In order to improve the efficiency of the allocation and use of medical and health resources at the county level, accelerate the improvement of the capacity of primary medical and health services, promote the construction of a new order of hierarchical diagnosis and treatment, reasonable diagnosis and treatment, and orderly medical treatment, and effectively solve the problem of difficult and expensive medical treatment for the grassroots people, one of the very important measures is to promote the construction and development of the county-level medical community. To this end, in recent years, national and local governments at all levels and their relevant departments have formulated and issued a series of policy documents to support the construction and development of county-level medical communities.
Previously, a complete and continuous medical service for the diagnosis and treatment of a patient's illness was usually provided in a single medical facility. Because of this, the medical insurance department usually settles medical insurance expenses with a single medical insurance designated medical institution.
With the introduction of the county-level medical community, a new form of medical and health resource organization, ideally, for a mature county-level medical community, for the sake of cost and benefit, the diagnosis and treatment of some diseases may no longer be completed independently by a member unit from beginning to end, but by the cooperation of each member unit within the county-level medical community, by providing a series of integrated and continuous medical services, including: unified procurement and distribution management of drugs and medical consumables, Mutual recognition of the results of the examination or unified completion by the medical examination and testing center within the county-level medical community, acute and slow treatment, two-way referral, etc. Therefore, the settlement object of the medical insurance fund objectively needs to be transformed from the original single medical institution to the county-level medical community. To this end, 10 departments, including the National Health Commission and the National Health Insurance Administration, jointly issued the "Guiding Opinions on Comprehensively Promoting the Construction of Close-knit County-level Medical and Health Communities" (Guowei Ji Ji Fa [2023] No. 41), which proposed to implement the total payment of medical insurance funds for close-knit county-level medical communities.
At present, many localities have actively carried out the practical exploration of the implementation of the total payment of medical insurance funds for county-level medical communities, mainly including the total budget, payment methods, year-end liquidation, treatment guarantees, etc.
- Total budget
On the whole, the local practice basically carries out the total budget of the medical insurance fund for the county-level medical community, and does not carry out the annual total budget for its member units. However, the specific implementation path and operation strategy vary from place to place. There are five main situations:
The first is to only implement the total budget of the outpatient medical insurance fund for the county medical community, while the inpatient medical insurance fund is to implement the total budget within the overall planning area, and no longer subdivide it into the county medical community and other medical institutions. For example, Zhejiang stipulates in the "Opinions on Promoting the Reform of the Payment Method of Basic Medical Insurance of the Provincial County Medical Community" (Zhejiang Medical Insurance Lianfa [2019] No. 12) that the budget allocation of the hospitalization medical insurance fund and the implementation of the DRGs point method should be taken as an overall budget unit (including the cost of medical treatment in other places) in the overall planning area, and will no longer be subdivided into various medical communities and other medical institutions. The allocation of the budget amount of the outpatient medical insurance fund can be packaged to each medical community in proportion to the total budget of the outpatient medical insurance fund in the overall planning area (including the cost of medical treatment in other places), and the distribution ratio can be reasonably determined by negotiation and negotiation by comprehensively considering the historical expenditure weight, capitation ratio, average outpatient cost and other factors of the outpatient medical insurance fund as a whole.
The second is to calculate and determine the budget amount of the medical insurance fund according to the capitation to the county-level medical community, and connect it with the DRG/DIP payment method. For example, Fujian stipulates in the "Guiding Opinions on the Packaged Payment of Medical Insurance Funds of Compact County Medical and Health Communities" (Min Yibao [2021] No. 114) that the budget of a medical community's packaged medical insurance fund = ∑ (the number of insured people of each age group at the end of the previous year × the per capita packaged fund standard of the corresponding age group) × location adjustment coefficient. At the same time, it is stipulated that the medical community participating in the DIP pilot project shall be included in the total DIP budget from the budget of the medical community's packaged medical insurance fund according to the budget amount of the medical community's inclusion of the regional point method and the payment according to the value of the disease (DIP) project. From the second year onwards, the amount received from the total DIP budget in the previous year and the growth rate of the total DIP budget shall be calculated and transferred to the total DIP budget, and the amount due shall be allocated and calculated according to the DIP pilot method.
The third is to determine the total budget of the medical insurance fund according to the number of family doctors who have signed contracts, and start with outpatient clinics, and then gradually expand to other medical categories. For example, Tianjin stipulates in the "Notice on the Trial Implementation of Capitation Total Payment for Close-knit Regional Medical Consortiums Carrying out Family Doctor Contracted Services" (Tianjin Medical Insurance Bureau Fa [2021] No. 116) that the insured persons of family doctor contracted services in primary medical and health institutions within the close medical alliance, as well as their outpatient specific diseases, general outpatient (emergency) and inpatient medical expenses, are all included in the scope of capitation payment accounting. At the initial stage of implementation, the payment per capita was implemented starting from the two payment categories of Gate and general outpatient services, and gradually expanded to all payment categories. The method for approving the total amount of capitation is based on the scope of insured persons and payment categories included in the total capitation payment accounting of the close medical alliance in the current year, based on the actual total medical expenses incurred in various designated medical institutions at all levels in the city in 2019, and after considering the growth factors according to the increase in the total amount of purchases in the city in the current year compared with the total medical expenses in the city in 2019, the annual payment amount per capita of the close medical alliance is approved.
The fourth is to calculate and determine the budget amount of the medical insurance fund of the county medical community according to the total settlement and payment of the medical insurance fund of each member unit in the county medical community in the previous year, and due consideration of the growth factor of medical expenses. For example, Jiangxi stipulates in the "Notice on Promoting the Implementation Plan for the Reform of Medical Insurance Payment Methods of Compact County Medical and Health Communities" (Gan Yi Bao Fa [2022] No. 23) that the total amount of settlement and payment of the medical insurance fund of the designated medical institutions within the scope of the medical community in the previous year shall be referred to the growth rate of the settlement and payment of the medical insurance fund in the previous three years, and the increase in the number of medical services of the medical community shall be appropriately considered, and the growth rate shall be controlled within the growth rate of the income budget of the medical insurance fund in the overall planning area, and the total amount of the annual medical community medical insurance fund "packaged" shall be determined.
The fifth is to calculate and determine the annual budget of the county medical insurance fund on the basis of the total budget of the district medical insurance fund, and then determine the annual budget of the county medical community medical insurance fund through consultation and negotiation according to the specific situation of the county medical community. For example, Guangxi stipulates in the "Implementation Plan for Promoting the Reform of Medical Insurance Payment Methods in Compact County-level Medical and Health Communities" (Gui Yi Bao Fa [2023] No. 24) that based on the overall planning of the region's revenue and expenditure accounts of the previous year, comprehensive consideration of the annual revenue budget, major policy adjustments, and the quantity, quality and quality of medical services, capacity and other factors, with reference to the growth rate of medical insurance fund expenditure in the previous three years, after determining the total budget of the overall regional medical insurance fund, the annual budget of the county medical insurance fund is calculated based on the balance of income and expenditure of the county medical insurance fund and the proportion of the expenditure of the medical insurance fund in the overall area. On the basis of the annual budget of the county-level medical insurance fund, the total amount of "packaged" medical insurance funds of each medical community is reasonably determined through consultation and negotiation by comprehensively considering the number, age, health status and quality of medical services of the medical community.
- Payment methods
For example, it is stipulated in the relevant policy documents that the inpatient medical services in the county medical community are mainly paid according to DRG/DIP; For rehabilitation patients, the payment is mainly based on the bed day, and for outpatient medical services, we will explore the combination of family doctor contract services, which are mainly paid per capitation, etc.
At present, since the diagnosis and treatment of diseases that occur in the county-level medical community are mostly completed in a certain member unit, the above provisions can basically meet the needs of medical insurance payment under normal circumstances. However, it is undeniable that each member unit of the county medical community is a community of service, responsibility, interests and management, with the continuous promotion and maturity of the construction of the county medical community, under the condition that the medical insurance fund implements the total payment of the county medical community, its rational behavior must be to ensure the quality of medical services and meet the diagnosis and treatment standards under the premise of integrating and optimizing the allocation of medical resources within the county medical community, so as to effectively reduce the cost of medical services, so as to maximize the benefits of medical services. One of its measures is to coordinate and cooperate with each other according to the comparative advantages of different medical services among the members of the county-level medical community, so as to provide integrated and continuous medical services for the diagnosis and treatment of diseases. Based on this, a disease may be completed in different member units within the county medical community at different stages of medical treatment.
However, judging from the current policy documents issued by the pilot areas, the integrated and For example, if the operation is completed in a county-level hospital within the county-level medical community, and the subsequent rehabilitation stage is carried out in the township health center within the county-level medical community, or the pre-admission examination and clinical observation are completed in the primary medical institution, the targeted treatment is completed in the county-level hospital, and the follow-up rehabilitation and nursing are completed in the primary medical institution within the county-level medical community, etc. For the above situation, the medical insurance payment policy obviously needs to be clear, whether to pay according to a single disease diagnosis and treatment, or according to multiple disease diagnosis and treatment separately (at present, in addition to Zhejiang Province's clear provisions, "for the first diagnosis and two-way referral of the primary level in the medical community, the hospitalization insured personnel are regarded as one hospitalization, and the starting line is no longer double-counted, and the starting line is determined according to the standards of higher-level medical institutions", and most other regions are vague)? If the amount of medical insurance payment is calculated according to the diagnosis and treatment of a disease, how will the medical insurance payment standard be determined in the areas where DRG/DIP payment is implemented? In addition, does the examination and examination that has been completed in the primary medical institution need to be re-conducted in the county-level hospital? If it is not re-conducted, is it considered a reduction in the service content? Does it meet the standard of diagnosis and treatment? And so on. If the medical insurance payment policy does not clearly stipulate this, it will inevitably bring some unnecessary troubles and doubts to the actual operation, which will not only affect the smooth settlement of the medical insurance fund, but also affect the smooth progress of hierarchical diagnosis and treatment.
- Year-end liquidation
From the perspective of local practice, the year-end liquidation of the medical insurance fund usually takes the county-level medical community as a settlement unit, and carries out the year-end liquidation of the county-level medical community with the leading hospital. However, in terms of specific implementation, there are slight differences in local practices. Specifically:
One is that the provincial medical insurance department only determines the basic principle of surplus retention and overexpenditure sharing, and the specific retention or sharing ratio is stipulated by the overall regional medical insurance department. For example, Zhejiang stipulates in the "Opinions on Promoting the Reform of the Payment Method of Basic Medical Insurance of the Provincial County Medical Community" (Zhejiang Medical Insurance Lianfa [2019] No. 12) that if there is a balance or overexpenditure in the annual liquidation of the medical insurance fund in the overall planning area, it should be retained or shared by the medical institution and the medical insurance fund according to a certain proportion on the basis of analyzing the reasons and clarifying the responsibility. The appropriate retention and sharing ratio can be set by each coordinating area and dynamically adjusted. Fujian stipulates in the "Guiding Opinions on the Packaged Payment of Medical Insurance Funds of Fujian Compact County Medical and Health Communities" (Min Yibao [2021] No. 114) that the medical insurance department and the medical community shall jointly analyze the overspending part of the medical insurance packaging fund in the current year, clarify their responsibilities, and negotiate to determine the reasonable amount and sharing ratio of the overspending. The part of the fund overrun caused by the adjustment of the medical insurance treatment policy and the price of medical services shall be paid to the medical community from the reserved risk fund according to the balance of the medical insurance fund, and the part of the reduced fund expenditure shall be retained by the medical community.
The other is that the provincial medical insurance department has made clear provisions on the proportion of surplus retention and overexpenditure sharing. For example, Jiangxi stipulates in the "Notice on the Implementation Plan for Promoting the Reform of Medical Insurance Payment Methods in Compact County-level Medical and Health Communities in Jiangxi Province" (Gan Yi Bao Fa [2022] No. 23) that the part of the annual settlement of medical expenses exceeding 10% of the total annual "packaged" amount of the medical community will not be shared by the medical insurance fund and will be borne by the medical community itself; if the total amount exceeds 5%, the medical insurance fund will share 80%; if the excess is less than 5% and less than 10% (inclusive), the medical insurance fund will share 60%; and the overexpenditure sharing shall be calculated in stages. The balance of medical expenses in the annual settlement exceeds 15% (exclusive) of the total "packaged" amount of the medical community, and all the parts exceeding the prescribed proportion shall be returned to the pooled fund. If the surplus ratio is less than 10%, 80% of the medical community shall be retained; if the surplus ratio reaches 10% but is less than 15%, 60% of the medical community shall be retained; Guangxi stipulates in the "Implementation Plan of Guangxi Zhuang Autonomous Region for Promoting the Reform of Medical Insurance Payment Methods of Compact County-level Medical and Health Communities" (Gui Yi Bao Fa [2023] No. 24) that the remaining retained funds shall not exceed 15% of the total "packaged" amount of the medical community in principle, and the remaining retention costs of the policy of centralized procurement of drug consumables will not be double-counted. The proportion of surplus retained funds and specific assessment measures shall be formulated separately by the local medical insurance departments. If the total amount exceeds 5% (inclusive), the medical insurance fund will share 80%; if the total amount exceeds 5% (inclusive), the medical insurance fund will share 60%; and the overexpenditure share shall be calculated in stages.
Another approach is to stipulate that the surplus is retained in its entirety and that the overexpenditure is borne by oneself. For example, Sichuan has made a provision in the "Opinions on Promoting the Reform of Medical Security Management in Close-knit County-level Medical and Health Communities (Trial)" (Chuan Yi Bao Fa [2020] No. 11) that the surplus part shall be owned by the medical community as medical service income and used for the development of medical and health undertakings, and the overexpenditure part shall be borne by the medical community itself.
-- Guarantee of treatment
The insured people receive medical services in the member units of the county medical community, and usually enjoy differentiated medical expense reimbursement policies according to the different levels of the member units of the county medical community. For the inpatient insured persons who have achieved the first diagnosis and two-way referral at the grassroots level in the medical community, the calculation of the minimum payment line is basically implemented in accordance with the national policies and regulations, that is, "the minimum payment line is continuously calculated for the referred inpatients who meet the regulations". However, further refinements have been made in various localities. For example, Zhejiang stipulates that the minimum payment line will no longer be double-counted, and the minimum payment line will be determined according to the standards of higher-level medical institutions, while Jiangxi further stipulates that the initial diagnosis and two-way referral of inpatients who have achieved the first diagnosis and two-way referral at the grassroots level within the medical community will no longer be double-counted and the minimum payment for hospitalization will not be charged. If the lower-level hospital is transferred to the higher-level hospital for inpatient treatment, only the part of the standard difference between the two levels of hospitals shall be paid, that is, the inpatient threshold shall be calculated together. If the higher-level hospital is transferred to the lower-level hospital to continue rehabilitation and hospitalization, the standard fee for hospitalization in the lower-level hospital will no longer be paid, that is, the hospitalization threshold will be exempted.
At present, what is slightly insufficient is that the reimbursement policy for the medical expenses incurred by the insured people receiving continuous medical services between different member units of the county medical community has not been clearly stipulated, which may bring trouble to the actual medical insurance management work. In the author's opinion, it is necessary to make further clear provisions. Specifically, it is clearly stipulated as follows:
First, if the disease patients who belong to the same inpatient treatment process receive integrated continuous medical services from different levels of medical institutions within the county-level medical community, the reimbursement ratio of expenses shall be calculated in stages.
Second, patients who need long-term hospitalization for psychiatric, nursing, rehabilitation and other diseases in the non-acute attack period, or outpatient diagnosis and treatment and prescription services (including general outpatient and outpatient chronic diseases) can enjoy differentiated treatment and reimbursement policies according to the different levels of each member unit in the county-level medical community.
- Summary
To sum up, in order to promote the construction and development of county-level medical communities, local medical insurance departments have formulated and introduced a series of active and effective medical insurance support policies in accordance with the unified deployment of the state, contributing to the strength of medical insurance. However, we must also be soberly aware that with the in-depth promotion of the construction of the county-level medical community, the medical insurance support policies that meet the requirements of the development of the county-level medical community need to change with time and demand, and continue to improve the medical insurance system and continue to reform the medical insurance payment policy, so as to promote the further development of medical reform.
Author | Cai Haiqing, former director of the Treatment and Security Department of Jiangxi Provincial Medical Insurance Bureau, and former first-level researcher
Source | China Medical Insurance
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