The Ministry of Human Resources and Social Security, the Ministry of Finance, and the Ministry of Health jointly issued the "Opinions on the Control of the Total Payment of Basic Medical Insurance Payments" in recent days, clarifying that China's medical insurance system will implement full-scale payment control (hereinafter referred to as the "total amount control") within two years and pass reasonable The budget controls the expenditure of medical insurance to make it grow reasonably.

Unreasonable increase in medical insurance costs into reform priorities

With the full coverage of China's medical insurance, the problem of over-expanding medical insurance costs has gradually emerged. In some places, there have even been losses in health insurance funds.

Fudan University Department of Economics, deputy director of the Department of Social Security Research Center researcher Feng introduced the past, hospitals and medical insurance settlement fee is a postpay system, doctor-led costs are profitable; and medical insurance coverage, the patient because of reimbursement, will also be more go to hospital. The former, in particular, is the main cause of excessive medical treatment at the moment. All these will lead to an unreasonable increase in the expenditure on medical insurance and bring risks to the health insurance fund.

The control fee must be based on the last three years of data

Recently, the three ministries and commissions jointly issued the "opinions" to specify that China's medical insurance will implement the total amount of payment control (hereinafter referred to as the "total amount control") within two years, and adopt reasonable budgets to control the expenditure on medical insurance to make it grow reasonably.

The "Opinions" specify the method of cost measurement for total control. That is, based on the historical cost data of fixed-point medical institutions and the budget of the medical insurance fund, it is also reasonable to take into account the rise in medical costs, changes in funds and medical services.

When determining the total amount of control fees, the one-time prepaid premiums paid by the participating units and individuals, the medical expenses incurred by the co-ordinating outside the region, the medical expenses of the retired personnel, and the fixed-point retail pharmacy expenses shall be deducted. Considering various types of expenditure risks in a comprehensive manner, we shall take into consideration the factors such as the level of prices and the level of medical expenses of insured personnel, and determine the annual total control targets for payment by the medical insurance fund.

After the total amount of control fees is determined, it will be further refined into various types of medical institutions. With clear opinions and detailed control cost targets, the data for the past three years shall prevail, which mainly includes service provision and actual medical expenses. Then, according to different levels, categories, fixed-point service scope, effective service volume, as well as the first consultation and referral tasks, the cost of out-patient services and hospitalization will be differentiated and implemented in each designated medical institution.

[Regulatory] to control the situation of public notice

The total amount payment reform will gradually establish a medical service evaluation and supervision system centered on quality assurance, cost control and standardized medical treatment. Control the rapid growth of medical expenses and improve the performance of medical insurance protection.

The reporter learned that some of the places had piloted the total amount of medical insurance payment, but most of them were limited to the medical insurance department and the hospital. The public knows little about the procedures for controlling fees and the effect of controlling fees.

In this regard, this opinion is particularly clear, and the total amount of medical insurance must be regularly disclosed. Its management procedures should be open and transparent, and control and management should be regularly reported to the public.

At the same time, it is necessary to establish a mechanism for consultation between medical insurance agencies and hospitals. When decomposing regional total control targets, opinions from hospitals, relevant industry associations, and representatives of insured personnel were extensively solicited.

In order to avoid the occurrence of obscure operations in the negotiations, the opinions were clear. The medical insurance agency and the hospital did not engage in “one-to-one discussion” with the hospital. The total control indicators determined through consultation must be disclosed to the society in a timely manner.

[Punishment] pushing the patient to withhold the deposit

The purpose of total control is to control medical insurance expenditures through reasonable budgets so that they can grow reasonably. However, there were also some negative effects in the pilot projects in the early stages. Some hospitals either push patients or reduce medical services in order to complete cost control goals.

Regarding this, the opinion puts forward that after determining the total amount of control fees in the hospital, local governments may set aside a certain percentage of quality guarantee funds and year-end liquidation funds. The control fee target is settled on a monthly basis and is reviewed at the end of the year. On this basis, if the quantity or quality of medical services does not meet the requirements, the deposit will be deducted.

In addition, all regions will improve the medical insurance information system, open channels for complaints and complaints, specify monitoring indicators, and strengthen key risk prevention. At the same time, a joint working mechanism for departments has been established to strengthen the investigation and punishment of breach of contract and non-compliance medical behavior.