Nearly 10 million settlements in 2021!One article reads the outpatient clinic cross -provincial direct settlement

Recently, the National Medical Insurance Bureau announced the "Statistics of the National Medical Security Development Statistics of 2021". Data show that in 2021, employee medical insurance insured persons have 64.34 million people in different places, and the cost of medical treatment for different places is 166.3 billion yuan; residents' medical insurance insured persons have 43.18 million person -times in different places, and the medical expenses for medical treatment are 298.5 billion yuan. The hospitalization expenses were directly settled by 4.4.059 million, involving medical expenses of 107.02 billion yuan, and a medical insurance fund paid 62.463 billion yuan. At the same time, the outpatient expenses across the province's direct settlement pilot work have been steadily advanced, 45,600 fixed -point medical institutions were opened, 82,700 fixed -point retail pharmacies were connected to the Internet. The medical insurance fund paid 1.321 billion yuan.

Undoubtedly, today, where the population flow is increasingly frequent, the continuous promotion of cross -provincial medical direct settlement has become an important reform measure to improve the medical insurance system and solve the outstanding concerns of the people. With the gradual improvement of the inter -provincial direct settlement system, how to ensure that the more difficult and more complex outpatient clinic cross -provincial direct settlement will be implemented smoothly nationwide, which will be the next step in the direct settlement of medical direct settlement work in different places. Heavy.

It's about people's livelihood, and continue to reduce the burden of medical treatment in different places

With the sustainable development of my country's economy and society, it has created conditions for the migration and flow of the population. The trend of population flow is more obvious, and the scale of the flow population has further expanded. The main data results of the seventh national census of the National Bureau of Statistics showed that in 2021, the migrant population was 375.82 million, of which 124.84 million were across provinces, which increased by 69.73%compared with 2010. In this case, cross -provincial direct settlement has become a people's livelihood project that is related to the vital interests of patients, which can not only provide great convenience for the people to see a doctor in different places, but also effectively reduce the burden of medical expenses for such patients.

In the past two years, the promotion of cross -provincial direct settlement has been repeatedly mentioned in the executive meeting of the State Council and the government work report. The principle of "pilot and then promotion" leads the stable and efficiently promoting cross -province direct settlement at all levels of medical insurance systems across the country. Related results have gradually emerged -from the widening of hospitalization expenses to outpatient costs, from padding reimbursement to card -free direct settlement, expanding from ordinary outpatient clinics to slow special diseases -the direct settlement system for medical insurance cross -provinces in my country is towards the scheduled The direction is gradually improved.

In terms of direct settlement of the outpatient cross -province, in the "Deepening the Reform of the Medical and Health System 2022 Key Work Tasks", it also proposed that "further expanding the outpatient expenses directly settled in the province. The cost of medical expenses, including expenses, cross -provincial direct settlement services. "The task of this work is the work goals of the" National Medical Insurance Bureau and the Ministry of Finance on Accelerating Outpatient Cost Conduct Cross -Provincial Direct Settlement "issued in May last year. First, this year's key task of medical reform is also indicated that this work will be vigorously promoted as one of the work priorities of the National Medical Insurance Bureau this year.

From the pilot to the promotion, the direct settlement of the outpatient clinic has achieved 96 % of the county coverage

After the establishment of the State Medical Insurance Bureau, it quickly launched the outpatient cost of direct settlement related to provincial settlement. On September 28, 2018, the outpatient cost of direct settlement was first launched in the Yangtze River Delta region (three provinces and one city). Subsequently, the Southwest District (Sichuan, Chongqing, Guizhou, Yunnan, Tibet) and Beijing -Tianjin -Hebei regions successively set up direct settlement of outpatient clinics on December 23 and December 26, 2019, respectively.

After obtaining regional pilot experience, in September 2020, the State Medical Insurance Bureau and the Ministry of Finance jointly issued a document that it will expand the coverage area of ​​pilot areas, designated pharmaceutical institutions and outpatient settlement based on the decision to decide on the original pilot area. The pilot principles of the province and then across provinces, first outpatient clinics and postnatania ", combine the actual situation of the construction of information platforms in various places and the requirements of the national unified information platform construction, give priority to regions with a concentrated and high willingness to participate in medical sites, and steadily promote outpatient clinics Expenses cross -provincial direct settlement pilot work. At the same time, it is clear that the key work content of the six aspects of the pilot area in the pilot process, that is, uniformly uniformly reformed the process of medical treatment, standardize the processing process and treatment policies of the different places, the qualification identification of slow special diseases and medical insurance management services, and effectively strengthened the regulatory of the medical area, Strengthen the management of medical funds in different places and create a convenient and efficient medical treatment settlement service. In February 2021, the list of new pilot areas was announced, including 15 provinces including Shanxi, Inner Mongolia Autonomous Region, and Liaoning Province. Since then, the pilot work of direct settlement of outpatient clinics has basically been rolled out at the national level.

After extensively carried out the pilot, the outpatient clinic's direct settlement has quickly accumulated a lot of work experience. At the same time, with the steady advancement of other medical insurance reform work, such as the start of the reform of the outpatient protection system, the introduction of the medical security treatment list system, the whole country The unified medical insurance business coding standard has gradually landed, and the national unified medical insurance information platform has been launched in various places. It has also created more favorable conditions for the steady advancement of direct settlement of outpatient clinics. Subsequently, the State Medical Insurance Bureau jointly issued the "Notice on Accelerating the Conduct Cross Settlement of Outpatient Clinics", which clearly proposed the work goals and key tasks of the outpatient clinic for medical treatment at the end of 2022, and also marked the entry of this work. Comprehensive advancement stage. Photo outpatient expenses Cross -provincial medical treatment directly settle key nodes

With the efforts of the medical insurance system at all levels across the country, the direct settlement of the outpatient clinic has achieved great results. On the official website of the National Medical Insurance Bureau's official website, regular release of "Medical Security Cross -Provincial Different Places Direct Settlement Information Release" is regularly released every month. In the change, the outpatient costs directly settled the data of various data from the 19th issue of January 2020. The latest statistics show that as of the end of April 2022, at least one designated medical institution in the country in the country can directly settle the cost of ordinary outpatient clinics across provinces. Compared with the work goals proposed by the previous relevant documents- "At the end of 2022, at least one designated medical institution in each county can provide direct settlement services for medical expenses, including outpatient expenses," which is only one step away.

Promote the direct settlement of slow special diseases across provinces, and further reduce the burden of medical treatment in different places

my country's basic medical insurance benefits payment policy is divided into hospitalization, ordinary outpatient, and outpatient slow special disease payment policies. Correspondingly, cross -provincial direct settlement should also achieve full coverage of the above three types of medical expenses. However, compared to the inter -provincial direct settlement of hospitalization and general outpatient clinics, it is obviously more preparations, and the launch time is relatively late. In this regard, the relevant person in charge of the National Medical Insurance Bureau had publicly stated that the reason why the outpatient clinic was settled directly to the end, mainly because there were three aspects: First, compared with ordinary outpatient clinics, there is also a high frequency of medical treatment. The characteristics of strong timeliness, in order to achieve instant outpatient and instant settlement, need to be "equal"; second, compared with the cost of hospitalization, there are also the characteristics of relatively high costs and high reimbursement ratios. Third, because of its identification standards, identification processes, and medical management, there is a large locality difference in management, so the status quo that can best reflects national medical insurance benefits.

Therefore, after the direct settlement of the hospitalization and ordinary outpatient clinics, the outpatient -specific specialties were also put on the agenda. The "Notice on Accelerating Outpatient Cost Conduct Cross -Provincial Direct Settlement Work" has been clearly stated that 5 people have large demand for 5 people, such as hypertension, diabetes, malignant tumor outpatient chemotherapy, uremia dialysis, and organ transplantation. Slowly clinic diseases commonly carried out in various places have actively promoted the direct settlement of relevant treatment expenses across provinces, and put forward work goals and work requirements. Relevant specific deployment was refined in the "Notice on the Pilot Work of Cross -provincial Direct Settlement Pilot Work" jointly released by the National Medical Insurance Bureau and the Ministry of Finance in September 2021. On the one hand The scope of crowd, diseases, and designated medical institutions, on the other hand, specifically specifically regulates cross -provincial direct settlement policies, unified medical settlement rules, improves the construction of information systems, implements the responsibilities of medical supervision, and do a good job of prepaying funds and liquidation. At this point, the inter -provincial direct settlement pilot work of the outpatient clinic is fully launched nationwide. According to the latest data released by the State Medical Insurance Bureau, the above five outpatients' slow special disease costs cross -provincial direct settlement pilots have expanded to 74 overall regions, further reducing the burden of medical treatment in different places.

Outlook: In what are the aspects of direct settlement of outpatient clinics?

Compared with hospitalization, the outpatient medical service frequency, the scale of service personnel, a larger scale of service, a more scattered visits, a higher degree of complexity and difficulty in cross -provincial direct settlement operations. At the same time, the level of economic development in various places is different. The standards of medical insurance payment lines, reimbursement ratios, and reimbursement quotas have also brought certain resistance to direct settlement of outpatient expenses, especially for the identification standards, identification processes and medical management management. Slowly clinic is even more significant. Take the promotion of the Yangtze River Delta region of directly settlement of the outpatient clinic as an example. The Shanghai outpatient policy attribute chronic diseases such as hypertension and diabetes and coordinates the payment in ordinary outpatient clinics. Species, setting the category of slow diseases separately.

Furthermore, the work of direct settlement of the outpatient clinic also challenged the information system. When developing direct settlement, the data information needs to be circulated at multiple levels such as the country, medical province, medical place, insurance province, insurance, and designated pharmaceutical institutions. The settlement is not smooth. In addition, the medical insurance information system of each overall planning area is large in terms of platform sector design, data interface and data format, which cannot achieve the docking between regions, resulting in long outpatient settlement links and many nodes. If a cross -provincial settlement of outpatient costs is implemented nationwide, the information system needs a stronger response and accuracy. In this case, it has become a top priority to promote the application of unified across provinces in the country across provinces. At the same time, the National Medical Insurance Bureau also issued corresponding interface specifications and unified technical standards, which simultaneously established a systematic reporting error information rapid response mechanism and error issues, and timely solve the problems encountered by the masses in cross -provincial direct settlement services. In addition, the real -time settlement of medical clinics in different places, while it is convenient for the insured residents, it may also exacerbate the disorderly medical problem to a certain extent. In addition The transformation to online informationization has also put forward new challenges for fund supervision. To this end, the National Medical Insurance Bureau has included medical treatment for medical insurance fund supervision in recent years: First, to verify daily supervision through the place of insurance and medical place, regularly analyze the settlement data for cross -province medical treatment, and transfer suspected violations of regulations. Cases to relevant provinces for inspection and processing, and explore the establishment of cross -regional cooperative inspection working mechanisms; the second is to rely on medical security intelligent audit systems to intelligently review and supervise medical behavior and expenses. Fake patients, fake illness, and fake bills have a severe blow. As a result, to a certain extent, the fund risks of direct settlement of provinces have been avoided, so that this business can provide medical treatment and reimbursement for the majority of medical participants in different places.

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