Since 2019, when the National Health Commission launched the pilot project for the construction of a close-knit county-level medical and health community, the National Health Insurance Administration and other departments have responded positively and jointly promoted the comprehensive development of the construction of county-level medical communities by deploying key tasks, issuing reform measures, and strengthening supervision.
2019-2023 medical insurance policy changes
In 2019, deepening the reform of the medical and health system clarified the goal of building a county-level medical community in 500 counties, and emphasized that reforms in the fields of medical care, medical insurance, medicine and public health need to be promoted in a coordinated manner. In the same year, the National Health Insurance Administration proposed at the National Medical Security Work Conference to deepen the reform of medical insurance payment methods, use big data and other technologies to promote the rational allocation of medical resources, and launched the DRG national pilot.
In 2020, the National Health Insurance Administration (NHSA) promoted the reform of medical insurance payment methods, explored the adoption of a lump sum payment model for close medical associations, and implemented a surplus retention and reasonable overexpenditure sharing mechanism. In October of the same year, the "Pilot Work Plan for the Total Budget of the Regional Point Method and the Payment by Disease Score" was promulgated to implement the management of the regional total budget.
In 2021, the National Health Insurance Administration will continue to promote the implementation of lump sum payment for close-knit medical associations, strengthen supervision and assessment, and guide medical alliances and medical communities to pay attention to disease prevention, improvement of grassroots service capacity, and mechanisms such as primary diagnosis and two-way referral. In the same year, the National Healthcare Security Administration issued the "Three-Year Action Plan for the Reform of DRG/DIP Payment Methods", which requires that within the framework of the DRG/DIP policy, the "packaged" payment of close medical associations should be promoted in a coordinated manner, and patients should be guided to sink to the grassroots level.
By 2023, 10 national departments have jointly issued the "Guiding Opinions on Comprehensively Promoting the Construction of a Close-knit County-level Medical and Health Community", which provides clear guidance for the construction of county-level medical communities. The National Health Insurance Administration also made it clear that in 2024, it is necessary to give full play to the supporting role of medical insurance in the construction of a close-knit county-level medical community.
Huang Xinyu, director of the Department of Pharmaceutical Management of the National Health Insurance Administration, elaborated on the reform of payment methods, the adjustment of medical service prices and the support of primary medical institutions.
1. How to carry out the reform of payment methods in a close-knit county-level medical community?
In accordance with the requirements of "total payment, strengthening supervision and assessment, surplus retention, and reasonable overspending sharing", guide local governments to implement relevant work. There are four main aspects:
First, the total payment system for the medical community should be implemented and an internal incentive mechanism should be established. For the close-knit county-level medical community, the medical insurance fund takes the medical community as a whole. Specifically, on the basis of the annual fund expenditure budget, combined with the past historical cost data of each medical institution of the medical community, and comprehensively considering the functional positioning, service quantity and quality of the medical community, the annual total budget index of the close-knit medical community is reasonably determined.
Second, strengthen the supervision and assessment mechanism of the medical insurance fund to ensure that the medical insurance fund is used in a standardized manner within the medical community. For the assessment of the medical community, it not only involves the quality of medical services, medical expenses, satisfaction of insured personnel and other routine aspects, but also pays special attention to the indicators and results of hierarchical diagnosis and treatment, such as the medical treatment rate in the county, the grassroots medical treatment rate, etc., and the assessment results are linked to the year-end medical insurance cost settlement.
Third, implement the surplus retention policy to stimulate the enthusiasm of medical personnel. The surplus retention refers to the surplus part that can be used as the income of the medical community when the use of the medical insurance fund is lower than the total budget target under the premise of completing the established task objectives. The balance retention is mainly reflected in two levels: one is the difference between the payment standard of the disease type and the actual medical cost when the specific payment method such as according to the disease group (DRG) or the score by disease type (DIP), and the other is the difference between the total budget index of the medical community and the actual medical insurance cost when the settlement is made at the end of the year. The surplus retained funds that meet the requirements of medical insurance can be reserved for unified adjustment within the medical community after the annual liquidation.
Fourth, clarify the boundaries of reasonable overexpenditure sharing to ensure reasonable diagnosis and treatment of medical institutions. Due to the uncertainty or unpredictability of medical services, the medical insurance department will establish a corresponding management mechanism for reasonable overspending and sharing when formulating the total budget target. On the premise of ensuring the quality and safety of medical care, reasonable compensation will be given for reasonable overspending caused by the significant increase in the number of insured persons seeking medical treatment.
In the future, the National Health Insurance Administration will further promote the medical insurance fund to favor the medical community and grassroots medical institutions in the county, improve the diagnosis and treatment capacity of difficult and severe diseases in the county, and encourage grassroots medical institutions to provide more medical services, so as to improve the efficiency of the use of the medical insurance fund.
2. How does the medical service price policy support and promote the construction of county-level medical community?
The National Health Insurance Administration actively guides all provinces to establish a dynamic adjustment mechanism for medical service prices, and continuously increases the optimization and adjustment of medical service prices. On the premise of not increasing the burden of medical treatment on the public, the National Health Insurance Administration guides all localities to dynamically adjust the prices of technical labor services such as outpatient and emergency diagnosis and nursing according to the actual situation to ensure that the prices are reasonable. At the same time, the National Health Insurance Bureau has also standardized the price of general diagnosis and treatment fees in primary medical institutions, and promoted the same price of medical service projects with a high degree of homogenization in the same city, so as to promote the sinking of high-quality medical resources and support the development of rural medical institutions as a whole.
In addition, the National Health Insurance Administration also guides all provinces to formulate "Internet +" medical service price policy documents, further standardize the fees for Internet follow-up, remote consultation, remote monitoring and other medical service items, and promote the extension of Internet diagnosis and treatment services to the grassroots to meet the public's demand for Internet medical services.
In the future, the National Health Insurance Administration will continue to coordinate policies such as medical service prices and hierarchical diagnosis and treatment, better match the functional positioning of primary medical institutions, further support the development of primary medical institutions, and stimulate their internal vitality.
3. How does medical insurance reflect the support for primary medical institutions?
In the process of improving and perfecting the basic medical security system, the medical insurance department has always put the service function of primary medical institutions in an important position, promoted the healthy development of primary medical institutions through a series of measures, and guided patients to choose the nearest medical treatment at the grassroots level. This is mainly reflected in the following three aspects:
The first is to weave a dense grassroots service network. In order to strengthen the construction of the grassroots service network, the medical insurance department pays attention to the balance between primary medical institutions, specialized hospitals and general hospitals when determining the designated medical institutions for medical insurance. At the same time, in order to encourage the development of primary medical institutions, the conditions for applying for designated medical institutions are inclined to primary medical institutions, and through the integrated management of villages, the village clinics can also realize medical insurance settlement.
The second is to support the use of primary medical services. In terms of outpatient services, the medical insurance department has established a general outpatient co-ordination system for employee medical insurance, which includes ordinary outpatient expenses such as frequent diseases and common diseases into the scope of payment of the medical insurance co-ordination fund, and gives preferential treatment to primary medical institutions in terms of reimbursement ratio. For residents' medical insurance, outpatient co-ordination mainly relies on primary medical institutions, and special guarantees for "two diseases" such as hypertension and diabetes have been set up, mainly to pay for the "two diseases" drugs of secondary and below primary medical institutions. In terms of hospitalization, the medical insurance department implements differentiated payment policies for different levels of medical institutions, so that the reimbursement ratio of primary medical institutions is higher and the starting line is lower. According to statistics, within the scope of the policy in 2022, the average hospitalization reimbursement ratio of medical insurance for employees and residents in primary medical institutions is 10 percentage points and 17 percentage points higher than that of secondary and tertiary hospitals, respectively.
Third, in the process of payment method reform, the grassroots should be encouraged to provide reasonable medical services. When the total budget of the new medical insurance fund is added in the year, the focus is on primary medical institutions and supports them as a platform to carry out family doctor contract services. In addition, in the reform of payment methods according to disease group (DRG) or disease type score (DIP), the medical insurance department promotes the "same price for the same disease in the same city" for common and frequently occurring diseases, so as to stimulate the enthusiasm of primary medical institutions to provide services.
In the future, combined with the service capacity of the current primary medical institutions and the function of the medical insurance system, the national medical insurance department plans to promote the diagnosis and treatment of common diseases and frequent diseases at the grassroots level as a breakthrough, and encourage the insured to give priority to primary medical services. On the basis of ensuring the smooth operation of the medical insurance fund, we will continue to improve the convenience of medical treatment for insured patients to better meet the medical service needs of the masses.
Original title: How does medical insurance support the construction of county-level medical community?From 2019 to the present, what explorations and breakthroughs have we seen?
Source | Huawei County Development Research Platform
Edit | Yang Zixuan, Liu Xinyu
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