Jiashan County, Jiaxing City, Zhejiang Province, is located in the core area of the Yangtze River Delta, and undertakes the leading function of "double demonstration" in the construction of high-quality development demonstration sites in counties in the new development stage and ecological green integrated development demonstration zones in the Yangtze River Delta. Since the reform of the integration of medical insurance in the Yangtze River Delta Demonstration Zone, the medical insurance card settlement of outpatient and inpatient treatment has been realized, but the demand for reimbursement of drug purchase in retail pharmacies and the cross-provincial direct settlement of outpatient chronic diseases are still in their infancy, and there is still a certain gap with the needs of the masses; there is a certain contradiction between the medical needs of enterprise employees and the threshold of insurance; there are many reimbursement materials after self-payment settlement, the process is annoying, the time limit is long, and other "blocking points and pain points" that plague the masses are the driving force for medical insurance reform and innovation. Jiashan County Medical Insurance Bureau adheres to the concept of "medical insurance service is also a business environment", implements the goal of "medical insurance service is also value-added treatment", implements the idea of "medical insurance service is also an innovative element", and explores the "deep water area" of medical insurance reform with convenient services such as helping enterprises and benefiting the people to optimize the business environment, direct settlement of cross-provincial outpatient chronic diseases, direct settlement of designated retail pharmacies in the demonstration area without filing, and "blockchain + medical insurance services" , improve the breadth and depth of medical insurance services for the people, and realize the leap from the facilitation of medical insurance public services to value-added. Fully implement the national, provincial and municipal decision-making and deployment on medical insurance work, focus on the three "No. 1 projects", implement the "seven preferential enjoyment" projects of public services, deepen regional coordination, facilitate sporadic reimbursement, improve handling capabilities, etc., and earnestly take the responsibility of benefiting the people, strengthen digital empowerment, and explore the first and first trials, so as to build the most convenient county for medical insurance services in the Yangtze River Delta and promote the high-quality development of people's livelihood.
1. Anchor regional coordination and write a new chapter in the integrated development of medical insurance
The first is to clarify goals, detailed tasks, and efficient communication and coordination. With the goal of policy coordination, break through the policy barriers that cross-provincial retail pharmacies are not included in the scope of basic medical insurance payment, explore the exemption of medical insurance settlement for drug purchases in other places, and make reimbursement and settlement in pilot pharmacies in Qingpu and Wujiang according to the overall payment ratio of local drug purchases and the rules for the use of personal accounts;
The second is to build a special class, manage the list, and gather a joint force. Set up a special team for medical insurance digital reform, organize the backbone of medical insurance business in the three places to set up a "joint online working group", carry out special research, and draw "three lists" of needs, resources and tasks. Break through the cross-regional data problem, assign special personnel to be responsible and promote, actively carry out the development and construction of the applicability of the local medical insurance system, and simultaneously carry out the development and construction of pilot pharmacies and interface testing.
The third is to focus on innovation, general thinking, and reshape business processes. Adhere to the unified information standard as the core, with the goal of full coverage of cross-regional business, on the basis of the original settlement type, Jiaxing City cross-provincial drug purchase settlement type is added, on the basis of the settlement type maintenance and the designated pharmacy system online, to provide the demonstration area without filing direct settlement services, the insured can achieve convenient direct settlement of drug purchase in the designated retail pharmacy in the demonstration area without going through any procedures. Since its launch, 872 designated retail pharmacies in the Yangtze River Delta Demonstration Zone have achieved full coverage of direct settlement of medical insurance without filing, and more than 100 cross-provincial drug purchase settlements have been completed in the three places. Breaking the pain points of large demand for cross-provincial and non-local drug purchase and difficult medical insurance settlement, it has been widely publicized and reported by Zhejiang Satellite TV and other mainstream media.
On September 7, 2023, Aunt Wu in Wujiang, Jiangsu Province, successfully completed the direct settlement of cross-provincial drug purchase and medical insurance at the Zhengda Pharmacy Shijia Road store in Jiashan
2. Innovate digital empowerment and improve the new efficiency of intelligent medical insurance services
The first is smooth communication, strong collaboration, and promote data sharing. For the first time, blockchain technology was applied to the field of medical insurance public services, relying on the advantages of medical insurance integration in the demonstration area, and the blockchain data channel of the three places was built to realize the real-time sharing of electronic medical records, expense lists, and bills. It is the first to create the framework idea of "one library, one code, and one platform", and realizes the intelligent flow of electronic data, online rapid reimbursement, and rapid arrival of funds through the cross-provincial medical insurance intelligent claim application platform, and the medical insurance reimbursement business is handled online with "zero errands".
The second is to break down barriers and strictly review to ensure data security. Give full play to the advantages of blockchain technology, such as distributed collaboration, identity verification, traceability, and non-tampering, break through the "barriers" of financial electronic bill data, form a unified data specification, use unified digital encryption and counterfeit identification technology, synchronously complete the reimbursement marking, avoid the risk of repeated reimbursement, and let the insured people feel at ease to declare, the handling personnel can rest assured that the operation of the medical insurance fund is safer.
The third is to optimize the configuration, seek deepening, and achieve iterative upgrading. As the only county-level pilot unit in the province, it has been approved as a national-level pilot for the application of electronic settlement vouchers for medical charges, and has formulated "smart medical insurance" data sharing interface rules, selected pilot medical institutions in the county, and promoted the seamless connection between the blockchain application of medical insurance electronic bills and "smart medical insurance" through interface transformation, system joint debugging and optimization process. At the same time, the medical insurance intelligent claim application platform was upgraded, and high-frequency services such as electronic settlement list printing and health examination appointments were launched, so as to achieve one platform and multiple businesses. The experience and practice of the "Blockchain + Medical Insurance Intelligent Claims" project have been affirmed by the leaders of the municipal government, and have been rated as the "Top Ten Cases" of Jiaxing City to optimize the business environment, the construction achievements have been affirmed by the provincial and municipal medical insurance bureaus, and the publicity information has been praised and reported by many mainstream media at or above the provincial and ministerial level, "Zhejiang Reform" and "Runner". The number of application visits exceeded more than 26,000, and the average business processing time per capita was 1 day, which greatly improved the public's sense of gain and satisfaction.
The medical insurance staff of Jiashan County instructed the masses to use the "blockchain + medical insurance intelligent claim" to quickly declare sporadic reimbursement of medical expenses
3. Optimize the business environment and achieve new breakthroughs in the value-added of medical insurance to benefit the people
The first is to gather demand, put forward measures, and compete for pilot projects. Combined with the high-quality development needs of enterprises, eight measures to help enterprises benefit the people, such as "exploring a new mechanism for flexible employment insurance, early participation in medical insurance for enterprise employees, and exemption from application for medical insurance transfer and renewal in the province", are put forward to promote cadres to dare to work, improve public service capabilities, and help improve the quality of the business environment. The "Eight Measures for Medical Insurance to Help Enterprises and Benefit the People" was supported by the leaders of the provincial bureau and promoted as the construction of the pilot project of "Improving Public Service Capabilities and Helping to Optimize the Business Environment" of the province's medical insurance.
The second is to carefully study and judge, find a balance, and steadily and prudently advance the difficult points. From the aspects of fund security, risk prevention, and precise management, we carefully analyze the development situation of medical insurance, accurately study and judge the risks of pilot policy promotion, and ensure policy compliance and controllable risks. Actively communicate with the county human resources and social security bureau to discuss the optimization of pension insurance and medical insurance participation steps, adopt a "small incision" pilot method, and conditionally allow enterprises to apply for basic medical insurance in advance, so as to achieve a balance between reform and stability.
The third is to set a plan, stabilize development, and improve a new chapter in the service spectrum. In view of the difficulties in cross-provincial handling of enterprise employment and medical insurance, and the low efficiency of bidding, we took the lead in completing the transfer of medical insurance relations in the province and the "transfer without examination" of small account funds, and the number of settlements on the day of the launch ranked first in the province, increasing the confidence of enterprises to build nests and attract phoenixes and the courage of business development, and realizing "two-way running". More than 1,800 migrant workers enjoy medical insurance treatment in the form of early insurance, and 1,195 enterprises have carried out early insurance for more than 5,300 employees, further broadening the channels for enterprises to attract and retain talents. The county has piloted the transfer of medical insurance within the province without applying for it, and has handled 12,956 non-inductive transfers and 7,183 non-inductive transfers. It is the first in the province to implement the automatic review and real-time arrival of the medical insurance small account fund (within 1,000 yuan) system, and has handled 1,391 person-times of "transfer without examination", and the processing time has been accelerated to 20 working days, and the satisfaction of the masses has exceeded 99.9%.
The main leaders of Jiashan County Medical Security Bureau led a team to visit enterprises to optimize the business environment
Author | Jiashan County Medical Insurance Center, Jiaxing City, Zhejiang Province
Source | China Medical Insurance
Edit | Fu Meiru Liu Xinyu
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