Discussion | How to solve the difficult problem of the slow special disease management of outpatient clinics?

According to the National Medical Insurance Administration, as of the end of August 2022, the number of direct settlement of hospitalizations across provinces in the country was 59,500. In August, the national outpatient expenses were directly settled by 3.2077 million across provinces, involving medical expenses of 769 million yuan, and the fund paid 449 million yuan, an increase of 10.1%, 13.4%, and 9.6%from the previous month. Five outpatient treatment expenses such as malignant tumor outpatient chemotherapy, uremia dialysis, and organ transplantation of anti -reinforcement therapy are directly settled by the treatment expenses related to slow special diseases, and further expand the direct settlement coverage of the outpatient expenses across provinces.

The continuous changes in disease spectrum, ecological environment and lifestyle have continued to rise in the disease rate of chronic patients in my country. The survey shows that chronic diseases have become the primary problems that endanger national health in recent years. As of 2020, there have been more than 300 million patients with chronic diseases in my country. "Report on the Nutrition and Chronic Diseases of Chinese Residents (2020)" shows that the prevalence of hypertension at the age of 18 and above is 27.5%, the prevalence of diabetes is 11.9%, and the number of deaths in the country is as high as 80%of the death of chronic diseases. Essence

With the increasingly complete medical insurance system, the continuous development of medical technology, and the continuous improvement of the economic level, the awareness of health rights and interests of the people is increasing, and the needs of patients with chronic diseases and special diseases (hereinafter referred to as outpatient diseases) have been fully released. To do a good job of designing the Slow Special Disease Guarantee Mechanism, effectively ensure the insured's diagnosis and treatment needs, improve the efficiency of medical insurance funds, and become an important research topic.

1. Summary of the Slow Special Disease Guarantee System

my country's basic medical insurance has achieved the coverage of the whole people, and the participation rate has continued to stabilize more than 95%. In order to further reduce the burden of medical treatment and improve people's livelihood, the Opinions of the Central Committee of the Communist Party of China on Deepening the Reform of the Medical Security System (hereinafter referred to as the "Opinions") issued in February 2020 clearly put forward that the outpatient medical expenses are gradually incorporated into basic medical insurance overall planning coordinated planning Fund payment scope, reforming employees' basic medical insurance accounts, and establishing a sound guarantee mechanism for outpatients.

In order to reduce the medical burden of patients with chronic special diseases, since 1999, my country has begun to explore chronic diseases that have been relatively long, the overall medical expenses are relatively long, the overall medical expenses are high, and the appropriate use of outpatient treatment is included in the scope of medical insurance. Not only that, in combination with the actual situation, various regions have gradually incorporated special diseases with heavy cost burdens, and have successively introduced a number of outpatient slow special disease protection policies. Nowadays, the outpatient disease protection has been clearly included in the scope of basic medical insurance protection, and one is the important part of the basic medical insurance policy.

Compared with ordinary outpatient clinics, the protection of slow special diseases in outpatient clinics has three characteristics: first, the use of disease access, and the scope and access standards of local outpatient clinics according to the characteristics of the disease, clinical manifestations, and classification principles in various places; The qualifications confirm that the insured submits case information, diagnostic basis, inspection report and other materials for the insured, and if it is reviewed and confirmed to meet the scope and access standards of the disease, the outpatient clinic is eligible for slow special disease guarantee (Note: Optimized the identification procedures in many places, use fixed points to use fixed points, and use fixed points. Medical institution filing system); Third, fixed -point management, insureds choose medical institutions with relevant qualifications, and the outpatient clinic slow special diseases here can enjoy relevant treatment guarantees.

2. There are four major difficulties in the management of slow special diseases in outpatient clinics

1. The number of people grows rapidly, and the medical insurance fund is under pressure

Taking Qingdao as an example, the city's outpatient clinic qualifications from less than 620,000 people at the end of 2019 quickly increased to more than 770,000 people at the end of 2021, with an average annual growth rate of more than 11.4%. In my opinion, there are four main reasons for growth.

First, the catalog of slow special diseases continues to expand. In 2019, the clinic of Qingdao City Clinic includes 54 diseases, which increased to 78 at the end of 2021. The expansion of the disease not only reduced the economic burden of patients, but also increased the expenditure of medical insurance funds.

Second, the qualification identification "can only enter." At present, the clinic chronic diseases are mainly covered with diabetes, coronary heart disease, uremia dialysis, and respiratory, blood system, rheumatism and immune system diseases, and malignant tumors. Qualifications are valid for life.

Third, a large number of negotiated drugs enter medical insurance. Since the establishment of the National Medical Insurance Bureau, a series of effective innovations have been made in the reform of the medical insurance system, especially in the establishment of dynamic adjustments to the establishment of the medical insurance directory and the improvement of the medical insurance access negotiation system. The "Statistics of the Development of the National Medical Security Development in 2021" shows that since the establishment of the State Medical Insurance Bureau in 2018, it has conducted four consecutive negotiations for medical insurance and drug directory. %; Among them, 221 negotiating drugs during the 2021 agreement period were reimbursed by 140 million. The negotiated drugs are mainly targeted drugs and rare diseases for malignant tumor immunotherapy. In order to protect the people's livelihood rights and interests of patients with chronic diseases, the medical insurance fund continues to expand the scope of protection and improve the level of treatment.

Fourth, the level of medical insurance fundraising is relatively insufficient. Taking Qingdao as an example, compared with 2019, Qingdao Enterprises, organs and institutions paid the basic medical insurance (including maternity insurance) from 10.3% to 8% in 2021, and the payment rate of flexible employment payment was adjusted by 10.8%. For 8.5%, the rate of payment of unemployed personnel during the receiving unemployment insurance premium was adjusted from 10.8%to 9%. The three consecutive years of adjustment and fee reduction policies for three consecutive years have reduced costs of 11.52 billion yuan; in terms of personal payment of residents' medical insurance, from 2019 to 2021, the personal payment amount of residents in Qingdao has remained unchanged for three consecutive years. In the context of the rapid growth of the slow -specific patients with medical insurance clinics and the increase in drugs in the medical insurance directory year by year, the level of medical insurance funding has not maintained simultaneously with fund expenditure, which has further pressured the medical insurance fund. 2. There are great differences in policies in various places and serious fragmentation

As my country ’s multi -level, wide -coverage medical security system has been established, the problem of fragmentation of institutional fragmentation caused by the low level of overall levels has increased the management difficulty of the medical insurance department to a considerable extent. There are three aspects.

First, the number of slow diseases, access standards and payment policies of outpatient diseases in various places are different. Taking Shandong Province as an example, the number of slow disease diseases in different regional outpatient clinics is very different. For example, there are 139 species of slow disease diseases in Weihai City, only 18 types of Jinan City, and the number of other regional diseases is concentrated at 30 At the same time, the names and access standards of the diseased types in various coordinated areas are also inconsistent. In September 2021, Shandong Province fully realized the settlement of outpatients in the province's slow special diseases. From 2022, it has canceled the approval procedures for temporary medical treatment for slow medical treatment in the province. The crowd has also increased sharply. Due to the large differences in cities and cities and cities, and the information system is not stable enough, medical institutions are facing large settlement and management pressure.

Second, the outpatient clinic lacks a special unified catalog. At present, most of the drug and diagnosis and treatment items that have not set up clinics have not set up clinics and do not formulate the corresponding medical insurance payment standards in accordance with the specific type of disease insurance. It should be noted that many of the projects in the three major directory are suitable for hospitalization diagnosis and treatment, but there are large differences in outpatient and hospitalization in the scope of resource consumption, the scope of protection, and the diagnosis and treatment path. Management, at the same time, will also be difficult to give the daily work of the index medical institution and the supervision and management of the medical insurance department. Of course, due to factors such as individual differences in patients, the complexity of clinical diagnosis and treatment, and the correlation between diseases, it is difficult to set the slow special disease catalog of outpatient clinics. Essence

Third, the standards of disease protection are not accurate enough, and the excessive guarantee and guarantee coexist. It is still taken as an example of Shandong Province. There are large differences in the guarantee standards of slow disease diseases in different local cities. Special diseases are different according to their payment grade; and Qingdao's outpatient clinic is divided into limited management diseases and non -limited management diseases. There is no upper limit. Due to the superposition of policies such as medical assistance and reimbursement of major illnesses, the proportion of some diseases and some people has a high proportion of reimbursement, and the individual insured persons are too expensive at their own negative costs. Although the original intention of the policy is to reduce the burden of medical treatment of specific personnel, the risk of individual insureds using medical insurance policies to be maliciously repeatedly prescribed to obtain improper benefits. At the same time, the limited amount of some limits is too low to set up too low to ensure insufficient protection. Taking Crotn's disease as an example, the annual medical insurance reimbursement limit for a city is 4,000 yuan. With the development of medical technology and the listing of innovative drugs, some patients with innovative drug indications and no need to be hospitalized. The cost of medicine exceeds 4,000 yuan.

3. Policy is professional, and relevant personnel are insufficient medical insurance awareness

Although the difficulty of diagnosis and treatment and the cost of a single medical treatment are significantly lower than the hospitalization, the many characteristics of the slow specialties of outpatient clinics determine that its management difficulty is higher than the hospital diagnosis and treatment, which is mainly reflected in three aspects.

First, the connotation of the slow special disease system is more complicated. In recent years, the relevant diseases and drug directory have been updated frequently. Once medical staff fails to master these adjustments in time, it will have a deviation in the implementation of the policy. In addition to the specified indications, courses, and dosage, it is also necessary to meet the pharmaceutical and medical insurance limited payment conditions at the same time, otherwise the patient can only be borne by patients at their own expense. According to statistics, 747 kinds of drugs collected by the 2021 version of the national medical insurance drug directory set a separate medical insurance limit payment condition. Although the policy played a positive role in ensuring the security and reasonable use of funds, it caused some controversy between the medical staff and the insured. Medical staff is based on clinical diagnosis and treatment guidelines, medical conventional and industry standards during diagnosis and treatment. It often adopts the principle of "safety and effectiveness, that is, promotion and application". Factors such as the adjustment of the pharmaceutical instructions and the adjustment of medical insurance limited payment conditions have caused some drugs and diagnosis and treatment items that are effective for patients' disease treatment, which can not be reimbursed by medical insurance, which has reduced the satisfaction of patients, and even triggers contradictions and disputes between insureds and medical staff. Complaints and visits are also common. Although the secondary hospitals and even the community health service institutions have sufficient diagnosis and treatment ability, many patients with chronic diseases will still set their fixed -point diagnosis and treatment institutions in large -scale three hospitals. /Affiliated Hospital of Qingdao University

Second, the supervision of the use of slow specialties for outpatient clinics is difficult. Compared with the hospital diagnosis and treatment, although the diagnosis and treatment plan of a patient with a slow special disease is also determined by the medical personnel in the medical institution, the implementation and execution require the patient's home. The risk is: due to the qualifications of slow special diseases and related expenses, the medical insurance fund is borne. Whether the insured person really needs or use the drug, it will regularly prescribe the medicine in the medical institution Phenomenon of conditions for family members or specific relations. In recent years, the diagnosis of fictional medical records in different regions has been eligible to obtain a slow special disease for outpatient clinics. It is not uncommon for over -dose repeatedly prescribing drugs or even reselling medicines.

Third, the insured has insufficient control of medical insurance policies. The medical insurance policy is very professional and the social attention is high. However, most of the participants' awareness of related medical insurance policies is low. The focus is mainly concentrated in the aspects of personal burden and reimbursement ratio. Payment capacity, medical insurance directory management, medical insurance treatment list and other policies are insufficient. When the actual reimbursement amount of patients is different from its expected value, it is easy to cause dissatisfaction. It may even bring the work management of medical insurance agencies and designated medical institutions. difficulty.

Ordinary chronic disease crowds occupy high -quality medical resources to accelerate the construction of a hierarchical diagnosis and treatment system of "grass -roots first diagnosis, two -way referral, rapid division of treatment, and up and down linkage" is the fundamental strategy of reconstructing the medical and health service system and enhancing the service capabilities of grass -roots medical institutions.

In recent years, the administrative departments at all levels in my country have successively introduced relevant policies and documents to promote hierarchical diagnosis and treatment. However, there is still a gap between the current hierarchical diagnosis and treatment. Most of the patients with stable diseases are mostly concentrated in large -scale hospitals, causing medical resource crowding. In fact, in the outpatient clinics, the treatment plan of chronic diseases such as diabetes, hypertension, chronic mental dysfunction, and bronchial expansion with higher incidence and more patients have been very clear. The service institutions have sufficient diagnosis and treatment capabilities, but many patients will still set their own designated diagnosis and treatment institutions in large -scale three hospitals, which is obviously not consistent with the policy orientation of hierarchical diagnosis and treatment. The reason, although the relevant departments have made a lot of positive efforts in consolidating the diagnosis and treatment capabilities of grass -roots medical institutions in recent years, the service capabilities, resource allocation, technical level and large -scale three -level hospitals of grass -roots medical institutions still have a small gap, which leads to a small gap, which leads to leading to, leading to a small gap, which leads to a small gap, which leads to a small gap, which leads to a small gap, leading to a small gap, leading to a small gap, leading to a small gap, leading to a small gap, leading to a small gap, resulting It is difficult to find a bed in a large hospital, and people are overcrowded, while grass -roots medical institutions can be seen without disease.

Although the difficulty of diagnosis and treatment and the cost of a single medical treatment are significantly lower than the hospitalization, the many characteristics of the slower disease of the outpatient clinic determine that its management difficulty is higher than the hospital diagnosis and treatment.

3. Optimize the management of slow special diseases for outpatient clinics. Five suggestions

Compared with the rapidly growing medical service needs, especially the needs of slow special disease diagnosis and treatment of outpatient clinics, how to improve the basic medical insurance treatment guarantee mechanism according to the level of economic and social development and fund tolerance, and optimize the clinic slow special disease system. Important issues of serious thinking. In response to the management difficulties proposed above, the author proposes five suggestions.

The first is to explore the implementation of the guarantee mechanism for outpatient forensics of employees. With the comprehensive landing of DRG/DIP paid reform three -year action plan, it is difficult for hospitalization medical expenses to grow unreasonable. While stabilizing basic medical insurance hospitalization, the call for improving outpatient treatment will become higher and higher. In recent years, cities such as Beijing, Shanghai, Liuzhou and other cities have conducted useful explorations on the payment methods of slow special diseases. In April 2021, the General Office of the State Council issued the "Guiding Opinions on the Establishment and improvement of the basic medical insurance outpatient protection mechanism for employees", which provided an institutional follow for personal account reform and outpatient medical expense protection reform. On this basis, we should focus on the current long -term, and gradually incorporate outpatient medical expenses into the scope of payment of the basic medical insurance overall fund payment, reform the personal account of employee medical insurance, establish a sound outpatient help mechanism, steadily promote the reform of the outpatient medical insurance payment mechanism, realize medical insurance The fund's long -term stable, sustainable development, and safe and reasonable use of the fund has laid a more solid foundation for social and economic development and ensuring the health of the people's lives and health. In addition, while scientifically set outpatient payment standards, reimbursement ratios, and maximum payment limit, it is recommended to consider retaining special diseases of medical resources such as malignant tumors, organ transplantation, and uremia dialysis, and scientifically set the payment limit. Under the premise of ensuring that the medical insurance treatment of such crowds does not decrease, the safe use of medical insurance funds is achieved. The second is to timely calculate and adjust the standards of disease protection to achieve scientific guarantee and moderate guarantee. With the continuous development of medical technology and the implementation of policies such as pharmaceutical consumables, medical resources consumption of different types of diseases in clinics are constantly changing. It is recommended that the medical insurance department re -determines and dynamically adjusts the payment standards of each disease on the basis of analyzing and calculating different diseases on the payment level of different levels of medical institution funds. The moral risks used, improve the efficiency of medical insurance funds, better realize the relatively fair treatment of insured treatment enjoyment and fundraising responsibilities, and promote the safety and effective management of medical insurance funds and long -term sustainable development.

The third is to further diversify the people through medical insurance payment policies. It is recommended that while further improving the technical capacity level of grass -roots medical institutions, moderate adjustment of medical insurance payment policies of designated medical institutions at different levels, increasing the proportion of slow disease reimbursement of general outpatient clinics of grassroots medical institutions, and making medical insurance payment leverage play a greater role in the implementation of the hierarchical diagnosis and treatment system Essence Continue to deepen the reform of medical insurance payment methods. The medical services of grass -roots outpatient clinics can be paid according to people, and actively explore the combination of the first payment of the person with the head of the person with chronic disease costs. For eligible outpatient diseases and diseases, the implementation of the diseased or disease diagnosis of related groups is implemented, thereby improving the accuracy, targeted, and scientific nature of medical insurance funds, and improving the efficiency of medical insurance funds.

In May 2022, in the three -year action plan for the reform of the medical insurance payment method launched by Zhejiang Province, the reform of the outpatient APG (that is, the outpatient clinic is combined with the outpatient case) payment method was used as an important content. This is an innovative exploration in the field of outpatient payment methods. Through scientifically determining the quota of human head funds, classification and dividing the types of drying and drying, promote medical insurance funds to signing services and grassroots at the grassroots level, alleviating the pressure of large hospitals, and promoting the gradual formation of graded diagnosis and treatment.

The fourth is to strengthen the training and education of the outpatient slow disease policy of medical institutions, and improve the level of refined management level of slow special diseases on the outpatient clinic of the hospital. Fixed -point medical institutions should strengthen professional ethics and education of medical personnel, strictly implement the standards of diagnosis and treatment technical operations and industry guidelines, and prevent illegal acts such as large prescriptions, repetitive medication, over -examination, over -examination and other illegal acts in the clinic diagnosis and treatment of medical staff Essence At the same time, improve the level of refined management of the slow special disease of the hospital's outpatient clinic, and the names of the physical disease qualifications for the outpatient clinic, combined with the name of the physical disease, clinical diagnosis, and drug types of the outpatient clinic. In the HIS system in the hospital, the drug use cycle, cumulative amount, annual dosage of the year, and repeated medication interception to ensure that the medical use of the clinic is in line with the principle and guide of medication.

Explore the establishment of a slow special disease indicator management system for outpatient clinics, according to the consumption and historical costs of the disease, and conduct special management of key indicators such as the annual average cost, drug costs, inspection and inspection ratio, and personal burden ratio of the departmental clinic. Incident in performance control. Pay attention to strengthening the training of medical insurance policies of slow special disease physicians, strengthen the awareness of payment of slow disease diseases, and avoid non -disease expenses to be included in medical insurance payment. Actively conduct medical insurance policies for the insured patients and family members who come to the hospital, and reasonably guide the expectations of patients participating patients to improve the understanding and understanding of medical insurance policies in the insurance policy.

Actively conduct medical insurance policies for patients and family members, and reasonably guide patients' expectations, and increase the understanding and understanding of medical insurance policies in the insurance policy. /Information pictures

Fifth, in -depth promotion of medical insurance informatization construction. Under the current situation of medical insurance reform, in -depth promotion of regional medical insurance information construction, and realizing that the information interconnection of medical insurance agencies and designated medical institutions is imminent. As the national medical insurance information platform is fully launched, the local area must further optimize the medical insurance information system. Based on this, build a more convenient and efficient, secure and smooth upload and settlement network, realize the informationization of slow specialties for outpatient clinics. At the same time as the diagnosis and treatment of the diseased and the drug catalog, the information management of the medical insurance payment of slow special diseases is truly realized, the burden of the staff of the designated medical institutions is reduced, and the convenience of the insured to settle the settlement and settlement. Fair and moderate treatment guarantees are the inherent requirements for improving the health and well -being of the people. Slow special treatment guarantee for outpatient disease involves a wide range of faces, strong professionalism, and high social attention. At present, in the face of new situations and new challenges such as population aging and slow diseases, the growth of medical insurance funds for the increase in medical insurance funds in the clinic has gradually increased the pressure of medical insurance funds. As an important part of the medical security system, the optimization trend of the outpatient slow special disease protection policy is imperative. In the reform of the slow special disease system of outpatient clinics, we should further improve the protection policy of medical insurance clinics in urban and rural residents on the basis of stabilizing basic medical insurance hospitalization, gradually improving outpatient guarantee benefits, improving outpatient protection mechanisms, and improving major disease protection protection protection mechanisms Mechanism, in -depth promotion of hierarchical diagnosis and treatment, optimizing the construction of an information security system for outpatient medical security, and in -depth promotion of the "early treatment and early medical and prevention integration" of outpatient clinics, and improving the health level and health awareness of the majority of patients with insurance.

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