This is another new measure for human social system to control medical insurance expenditure when the reform of medical insurance payment method is in trouble. The embedded monitoring software can realize real-time monitoring of medical insurance payment, promote the rationalization of diagnosis and treatment, and improve the efficiency of fund use.
The construction of this system will not only greatly enhance the management ability of the human society system to medical insurance, but also increase its weight in the dispute of medical insurance management integration; The accumulation of basic data and the unification of its standards will also lay a good foundation for the future third-party management of medical insurance.
However, the concept of human-social system is still facing the strong game of medical institutions. Without reforming the public medical system which is monopolized as a whole, the role that medical insurance can play will be limited.
Technology reversal management
Ministry of Human Resources and Social Security plans to establish a monitoring system for basic medical insurance services, which was launched in the second half of 20 12. In February this year, the "Qinling Incident" broke out in Shanghai, which showed the distorted consequences of the total prepayment system in a very dramatic way: indiscriminate and frequent shirking of critically ill patients.
However, the increasingly stretched medical insurance fund makes it urgent to control fees. According to Peng Wei, the number of urban workers and urban residents participating in medical insurance in Changzhou is 1.2 million, and the medical insurance fund pays 2.7-2.8 billion yuan and spends 2.5-2.6 billion yuan each year, which is very close to the balance point of that year. In other parts of the country, in the past year or two, the news that the medical insurance fund was "warned" frequently came out.
In September of 20 12, Ministry of Human Resources and Social Security began to deploy relevant work, and in September of 20 13, it issued the Notice on Printing and Distributing the Technical Plan for the Construction of Medical Service Monitoring System (Ministry of Human Resources and Social Security Information Letter [2065438+03] No.26), requiring all localities to start work as soon as possible.
Taking Hangzhou 17 as the representative, the medical service monitoring system adopts professional software for intelligent audit, which can not only improve the batch processing, but also realize real-time audit. Shi Xiaoxiang, deputy director of Zhenjiang Social Security Center, a national medical insurance pilot city, told 2 1 Century Business Herald that real-time monitoring of medical insurance was not fully realized before.
The basic medical insurance service monitoring system promoted by Ministry of Human Resources and Social Security will also build a basic medical insurance information base, covering more than 400 indicators such as drugs, medical institutions, medical personnel, diseases, medical treatment settlement, etc. 10, laying a data foundation for the fine management of medical insurance by the human resources and social security system.
This system will also directly benefit the serious illness insurance promoted by the state. "The design of the critical illness insurance (He Xun Guarantee Insurance) system requires a very detailed breakdown analysis of the data of basic medical insurance." Qian Qiqi, director of the medical insurance settlement center in Taicang City, Jiangsu Province, said.
Game medical institution
In addition to the above-mentioned basic information base, another core content of the proposed basic medical insurance medical service monitoring system is the flexibly configurable monitoring rule base. Ministry of Human Resources and Social Security requested that a relatively complete monitoring rule base be compiled by collecting the practical experience of medical service monitoring in various places and the management methods of designated institutions.
It is understood that the monitoring rules compiled by Ministry of Human Resources and Social Security include 24/kloc-0 monitoring rules and 294 analysis rules, such as frequent medical visits, excessive expenses, excessive medication, excessive diagnosis and treatment, repeated diagnosis and treatment, unreasonable medication, unreasonable hospitalization, false medical treatment and decomposed hospitalization.
However, all localities will add or delete according to local conditions. For example, the Jiangsu Provincial People's Social Security System simplified the relevant rules to 64, and listed very detailed monitoring rules, such as too many empty registration times, too many cumulative visits by employees in our hospital, and unqualified doctors providing outpatient services for serious illnesses.
In addition to the increase or decrease of items, the system envisaged by Ministry of Human Resources and Social Security can also realize the flexible definition of monitoring rules, and support the setting of monitoring objects, business scenarios, time periods, thresholds, medical categories, insurance types, hospital grades, disease classification and other parameters to adapt to the actual situation in various places.
According to the reporter of 265438+20th Century Business Herald, some provincial capitals develop rule bases in a unified way, and some delegate the bidding right to local governments, and government departments are responsible for purchasing commercial embedded monitoring software. No matter what form, the corresponding monitoring rules are regarded as the right-hand man in the people's social system by medical insurance managers.
However, the views of the outside world are not consistent. "As far as Jiangsu Province is concerned, the medication habits of the north and the south are different." The person in charge of the Jiangsu Pharmaceutical Business Association said that if the rules are not used well, it will either easily lead to disputes or increase the workload of manual audit in the medical insurance center.
People in the top three hospitals have reservations about this new system. "Its biggest deterrent is that some embedded software can directly deduct the non-compliant fees, but the medical insurance income only accounts for less than half of our hospital income." A person from a top three hospital in Shanghai said.
Hu Suyun, a researcher at the Shanghai Academy of Social Sciences who has been studying the reform of medical insurance for a long time, believes that medical insurance is not dominant in the game with public hospitals at present, which is not only reflected in the source of funds, but also in the disparity in the matching of human resources. Even if there are technical means to monitor and find some problems in time, the methods, means and efforts to deal with them in time after discovery are an unbearable burden for the human and social departments at present. Therefore, the reform of payment method needs the cooperation of public hospitals' own reform, and also needs the human and social departments to get out of the predicament of poor supervision and law enforcement, which involves the socialized entrustment of medical insurance management affairs.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.