Tianjin adheres to the people's health as the center, in accordance with the deployment requirements of the National Health Insurance Bureau, the Municipal Party Committee and the Municipal Government, based on the first-mover advantage of outpatient security in Tianjin, coordinates various policies such as payment methods and centralized procurement, takes diabetes, a major chronic disease, as the entry point, implements diabetes gate payment according to the total amount per capita, implements the reform of the responsibility system of health supervisors in medical institutions, and continuously improves the incentive mechanism of total payment per capita oriented by health management results, so as to promote the transformation of medical institutions from treatment-centered to people's health-centered.
1. Background of reform
(1) Implement the reform requirements of the Party Central Committee and the State Council. General Secretary Xi Jinping has repeatedly stressed the need to give priority to the people's health in the strategic position of priority development. The "Healthy China Action (2019-2030)" clearly requires the "implementation of diabetes prevention and control actions", and proposes to strengthen the health management of diabetic patients and the self-health management of diabetic patients through medical institutions, improve the standardized management rate of diabetes, delay the occurrence and development of diabetic complications, and improve the health level of diabetic patients.
(2) Implement the work arrangements of the Municipal Party Committee and Municipal Government. In the actual operation of gate management, there are problems such as non-standard medical diagnosis and treatment, lack of health management, and excessive growth of medical expenses. In accordance with the requirements of the Municipal Party Committee and the Municipal Government on strengthening the governance of the clinic, we take the diabetes gate as the starting point, implement the diabetes gate health supervisor responsibility system as the main line, and comprehensively implement policies to standardize the governance path of the diabetes gate management.
(3) Provide support and assistance for the reform of the linkage of the three medical institutions. In recent years, with the continuous promotion of family doctor contract services and the construction of medical associations, the management and service capabilities of primary medical and health institutions have been continuously improved, and the mechanism of division of labor and cooperation between upper and lower medical institutions and the implementation of hierarchical diagnosis and treatment has been continuously improved.
Second, the main policy advantages
(1) Implement the responsibility system for diabetes gate health supervisors. Relying on the contracted service of family doctors and the construction of medical alliances, on the basis of the voluntary nature of diabetic patients, patients can independently choose the management service model of 1 health competent institution for first diagnosis and referral to N cooperative institutions.
After the diabetic patients sign a contract and select the health authority, the services provided by the health authority to the diabetic patient will be upgraded from the original simple diagnosis and treatment drug service to the health management service package including disease monitoring, complication screening, health education, treatment and drug treatment and referral services, so as to consolidate the main responsibility of the health authority to standardize diagnosis and treatment and health management, and gradually realize the transformation from treatment-centered to health-centered.
(2) Simultaneously implement capitation payment for diabetes. Based on the total amount of diabetes expenses actually incurred in medical institutions in 2019 by the diabetic patients under its management, the amount of diabetes payment by the competent health institution is approved in accordance with the principles of admission with volume, high support limit and overall balance, which not only considers the difference in the cost of medication caused by the severity of the patient's condition, but also leaves the space for drug price reduction after the centralized procurement organized by the state to the medical institution as an incentive, and fully protects the drug rights and interests of patients and the reasonable interests of medical institutions from the level of system design.
(3) Incentive mechanism oriented by the results of health management. After the health authority takes the lead in providing comprehensive health management services to diabetic patients, and realizes the balance of the total capitation payment amount by standardizing the diagnosis and treatment behavior and controlling the medical cost, the medical insurance agency shall implement the incentive mechanism for the balance to be retained by the health authority on the basis of the assessment of its health management results. After soliciting the opinions of clinical experts, the medical insurance handling department has determined the health management matters of diabetes on the basis of the authoritative diabetes prevention and control guidelines, and after the medical institutions carry out health management on a regular basis in accordance with the prevention and treatment guidelines, they shall submit relevant data and information on health management matters to the medical insurance standards, including relevant examination and laboratory index data, complication screening, and diagnosis and treatment drug plans. Accordingly, the medical insurance agency shall evaluate the process and results of the health management carried out by the health authority, and allocate the remaining retained funds to the medical institution after the assessment is met.
(4) Implement incentives for medical personnel carrying out health management. In order to allow medical staff to continue to have the motivation to standardize health management, it is necessary to extend the incentive mechanism of medical insurance to medical institutions to the incentives of medical institutions to form a closed loop of incentives. In this regard, the policy clearly states that after the health authority obtains the surplus funds of the medical insurance, it can establish a performance-based performance distribution mechanism guided by the results of medical and health management under the guidance of the health and other departments, and implement the medical insurance incentive mechanism to the salary expenditure of medical personnel; The responsibility sharing mechanism extends the medical insurance incentive mechanism to the cooperative medical institutions and their medical personnel involved in health management according to the contribution of the cooperative medical institutions to the medical and health management process and results.
3. Innovate service safeguard measures
(1) Voluntarily participate in independent choice. Diabetic patients can choose one health authority on a voluntary basis, and if they are not satisfied with the selected health authority, they can choose to change the health authority or return to the mode of treatment in three medical institutions of their choice. If a diabetic patient has not yet selected a health authority, the model of choosing three medical institutions for treatment will continue to be implemented.
(2) Upgrade of health management services. After the diabetic patients sign a contract and select the health authority, the services provided by the health authority to the diabetic patients will be upgraded from the original simple diagnosis and treatment drug service to the health management service package including disease monitoring, complication screening, health education, treatment and referral services, and gradually realize the transformation from treatment-centered to health-centered.
(3) The scope of gate medication has been expanded. After the diabetic patient signs a contract and selects the health authority, the health authority can select the appropriate medical service items from the scope of payment of the basic medical insurance in Tianjin according to the actual condition of the diabetic patient, and formulate a standardized diagnosis and treatment drug plan for diabetes and complications. However, if the diabetic patient has not selected a health authority, the reimbursement scope shall be implemented in accordance with the payment scope of the Tianjin Diabetic Gate Project.
(4) There is no limit to the number of referral institutions. According to the actual situation of the diabetic patient, the health authority can refer the patient to N cooperative institutions for diabetic diagnosis and treatment, and the policy does not limit the number of referrals, which is actually more lenient than the original policy that patients can only choose 3 medical institutions for treatment. In the actual implementation process, the medical insurance agency shall authorize the number of hospitals to which patients can be referred to the medical institution with the responsibility of the health supervisor from the management point of view, and the competent hospital shall refer the patient according to the patient's condition.
(5) The level of treatment and protection remains unchanged. Diabetic patients who choose a health authority or do not choose a health authority can enjoy the reimbursement treatment of Tianjin outpatient specific disease medical insurance according to the regulations, and there is no difference in the starting line, reimbursement ratio and maximum payment limit.
Fourth, progress and effectiveness
(1) The implementation of the voting mechanism with feet, the overall recognition of patients is high. As of the end of March 2023, 230,000 diabetic patients have signed up to select health authorities, accounting for more than 55% of the city's 420,000 active diabetic patients, an increase of 200,000 compared with the initial stage of the system in June 2022, indicating that diabetic patients have a high degree of recognition of the health supervisor responsibility system. In mid-April 2023, we launched a satisfaction survey to 230,000 contracted diabetic patients in the city, and invited them to evaluate their satisfaction with the drug guarantee, referral services and health management provided by the selected health authorities through the Tianjin Medical Insurance APP. As of the end of April, 97% of the participating patients were satisfied. At present, the satisfaction survey is still ongoing.
(2) The amount of medical insurance is in place, and the enthusiasm of the institution is generally high. By monitoring the operation from December 2022 to March 2023, the overall balance rate of health authorities and cooperative medical institutions is 23.3%. On the whole, the amount of diabetes payment approved by the medical insurance department to the health authority is based on the total capitation amount, which can effectively meet the needs of patients for diagnosis and treatment drugs and referrals, and also reserves more incentive space for the health authority. As of the end of March 2023, more than 740 of the more than 940 medical institutions in the city that have carried out diabetes clinic diagnosis and treatment have declared to become diabetes clinic health authorities.
(3) Medical treatment and diagnosis have been gradually standardized, and the effect of reform has initially appeared. Under the role of the incentive mechanism of medical insurance, the competent health institutions are gradually returning from the previous patients ordering drugs and doctors prescribing to treating diseases and standardizing diagnosis and treatment. Before and after the acceleration of the implementation of the diabetic gate health supervisor responsibility system, the monthly per capita medical expenses of diabetic patients decreased from 1,643 yuan to 1,255 yuan, a decrease of 23.6%. In the actual operation process, the primary medical and health institutions have also taken the initiative to strengthen the construction of the contracted team of family doctors, and provide health management services such as health education, disease monitoring and complication screening to patients with diabetes mellitus with health management personnel as assistants.
(4) The distribution of medical treatment flows to the grassroots level to help promote hierarchical diagnosis and treatment. In the process of promoting the health supervisor responsibility system, the teams of primary medical and health institutions and family doctors actively guide diabetic patients to choose primary medical and health institutions as their own health authorities by improving drug use guarantee and health management capabilities in combination with their own functional positioning. As of the end of March 2023, 44% of the 230,000 diabetic patients who have chosen a health authority have chosen a family doctor contracted institution as the health authority, while only 23% of patients were treated in a family doctor contracted institution before the implementation of the health supervisor responsibility system, an increase of 21 percentage points.
Original title: Tianjin implements diabetes payment according to the total amount per capita, and implements the responsibility system of health supervisors of medical institutions
Author | Tianjin Medical Insurance Center
Source | China Medical Insurance
Edit | Yang Zixuan bought Xiaofei
Hot Article
• Hold an umbrella for others!3 stories behind long-term care caregivers
• Under DRG/DIP, be careful of the three drawbacks of using the cost consumption index!
• The triple system of medical insurance has built a health "moat" for thousands of families