actual diseases in designated hospitals in recent three years were extensively investigated and counted, and more than 10 cases of actual diseases per year were sorted and summarized as common diseases, and 892 diseases in different departments covering more than 90% of the cases in the city were screened out.

2. Determine the score. Classify and summarize the disease types and cost data of all discharged patients (including non-employee medical insurance patients) in the past three years. According to the historical average level of different treatment requirements and expenses of each disease, the preliminary score of each disease is determined. Experts correct the deviation, and after synthesizing the feedback from hospitals, determine the score of each disease (high "score" for serious illness and low "score" for minor illness). The hospital grade coefficient (that is, the conversion coefficient when calculating the score) is determined according to the proportion of average expenses of various diseases in hospitals of different grades, and the settlement score of each hospital is determined according to the corresponding grade coefficient (the grade coefficients of tertiary, secondary and primary hospitals are 1.0, 0.85 and 0.6 respectively).

3. Total budget. At the beginning of each year, according to the number of insured persons, payment base and other factors, and referring to the use of funds in previous years, the total amount of funds available for distribution in that year is calculated. After 5% of the comprehensive adjustment fund is withdrawn (used for year-end final accounts adjustment), 15% of the total amount is used for specific outpatient items and medical expenses of transferred personnel, and the remaining 70% is used as the total distributable medical expenses of designated hospitals and distributed monthly.

4. Prepaid expenses. At the beginning of the year, according to the actual expenses of designated hospitals in the previous year, combined with the level of grading management assessment of medical institutions, the working capital was prepaid at the rate of 8- 12%.

5. Monthly settlement. Calculate the specific price of monthly points based on the sum of disease points of insured patients discharged from designated hospitals (points converted by corresponding grade coefficients), and settle the medical insurance expenses according to the cumulative points of discharged patients from hospitals.

6. Budget adjustment. Every July, according to the adjustment of payment base and the expansion of insurance coverage, the distributable overall fund is recalculated and adjusted, so that the monthly allocated fund is more consistent with the actual income and expenditure of the fund.

7. Year-end accounts. At the end of the year, according to the actual income of the overall fund, specific outpatient items, medical expenses overruns or balances of people going abroad and transferring to other hospitals, the use of critical cases, long-term inpatients and special materials throughout the year, combined with the implementation of the agreement, we will make final accounts with designated hospitals.

8. Corresponding supporting mechanisms have also been adopted in the specific settlement process. Including: first, the special case single discussion mechanism. In view of the obvious special condition and complicated treatment, hospital representatives and experts will be organized to discuss and determine a reasonable score if there is obvious deviation in the score determined by the first visit after discharge. The second is the collegial mechanism of major cases. For similar disease cases with critical illness, high treatment cost and large difference in settlement by score, experts will re-determine the appropriate score before the year-end final accounts. The third is the compensation mechanism for long-term inpatients. For mental patients who have been hospitalized for a long time, experts will review and confirm reasonable subsidy standards at the time of final accounts. The fourth is the deferred payment mechanism for special materials. For cardiovascular stents, pacemakers, orthopedic special materials and other expensive, easy to abuse, difficult to control medical materials, according to the fund balance at the end of the year to study and solve, so that the use of special materials to meet the needs of the disease. The fifth is the integrity mechanism of scoring control. The disease points will be included in the fixed-point agreement for daily management, and corresponding punishment measures will be taken for "diagnosis upgrade" and "high score" at the time of settlement.

(C) Analysis and comparison of two total control methods

Judging from the implementation of the total payment control of basic medical insurance in some overall planning areas, the total payment control of medical insurance has a high degree of control over the service volume and expenses of medical service institutions, and it is the most reliable and effective way to control medical expenses, and it is also an easy-to-operate cost control method. Although there are some differences in the specific implementation scope and settlement methods, it has achieved results in controlling the growth rate of medical insurance expenditure, standardizing hospital medical service behavior, reducing excessive consumption of medical expenses, and rationally utilizing health resources.

Compared with the above two total control methods, the first control method is relatively simple, and more and more co-ordination areas are used in handling practice. But there are:

First, it is difficult to determine the scientific and reasonable total control quota for each specific designated medical institution. Due to the rapid development of medical technology, the introduction and use of drugs and medical equipment are frequently updated, and the convenience and accessibility of medical services, it is difficult for medical insurance departments to accurately predict the amount of medical treatment in each medical institution, and it is also difficult to determine a reasonable medical institution quota. Excessive budget will lead to unreasonable growth of medical supply; If the budget is insufficient, it will affect the enthusiasm of designated hospitals and the interests of medical insurance patients.

Second, the way to determine the quota at the beginning was not conducive to the competition among medical institutions, but also affected the enthusiasm of designated hospitals to provide medical services and the potential motivation to develop new technologies. Once the total quota is determined, medical service institutions will no longer compete for the market through competition. On the contrary, because the quota is too tight, their service attitude and quality will be affected, and the use of high technology will be restricted, which is not conducive to the improvement of medical technology. In this way, the enthusiasm of medical institutions will be restrained and the pace of technological development will be limited.

Third, medical service providers may blindly save costs and restrain the reasonable medical needs of demanders. In order to save costs, medical service providers may artificially cut services, shirk patients, and artificially delay medical treatment, resulting in the insured being unable to enjoy the basic medical security they deserve, the rights and interests of the insured being damaged, and the reasonable needs of the demanders not being met, resulting in contradictions between the supply and demand sides. Some hospitals take into account the assessment of the number of inpatients and the average cost by the medical insurance agency, and there are phenomena such as decomposing services, limiting services, and shirking serious illnesses. (Limit prescription quantity, increase outpatient quantity, and shirk the high medical expenses of patients, etc. ), or pass the cost burden on to the insured (requiring patients to pay for themselves). In the internal management of the hospital, the hospital simply decomposes the total amount into departments, and turns the "average cost" and "average length of stay" originally calculated according to the law of large numbers into mandatory standards, which infringes on the legitimate interests of the insured.

Compared with the decomposition quota method, the second total control method has the following characteristics:

First, the total indicators are relatively scientific and reasonable, and regional control is coordinated. How to carry out scientific and reasonable inter-hospital distribution under a certain total amount is the key and difficult point in the process of implementing total amount control. When the settlement is based on disease points, under the distributable total budget, it is not distributed in designated medical institutions from the beginning, and the insured person's medical treatment in designated hospitals presents a changing relationship, thus breaking the distribution pattern of the first control mode and creating an atmosphere of fair competition.

Second, medical service behavior is encouraged and restrained. Disease scoring is based on the relationship between the treatment costs of different diseases and the diagnosis, which embodies the principle of "the same disease and the same fee". When there are differences between medical institutions (or diagnosis and treatment groups) in reasonable treatment or overtreatment, reasonable treatment can obtain a distribution that is relatively more than the actual cost; However, those who overtreate can only get a distribution that is relatively less than the actual cost, which reflects the incentive to reasonable treatment and the constraint to overtreatment.

The third is to establish a special case discussion mechanism for special medical service behavior. Due to the complexity and uncertainty of disease treatment, some cases of the same disease are in critical condition and the treatment cost is obviously high. If the settlement cannot provide a channel for this case, even if the hospital carries out necessary treatment from the perspective of saving lives, it will also have dissatisfaction and resistance to the payment system. In view of this situation, we can solve it by organizing experts' special case discussion every month and holding collegiate discussion on critical cases every year, which not only relieves the worries of doctors when treating critical patients, but also effectively solves the problems of shirking patients and decomposing hospitalization.

Three, improve the basic medical insurance payment control measures

Through the analysis and comparison of the above two typical total amount control methods, it can be seen that the total amount control of basic medical insurance is to determine the total amount of funds that can be distributed in the overall planning area according to the principle of "fixed expenditure by income, balance of payments and slight balance", and the difference lies in how to decompose the total budget into designated medical institutions. The first way is to determine the quota of each designated medical institution this year through a certain form (negotiation or according to the corresponding indicators and parameters in previous years) after the total amount of funds that can be allocated in the overall planning area is determined, and then pay it after assessment according to different situations at the time of monthly settlement; The second way is to allocate funds according to the budget according to the number of discharged patients and diseases each month. Take the first method as an overall planning area, no matter how the number of discharged patients in each hospital changes every month, there are so many quotas, and hospitals usually follow the practice of medical insurance departments and further implement the total budget indicators to departments, and some departments further implement them to doctors, and even limit the unit price of prescriptions. In this way, the principle of "law of large numbers" is highly reasonable at the level of overall planning, but the rationality is often reduced when it is distributed to smaller parts. Especially when the method of average distribution is simply adopted, its rationality is even lower. Designated hospitals will inevitably weaken competition, restrict medical care and shift costs, which will have a considerable negative impact on the reform of medical insurance payment system. The second way is to give each hospitalized disease a corresponding score according to the proportional relationship between the medical expenses of discharged patients for treating different diseases, so as to objectively reflect the level and amount of medical expenses, and calculate the total score according to the composition of discharged diseases and the number of discharged patients of each disease every month, representing the service volume of each hospital as the basis for reimbursement and expense settlement. Because there is no quota for hospitals and corresponding departments, there is no reason to restrict medical treatment, such as shirking patients. At the same time, due to the mechanism of special case discussion, there are also solutions for patients with high medical expenses. Moreover, the score does not directly represent the "cost", but only the "weight" used for weighted distribution. The monthly average integral unit price changes dynamically with the number of discharged patients and the severity of diseases, which eliminates the direct correspondence between diseases and expenses, not only effectively controls the total amount, but also makes it easier to form a cost-sharing mechanism when the total amount is insufficient. Therefore, the total payment control of basic medical insurance should consider the following aspects to improve:

(1) Strengthen communication and coordination with designated medical institutions, and enhance understanding and recognition of total amount control.

Medical insurance agencies should strengthen communication, consultation and negotiation with designated hospitals in total amount control, and improve the initiative of designated hospitals in implementing total amount payment. Through communication and consultation, it is beneficial for designated hospitals to fully accept the management requirements of lump sum payment and stimulate their enthusiasm for internal management; It is beneficial to reflect the fairness and scientificity of the budget allocation process of designated hospitals and the rationality of year-end assessment and liquidation; It is helpful to realize the "win-win" effect of the insured, the medical insurance agency and the designated hospital. Consultation and negotiation shall follow the principles of openness, fairness and impartiality, disclose the annual medical insurance fund revenue and expenditure budget and total payment plan to designated hospitals, and fully solicit the opinions of designated hospitals. Through consultation and negotiation with designated hospitals, the standards such as cost standard, service content and assessment index are reasonably determined.

(two) scientific design to determine the hospital quota parameters, and increase the reasonable adjustment range in the settlement.

In order to ensure that medical institutions can implement the basic medical insurance policy and protect the rights and interests of the insured when implementing medical services, there must be a reliable and true basis for the settlement of expenses, and the extensive management currently existing in some areas should be changed into refined management and flexible payment should be implemented. It is necessary to promote the integral settlement method of diseases in conditional areas, and change the focus of total control from specific decomposition quota to medical institutions to total distribution according to the amount of medical services provided by medical institutions in a certain period of time, so as to realize the scientific and reasonable quota of designated institutions; If the conditions are not available for the time being, enough room should be left when determining the total number of medical institutions in order to better adjust the index system. Specific parameters and indicators should include: total fund expenditure, number and age structure of participants, expenditure level of different types and levels of medical institutions, service quality and quantity requirements.

(2) Strengthen incentives and constraints to guide orderly competition.

The key to total control is to establish a scientific incentive and restraint mechanism to effectively control medical expenses and standardize the behavior of medical institutions. Because the focus of medical expenses control lies in the self-management of hospitals, only by fully introducing the competition mechanism can medical institutions truly become the managers and responsibility bearers of total amount control, effectively form an incentive and restraint mechanism, and create an atmosphere of reasonable treatment, rational drug use and "excellent work and excellent income". It is necessary to reasonably determine the sharing ratio between the medical insurance fund and the designated medical institutions for surplus funds and overspending medical expenses, and fully mobilize the enthusiasm and initiative of medical institutions to control medical expenses. At the same time, we should establish a positive incentive mechanism, fully mobilize the enthusiasm of doctors to actively participate in fee control, and strive to seek "the same disease and the same fee" so that the interests of medical insurance, hospitals, doctors and patients tend to be consistent.

(4) Strengthen supervision and management and provide quality services.

Perfect supervision service is the key link to standardize medical behavior. In view of the quality and quantity problems of medical services that may be caused by total amount control, it can not be prevented only by auditing the expenses afterwards. When determining the total budget, we must formulate a set of guarantee indicators to realize the quality and quantity of medical services. By reviewing these service guarantee indicators and cashing in rewards and punishments, we can prevent medical institutions from reducing necessary medical services to reduce medical expenses and damage the rights and interests of insured persons to obtain basic medical security. Specifically, it includes: establishing and improving the standards and management norms of doctors' medical service behavior, and scientifically determining monitoring indicators (such as average cost, follow-up rate, hospitalization rate, population-land ratio, out-of-pocket expenses of insured personnel, referral rate, operation rate, elective operation rate, and proportion of severe patients, etc.). ), improve the medical insurance information system, improve the evaluation method, and encourage the society to participate in supervision through multiple channels and directions. At the same time, it is necessary to strengthen the service for designated institutions and insured patients, and strive to meet their reasonable requirements, especially to smooth the channels of appeal, properly handle exceptional disputes, and establish long-term and sustainable adjustment mechanisms and supporting mechanisms according to the problems found in daily management and the reasonable demands of both doctors and patients, so as to make the settlement model more reasonable and perfect.

;