The investigation report on medical insurance can be divided into three parts. First, it can describe the main contents of the survey; Second, it can describe the problems existing in the investigation; Third, we can describe the improvement suggestions for these problems.
Medical insurance survey report 1
In recent years, under the strong leadership of Baoshan Municipal Party Committee and Municipal Government, municipal medical insurance agencies have taken a series of effective measures in the management of designated medical institutions, solved outstanding contradictions and problems, and achieved remarkable results. However, the problems of "difficult to see a doctor" and "expensive to see a doctor" in the reform of medical and health system have not been fundamentally solved. Recently, our city has carried out a study on the influence of medical insurance fund allocation on patients admitted to medical institutions. The relevant information is hereby notified as follows:
I. Investigation and Existing Problems
Through investigation, the city did not find that there was a gap between the quota allocated to designated medical institutions and the expectations of designated medical institutions, which led to the phenomenon that designated medical institutions shirked patients on the grounds of "running out of medical insurance funds". Some medical institutions had the phenomenon that insured patients bought drugs at their own expense during hospitalization, but it was not prominent.
For example: 2065438+at the beginning of June 2007, Yunmou, a retired cadre, reported to Baoshan Medical Insurance Center that he was required to buy * * * meters at his own expense during his hospitalization in the Second People's Hospital of the city from 20 1 19/0/29. According to this clue, Baoshan Medical Insurance Center conducted a field survey on this issue on June 9, 20 17 and June 4 14. Collect patient's medical records, examination and treatment data on site, and interview with medical staff. After investigation and verification, during hospitalization, Yunmou was indeed asked to purchase medical materials at his own expense at the outpatient clinic, and passed on the 6,394 yuan material fee that should have been paid by the medical insurance fund to the patient himself. In this regard, Baoshan Medical Insurance Center ordered the Second People's Hospital to immediately stop illegal activities, strengthen the study of medical insurance policies and service agreements, and demand to effectively improve the management and service level of medical insurance; At the same time, the hospital is required to re-settle the cost of self-purchased materials and return the patient at his own expense of 5434.90 yuan; According to the service agreement, the hospital was fined 24,324.00 yuan for hospital settlement.
Second, the reasons for the problems
Since 2005, the reform of medical insurance payment mode in our city has been carried out in accordance with the requirements of the state and the province. At present, the city has formed a multi-component compound medical insurance payment system for different medical service characteristics. According to the budget situation at the beginning of the year, hospital medical services mainly implement various composite payment methods, such as paying by bed day, paying by disease type, paying by project and paying by DRGs. After years of practice, it has been proved that the payment method of multiple compound medical insurance under the total prepayment system is effective in controlling the unreasonable growth of medical expenses, rationally allocating medical resources and protecting the interests of the insured. However, because the indicators allocated by medical institutions are approved by different levels of departments and doctors in the hospital, some medical staff misunderstand the concept of average indicators as the boundary of individual cases, which leads to the phenomenon that insured patients arrange items that should be paid by medical insurance funds to be purchased at their own expense in outpatient clinics during hospitalization.
Third, the response measures taken
In view of the above situation, the medical insurance agencies in our city take the following measures to prevent the occurrence of related problems:
1, strengthen budget management, and the indicators are scientific and reasonable. Medical insurance adopts the revenue and expenditure management mode of "fixed expenditure by income". When formulating the indicators, it was scientifically approved according to the fund raising situation, social and economic development level and the expenses of designated medical institutions in the past three years. After approval, it will be incorporated into the service agreement for management through the approval of designated medical institutions to ensure the operability of the service agreement.
2. In order to prevent designated medical institutions from refusing to accept patients, shirking patients, reducing services or lowering service standards, or the insured who did not meet the discharge standards from the hospital, through agreement management, the treatment measures were specially formulated for this situation. At the same time, medical insurance agencies use intelligent audit system and daily supervision and inspection of designated medical institutions to find problems in time and effectively curb the occurrence of hospital procurement of drugs during hospitalization.
3. In view of the uncertainty of the occurrence of diseases and the problems caused by the deviation of the approved indicators, our city has introduced a reasonable sharing mechanism for the expenses exceeding the indicators to relieve the worries of medical institutions. In 20 16 years, according to the year-end liquidation results of designated medical institutions, the medical insurance fund will fully bear the excess overall expenses for designated medical institutions whose average overall payment exceeds 10%; For designated medical institutions that pay more than 20% on average, 90% of the over-standard overall expenses shall be borne by the medical insurance fund and10% by the medical institutions; For designated medical institutions that pay more than 30% on average, 85% of the over-standard overall expenses shall be borne by the medical insurance fund and15% by the medical institutions; For designated medical institutions with an average payment of more than 50%, 80% of the over-standard overall expenses shall be borne by the medical insurance fund and 20% by the medical institutions; For designated medical institutions that pay more than 50% on average, 70% of the over-standard overall expenses shall be borne by the medical insurance fund and 30% by the medical institutions.
Four. Comments and suggestions
In view of the irregular problems existing in designated medical institutions, it is suggested that: First, the Health Planning Commission, the People's Social Welfare Institute and other relevant departments should form a joint force, especially the Health Planning Commission should strengthen the management of medical institutions, strengthen the supervision and inspection of medical behaviors, and give corresponding punishments to unreasonable behaviors, and notify them, so as to effectively play the role of "investigating one and educating one"; The second is to increase financial input and enrich the medical insurance fund; The third is to strengthen the guidance of medical treatment behavior of insured persons and implement graded diagnosis and treatment measures; The fourth is to strengthen the capacity building of primary medical institutions, especially township medical institutions, and provide convenient and accessible medical services for the grassroots. (Lin Min)
Investigation report on medical insurance II
Class: Investigation report on rural cooperative medical security system of the Ministry of Labor and Social Security of the Department of Nationalities
Practice theme: Report time of rural cooperative medical security system: 20 14 12.4 Location: Gaosuntang Square, Wanzhou District, City.
The medical insurance system aims to improve the medical situation in rural areas and improve the health level of farmers. The practical benefits brought by the construction of rural cooperative medical system to farmers are obvious, especially the attempt of the new rural cooperative medical system in the vast rural areas and its great achievements. This is an important link in China's economic construction, but the situation of expensive and difficult medical treatment has not completely disappeared, and the defects of the medical insurance system and the problems existing in the implementation process are increasingly exposed. Through investigation, find out the shortcomings of current rural medical security, and put forward relevant suggestions to make it increasingly perfect and serve the people. Keywords: rural areas; Medical insurance; Problems; It is pointed out that China is a big agricultural country, and the agricultural population accounts for more than 60% of the national population. However, the backward rural economic development and rural social security have seriously hindered China's economic development and social stability. Rural medical security has broken through the dead corner of rural social security and is also a new dawn of rural social security. However, rural medical insurance is in the early stage of development, and there are many problems, which will inevitably hinder its development process. The purpose of this paper is to explore its causes and put forward suggestions to solve the problems, so as to make it more perfect, serve the people and promote the better and faster development of our economy. First, the emergence and development of rural cooperative medical system in China
Theoretically speaking, the rural cooperative medical system is a comprehensive medical security measure that mainly relies on the strength of community residents and raises funds in various ways within the community according to the principle of "sharing risks and helping each other" to pay for the medical, preventive and health care services of the insured and their families. China's rural cooperative medical system has its own development footprint, and it is also an inevitable choice under China's special national conditions. The World Health Organization once said in a report, "The formulation of primary health personnel was mainly inspired by China. The people of China have established a successful primary health care system in rural areas, accounting for 80% of the population, providing people with low-cost and appropriate medical and health technical services and meeting the basic health needs of most people. This model is very suitable for the needs of developing countries. " The development course of rural cooperative medical system in China is: 1. The emergence of cooperative medical system can be traced back to War of Resistance against Japanese Aggression, when the medical and health undertakings were held in the form of "cooperatives", which was actually the bud of a rural medical security system. In the early days of the People's Republic of China, due to limited resources, the principle of differential treatment between urban and rural areas was chosen, that is to say, most farmers in rural areas were basically separated from the national social welfare system, and farmers who lacked medical care and medicine took the form of spontaneous mutual assistance to solve medical problems. The mutual aid and cooperative medical system officially appeared in rural areas of China at the climax stage of 1955 rural cooperation. In some places, such as Shanxi and Henan, health stations organized by rural production cooperatives have appeared, and the method of combining members' "health care fees" with subsidies from production cooperatives' public welfare funds has been adopted, and the masses have raised funds for cooperative medical care and implemented mutual assistance. At the beginning of 1955, Mi Shan Township, Gaoping County, Shanxi Province established the first medical and health care station in China, which realized the farmers' desire of "preventing diseases early, making paper with diseases, saving labor and money, being convenient and reliable". 12. Promotion and development of cooperative medical system After the Ministry of Health affirmed the practice of Mishan Town, its experience was promoted in some parts of the country. 1959165438+1October, the Ministry of Health affirmed the form of rural cooperative medical care at the national health work conference, which promoted its further rise and development. 1960 in February, the central government affirmed the cooperative medical care as a medical form, and forwarded the report of the field meeting of rural health work of the Ministry of Health, making this system a collective medical system. 21960 may 18 "health news" affirmed this method of financing medical system in its editorial "actively promoting the basic medical system", which played a certain role in promoting the development of rural cooperative medical system in China. At this time, the cooperative medical system organized by the National Agricultural Production Brigade has reached 40%. "The emerging rural cooperative medical system has been vigorously promoted. According to the statistics of the World Bank (1996), the cost of cooperative medical care only accounted for about 20% of the national health expenditure, but it initially solved the medical problem of 80% of the rural population at that time. By 1976, about 90% administrative villages in rural areas of China have implemented the cooperative medical system. 3. The decline of cooperative medical system
At the end of 1970s, due to the economic system reform with household contract responsibility system as the main content in rural areas, a two-tier management system combining unification and separation was established, and the original social organization form of "one hospital, two schools" and "team-oriented" disintegrated, and the rural cooperative medical system also declined greatly. Statistics from 65438 to 0989 show that only 5% administrative villages continue to adhere to the cooperative medical system. three
Second, the status quo and problems of rural medical insurance
(A) the status of rural medical insurance
1. The rural security level is low. The agricultural population in China accounts for 63.9 1% of the total population in China. In rural areas 100 people, only 12 people enjoy commercial or social medical insurance to varying degrees, and the figure in large and medium-sized cities is 54. Since the social security reform was officially implemented in 1999, 10895 million people have benefited, of which nearly 65% are employees and retirees of urban enterprises, while the social security rate enjoyed by farmers is extremely low, and the coverage rate of serious illness medical insurance, which is the largest social pooling among various commercial and social insurances, is less than 20%. Moreover, 79% of farmers in rural areas pay for medical treatment at their own expense, and the level of protection is low. It is not enough for China to develop social security only in cities. Let farmers enjoy social security is one of the important links in China's economic construction.
2. Insufficient investment in rural areas and large gap between urban and rural areas. Over the years, we have been following the idea that economic and social development is tilted towards cities. For a long time, the allocation of urban and rural health resources in China is unbalanced, and 70% of the rural population only occupies 30% of the health resources. The rural medical insurance fund is seriously insufficient. With the development of rural tax and fee reform, the local finance is tight, the collective economy of many villages is little, the subsidies to rural health institutions are reduced, and rural health resources will be more scarce.
3. The phenomenon of "poverty due to illness" is serious. At present, in the vast rural areas of China, the supply of medical services is gradually marketized, the self-funded medical system is still dominant, and the cost of rural medical services is rising. "Poverty due to illness" and "difficulty in seeking medical treatment due to illness" are not accidental phenomena in rural areas, and farmers are worried about seeing a doctor. In recent years, the increase of farmers' medical expenses has exceeded the increase of farmers' actual average income. Many farmers have been unable to bear the increasing medical expenses, forming a general situation of "relieving minor illness and resisting serious illness". The contradiction of rural medical and health security in China is prominent, and the rural medical insurance system must be reformed, otherwise the management and control of rural medical and health work such as family planning, infectious diseases and epidemics will face severe challenges. A lot of theoretical research and practical experience show that it is imperative to establish a new rural cooperative medical insurance system.
4. The new rural cooperative medical system has great defects.
First of all, farmers who lack incentive mechanism are not enthusiastic about participating in insurance, because the new rural cooperative medical system aims at coordinating serious illness, mainly to solve the medical burden of serious illness for farmers. Being seriously ill is accidental. Therefore, farmers are unwilling to participate in the overall planning because of the small probability of suffering from serious illness. Secondly, there are loopholes in management and insufficient fund raising. In some places, there are practices that violate the relevant policies and pilot guiding principles of the central government on the new rural cooperative medical system. In addition, ignoring regional differences has caused the problem that farmers at different levels cannot meet the medical insurance.
(B) China rural medical insurance problems
The legal construction of the new rural cooperative medical system lags behind. In China, 80% of the population lives in rural areas. China's stability depends on this 80% stability. No matter how beautiful the city is, it is impossible without the foundation of rural stability. In June 20 14, the Central Committee and the State Council issued the Decision on Further Strengthening Rural Health Work, which also clearly pointed out: "Rural health work is the focus of China's health work, which is related to the overall situation of protecting rural productive forces, revitalizing rural economy, maintaining rural social development and stability, and is of great significance to improving the quality of the whole nation."
Investigation report on medical insurance III
Director, deputy directors and members:
According to the work points and monthly arrangement of the Standing Committee of the Municipal People's Congress in 20 17, on May 10, Hong Xiubo, deputy director of the Standing Committee of the Municipal People's Congress, led some members of the Standing Committee of the Municipal People's Congress and members of the Legal Committee to investigate the operation of the medical insurance fund in our city, and made on-the-spot visits to the Municipal Hospital of Traditional Chinese Medicine and the Municipal Medical Insurance Bureau, and listened to the report of the Municipal People's Social Security Bureau on the operation of the medical insurance fund in our city and had a discussion. The relevant information is hereby notified as follows:
I. Basic information
The basic medical insurance system in our city is mainly composed of three parts: the basic medical insurance for urban workers (hereinafter referred to as employee medical insurance), the original basic medical insurance for urban residents (hereinafter referred to as the original residents' medical insurance) and the original new rural cooperative medical system (hereinafter referred to as the original new rural cooperative medical system).
(1) Employee medical insurance. There are 8 1.500 people in the city, with a participation rate of 96.47%. In 20 16, the fund income was 239,639,700 yuan, the fund expenditure was144,637,800 yuan, the current fund balance was 9500 190,000 yuan, and the accumulated balance was 308,008,200 yuan, which can guarantee19 months.
(2) Medical insurance for indigenous residents. The number of participants in the city is 120900, and the participation rate is 100%. In 20 16, the fund income was 62,593,300 yuan, the fund expenditure was 54,896,300 yuan, and the current balance of the fund was 7,697,000 yuan, with a cumulative balance of148,848,800 yuan. The accumulated balance of the fund can be guaranteed for 22 months.
(3) The original new rural cooperative medical system. There are 707,800 participants in the city, and the participation rate is 100%. In 20 16, the fund income was 382,204,400 yuan, the fund expenditure was 362,343,200 yuan, and the current balance of the fund was 2,932,500 yuan, with a cumulative balance of11759,940 yuan.
Second, the main practices
Since the implementation of the reform of the basic medical insurance system in our city, the Municipal People's Social Security Bureau has strictly implemented the "two lines of revenue and expenditure" and the financial management system for special funds and special accounts, and adopted the operating mechanisms of separation of revenue and expenditure, separation of management and management, separation of money and accounts, and separation of use and allocation, which standardized and improved the financial management model and ensured the safe and stable operation of the fund.
(1) Strengthen fund supervision to ensure the safe operation of funds. First, implement fund-level settlement to reduce fund income and expenditure links; Strengthen the early warning analysis of statements, strengthen the management and control of fund operation, and effectively prevent and resolve the risk of fund operation. The second is to revise and improve the management rules and regulations of medical insurance audit and settlement, and sort out and standardize the procedures for reporting and reviewing various examination and approval items. The working mechanism of "vertical responsibility and horizontal supervision" has been implemented, and an internal control system with clear responsibilities from income to expenditure and from competent leaders to employees has been established.
(2) Deepen the reform of medical insurance and solve the problem of fund operation. First, the fund management mode of "single disease fixed settlement under total control" was created, and the "fuzzy" management was changed into "actuarial" management, which further improved the settlement management of medical insurance fund in our city. The second is to establish a standardized, real-time and safe medical insurance information system, and realize the real-time transmission of medical insurance business data. At the same time, it signed an online instant settlement agreement with 78 designated medical institutions in the province, and implemented a "five-working-day settlement system", which simplified the process of transferring insured patients to hospitals (outpatient clinics) and outpatient and emergency departments, and solved the problem of "more expenses and complicated reimbursement" for medical treatment in different places.
(three) strict institutional management, standardize the services of designated institutions. Take the management mode of signing an "agreement" with designated medical institutions every year, and make quantitative assessment with a percentage system. At the same time, strictly control the "three customs" and strengthen the management of hospitalization behavior, that is, manage inpatients well and put an end to imposters; Keep the hospitalized diseases well, and strictly implement the management standard of single disease quota settlement; Properly implement the "three catalogues", focus on checking the implementation of designated medical institutions, and effectively avoid the loss of medical insurance funds. In recent years, * * * investigated and dealt with 56 cases of daily necessities in designated retail pharmacies, 65,438 cases of prescription, random inspection and overcharge in designated medical institutions, 38 cases of broken hospitalization and bed hanging hospitalization, and recovered the loss of medical insurance fund of more than 3 million yuan.
(4) Establish a long-term mechanism to combat medical insurance fraud. First, a video surveillance system was installed in all designated pharmacies of chronic disease clinics in the city to check the placement and sales of drugs in real time. The second is to establish a long-term mechanism for prevention and control. Anyone who finds that a designated medical institution has violated discipline and discipline will be punished according to the seriousness of the case, and all the incomes from fines and confiscations will be included in the medical insurance pooling fund. Third, the designated medical institutions and retail pharmacies in the city have set up special telephone numbers and mailboxes to report complaints, investigate the clues of cases reflected by the masses one by one, and report them in real names 100% feedback. The fourth is to start the online monitoring system of medical service behavior, further standardize the medical service behavior of medical insurance, realize the functions of pre-warning, in-process warning and post-event inspection, and ensure the safe and effective operation of the fund. In 20 16, * * investigated and dealt with 13 designated medical institutions and 52 designated retail pharmacies, involving an amount of 1369600 yuan, and all of them were recovered to the medical insurance fund.
(5) Pay close attention to team building and improve the management service level. First, the system of "study lecture hall" and "study examination" is implemented, and various forms such as taking charge of leaders and taking turns among departments are adopted to comprehensively improve the comprehensive quality of political work of all cadres and workers. Second, the first inquiry responsibility system, the time-limited completion system, the accountability system and the "window star" selection activity were fully implemented, which further improved and improved the work style, service awareness and efficiency. The third is to set up special consultation telephones and mass suggestion boxes, announce supervision telephones, accept social supervision, continuously improve service levels, and ensure the scientific, standardized and orderly development of medical insurance work.
Three. Existing problems and difficulties
(1) It is difficult to raise expansion funds. First, most non-public economic organizations belong to small and micro enterprises, with a small number of employees, short employment period, great mobility, irregular establishment of labor relations and great difficulty in expanding their scope. Second, some enterprises are in recession, with serious losses and arrears. Third, some units and employees do not have a strong sense of participating in insurance, the legal representatives pursue their own interests excessively, and the enthusiasm of employees for participating in insurance payment is not high.
(2) The medical expenses outside the city are difficult to control. The hospitalization expenses of designated medical institutions in our city adopt the management mode of "single disease fixed settlement under total control", while the hospitalization expenses of provincial designated medical institutions still adopt the management mode of "factual settlement", and the lack of effective regulation and supervision means leads to the increase of hospitalization expenses outside the city and the increase of fund operation risk year by year.
(3) The medical insurance payment policy needs to be improved. Flexible employees need to pay medical insurance 1.782 yuan per year, while urban and rural residents only need to pay 1.2 yuan per year. The difference of individual payment standards is nearly fifteen times, which leads to the continuous flow of flexible employees who participate in employee medical insurance to urban and rural residents' medical insurance, resulting in the continuous decrease of the number of employees who participate in medical insurance and the weakening of the fund's ability to resist risks.
(4) There is a serious shortage of working funds. First, the personnel funds and daily office funds are insufficient. After the integration of the original medical insurance bureau and the original new rural cooperative medical system, the number of staff will increase to 74, and the personnel funds and daily office funds are seriously insufficient in 20 17. Second, the medical insurance network transformation and maintenance costs are insufficient. According to the requirements of the provincial government, the city needs to integrate the basic medical insurance information management system for urban and rural residents, transform the telemedicine network settlement platform, and establish a four-level management service information system covering cities, towns, townships and villages. The budget has been included in the budget, which is far from the required expenses.
Four. Comments and suggestions
(a) to further improve the ideological understanding, strengthen the implementation of responsibility. Medical security is an important part of the social security system and the focus of people's concern and social concern. Relevant departments should further raise awareness, people-oriented, convenience-oriented, strengthen responsibilities, pay close attention to implementation, and ensure the safe and effective operation of medical insurance funds.
(2) Further establish and improve the mechanism and strengthen the supervision of funds. According to the medical insurance policy and actual work, improve the working system, standardize working procedures, and improve work efficiency and service quality; Strengthen the supervision and inspection of designated hospitals and pharmacies, find problems in time and put an end to loopholes; Intensify the investigation and punishment of crimes of defrauding funds according to law to ensure the safe and efficient operation of funds.
(three) to further strengthen the collection measures, expand the fund collection. It is necessary to establish an overall linkage working mechanism led by the human and social departments, with the cooperation of relevant departments and the participation of the whole society, and promote the continuous deepening of medical insurance collection and payment. It is necessary to innovate propaganda ideas and methods, increase propaganda efforts, improve the broad masses of people's understanding of laws, regulations and policies related to medical insurance, accelerate the extension of urban medical insurance to non-public economic organizations and all kinds of employed people, and achieve full coverage.
(four) to further improve the medical insurance policy, improve the level of medical security. According to the actual situation of medical insurance in this city, the collection standard of medical insurance, the scope and standard of medical reimbursement should be adjusted reasonably and timely. It is necessary to explore the "seamless connection" between urban workers' medical insurance, urban and rural residents' medical insurance, serious illness medical insurance and medical assistance policies, improve the medical security policy system and improve the level of medical security.
(five) to further strengthen the team building, improve the level of management services. It is necessary to speed up the construction of medical insurance information system engineering and comprehensively improve the information management level of medical insurance. To speed up the construction of agencies, work funds will be included in the fiscal budget at the corresponding level, and the staffing of medical insurance agencies will be fully equipped. At the same time, it is necessary to constantly improve the sense of responsibility and work level of staff and improve the level of management services.
The above is what Bian Xiao shared today, and I hope it will help everyone.