In -depth analysis | What is the effect of direct settlement pilots in the outpatient clinic?

With the rapid development of my country's socio -economic development and the acceleration of population aging and urbanization, my country's population migration and flow are becoming more and more frequent. According to the seventh census data of the country, in 2020, my country's migrant population is as high as 331 million, of which about 125 million across provinces, accounting for about 8.84%of the country's total population, an increase of nearly 45.57%in 10 years. Large -scale population flow has made cross -province medical treatment become the norm. The increasing demand for medical treatment and relatively fixed medical insurance in the increasingly fixed medical insurance is increasingly acute. Since the Ministry of Health of the State Health in 2009, the Ministry of Health proposed to carry out direct settlement of different places, and the need for medical expenses for the urgent medical expenses of the people in different places began to alleviate. By mid -August 2017, more than 400 regions across the country were connected to the country's cross -provincial medical treatment. The direct settlement platform properly solves the problem of cashier and leg running in the province and cross -provinces. Compared with the reimbursement of hospitalization in different places, the clinic reimbursement of outpatient clinics is more frequently and the frequency is higher. With the introduction and improvement of the direct settlement policy of the State Medical Insurance Bureau, the cost of direct settlement policies of the provincial direct settlement, the cost of minor and chronic diseases in patients with medical treatment for medical insurance The settlement problem has also been gradually solved.

Outpatient expenses The evolution of direct settlement of provinces

On September 28, 2018, the three provinces and one city in the Yangtze River Delta (Jiangsu Province, Zhejiang Province, Anhui Province, and Shanghai) took the lead in carrying out the outpatient costs within 8 overall regions to settle the outpatient expenses directly to the province, marking the outpatient expenses across the province directly The beginning of settlement. On the first anniversary of the pilot work in September 2019, the Yangtze River Delta region realized the full coverage of Shanghai Medical Institutions and all districts and cities in the three provinces of Jiangsu, Zhejiang and Anhui, and completed the two -way direct settlement between the three provinces and one city. By the end of August 2020, the Yangtze River Delta region would achieve direct settlement and interconnection of outpatient expenses of cross -provinces in the Yangtze River Delta region. In addition, the Beijing -Tianjin -Hebei region (Beijing, Tianjin, Hebei Province) and the five provinces of the southwest (Sichuan Province, Chongqing, Guizhou, Yunnan, Tibet Autonomous Region) will be launched in December 2019 Direct settlement pilot work.

In order to implement the spirit of the Fourth Plenary Session of the 19th Central Committee of the Party, in accordance with the "Opinions of the Central Committee of the Communist Party of China on Deepening the Reform of the Medical Security System" and the "Government Work Report" in 2020 The notice of the provincial direct settlement pilot work "(medical insurance [2020] No. 40), decided on the basis of 12 pilot provinces (autonomous regions, municipalities), further expand the direct settlement coverage of ordinary outpatient expenses across provinces, and explore the unified outpatient clinic in the country Expenses cross -provincial direct settlement system, operating mechanism and implementation path. In April 2021, the "Notice on Accelerating the Express Clinic Course Cross -Provincial Direct Settlement Work" (Medical Insurance Office [2021] No. 27) required to accelerate the direct settlement of the outpatient expenses across provinces. The cost is directly settled by the province. Before the end of 2022, there are at least one scheduled medical institution in each county can provide direct settlement services for medical expenses including outpatient costs. By the end of April 2022, the general outpatient expenses were directly settled by 188,300 direct settlement. At least one designated medical institution in more than 96%of counties could achieve cross -provincial direct settlement costs.

In addition, the State Medical Insurance Bureau is also actively exploring cross -provincial direct settlement work with the cost of slow special diseases. In September 2021, the National Medical Insurance Bureau and the Ministry of Finance issued the "Notice on the Pilot Related Treatment Costs for Slow Special Diseases of Outpatient Clinics" (Medical Insurance Office letter [2021] No. 4), requiring before the end of 2021, each province At least one -chose a coordinating area to carry out outpatient clinics -related treatment costs for direct settlement pilots across provinces, which can provide five outpatient slow special specialties including hypertension, diabetes, malignant tumor outpatient chemotherapy, uremia dialysis, organs postoperative anti -exclusion therapy after treatment. Conductive treatment costs are directly settled by provinces. As of February 2022, the cumulative cumulative treatment cost of slow specialties for outpatient clinics directly settled more than 15.62 million people, involving a total medical expenses of 3.905 billion yuan, and a medical insurance fund expenditure of 2.202 billion yuan.

Six operating results obtained by the pilot work

In order to further promote the direct settlement of cross -provincial medical medical clinics, this article evaluates the pilot work experience of the Yangtze River Delta region from September 2018 to December 2020, and analyzes the direct settlement effect of cross -provincial medical clinics in a variety of province Quality and efficiency provide reference.

First, the number of policies benefit the number of people continues to increase, and effectively reduces the burden on cashier. Since the Yangtze River Delta region officially launched the general outpatient expenses across provinces on September 28, 2018, the direct settlement policy for medical clinics for inter -provincial and different places benefited from increasing the number of people. Essence In the first month of the settlement, the outpatient costs in the region were settled directly 277, which increased to 306,100 by December 2020. In September 2018, the total medical expenses and medical insurance payment costs of direct settlement clinics in the region were 126,800 yuan and 712,000 yuan, respectively, and increased to 79.8903 million yuan and 43.859 million yuan by December 2020. From the date of the direct settlement of the inter -provincial outpatient clinic to the end of 2020, the cumulative settlement was 2.8778 million, and the cumulative medical expenses were 720 million yuan, and the cumulative fund payment reached 406 million yuan. Taking a cities in Jiangsu Province to go to Shanghai's outpatient medical treatment directly as an example, since the city was opened in May 2019 to the end of December 2020, the per capita reduction of patients with insured patients was 2413.44 yuan. Among them, the cumulative cumulative paid was reduced by 126,600 yuan, which greatly reduced the pressure on the cashier of patients during medical treatment.

The second is to reduce the burden of running back and forth. In the past manual reimbursement model, the insured persons need to stamp the 1 to 3 medical institutions they have selected and the medical insurance agency in the medical and land medical insurance. Between the place of insurance, the sense of gain is greatly reduced. Since the introduction of cross -provincial medical direct settlement policies, cities have gradually streamlined the registration procedures, optimized the filing process, canceled the filing requirements for providing seal certifications for medical place, and can achieve different places for medical treatment through telephone, mobile phones, etc. In addition, the insured person only needs to obtain instant medical expenses for medical insurance cards based on the filing category of the filing category to obtain instant medical expenses in accordance with the medical insurance card.

After the direct settlement policy of cross -provincial medical clinic costs, the number of direct settlement has gradually increased. Taking an insured person in Jiangsu Province to go to the Shanghai outpatient medical treatment as an example, the number of direct settlement in the second half of 2019 accounted for 40.60%, and the proportion of direct settlement in the second half of 2020 increased to 77.30%, an increase of 36.70%year -on -year. At the same time, the number of manual reimbursement decreased by 2.73%year -on -year.

Third, the average cost of hospitalization in different provinces decreased significantly. The average hospitalization expenses of "long -term different places" (including retirement, long -term residential residence in different places, and residents in different places) have been reduced by 13.94%after the implementation of the outpatient cost direct settlement policy. The decline in the average hospital hospitalization cost may be due to the direct settlement of outpatient costs in different places. By expanding the coverage of the coverage, some patients transfer the examination and test items that were originally carried out in the hospitalization to the outpatient clinic. The efficiency of the use of medical resources; on the other hand, it may be because the outpatient service has a certain "alternative effect" for the hospitalization service. The direct settlement policy facilitates the outpatient medical insurance reimbursement process. , To reduce the health risks of the masses with serious illnesses, and thus effectively reduced the expenses of hospitalization. At the same time, from the perspective of the safe operation of medical insurance funds, the reduction in the average residential costs can make the risk of fund expenditure better.

The fourth is to improve the work efficiency and supervision capacity of the medical insurance agency. First of all, the direct settlement policy relies on informatization. In the filing session, the patient has exempted the excessive seal certificate between the medical insurance agencies and the medical institution. At the same time as the burden of cashier, the staff also liberated the staff from the tedious repetitive affairs, improved the work efficiency of the medical insurance agency, and eliminated the waste of human, material and time resources. Secondly, the direct settlement policy provides institutional guarantee for the supervision of the medical insurance fund in different places. In the past, the risks such as fake bill materials, repeated reimbursement, and medical treatment were existed during the manual reimbursement process. There were also medical institutions on excessive medical treatment and induction of medical care in patients with different places. The place of insurance had no permissions and had the ability to supervise the medical services of different places. After the implementation of the direct settlement policy, it can strengthen the unified settlement system system and operating mechanism, clarify the relationship between the rights and responsibilities and responsibilities of the medical place, and realize the interconnection and interoperability of patients to strengthen the medical insurance supervision capabilities. Essence

Figure 1 The choice of different levels of medical institutions in different levels of medical institutions in different levels of medical institutions in different levels of medical institutions in a cities in Jiangsu Province

Fifth, the impact of the direct settlement policy of the outpatient clinic has limited impact on the diagnosis and treatment of the medical place. It can be seen from Figure 1 that compared with local outpatient patients, the insured people are more concentrated in third -level medical institutions when they seek medical treatment in Shanghai's inter -provincial outpatient clinics. However, during the pilot work, the total number of direct settlement of medical clinics in the Yangtze River Delta region was only about 0.20%of the total number of regional annual emergency medical services. As a "medical province (city)" in Jiangsu Province, Zhejiang Province, Anhui Province, and Shanghai, they accepted 0.11%, 0.04%, and 0.04%of the total number of emergency medical services in the province (cities) of the province (cities), respectively. 0.004%and 0.79%. Overall, patients tend to be tendency to go to tertiary medical institutions during medical treatment in different places, but the demand for high -level medical resources does not stimulate large -scale patients with large -scale patients into large cities to seek medical treatment. The direct settlement policy regulates the filing process of different places, while providing convenience for medical treatment at different places, and maintaining the diagnosis and treatment order of medical treatment. On the contrary, the choice of medical treatment of patients with different places also shows that the direct settlement policy can alleviate the contradiction caused by the differences in the distribution of medical resources between regions to a certain extent. Sixth, the risk of the direct settlement policy of the outpatient clinic has limited risks to the stable operation of the medical insurance fund. It can be seen from the previous article that although the pilot work has gradually advanced and the cities that have opened direct settlement have continued to increase, the direct settlement of cross -provincial medical treatment has continued to grow, but direct settlement does not induce patients to choose cross -provincial medical treatment too much. Further discovered that the total expenditure of direct settlement funds in the Yangtze River Delta region cross -provincial medical clinic expenses accounted for approximately 0.056%of the total annual medical insurance funds in the Yangtze River Delta region. As a "provincial (city)", cross -provincial outpatient funds in Jiangsu Province, Zhejiang Province, Anhui Province and Shanghai accounted for 0.075%, 0.065%, 0.0071%, and 0.049%of the total income of the annual fund, which shows that cross -provinces are direct direct provinces The risk of settlement to the stable operation of funds in various places is limited, and the policy is sustainable. Therefore, it can further promote the direct settlement of outpatient expenses across provinces to seek medical treatment, and explore the cross -provincial direct settlement work with slow specialties for outpatient clinics.

In summary, the direct settlement policy for medical clinics for inter -provincial and different places meets the demand for medical treatment of different places for inter -provincial migrants, reducing the pressure on the legs of the insured people, and to a certain extent standardize the medical service behavior of different places. At the same time, in the process of policy implementation, the impact on the order of medical treatment and the sustainable operation of medical insurance funds in the place of medical treatment is limited. In addition, the direct settlement policy as an institutional reform, while improving the efficiency of medical insurance agencies, also provides a material basis for promoting the reform of the regulatory system of the medical security fund in different places.

Gradually expand the scope of payment and strengthen supervision "two -pronged approach"

First of all, we must further consolidate the effectiveness of policy reform, and gradually expand the scope of direct settlement payment for outpatient expenses. Direct settlement in different places has increased the level of use of medical and health services in different places for patients with insured patients, reducing patients with medical treatment and running legs in different places. Therefore, the direct settlement of medical expenses in different places should continue to promote the medical expenses of different places, and continue to protect the rights and interests of medical treatment for patients with other places. The State Medical Insurance Bureau has issued a document to gradually expand the scope of medical insurance reimbursement in the medical insurance reimbursement of medical insurance, and incorporates the scope of the medical expenses of malignant tumor chemotherapy, hypertension, diabetes and other outpatient diseases and specific diseases. With the gradual expansion of the direct settlement of medical clinics in different places, the demand for medical residents to participate in the medical residents will be more satisfied. At the same time, the alternative effect of medical services in different places on different local hospitalization medical services will be more obvious.

Secondly, the supervision of medical insurance funds for medical treatment in different places must be strengthened. With the continuous expansion of cross -provincial medical treatment, the amount of direct settlement has increased rapidly. The payment scope has been expanded from hospitalization medical expenses to medical expenses for general outpatient and outpatient slow special diseases. In order to diversify, the supervision system of cross -provincial medical treatment funds needs to be implemented urgently. At present, the rights and responsibilities of the insured are unknown, and the coordination is not unknown. Therefore, how to proceed from the top floor and further clarify the work responsibilities, work processes and synergy methods of medical and insurance areas under the existing policy framework, which is the key issue of the supervision of the medical insurance funds across provinces. Through the top -level design, the regulatory process can be standardized, the audit mechanism is improved, and the inter -provincial medical fund supervision cooperative work plan and joint review and mutual inspection mechanism are actively explored, and intelligent supervision of medical insurance based on medical insurance big data is established to ensure the safety of medical insurance funds.

- END -