Unprecedented reform efforts, medical insurance so "warm" your and my life!
2022-01-22
"It's great to use this medicine!" In 2022, on the first day of the new year, in the inpatient department of Neurology of Henan children's Hospital, a child with congenital spinal muscular atrophy (SMA) less than 3 years old was being treated with sodium nosinogenase injection. The child is being treated with sodium nosinogenase injection. From nearly 70000 yuan to tens of thousands of yuan, nosinasheng sodium injection entered the medical insurance, which greatly reduced the medical burden of children. "Now you can cure the disease, and the child has hope." The child's mother's words reveal a beautiful vision for the future. This is only an epitome of China's more sense of gain for the people in the field of medical insurance. *** He stressed that we should continue to strengthen the reform of medical insurance, normalize and institutionalize the centralized purchase of drugs, improve the medical insurance and relief system for major diseases, deepen the reform of the supervision system of medical insurance funds, and keep the people's "life-saving money" and "life-saving money". In 2021, the reform in the field of medical insurance was unprecedented, the burden of drug consumption was significantly reduced, the experience of cross provincial and remote medical treatment was steadily improved, and the "medical treatment money" and "life-saving money" were safer. In order to meet the more expectations of the people, China is writing more warm "health answers" with the "pen of innovation". The effect of "combined price reduction" has been released, and the drug burden of the masses has been continuously reduced "Every small group should not be abandoned" "It's really hard. In fact, just now I thought my tears were falling." —— Zhang jinni, negotiator of the national medical insurance bureau and director of the procurement supervision department of pharmaceutical equipment of Fujian Medical Insurance Bureau On November 11, 2021, the negotiation site of medical insurance catalogue. At the end of 2021, a video of the drug negotiation site of the national medical insurance catalogue was hot on the Internet. After two rounds of 9 negotiations by the medical insurance department, the price of nosinasheng sodium injection was finally traded at the price of tens of thousands of yuan per needle. Previously, the drug was called "sky high price drug" because one needle was priced at 699700 yuan. Patients need to inject four needles in the first 63 days and one needle every four months. It is used for life, and the price is high. In order to enable people to use good drugs with high quality and low price, since the establishment of the National Medical Insurance Bureau in 2018, the medical insurance drug directory has been dynamically adjusted once a year for four consecutive years, and 507 new drugs and good drugs have been included in the directory. Patients' medical treatment and use of drugs are more and more guaranteed. In 2021, on the basis of increasing innovative drugs and antitumor drugs, the "zero breakthrough" of bringing high-value drugs for rare diseases into medical insurance was realized. Li Tao, deputy director of the state medical security administration, introduced that in 2021, a total of 7 rare disease drugs were successfully negotiated, with an average price drop of 65%. At the same time, the centralized procurement of drugs with volume is gradually normalized and institutionalized. Since the opening of centralized drug procurement in "4 + 7" pilot cities in Shanghai in December 2018, the national drug joint procurement office has successively organized 6 batches and 7 rounds of national centralized procurement. The average price reduction of "centralized purchase" of drugs is more than 50%, and the average price reduction of "centralized purchase" of consumables is more than 80%, which has reduced the burden of the masses by more than 250 billion yuan. In March this year, the varieties of artificial total knee joint and artificial total hip joint will also be launched nationwide, with an average price reduction of 82%. It is expected to benefit nearly 11 million patients and reduce the burden by nearly 30 billion yuan per year. "Under the principles of safety, effectiveness and economy, the medical insurance catalogue adjustment in 2021 will include more high-quality and low-cost drugs. At the same time, the centralized volume procurement of drugs has become a norm. Through the 'combination fist' of centralized volume procurement and directory access negotiation, the drug burden of the masses has been significantly reduced." Wang Zhen, a researcher at the Institute of economics of the Chinese Academy of Social Sciences, said in an interview with people.com. Direct settlement of medical treatment in different places makes reimbursement no longer "rush" "There is always a headache. You only need to click your mobile phone to complete the cross provincial and non local reimbursement." In order to take care of her granddaughter, aunt Han came to Beijing from Shanxi, more than 600 kilometers away. She praises everyone. It's really convenient to use the medical insurance service platform app for medical treatment and reimbursement. It can also switch to "care version", which is easier to operate. The national medical insurance service platform app launched the "care version" to facilitate the elderly. In recent years, with the large increase of people living in different places, retiring in different places and working in different places, especially the growing group of elderly people moving with their children, there is a higher demand for direct settlement of medical treatment in different places. Focus on the medical settlement needs of 125 million inter provincial floating population, and further promote the reform of "release, management and service" in the field of medical insurance. Since 2021, the National Medical Insurance Bureau, together with relevant departments, has consolidated and expanded the achievements of inter provincial direct settlement of hospitalization expenses, and comprehensively promoted the inter provincial direct settlement of outpatient expenses. At present, the direct settlement service of cross provincial and non local medical and hospitalization expenses has covered all provinces, all overall planning areas, all kinds of insured personnel and main expatriates in China, connected 52900 networked designated medical institutions, and basically achieved the goal of full coverage of designated hospitals and at least one networked designated hospital in each county. At the same time, the direct settlement of general outpatient expenses across provinces has been accelerated. From fully opening up the pilot areas in the five provinces of Beijing, Tianjin, Hebei, Yangtze River Delta and southwest China to adding 15 provinces such as Shanxi as the pilot provinces, it has shifted from regional pilot to comprehensive promotion. By the end of November 2021, all provinces and Xinjiang production and Construction Corps have started direct inter provincial settlement of general outpatient expenses, covering 97.6% of the overall planning areas of the country, and there are more than 120000 networked designated medical institutions, 91.7% of the counties in China have at least one networked designated medical institution. "From the current promotion situation, there are no institutional and policy obstacles to the direct settlement of outpatient or inpatient medical treatment in different places." According to Wang Zhen's analysis, in terms of the management of medical insurance fund, there are no problems such as the rapid rise of medical expenses in different places and the impact on medical order after direct settlement, which benefits from the fine management of direct settlement of medical treatment in different places and the construction of information system. Ying Yazhen, vice president of the National Medical Security Research Institute and vice president of the China Medical Insurance Research Association, said that the main progress in promoting the remote settlement of medical insurance is reflected in: the inter provincial direct settlement system of hospitalization expenses covering the whole country runs smoothly and is becoming more and more mature; The number of effective filings on the national platform continues to increase and the scope of benefits continues to expand; Carrying out the settlement of medical insurance in other places is conducive to promoting the construction of medical insurance standardization; It is conducive to gradually improve the overall level of medical insurance. "Now, there are still some technical problems. For example, there are still blocking points in the direct settlement of outpatient services, and there are still problems in the actual settlement process of some connected medical institutions." Wang Zhen suggested to further open up the information system and improve the flexibility and convenience of filing. "We should also strengthen the connection and cooperation between insured places and medical treatment places, and between medical insurance departments in terms of medical insurance policies and handling management. In particular, we should strengthen joint supervision, prevent excessive medical treatment in the process of medical treatment in different places, and ensure the safety of medical insurance funds." Ying Yazhen stressed. The reform of payment method helps the tripartite win-win situation of "medical insurance patients" Once in the speech contest on the experience of medical reform held in Sanming City, a dean told a story of two invoices: "the same two hospitalization invoices of 30000 yuan were paid 70% at their own expense 10 years ago, 30% at their own expense, and the patients spent 21000 yuan; 10 years later, 30% at their own expense, 70% at their own expense, and the patients spent 9000 yuan."—— Sanming, Fujian, is known as one of the cheapest places for people to see a doctor in China. For a long time, China's traditional medical insurance payment method is to pay by project, that is, according to all drugs, medical service items and medical consumables used in the diagnosis and treatment process, how much the hospital uses in the diagnosis and treatment process, and how much the medical insurance and patients pay according to the proportion. Under this mode, excessive medical behaviors such as "big prescription" and "big inspection" may occur, which not only causes a waste of medical resources, but also makes the insured spend more money and the medical insurance fund spend more. In 2017, Sanming was selected as one of the three pilot cities of the national "collection and payment reform by disease diagnosis related group (c-drg)". For the first time in the country, medical insurance and patients and hospitals were settled according to the disease quota at the same time, without a starting line. The medical insurance fund was reimbursed 70% and 80% according to the disease quota, and the individual self payment was 30% and 20% respectively. Through reform, medical institutions at the same level, urban workers and urban and rural residents have achieved "the same disease, the same treatment, the same quality and the same price". Medical reform billboard in front of Youxi County General Hospital, Sanming City, Fujian Province. The effect of the reform is obvious. In 2020, there were 229600 discharged cases from medical institutions above the county level in Sanming City, of which 187300 were settled according to DRG, with an enrollment rate of 81.58%. The medical insurance fund contracted the cost balance of 69.71 million yuan according to the disease quota, effectively reducing the medical cost. Summing up the experience of Sanming, Fujian Province, combined with its own actual situation, based on the DRG collection and payment reform, has explored a reform road of "pay by disease score (DIP)" by using big data technology, so as to promote the development of medical insurance along the track of high quality and refinement. On the basis of the pilot in the early stage, the National Medical Insurance Bureau has launched two new payment modes: DRG and dip at the end of 2019 and 2020. As of October 2021, the actual DRG payment in 30 pilot cities has covered 807 medical institutions. "DRG / Dip payment reform highlights the value of medical care, which is bound to have an impact on hospitals, medical insurance and patients." Wang Zhen told reporters that in terms of hospitals, the operation mechanism under the previous payment by project has been changed from "seeing a doctor" to patient health; The more you see a doctor, the more money you make, and gradually turn to the healthier patients, the more money you make. In terms of medical insurance, from project management to "value" management, post supervision to simultaneous supervision in advance, during and after the event. In terms of patients, it reduces the burden of medical treatment and improves the quality of diagnosis and treatment. At the end of November 2021, the National Medical Security Bureau issued the three-year action plan for DRG / Dip payment reform, aiming at accelerating the establishment of a functional and efficient medical insurance payment mechanism, and accelerating the reform in stages and batches. According to the plan, by the end of 2025, DRG / Dip payment will cover all qualified medical institutions carrying out inpatient services, and basically realize the full coverage of diseases and medical insurance funds. "For the three parties of medical insurance patients, this is a win-win and mutually beneficial reform." Ying Yazhen commented. Find out the fraud and insurance fraud "rats" and guard the people's "life-saving money" Why did more than 2000 villagers in the village collectively "suffer from" stroke—— Last October, a report caused an uproar. Stroke is neither an infectious disease nor an endemic disease, but in cuikou village, Laihe Town, Shan county, Heze, Shandong Province, many villagers have inexplicable medical insurance settlement records of multiple strokes in their medical insurance accounts in the past five years. Immediately, the national medical insurance bureau sent a working group to Shan county for on-site supervision. Shan county, Heze, Shandong reported the "stroke in the whole village" incident. In fact, the case of medical insurance fraud in Shan county is not an individual case. There are also many "big rats" who are thinking of people's "life-saving money". According to the data of the National Medical Insurance Bureau, from 2018 to October 2021, the national medical insurance bureau and other relevant departments recovered about 50.6 billion yuan of medical insurance fund. In 2021, the National Medical Insurance Bureau exposed 58 typical cases in batches, only the latest batch of typical cases
Edit：Yuanqi Tang Responsible editor：Xiao Yu
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