Where is the reform of medical insurance payment?
Implement a variety of composite medical insurance payment methods.
For in-patient medical services, it is mainly paid according to the relevant population of diseases and disease diagnosis, and long-term and chronic in-patient medical services can be paid according to bed days.
For primary medical services, we can implement per capita payment and actively explore the combination of per capita payment and chronic disease management.
For complex cases and outpatient expenses that are not suitable for package payment, they can be paid according to the project.
Explore payment methods that meet the characteristics of Chinese medicine services and encourage the provision and use of appropriate Chinese medicine services.
Pay attention to paying by disease.
Gradually include day surgery and qualified outpatient treatment of Chinese and western diseases into the scope of payment of medical insurance funds.
Establish and improve the negotiation mechanism, based on the past cost data and the payment ability of the medical insurance fund, and on the basis of ensuring the curative effect, scientifically and reasonably determine the payment standards for diseases of Chinese and Western medicine, and guide the use of appropriate technologies.
Do a good job in linking up the charging and payment policies according to diseases, and reasonably determine the charging and payment standards, which shall be shared by medical insurance funds and individuals.
Carry out a pilot program to pay for groups related to disease diagnosis.
According to the severity of diseases, the complexity of treatment methods and the actual level of resource consumption, diseases are grouped, and the openness, logic and basic rate of grouping are adhered to.
With the support of disease diagnosis related grouping technology, we can measure and evaluate the diagnosis and treatment cost and curative effect of medical institutions, strengthen the horizontal comparison between different medical institutions in the same disease group, and improve the medical insurance payment mechanism by using the evaluation results.
Gradually use people related to disease diagnosis for actual payment and expand the scope of application.
All medical expenses, including medical insurance fund and individual payment, are included in the tour fee and payment standard related to disease diagnosis.
Improve the payment methods such as paying by head and paying by bed day.
All co-ordination areas should clarify the scope of basic medical service package based on per capita payment, and ensure the payment of drugs, basic medical service fees and general medical treatment fees in the medical insurance catalogue.
Gradually from diabetes, hypertension, chronic renal failure and other chronic diseases with clear treatment standards and evaluation indicators, special chronic diseases will be paid per head.
Conditional areas can explore the payment of the contracted residents' outpatient fund to grassroots medical and health institutions or family doctors. If the patient is referred to the hospital, the primary health care institution or the family doctor team will pay a certain referral fee.
For mental illness, hospice care, medical rehabilitation and other diseases that require long-term hospitalization and the average daily cost is relatively stable, you can pay by bed day, and at the same time strengthen the assessment of the average hospitalization day, average daily cost and treatment effect.
Strengthen the supervision of medical insurance on medical behavior
According to the functional orientation and service characteristics of various medical institutions at all levels, a scientific and reasonable evaluation system is classified and improved, and the evaluation results are linked to the payment of medical insurance funds.
The assessment indicators of Chinese medical institutions should include the proportion of Chinese medicine services.
Conditional local medical insurance agencies can prepay a part of the medical insurance fund to medical institutions as agreed, so as to ease the pressure on their capital operation.
How to reform medical insurance payment?
Strengthen the budget management of medical insurance fund
Accelerate the disclosure of final accounts of medical insurance funds.
The workload reasonably increased by medical institutions that exceed the total control index can be compensated according to the agreement and assessment.
The total control index should be appropriately tilted to the primary medical and health institutions and children's medical institutions, and the formulation process should be made public to medical institutions, relevant departments and the society according to regulations.
Conditional areas can actively explore the integration of integral method with total budget management and payment according to diseases, and gradually replace the total control of specific medical institutions with the total control of regional (or a certain range) medical insurance funds.
Improve medical insurance payment policies and measures
Strictly regulate the responsibility boundary of basic medical insurance, and the basic medical insurance focuses on ensuring the expenses related to drugs, medical services and basic service facilities that meet the principles of "clinical necessity, safety and effectiveness, and reasonable price".
Public health expenses, physical fitness or health care consumption that are not directly related to disease treatment shall not be included in the scope of medical insurance payment.
All localities should give full consideration to the ability of medical insurance fund to pay, the overall social affordability and the personal burden of the insured, adhere to the principle of basic security and shared responsibility, and adjust the treatment policy in accordance with the prescribed procedures.
Combined with the grading diagnosis and treatment mode and the construction of family doctor contract service system, the insured will be guided to give priority to the first visit at the grassroots level, and the deductible line can be continuously calculated for eligible inpatients, and the qualified family doctor contract service fee will be included in the scope of medical insurance payment.
Explore the implementation of the division of labor mode such as the total payment of medical insurance in the vertical cooperative medical consortium, reasonably guide the two-way referral, and give play to the role of family doctors as "gatekeepers" in controlling medical insurance costs.
Encourage designated retail pharmacies to ensure the supply of drugs for chronic diseases, and patients can freely choose to buy drugs in medical institutions or buy drugs in medical institutions with prescriptions.
Cooperate to promote the reform of medical and health system
Carry out clinical pathway management to improve the transparency of diagnosis and treatment.
Promote mutual recognition of physical examination results of medical institutions at the same level and reduce repeated inspections.
Establish an information disclosure mechanism for the efficiency and expenses of medical institutions, regularly disclose indicators such as expenses and patient burden levels, accept social supervision, and provide reference for the insured to choose medical treatment.
Standardize and promote multi-point practice of medical staff.
In short, this medical insurance reform is a policy that benefits the people and the people.