Since the establishment of the National Medical Insurance Bureau in March 2018 and its listing on May 31, medical insurance has undoubtedly entered a new era. So, what about health care in 2021?
The author | Xu Yucai
The source | Old Xu Pingyi
Since the establishment of the National Medical Insurance Bureau in March 2018 and its listing on May 31, medical insurance has undoubtedly entered a new era. The characteristics of this era can be summed up as cracking down on fraud and strict investigation of indiscriminate spending, efforts to save money by collecting and negotiating as a starting point to reduce the price of pharmaceutical consumables, the establishment of rules and regulations to standardize the supervision and use of medical insurance funds, and the deepening of reform to promote the three major reforms of the payment system, salary and medical service prices.
Along this path in 2021, health care reform has played its strongest voice. And these actions will not only affect the present, but will also change the future. Based on this, it is very necessary to take stock when 2021 is about to turn over, in order to carry on the past and open up the future. Here we use the "hot word" as the line to sort out the medical insurance in 2021.
Information encoding
On November 27, 2020, the Notice of the Office of the National Medical Security Administration on the Implementation of 15 Medical Security Information Business Coding Standards (Medical Insurance Office Issue [2020] No. 51) was issued. The notice pointed out that promoting the standardization of medical security from a high starting point is a basic project to realize the modernization of medical insurance governance. The circular requires that all provinces must ensure that by the end of March 2021, 15 medical security information business codes such as medical insurance drugs, medical consumables, medical service items, outpatient chronic diseases, settlement of diseases by disease, day surgery, diagnosis and surgical operation of medical insurance diseases, medical insurance system units, medical insurance system staff, designated medical institutions, medical insurance physicians, medical insurance nurses, designated retail pharmacies, medical insurance pharmacists, and medical insurance settlement lists are fully completed, so as to achieve "vertical and horizontal full coverage" of the coding standard.
Purchase with quantity
On December 17, 2020, the Opinions of the National Medical Security Bureau on the Centralized Procurement and Use of Coronary Stents organized by the State (Medical Insurance Fa [2020] No. 51) was issued, which is the first time that high-value medical consumables have been included in the collection on the basis of the orderly promotion of drug procurement. It is reported that the collection of coronary stents has reduced the average price of coronary stents of 13,000 yuan to 700 yuan on average, which has once again caused shock to the industry. By the end of the year, in addition to the special project of insulin, the drug collection has completed five batches of 218 varieties, the national collection of consumables has completed the collection of orthopedic joints after the coronary stent, and the current collection of luminescent reagents, the collection of local alliances of proprietary Chinese medicines, and the collection of implants are being tried locally, and the seventh batch of national collection is also in the making.
Negotiate procurement
On September 10, the National Health Commission of the National Medical Security Bureau issued a notice on adapting to the normalization of national medical insurance negotiations and continuing to do a good job in negotiating the landing of drugs (Medical Insurance Letter [2021] No. 182). The notice requires that medical institutions are the first responsible persons for negotiating the rational clinical use of drugs. Establish a linkage mechanism between the hospital's drug allocation and the adjustment of the medical insurance drug catalog, and since the official announcement of the new version of the catalog, it is necessary to timely convene a pharmaceutical conference according to the needs of clinical drugs, and "should be fully matched". The medical insurance department should strengthen the management of the agreement, and incorporate the reasonable allocation and use of negotiated drugs in designated medical institutions into the content of the agreement, and link it with the annual assessment. It is necessary to scientifically set the total amount of medical insurance, and the negotiated drugs that are paid separately are not included in the total amount of designated medical institutions. For diseases that implement the reform of payment methods such as DRG, the weight of the disease should be reasonably adjusted in a timely manner according to the actual use of the negotiated drugs.
Establish rules and regulations
On January 8, orders No. 2 and No. 3 of the National Medical Security Bureau issued the Interim Measures for the Designated Management of Medical Security for Medical Institutions and the Interim Measures for the Designated Management of Medical Security for Retail Pharmacies. The two measures have formulated rules for the medical insurance fixed points of medical institutions.
On June 11, Order No. 4 of the National Medical Security Bureau promulgated the Interim Provisions on Administrative Punishment Procedures for Medical Security. The purpose of the interim provisions is to standardize the administrative punishment procedures in the field of medical security, ensure that the administrative department of medical security implements administrative penalties in accordance with the law, maintain the safety of the medical security fund, and protect the legitimate rights and interests of citizens, legal persons and other organizations.
On June 25, the National Medical Security Bureau issued the Measures for Regulating the Discretionary Power of Administrative Penalties for the Supervision and Administration of the Use of Medical Security Funds. The measures are to standardize the use of medical security funds to supervise administrative law enforcement behaviors, ensure that medical security administrative departments lawfully, reasonably and appropriately exercise their administrative punishment discretion, and protect the legitimate rights and interests of citizens, legal persons and other organizations.
Since May 1, the first administrative regulation in the field of medical security, the Regulations on the Supervision and Administration of the Use of Medical Security Funds, has been officially implemented, which has the significance of a mileage plate on the road to the rule of law of medical insurance. The regulations stipulate that designated medical institutions and their staff shall implement the regulations on the management of real-name medical treatment and drug purchase, verify the medical security certificates of the insured personnel, provide reasonable and necessary medical services in accordance with the diagnosis and treatment specifications, truthfully issue fee documents and related materials to the insured personnel, and shall not decompose hospitalization or hang up the hospital, shall not violate the diagnosis and treatment norms, excessive diagnosis and treatment, excessive examination, decomposition prescription, excessive prescription, excessive prescription, repeated prescription, and repeated prescription, and shall not repeat charges, exceed standard charges, decomposition project charges, and shall not collude in drug exchanges, medical consumables, Diagnosis and treatment projects and service facilities must not induce or assist others to seek medical treatment or purchase drugs under false names.
Combat insurance fraud
On April 9, the National Medical Insurance Bureau, the Ministry of Public Security, the Ministry of Justice, and the National Health Commission jointly held a teleconference on the supervision of the National Medical Security Fund.
The meeting stressed that the medical security fund is the people's "medical treatment money" and "life-saving money", and is the "ballast stone" for maintaining the smooth operation of society and solving the medical worries of the masses, and all relevant departments in various regions should do a good job in the supervision of medical insurance funds with stronger determination, greater intensity and more effective measures, and weave a tightly anchored institutional cage of medical insurance funds.
The meeting stressed that it is necessary to clarify the work ideas, highlight the key points of special rectification, focus on the "three false" fraud and insurance fraud behaviors such as "fake patients", "fake diseases", and "fake bills", investigate and deal with a number of major and important cases, expose a number of typical cases, establish a number of advanced models, solidly promote special rectification work, and continue to maintain a high-pressure situation of cracking down on fraud and insurance fraud nationwide
On December 1, the National Medical Insurance Bureau issued the Administrative Measures for Flight Inspection of Medical Security Funds (Draft for Solicitation of Comments). The Draft for Comments points out that the purpose of the Administrative Measures for flight inspections of medical security funds is to "strengthen the supervision and inspection of medical security funds and standardize flight inspections". The "Regulations for the Supervision and Flight Inspection of the Medical Security Fund" that was replaced was changed to "strengthen the supervision and inspection of the medical security fund, crack down on various fraudulent acts of obtaining the medical security fund, and ensure the safe operation of the medical security fund", and will be regulated in five aspects. The first is to clarify the implementation department of the flight inspection, the second is to emphasize the professionalism of the flight inspection, the third is to set the "conditions" for the start of the flight inspection, the fourth is to set the rules for the implementation of the flight inspection, and the fifth is to classify the problems found in the flight inspection.
On December 8, the National Medical Insurance Bureau reported on the special rectification action to combat fraud and insurance fraud in the form of a media briefing. The meeting clarified that the end time of the special rectification action on the problem of medical insurance fraud was extended from the end of December 2021 to the end of December 2022, further focusing on the key areas of medical insurance supervision, and continuously improving the breadth and depth of the special rectification action. On the same day, the official website of the State Medical Insurance Bureau also published the "Notice of the Ministry of Public Security of the State Medical Insurance Bureau on Strengthening the Investigation and Handling of cases of fraudulent medical insurance funds", which determined the circumstances of the transfer of cases of fraudulent medical insurance funds. In the next step, the State Medical Insurance Bureau will further strengthen the supervision of medical insurance funds, focus on grass-roots designated medical institutions, medical institutions within the combination of medical and nursing institutions, tampering with the genetic test results of cancer patients, hemodialysis to defraud medical insurance funds, medical insurance card illegal cash payment and other key areas, in-depth crackdown on fraud and insurance fraud special rectification work, strengthen departmental coordination and data sharing, improve the execution linkage work mechanism, strengthen warning deterrence, with a zero-tolerance attitude, continue to build "dare not cheat, can not cheat, do not want to cheat" Crack down on medical insurance fraud and insurance fraud, and effectively maintain the safety of medical insurance funds.
Outpatient assistance
On April 22, the General Office of the State Council issued the Guiding Opinions on The Establishment and Improvement of the Outpatient Mutual Assistance Guarantee Mechanism for Basic Medical Insurance for Employees (Guo Ban Fa [2021] No. 14), which is an important step in the basic medical insurance outpatient clinic from a simple personal account to a combination of personal accounts and outpatient co-ordination, from a direct impact, marking the reduction of the amount of funds in the medical insurance personal account, which is conducive to reducing the precipitation of medical insurance funds, exerting limited capital benefits, and at the same time will have an impact on the common treatment of small diseases. In the future, it may be pushed to the medical insurance of urban and rural residents, because this is the direction of medical insurance outpatient reform.
Dual channels
On May 10, the National Health Insurance Bureau and the National Health Commission jointly issued the Guiding Opinions on Establishing and Improving the "Dual Channel" Management Mechanism for Drugs Negotiated by the National Medical Insurance (Medical Insurance Fa [2021] No. 28). The so-called "dual channel" refers to the reasonable needs of negotiating drug supply guarantee and clinical use through two channels of designated medical institutions and designated retail pharmacies, and is synchronously included in the mechanism of medical insurance payment. The purpose of the opinions is to ensure the smooth landing of national medical insurance negotiated drugs, better meet the reasonable drug needs of the majority of insured patients, and improve the accessibility of negotiated drugs.
DIP Handling Procedures
On July 15, the Office of the National Medical Security Bureau issued the Regulations for the Administration of Medical Security Handling by Disease Classification (DIP). The regulation requires medical security agencies to actively promote DIP management services in accordance with the requirements of the national medical security policy, do a good job in agreement management, carry out data collection and information construction, establish regional total budget management, formulate indicators such as scores, carry out audit and settlement, assessment and evaluation, audit and inspection, and do a good job in handling and management of consultation and negotiation and dispute handling. At the same time, establish incentive constraints and risk sharing mechanisms, encourage designated medical institutions to establish and improve internal management mechanisms compatible with DIP, reasonably control medical expenses, improve the quality of medical services, and orderly promote settlement with designated medical institutions according to the value of diseases. A collective consultation and negotiation mechanism should be established with designated medical institutions, promote collective consultation of designated medical institutions, organize experts or entrust third-party institutions to carry out work such as disease catalogues and dynamic adjustment of scores, and promote the formation of a new pattern of medical insurance governance of co-construction, co-governance and sharing.
List of Medicare benefits
On August 10, the Opinions of the Ministry of Finance of the State Medical Insurance Bureau on the Establishment of a Medical Security Benefits List System (Medical Insurance Fa [2021] No. 5) were issued. The opinions pointed out that the list of medical security benefits includes the basic system, basic policies, as well as the items and standards paid by the medical insurance fund, and the scope of non-payment. The opinions make it clear that the administrative department for medical security under the State Council, together with relevant departments, will uniformly formulate, adjust and issue basic policies for medical security. Each province, autonomous region, and municipality directly under the Central Government may, within the scope of national regulations, formulate specific policies such as financing and treatment and dynamically adjust them in accordance with the relevant requirements of the State. On the basis of the basic medical security system, the state uniformly formulates policies for the protection of special groups. Localities must not introduce new special treatment policies on the basis of occupation, age, status, etc. The list stipulates that the medical insurance fund shall not pay for six situations, such as those that should be paid from the work-related injury insurance fund, those that should be borne by a third party, those that should be borne by public health, those who seek medical treatment abroad, as well as sports and fitness, health care consumption, health examinations, other expenses that the basic medical insurance fund stipulated by the state and the state do not pay, but in the event of a major impact on economic and social development, temporary adjustments may be made after legal procedures.
Long-term prescription management
On August 13, the Office of the General Office of the National Health Commission and the Office of the National Medical Insurance Bureau jointly issued the Long-term Prescription Management Specification (Trial), the purpose of which is to standardize the management of long-term prescriptions, promote hierarchical diagnosis and treatment, ensure medical quality and medical safety, and meet the long-term medication needs of patients with chronic diseases. The specification points out that long-term prescription is suitable for patients with chronic diseases with clear clinical diagnosis, stable medication regimen, good compliance, smooth disease control, and long-term drug treatment. Commonly used medicines for the treatment of chronic diseases can be used for long-term prescriptions. Toxic drugs for medical use, radioactive drugs, precursor drugs, narcotic drugs, psychotropic substances of the first and second categories, antimicrobial drugs (except for drugs for the treatment of chronic bacterial fungal infectious diseases such as tuberculosis), and drugs with special requirements for storage conditions shall not be used for long-term prescription. According to the needs of patient diagnosis and treatment, the amount of long-term prescription is generally within 4 weeks; according to the characteristics of chronic diseases, patients with stable conditions are appropriately extended, up to a maximum of 12 weeks. For long-term prescriptions of more than 4 weeks, physicians should strictly evaluate, strengthen patient education, and record them in the medical records, and confirm them by signing. Local medical insurance departments pay for drugs that meet the requirements issued by long-term prescriptions, and do not limit the number and amount of single prescriptions, and the insured enjoys treatment in accordance with regulations.
Reform of the price of medical services
On August 31, the State Medical Insurance Bureau, the National Health Commission, the National Development and Reform Commission, the Ministry of Finance, the Ministry of Human Resources and Social Security, the State Administration of Market Supervision, the State Administration of Traditional Chinese Medicine, and the State Food and Drug Administration issued a notice on the "Pilot Program for Deepening the Reform of Medical Service Prices"
(Medical Insurance Issue [2021] No. 41). The plan has been deliberated and approved by the 19th meeting of the Central Committee for Comprehensively Deepening Reform and approved by the State Council. The programme hopes to explore the formation of replicable and replicable experiences in price reform of medical services through 3 to 5 years of pilots. By 2025, the pilot experience of deepening the reform of medical service prices will be promoted to the whole country, and the price mechanism of medical service with classified management, hospital participation, scientific determination and dynamic adjustment will be mature and stereotyped, and the price leverage function will be fully utilized. The biggest feature of the program is different from the past is the establishment of a standardized and orderly price classification formation mechanism, for medical institutions generally carried out, the degree of service homogenization is high, diagnosis, nursing, beds, some traditional Chinese medicine services are included in the list of general medical services, and the government guidance price of general medical services floats around a unified benchmark. Complex medical services that are not included in the list of general-purpose medical services, build a government-led price formation mechanism with hospital participation, and respect the professional opinions and suggestions of hospitals and doctors. Establish a survey monitoring and policy guidance mechanism for weak disciplines, allow the price adjustment of weak disciplines with low historical prices and insufficient medical supply, and promote the rationalization of price comparison relationships. Fully consider the characteristics of TCM medical services, and support the innovative development of TCM inheritance. Supporting medical services that are technically difficult, risky, and necessary to carry out appropriate price differences. Market-adjusted prices will be applied to new projects in special needs services and during the trial period.
Medicare catalog adjustment
On March 1, the 2020 version of the medical insurance directory was officially implemented, and in the new version of the medical insurance directory, a number of drugs cannot be used or used by primary medical institutions will be restricted. Including 50 kinds of Chinese medicine injections, 92 kinds of oral proprietary Chinese medicines are restricted, and 36 kinds of Chinese medicine tablets are not reimbursed by medical insurance.
On December 3, the Ministry of Human Resources and Social Security of the State Medical Insurance Bureau issued the Catalogue of Drugs for National Basic Medical Insurance, Work Injury Insurance and Maternity Insurance (2021). The catalogue contains a total of 2860 kinds of Western medicines and proprietary Chinese medicines, including 1486 kinds of Western medicines and 1374 kinds of proprietary Chinese medicines. The fund can pay for 892 kinds of Chinese medicine tablets. All localities are required to strictly implement the "2021 Drug Catalogue" and must not adjust the limited payment scope and A and B classification of drugs in the catalogue. Timely adjust the information system, update and improve the database, and include the drugs transferred in this adjustment into the scope of payment of the fund according to regulations, and the drugs that are transferred out should be transferred out of the payment scope of the fund at the same time.
During the agreement period, the drugs negotiated implement the national unified medical insurance payment standard, and each co-ordinating region determines its self-payment ratio and reimbursement ratio according to the affordability of the fund, and no secondary bargaining is allowed during the agreement period. The 2021 Drug Catalogue will be officially implemented from January 1, 2022, and the 2020 edition of the Medical Insurance Catalogue will be abolished at the same time.
Integrity In Practice Action
On August 6, the National Health Commission issued a notice on the National Action Plan for The Integrity of Medical Institutions and Their Staff (2021-2024). Subsequently, together with the National Medical Insurance Bureau, the Nine Guidelines for the Honest Practice of Medical Institution Staff were jointly issued, which is also an upgraded version of the "Nine Prohibitions" in 2013. It is worth noting that the staff of medical institutions subject to the nine guidelines include, but are not limited to, health professionals and technicians, managers, logistics personnel, and other social practitioners who provide services within medical institutions and accept the management of medical institutions. The nine guidelines stipulate that the staff of medical institutions should strictly abide by the principle of good faith and not participate in fraud and insurance fraud. Reasonably use the medical security fund in accordance with laws and regulations, abide by the management of medical insurance agreements, and inform medical insurance patients whether the medical services provided are within the payment range stipulated by medical insurance. It is strictly forbidden to induce or assist others to fraudulently obtain or arbitrage medical security funds by means such as impersonating or falsely seeking medical treatment, purchasing drugs, providing false certification materials, colluding with others to falsely issue fee documents, and so forth.
Reform of the remuneration system
On August 27, the Guiding Opinions on Deepening the Reform of the Remuneration System in Public Hospitals was released. The guiding opinions require the implementation of a distribution policy oriented to increasing the value of knowledge, and the establishment of a public hospital salary system that adapts to the characteristics of China's medical industry. In terms of funding sources, the guiding opinions require all localities to broaden and deepen the funding channels for the reform of the salary system of public hospitals, further promote the linkage reform of medical, medical insurance, and medicine" linkage, promote the comprehensive cancellation of drug consumables bonuses, centralized procurement of drug consumables, optimization of medical service prices, reform of medical insurance payment methods, and supervision of the use of pharmaceutical consumables, gradually increase the proportion of medical service revenue in medical revenue such as diagnosis and treatment, traditional Chinese medicine, nursing, and surgery, and support the deepening of the reform of the public hospital salary system. For hospitals that reduce the expenditure of the medical insurance fund due to the centralized procurement and use of drugs, the total budget amount of medical insurance in the current year will not be reduced.
Payment range
For a long time, the scope of payment for drugs in the medical insurance catalogue is not consistent with the scope of treatment diseases in the drug instructions, and medical institutions have been "deeply affected", suffered and frequently punished. The limiting of the payment scope of medical insurance drugs has gradually become an important factor affecting the rational use of clinical drugs and even causing doctor-patient disputes. According to the latest news from the National Medical Insurance Bureau, the 94 drugs that were successfully negotiated in the adjustment of the medical insurance catalogue in 2021 are all consistent with the instructions. At the same time, it was decided to carry out a pilot of medical insurance payment standards for other drugs in the catalogue that originally had payment limits. In the next step, according to the progress of the pilot, under the premise of ensuring the safety of the fund and the fairness of patient medication, in accordance with the principle of reducing the increment and digesting the stock, the National Medical Insurance Bureau will gradually restore the payment scope of more drugs in the catalog to the scope of the drug instructions. Obviously, this is good news. It should be noted that limiting the scope of the drug medical insurance system is not the authority of the medical insurance administrative department, and its basis is the "Interim Measures for the Administration of Drugs in Basic Medical Insurance" promulgated by the National Medical Insurance Bureau on July 30, 2020. The Interim Measures stipulate that in order to maintain the safety of clinical drugs and improve the efficiency of the use of basic medical insurance funds, the Drug Catalogue restricts the medical insurance payment conditions for some drugs.
The 14th Five-Year Plan
On September 29, the General Office of the State Council issued the "14th Five-Year Plan" for universal medical security. This is China's first five-year plan for medical insurance.
The plan proposes that by 2025, the medical security system will be more mature and stereotyped, and the reform tasks of important mechanisms such as treatment guarantee, financing operation, medical insurance payment, fund supervision, and key areas such as medical service supply and medical insurance management services will be basically completed, and the standardization of medical security policies, fine management, convenient services, and the degree of reform coordination will be significantly improved. The participation rate remains above 95% every year, and by 2025, the number of national and provincial drugs in various provinces (autonomous regions and municipalities directly under the Central Government) will reach more than 500, and the centralized procurement of high-value medical consumables will reach more than 5 categories. Steady establishment of a long-term care insurance system.
Three-year action plan
On November 26, the National Medical Security Administration issued a three-year action plan for the reform of DRG/DIP payment methods, which proposed that in the next three years, it will accelerate the establishment of an effective and efficient medical insurance payment mechanism as the goal, accelerate the progress in stages and batches, and fully complete the task of DRG/DIP payment method reform from 2022 to 2024 to promote the high-quality development of medical insurance. By the end of 2024, all coordinated areas in the country will carry out the reform of DRG/DIP payment methods, and the pilot areas will be launched to continuously consolidate the results of reform; by the end of 2025, the DRG/DIP payment method will cover all medical institutions that meet the conditions to carry out inpatient services, and basically achieve full coverage of diseases and medical insurance funds. (Original title: Year-end inventory: 2021 annual medical insurance hot words)
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