The reform of medical insurance payment methods has been carried out in most parts of the country, and some people are worried that there will be changes in medical insurance treatment. How to change the payment method of medical insurance? What are the implications for the insured? Focusing on the issues of concern to the masses, the relevant person in charge of the National Health Insurance Bureau gave answers.
The purpose of the reform of payment methods is by no means simply "fee control"
Q: Some people say that the reform of medical insurance payment methods is because the medical insurance fund has no money and needs to control expenses. Is there any basis for this claim?
Answer: The medical insurance payment method is the specific way for the medical insurance agency to pay the fees to the medical institutions, including payment by project, payment by disease, payment by bed day, etc., and different ways have different guiding effects on clinical diagnosis and treatment behavior. The mainland has successively launched the pilot payment methods of DRG (according to disease group) and DIP (according to disease score). By the end of last year, more than ninety percent of the co-ordinating areas had carried out the reform of DRG/DIP payment methods. After the reform, the proportion of the hospital medical insurance fund paid by project in the reform area dropped to about 1/4.
It should be noted that the purpose of the reform of payment methods is by no means a simple "fee control", but to guide medical institutions to focus on clinical needs, adopt appropriate technology to treat diseases, reasonable diagnosis and treatment, avoid large prescriptions and indiscriminate examinations, and better protect the rights and interests of insured personnel. After the reform, the payment standard will be raised in a timely manner with social and economic development and changes in the price level. Every year, the expenditure of medical insurance funds has maintained an upward trend and is higher than the growth rate of GDP and prices.
There have never been restrictive rules such as "no more than 15 days in a single hospitalization".
Q: In recent years, in some areas, some patients have been discharged after two weeks of hospitalization and then re-admitted to the hospital, saying that after the reform of the payment method, there is a regulation that "a single hospitalization shall not exceed 15 days". What's going on?
A: The national medical insurance department has never issued restrictive regulations such as "a single hospitalization shall not exceed 15 days". In 2022, the National Health Insurance Administration also issued the "Notice on Comprehensively Investigating and Canceling Unreasonable Restrictions on Medical Insurance", requiring local medical insurance departments to conduct a comprehensive and in-depth investigation of unreasonable restrictions on medical institutions, and the areas with problems have been cleaned up.
In the case of "a single hospitalization does not exceed 15 days", it may be that some medical institutions have set up more extensive management measures in order to complete the assessment indicators such as "average length of stay" and "average cost per time". We resolutely oppose and welcome reports from the masses to change the "average" of medical insurance payment standards into "limits", and require patients to be discharged, transferred to hospitals or hospitalized at their own expense on the grounds that "the medical insurance quota has arrived", and will be dealt with seriously.
Eligible new drugs and technologies can be settled according to the actual expenses incurred
Q: Under the pay-by-disease model, will there be cost pressure on medical institutions to add new equipment or use high-priced new drugs to patients? If medical workers use new drugs and technologies in the process of consultation, will their performance income be affected?
Answer: The occurrence of such problems in individual medical institutions in individual regions is not the original intention of the reform of payment methods. On the contrary, in order to support the application of new clinical technologies and ensure that seriously ill patients receive adequate treatment, relevant rules have also been introduced in the reform of payment methods, such as the "exclusion payment" rule that qualified new drugs and technologies can not be included in the payment standard for diseases, and the "special case single discussion" rule for severe cases that are significantly higher than the average cost of the disease, which can be settled according to the actual expenses incurred, so please rest assured that the majority of insureds, medical institutions and medical personnel.
Medical problems are very complex, and the technological progress in the medical field is also very fast, and there must be some places where the medical insurance payment policy does not match the actual medical treatment and lags behind the clinical development. To this end, the National Health Insurance Administration is establishing an opinion collection mechanism and DRG/DIP grouping rule adjustment mechanism for the majority of medical institutions and medical personnel, based on the opinions and suggestions put forward by medical personnel and the objectively occurring medical expense data, the grouping is dynamically and normalized adjusted and improved, and the optimized version is regularly updated to fully respond to the demands of medical institutions to ensure the scientificity and rationality of medical insurance payment methods.
Original title: The reform of medical insurance payment methods has been carried out in most parts of the country What are the changes in medical insurance treatment?
Source | People's Daily
Edit | Fu Meiru Liu Xinyu
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