The reform of medical insurance payment methods has been carried out in most parts of the country. What are the changes in medical insurance benefits-瞭望新时代网-瞭望时代，放眼世界

The reform of medical insurance payment methods has been carried out in most parts of the country. What are the changes in medical insurance benefits

2024-05-11

The reform of medical insurance payment methods has been carried out in most parts of the country, and some people are concerned about changes in medical insurance benefits. How to change the payment method for medical insurance? What is the impact on insured individuals? The relevant person in charge of the National Medical Insurance Administration provided answers to the concerns of the public. The purpose of payment method reform is not simply to "control costs". Some people say that the reform of medical insurance payment method is because the medical insurance fund is out of money and expenses need to be controlled. Is this statement valid? Answer: The payment method of medical insurance is the specific way in which medical insurance agencies pay fees to medical institutions, including payment by project, payment by disease type, payment by bed day, etc. Different methods have different guiding effects on clinical diagnosis and treatment behavior. China has successively launched pilot payment methods such as DRG (by disease group) and DIP (by disease category). By the end of last year, over 90% of the coordinated regions had carried out DRG/DIP payment method reforms. After the reform, the proportion of project payment in the inpatient medical insurance fund in the reform areas has decreased to about 1/4. It should be noted that the purpose of payment method reform is not simply to "control costs", but to guide medical institutions to focus on clinical needs, adopt appropriate technology for disease specific treatment, reasonable diagnosis and treatment, avoid excessive prescriptions and excessive examinations, and better protect the rights and interests of insured persons. The payment standards after the reform will be raised in a timely manner with the development of the social economy and changes in price levels. Every year, the expenditure of the medical insurance fund maintains a growth trend and is higher than the growth rate of GDP and prices. There has never been a restrictive regulation such as "no more than 15 days for a single hospitalization". In recent years, in some regions, patients have been required to be discharged after being hospitalized for 2 weeks and then re admitted. It is said that after the reform of payment methods, there is a regulation that "no more than 15 days for a single hospitalization". What's going on? Answer: The national medical insurance department has never issued restrictive regulations such as "a single hospitalization does not exceed 15 days". In 2022, the National Medical Insurance Administration also issued a notice on comprehensive investigation and cancellation of unreasonable restrictions on medical insurance, requiring local medical insurance departments to conduct a comprehensive and in-depth investigation of unreasonable restrictions on medical institutions. The areas with problems have been cleared. The situation where a single hospitalization does not exceed 15 days may be due to some medical institutions implementing relatively extensive management measures in order to achieve assessment indicators such as "average length of stay" and "average cost per visit". We firmly oppose and welcome reports from the public regarding the change of the "mean" of medical insurance payment standards to "limit", and the requirement for patients to be discharged, transferred, or self hospitalized under the pretext of "medical insurance limit has reached". We will take serious measures. New drugs and technologies that meet the conditions can be settled based on the actual expenses incurred. Question: Under the payment model based on disease type, will there be cost pressure for medical institutions to purchase new equipment or use expensive new drugs for patients? Will the use of new drugs and technologies by healthcare workers during the consultation process be affected by their performance income? Answer: The problem of individual medical institutions in certain regions is not the original intention of payment method reform. On the contrary, in order to support the application of new clinical technologies and ensure that critically ill patients receive sufficient treatment, relevant rules have also been introduced in the reform of payment methods. For example, new drugs and technologies that meet the conditions may not be included in the "excluded payment" rule of the disease payment standard, and critically ill cases with significantly higher than the average cost of the disease can be excluded

Edit：He Chuanning Responsible editor：Su Suiyue

Source：Xinhua

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