Source: People's Daily Original manuscript
"It's great to be able to use this medicine!"
In 2022, on the first day of the new year, a child less than 3 years old with congenital spinal muscular atrophy (SMA) was being treated with sodium injections from Northinasson at the Neurology Department of Henan Children's Hospital.
The child is treated with a sodium injection of Northinasson. Photo courtesy of Henan Children's Hospital
From nearly 700,000 to tens of thousands of yuan, Nocinasine sodium injection entered medical insurance, which greatly reduced the burden of medical treatment for children. "Now that the disease can be cured, the child has hope." The words of the child's mother reveal a beautiful vision for the future.
And this is just a microcosm of the mainland's more sense of gain in the field of medical insurance. On March 6, 2021, General Secretary Xi Jinping visited members of the medical and health circles and education circles attending the Fourth Session of the 13th National Committee of the Chinese People's Political Consultative Conference, and participated in the joint group meeting to listen to opinions and suggestions. He stressed that it is necessary to continue to increase the intensity of medical insurance reform, normalize and institutionalize the centralized procurement of drugs, improve the medical insurance and rescue system for serious and exceptionally serious diseases, deepen the reform of the medical insurance fund supervision system, and keep the people's "life-saving money" and "life-saving money".
In 2021, the reform of the medical insurance field is unprecedented, the burden of drug consumption is significantly reduced, the experience of medical treatment in different places across provinces has been steadily improved, and the "medical treatment money" and "life-saving money" are safer. In order to meet the people's more expectations, China is using the "pen of innovation" to write more heart-warming "health answers".
The effect of "combined price reduction" is released, and the burden of medication on the masses continues to decrease
"Every small group should not be abandoned"
"It's really tough, in fact, just now I think my tears are about to fall"
——Zhang Jinni, negotiator of the National Medical Insurance Bureau and director of the Pharmaceutical equipment Procurement Supervision Department of the Fujian Provincial Medical Insurance Bureau
The scene of the medical insurance directory negotiation on November 11, 2021. Screenshot of CCTV network
At the end of 2021, a video of the negotiation scene of drugs in the national medical insurance catalogue went viral on the Internet. After two rounds of 9 negotiations by the medical insurance department, the price of Nocinasin sodium injection was finally sold at a price of tens of thousands of yuan per needle. Previously, the reason why the drug was called a "sky-high drug" was because its one injection was priced at 699,700 yuan, and patients needed to inject 4 injections in the first 63 days, and 1 injection every 4 months after that, which was a lifelong drug, and the price was high.
In order to let the people use good drugs with high quality and low price, since the establishment of the National Medical Insurance Bureau in 2018, the medical insurance drug catalogue has been dynamically adjusted once a year for 4 consecutive years, and 507 new drugs and good drugs have been included in the catalog, and patients have become more and more secure in seeking medical treatment and using drugs.
In 2021, on the basis of increasing innovative drugs and anti-tumor drugs, the "breakthrough of zero" of high-value drugs for rare diseases included in medical insurance was realized. Li Tao, deputy director of the National Medical Security Bureau, said that in 2021, a total of 7 rare disease drugs were successfully negotiated, and the average price reduction was 65%.
At the same time, the centralized procurement of drugs has gradually become normalized and institutionalized. Since the "4+7" pilot city drug centralized procurement in Shanghai in December 2018, the National Organization Drug Joint Procurement Office has organized 6 batches of 7 rounds of national collection. The average price of "collection and procurement" of drugs has been reduced by more than 50%, and the average price of consumables "collection and collection" has been reduced by more than 80%, which has reduced the burden of the masses by more than 250 billion yuan.
In March this year, the collection of artificial full knee joints and artificial full hip joints will also be landed nationwide, with an average price reduction of 82%. It is expected to benefit nearly 11 million patients and reduce the burden by nearly 30 billion yuan per year.
"Under the principle of safety, effectiveness and economy, the adjustment of the medical insurance catalogue in 2021 will include more high-quality and inexpensive drugs, and the centralized procurement of drugs has become normalized, and the 'combination fist' through centralized procurement and catalogue access negotiations has significantly reduced the burden of medication for the masses." Wang Zhen, a researcher at the Institute of Economics of the Chinese Academy of Social Sciences, said in an interview with People's Daily reporter.
Direct settlement of off-site medical treatment so that reimbursement is no longer "rushing"
"Usually, it is inevitable to have a headache and brain fever, and you only need to click on the mobile phone to complete the inter-provincial reimbursement."
In order to take care of her granddaughter, Aunt Han came to Beijing from Shanxi, more than 600 kilometers away. She boasted that it was convenient to use the medical insurance service platform APP to see a doctor and reimburse her now. You can also switch the "Caring Edition" for easier operation.
The national medical insurance service platform APP launched the "care version" to facilitate the elderly group. Screenshot of the APP of the National Medical Insurance Service Platform
In recent years, with the large increase in the number of people living in different places, retiring in different places, and working in different places, especially the elderly who move with their children are becoming more and more large, there is a higher demand for direct settlement of medical treatment in different places.
Focusing on the medical settlement needs of 125 million inter-provincial floating population, and deeply promoting the reform of "decentralization and management services" in the field of medical insurance, since 2021, the National Medical Insurance Bureau, together with relevant departments, has consolidated and expanded the results of cross-provincial direct settlement of hospitalization expenses, and comprehensively promoted the direct settlement of outpatient expenses across provinces.
At present, the direct settlement service for medical treatment and hospitalization expenses in different provinces has covered all provinces, all co-ordination areas, all kinds of insured personnel and major out-of-office personnel in the country, and has access to 52,900 networked designated medical institutions, basically achieving the goal of full coverage of designated hospitals and at least one networked designated hospital in each county.
At the same time, the direct settlement of general outpatient expenses across provinces has accelerated. From the comprehensive opening of the Beijing-Tianjin-Hebei, Yangtze River Delta, southwest 5 provinces pilot areas, to the addition of Shanxi and other 15 provinces as pilot provinces, from regional pilots to full promotion, as of the end of November 2021, all provinces and the Xinjiang Production and Construction Corps have launched cross-provincial direct settlement of general outpatient expenses, covering 97.6% of the country's overall planning areas, more than 120,000 networked designated medical institutions, and at least one networked designated medical institution in 91.7% of the counties in the country.
"Judging from the current progress situation, there are no institutional and policy obstacles, whether it is outpatient or inpatient direct settlement of off-site medical treatment." Wang Zhen analyzed that from the management of the medical insurance fund, after the direct settlement, there were no problems such as the rapid rise in the cost of medical treatment in different places and the impact on the order of medical treatment, which benefited from the refined management of direct settlement of medical treatment in different places and the construction of information systems.
Ying Yazhen, vice president of the National Medical Security Research Institute and vice president of the China Medical Insurance Research Association, said that the main progress in promoting the settlement of medical insurance in different places is reflected in: the inter-provincial direct settlement system covering the whole country is running smoothly and becoming more mature; the number of effective filings on the national platform is increasing, and the scope of benefits is expanding; through the development of medical insurance off-site settlement, it is conducive to promoting the standardization of medical insurance; and it is conducive to gradually improving the overall level of medical insurance.
"At present, there are still some technical problems, such as the direct settlement of outpatient clinics still has blockages, and some medical institutions that have been connected still have problems in the actual settlement process." Wang Zhen suggested that we should further open up the information system and improve the flexibility and convenience of filing.
"It is also necessary to strengthen the connection and cooperation between the medical insurance policy and the management of medical insurance between the insured place and the place of medical treatment, and between the medical insurance department, especially to strengthen joint supervision, prevent excessive medical treatment in the process of medical treatment in different places, and ensure the safety of the medical insurance fund." Ying Yazhen stressed.
Payment method reform to help "medical insurance patients" win-win situation
In the medical reform speech contest held in Sanming City, a dean told the story of two invoices: "The same two hospital invoices of 30,000 yuan, 10 years ago, 70% of the self-payment, reimbursement of 30%, the patient spent 21,000 yuan; 10 years later, 30% of the self-payment, reimbursement of 70%, the patient spent 9,000 yuan." Sanming, Fujian, is known as one of the cheapest places for ordinary people in the country to see a doctor.
For a long time, the traditional medical insurance payment method in the mainland is to pay by project, that is, according to all the drugs, medical service items, medical consumables, etc. used in the diagnosis and treatment process, how much the hospital uses in the diagnosis and treatment process, and how much medical insurance and patients pay according to the proportion. Under this model, excessive medical behaviors such as "big prescriptions" and "big inspections" may occur, which not only causes the waste of medical resources, but also makes the insured spend more money and the medical insurance fund spend more.
In 2017, Sanming was selected as one of the three pilot cities of the national "Reform of Charging and Paying by Disease Diagnosis Related Grouping (C-DRG)", which realized medical insurance and patients and hospitals at the same time according to the fixed amount of disease for the first time in the country, without a threshold, the medical insurance fund reimbursed 70% and 80% according to the fixed amount of disease, and the personal out-of-pocket payment was 30% and 20% respectively. Through the reform, the medical institutions of the same level, urban workers and urban and rural residents have realized the "same disease, the same treatment, the same quality, and the same price" for medical treatment.
A medical reform bulletin board in front of the General Hospital of Youxi County, Sanming City, Fujian Province. People's Daily reporter Yang Di photographed
The effects of the reforms are clear. In 2020, 229,600 cases were discharged from medical institutions at or above the county level in Sanming, of which 187,300 cases were settled by DRG, the enrollment rate reached 81.58%, and the balance of the medical insurance fund according to the fixed amount of the disease type was 69.71 million yuan, which effectively reduced the medical cost.
Summarizing the experience of Sanming, Fujian Province combined with its own actual situation, based on the reform of DRG collection and payment, used big data technology to explore a reform path of "payment by disease species (DIP)" to promote the development of medical insurance along the track of high quality and refinement.
On the basis of the previous pilot, the National Medical Insurance Bureau launched two new payment models, DRG and DIP, at the end of 2019 and 2020. As of October 2021, the actual DRG payment in 30 pilot cities has covered 807 medical institutions.
"The DRG/DIP payment method reform highlights value care and is bound to have an impact on hospitals, health insurance and patients." Wang Zhen analyzed to reporters that in terms of hospitals, the operating mechanism under the previous project payment has been changed, from "seeing a doctor" as the center to the patient's health as the center; from seeing more and more money, and gradually shifting to the healthier the patient and the more profitable. In terms of medical insurance, it has shifted from project management to "value" management, and has shifted from post-supervision to pre-, ex-post and ex-post simultaneous supervision. In terms of patients, the burden of medical treatment has been reduced and the quality of diagnosis and treatment has been improved.
At the end of November 2021, the National Medical Security Administration issued the "Three-Year Action Plan for the Reform of DRG/DIP Payment Methods", with the goal of accelerating the establishment of an effective and efficient medical insurance payment mechanism, and accelerating the reform in phases and batches. According to the plan, by the end of 2025, the DRG/DIP payment method will cover all eligible medical institutions that carry out inpatient services, and basically achieve full coverage of disease types and medical insurance funds.
"For the three parties of medical insurance, this is a win-win and mutually beneficial reform." Ying Yazhen commented.
Catch out the fraud and deceive the "giant rat" to guard the people's "life-saving money"
From the 70-year-old to the 5-year-old child, why did more than 2,000 villagers in the village collectively "suffer" from stroke? In October last year, a report caused an uproar.
Stroke is neither an infectious disease nor an endemic disease, but in Cuikou Village, Laihe Town, Hezedan County, Shandong Province, many villagers' medical insurance accounts have inexplicably appeared in the medical insurance settlement records of many strokes in the past 5 years. Subsequently, the National Medical Insurance Bureau sent a working group to Shan County to conduct on-site supervision.
Shandong Hezedan County reported the "whole village brain stroke" incident. Screenshot of the official website of the Shan County People's Government
In fact, such as the single county medical insurance fraud case, is not an isolated case. There are still many "giant rats" who are thinking of the people's "life-saving money".
According to the National Medical Insurance Bureau, from 2018 to October 2021, the National Medical Insurance Bureau and other relevant departments recovered a total of about 50.6 billion yuan of medical insurance funds. In 2021, the National Medical Insurance Bureau exposed 58 typical cases in batches, and only the latest batch of exposed typical cases involved defrauding medical insurance funds of more than 12 million yuan, and the regulatory situation was severe and urgent.
In order to strengthen the supervision of the use of medical insurance funds and effectively maintain the safety of medical insurance funds, in early 2021, the State Council promulgated the regulations on the supervision and administration of medical insurance in the mainland, the Regulations on the Supervision and Administration of the Use of Medical Security Funds, which changed the lack of special laws in the field of medical security in the mainland.
Subsequently, the Interim Measures for the Designated Management of Medical Security in Medical Institutions, the Interim Measures for the Designated Management of Medical Security in Retail Pharmacies, and the Measures for Regulating the Discretionary Power of Administrative Penalties for the Supervision and Administration of The Use of Medical Security Funds have been implemented successively, providing a basis and support for the medical insurance department to carry out fund supervision.
In order to strengthen the linkage between the execution of medical insurance fund cases, in November 2021, the National Medical Insurance Bureau and the Ministry of Public Security also jointly issued the Notice on Strengthening the Investigation and Handling of Execution Linkages in Cases of Fraudulent Medical Insurance Funds, which put forward specific requirements and practices.
By cracking down on violations of laws and regulations in the field of medical insurance, in 2021, the national medical insurance department inspected a total of 708,000 medical institutions, handled 414,000 times, recovered more than 23 billion yuan of funds, and exposed 70,000 cases.
What are the difficulties in eradicating medicare fraud and insurance fraud? Jin Weigang believes that it is mainly reflected in several aspects: the huge amount of medical insurance fund expenditure, the losses caused by fraud continue to expand; with the improvement of medical insurance treatment, the proportion of individual payments of patients decreases, the sensitivity to medical expenses decreases, and the opportunity for criminals to commit fraud increases; the number of insured persons has increased significantly, the composition of personnel is complex, and it is difficult to monitor the medical behavior of insured persons; the management of grass-roots medical institutions is loose, and it is difficult to supervise their medical service behavior.
In the face of the above situation, how should we maintain the safety of the medical insurance fund? Jin Weigang said that it is necessary to adhere to the treatment of both symptoms and root causes, and constantly improve the anti-fraud mechanism of medical insurance. Strengthen the construction of the medical insurance legal system, including improving the relevant legal and regulatory system, from the three levels of administrative punishment, civil liability, criminal liability and other three levels of clear provisions for severe punishment of medical insurance fraud; take targeted anti-fraud measures, such as improving the medical insurance information system, develop and promote a professional medical insurance fraud identification system; establish a special medical insurance anti-fraud agency, and equipped with corresponding professionals.
In addition, Wang Zhen also suggested that the first step is to update the regulatory means. "The devil is one foot taller" and "the road must be one foot higher"; especially for the new type of fraud and insurance fraud, it is all the more necessary to use new high-tech regulatory means based on modern information technology; second, it is necessary to improve the multi-departmental linkage mechanism and strengthen the linkage mechanism with the Discipline Inspection Commission Supervision Commission, public security, health and health, market management and other departments; it is also necessary to combine it with reform measures such as the reform of payment methods and the centralized procurement of drugs to improve the supervision methods.
At present, the reform of the medical insurance system in the mainland is still continuing to advance. Standing at the beginning of the new year, people are looking forward to the introduction of more reform "fierce materials". Focusing on enhancing the ability to provide support and reducing the burden on the masses, the mainland's medical security network is becoming more and more dense.