Deep | Different passive payment is active purchase. How can the medical insurance payment mechanism be efficient?

The medical insurance payment mechanism is directly related to the efficiency of the medical insurance fund, whether it can buy a suitable medical service for the people, and ensure that its legal medical insurance rights and interests are ensured; it is also related to whether the medical insurance system can operate steadily and sustainable. Since the establishment of the self -state medical insurance system, it has been paid attention to and valued. The Management Department of the Medical Insurance Office has firmly grasped it as a "bull nose" and continued to reform and innovate. The continuous reform and innovation of the medical insurance payment mechanism, the reform and development of related fields such as improving the use of medical insurance funds, ensuring the health needs of the people, ensuring the sustainable development of the medical insurance system, and promoting medical insurance system have exerted important and indispensable development and development Mechanical function and basic role. However, it is necessary to say that due to the constraints of many factors (such as institutional contradictions, mechanism obstacles, policy issues, etc.), the reform of the reform and the investment of reform is not matched, and even "hedge", which makes the medical insurance fund The efficiency of use is not very high, and the sense of gain of the masses is not very strong. Generally, there are many issues of "spending money", which is worthy of reflection and deep thought.

After the "Opinions of the Central Committee of the Communist Party of China and the State Council on Deepening the Medical Security System" put forward the reform task of "establishing a efficient medical insurance payment mechanism for management", everyone is thinking and exploring: What kind of medical insurance payment mechanism is efficient? How can we make it "efficiently"? As well as major issues such as the relationship between the efficient medical insurance payment mechanism and the new stage of building medical insurance governance and the promotion of the "three medical" high -quality coordinated development. Looking back at history and observation of reality, we think that the medical insurance payment mechanism must be thought about and understanding from the concept of updated dimensions, a broader perspective, and a more systematic concept. The internal relationship between the connotation is to build a new medical insurance governance pattern and promote the high -quality coordinated development of the "three medical", and consciously promote the systematic reform and synergy innovation of the medical insurance payment mechanism. Only in this way, the reform of the medical insurance payment mechanism can summarize the previous experience and the results of existing reforms, and then innovate the opportunity and open a new bureau to establish an efficient medical insurance payment mechanism as the starting point and breakthrough. Establish a new pattern of "three medical linkage", multi -party participation and collaborative governance of medical insurance governance, and accumulate experience, thereby promoting the "three medical" high -quality collaborative development.

(one)

The medical insurance payment mechanism is one of the most basic and critical mechanisms for the medical insurance system. Its reform and innovation has always been accompanied by the reform and development of the Chinese medical insurance system. In other words, the reform and development process of China's medical insurance system is also the process of continuous follow -up of the reform and innovation of the medical insurance payment mechanism. For a long period of time, the reform and innovation of the medical insurance payment mechanism mainly focuses on how to implement the basic principles of "basic and sustainable" and the fund management principle "with the fund management principles of settlement and expenditure, a slight balance" fund management principle. The theme and main line are performed. It is necessary to improve the efficiency of fund use, buy a considerable price -performance medical service for the people, but also ensure that the fund revenue and expenditure are balanced and prevent systemic financial risks. Gradually passive payment in practice is active purchase, mainly from three aspects (links).

The first is to delineate the scope of payment of medical insurance funds, dynamically adjust the "three directory" of medical insurance according to the fund tolerance, meet the basic medical needs of the masses, meet the progress of medical scientific and technological progress and clinical needs, and use it as the basic basis for medical insurance payment. Due to the influence of many factors such as the management system, there are two outstanding defects in this regard: on the one hand, the adjustment of the rhythm is not well grasped, and some adjustment cycles are too long; on the other hand The "tailoring is too large, resulting in comparison and imbalance between regions, the standard unity and rigid constraints of the damage system.

The second is to implement the management of fixed -point medical institutions and fixed -point retail pharmacies (referred to as "two fixed -point"). There are disputes over the "two fixed points" for a long time. Some claims should allow patients to choose doctors, choose hospitals, and repeatedly want to abolish this system in the name of "reducing administrative approval". Practice proves that the implementation of fixed -point management is an important carrier of medical insurance payment, which not only clarifies the object of medical insurance payment, but also helps regulating the behavior and responsibilities of medical and medical insurance. In the end, the title of "Medical Insurance Agreement Management" was persisted and continued to be perfect in practice.

The third is to persistently promote the reform of medical insurance payment methods, improve the efficiency of fund use, and give play to the promotion role of medical insurance payment in the reform of related fields such as medical and medicine. In general, the reform in this area is mainly based on the passive buy -type payment of the initial phase of the medical insurance at the initial stage of the project, and gradually moves towards the strategic purchase method based on the total budget management of the fund according to the total budget management of the fund. (Commonly known as "Paying Fist" type of payment method). In the process of the reform of the medical insurance payment method, two tendencies have occurred. Some people mistakenly equate the payment method with all of the medical insurance payment mechanism and ignore the other links of the medical insurance payment mechanism. The functional role has ignored the synergistic role of relevant institutional mechanisms and policy environments. In fact, medical insurance payment methods and even medical insurance payment mechanisms have not fully released the efficient mechanism efficiency of pipelines.

It is particularly worthy of recognition that in the process of promoting the reform of the medical insurance payment mechanism, it always emphasizes full mobilization and exerting places, especially the enthusiasm and creativity of the coordinated area, encourages and supports them to explore and innovate from the actual situation, and create a variety of improved funding efficiency efficiency , Taking the practical and feasible methods and methods of medical insurance for unreasonable growth of medical expenses. In the practice of promoting this reform, many coordinated areas starting from the local reality and practice, there are many distinctive and effective exploration innovation and fresh experience. Among them, the more typical significance and method of payment of Chinese characteristics is based on the method and experience of paying for the total amount of funds (pathogenesis) based on the total budget management of the fund in Huai'an City, Jiangsu Province. Significant (average cost of consultation, decrease in hospital beds, decreased fees for patients, slowing fund expenditure growth, etc.), and drawing on implementation and innovative development in dozens of cities across the country have achieved significant results. (two)

Since the establishment of the State Medical Security Bureau in 2018, with the comprehensive deepening of my country's medical insurance system reform, the reform of the medical insurance payment mechanism has also continued to advance. It has reached a new level, created a new situation, and achieved new results. The large end of its choice is mainly reflected in the following five aspects.

First, new changes have been made in the concept of ideas and development. The important role of the medical insurance payment mechanism in the construction and deepening reform of the medical insurance system pays more attention to the important role in the reform of the reform and deepening reform. It refers to a more prominent position. From the past as the "important starting point" of the medical insurance management department to promote the "three medical linkage", , Construct a "entry point" and "breakthrough" of the new pattern of medical insurance governance, and the new pattern of medical insurance governance.

The second is to pay attention to the overall promotion of the medical insurance payment mechanism and system integration (not just the "single soldiers"). It has improved the dynamic adjustment mechanism of the medical insurance directory, reasonably divided the responsibilities and authority of the central and local catalog adjustment, established a medical insurance treatment list system, and promoted the basic unified scope of medical insurance drugs across the country. Improve the management of medical insurance agreements, establish and improve the management mechanism of cross -regional medical agreement, and promote the establishment and improvement of medical insurance and drug payment standards.

The third is to further improve the development of multi -composite medical insurance payment methods (DIP) based on the total budget management of the fund area point method. Organize 101 regions to carry out DRG/DIP countries; implement the total regional fund management; it will promote DRG/DIP as the "highlight" of medical insurance payment methods; implement three years of action plan; hold 2 million people from online and offline DRG to participate /DIP Payment Method Reform Conference, etc., ensure that in 2022, covering no less than 40% of the coordinated regions, no less than 40% of medical institutions, no less than 70% of diseases, and 30% of medical insurance funds.

The fourth is to innovate the medical insurance payment mechanism in comprehensively deepening the reform of medical insurance. Among them, there are many innovative innovations with originality and effectiveness. Wait, this is actually a breakthrough innovation based on the original "321" (three directory, two fixed points, and one payment method). Through such innovation, first suppress the virtual high price and squeeze out the water. This is essentially consolidating the base of the fund payment. The sense of acquisition of ordinary people has also enhanced (according to statistics, the first five batches of national drugs are purchased, and the annual expenses for drugs are about 150 billion yuan).

Fifth, establish a level -by -level training training mechanism and theoretical and practical learning model for training working mechanisms and theories and practice of professional talents. Practice medical insurance payment professional team.

(three)

Establishing a truly efficient medical insurance payment mechanism, just like promoting other reforms and innovations. It is necessary to closely combine the "top -level design" and "touching stones" (accumulating experience, discovering problems, and grasping the laws in practice). Thinking and summarizing can continue to enhance consciousness, reduce, and avoid blindness. Looking back, thinking, and summing up the process of reforming the medical insurance payment mechanism in the past, especially in recent years, the practice of adhering to the reform of the medical insurance payment mechanism in recent years will definitely get many beneficial inspiration.

First, establish an efficient medical insurance payment mechanism for management. Both medical insurance and medical and medical "three medicines" must update the old concepts such as zero -harmony games, and establish a new concept of value recognition, consistent goals, and win -win governance. In the past, the medical insurance payment mechanism was often defined as a payment method for medical insurance (buyers) to the medical service (seller); in terms of management, it defined its important starting point for management and management to improve the efficiency of fund use efficiency A policy tool, or a kind of incentive constraint on the supply of pharmaceutical services. Although these concepts and definitions have certain truths and some effects, they have one -sided and limitations. It is an important source of the medical insurance payment mechanism that is far from reaching efficient goals. Therefore, it is necessary to update the old concept of time, establishing the reform of the deepening of the medical insurance payment mechanism is to promote the new concept of the "three medical linkage", the participation of multiple parties, and the new pattern of collaborative governance. At the stage, unremitting and coordinated the "three medical linkage", enhanced the overall, systemic, and synergistic reform, build a large background and framework of multi -party participation and collaborative governance of the new medical insurance governance pattern. The management of efficient medical insurance payment mechanisms can achieve the reform goals of value recognition, co -construction, co -construction and win -win. Second, the establishment of an efficient medical insurance payment mechanism for management must adhere to the path of system integration and collaborative innovation. System integration, first of all, the factors and links of the medical insurance payment mechanism (such as the scope of payment, payment objects, payment standards, payment methods, payment settlement, payment management, etc.) should be systemicized. Simplicate ", pay attention to strengthening the" weak term "of" payment standards "to make it a" hard constraint "of payment; followed by the relevant institutional mechanism and policies of medical insurance payment (two fixed points) Otherwise, no matter how good the payment mechanism is, it is difficult to produce the role of incentives and constraints; the third is that all parties of medical insurance and medicine must pay attention to coordination and innovation. Cooperation is the prerequisite and foundation of innovation. Collaborative innovation will produce "synergy effects" with 1 plus 1, or even greater than 10. In this regard, the reform practice of centralized procurement of drug bands in the past two years has been well empirical, and it has also been deeply enlightened to establish a real -efficient medical insurance payment mechanism (and the implementation of drugs in some places is not yet on the implementation of drugs. The ideal also shows that the collaboration is not in place, it is difficult to meet the standard). In general, the experience of the reform of the medical insurance payment mechanism in recent years warns that we cannot work in a certain link or method of medical insurance payment alone, but we must adhere to the system integration and collaborative innovation. The "hedge" situation of "one foot height, one foot high", "you have a policy, and he has a countermeasure" and "pressing the gourd", which is difficult to achieve efficient management.

Third, the establishment of an efficient medical insurance payment mechanism for management must adhere to the multi -composite payment method (that is, the "combination fist") based on the total fund budget management (that is, the "combination fist"). Although the medical behavior has its own regularity and the specifications of clinical paths, it has considerable complexity, uncertainty and difficult control. Therefore, it is impossible for any payment method to "bag the world" and must be a diversified composite payment. For example, the outpatient category can be paid unit or project, the community service category can be paid, and the medical community service can implement "packaging and payment", etc. As long as they have "three sex" (economics, convenience, win -win) The payment methods should be regarded as "efficient" and should be encouraged and supported.

Fourth, the establishment of an efficient medical insurance payment mechanism for the establishment of management must adhere to the time with the times and continue to work hard. The efficiency of the medical insurance payment mechanism is relative and developed, not static, unchanged, that is, it is often said that "there is no best, only better." Reform is always on the road. As far as DRG/DIP is concerned, it must be continuously adjusted, corrected and improved in practice. The reform and innovation of the medical insurance payment mechanism is an irresistible continuous process. It cannot be achieved overnight, and it cannot be done once and for all. It must continue to work hard. "The change of potential is also changing." Only by continuously conducting the cooperative innovation of the medical insurance payment mechanism can the medical insurance payment mechanism be full of vitality and maintain the efficient mechanism efficiency of the management.

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