To control the phenomenon of "false hospitalization", it is necessary to strengthen the disciplinary mechanism for primary hospitals
Words of a Family
Only by increasing the "high pressure" of supervision can the hand reaching out to the medical insurance fund be retracted.
According to a survey by the Beijing News, in Taihe County, Anhui Province, many hospitals used "free" routines to attract elderly people with no or mild illnesses to be hospitalized. Most of the "patients" are elderly people who are in good health and enjoy the medical insurance policy for urban and rural residents. They are hospitalized for one week. Around that, even if it costs thousands of yuan, the hospital only charges 200 yuan or even free, and most of the expenses are borne by medical insurance, and the relevant hospitals are suspected of drawing medical insurance funds.
This is actually a typical "fake medical insurance" phenomenon.
There are multiple reasons for this phenomenon.
For some basic-level small and medium-sized hospitals, due to their own brand influence and insufficient medical resources, the income cannot cover the expenditure, which leads to individual hospitals to take risks for profit.
According to data from the National Medical Security Administration, in 2019, the total income of the national basic medical insurance fund (including maternity insurance) was 2442.1 billion yuan, an increase of 10.2% over 2018, accounting for approximately 2.5% of GDP that year; the national basic medical insurance fund (including maternity insurance) ) The total expenditure is 2,085.4 billion yuan, an increase of 12.2% over 2018, accounting for approximately 2.1% of GDP that year; from the perspective of medical insurance revenue and expenditure in 2018, although the overall medical insurance still maintains revenue exceeding expenditures and fund balances, basic medical insurance fund expenditures The growth rate is significantly higher than the income growth rate.
On the one hand, the relevant departments are vigorously promoting the "throttling" of the medical insurance fund. As of 2020, five consecutive rounds of medical insurance negotiations have been launched. From the previous four rounds of negotiations, the average drop in almost every round of negotiations is 50%. Above, the average decline of new varieties in 2019 exceeded 60% for the first time.
These medicines enter the medical insurance through price reduction, which not only reduces the burden of medical care for the people, but also allows the total expenditure of the medical insurance fund to be favorably controlled.
However, if the phenomenon of "fake hospitalization" is allowed to spread in some basic-level small and medium-sized hospitals and infirmaries, it will inevitably cause a lot of waste of medical insurance funds.
To control the phenomenon of "false hospitalization", it is necessary to strengthen the disciplinary mechanism for primary hospitals.
The National Medical Insurance Administration reported 8 typical cases of fraudulent obtaining medical insurance funds in January 2019, including many cases of insurance fraud that were investigated for inducing hospitalization.
The hospital’s medical insurance designated medical institution qualifications were cancelled, and the hospital’s "Medical Institution Practice License" was also revoked.
The public security department arrested 2 persons in accordance with the law and released 1 person on bail pending trial.
There were similar cases in Anhui and other places where the hospital involved was punished, and many responsible personnel of the hospital were held accountable.
However, this kind of phenomenon still exists, indicating that some hospitals are still lucky. This requires management agencies to increase regular audits of hospital medical insurance expenditures and verify the surge in the number of inpatients in the short term.
In fact, the introduction of new technologies can alleviate the pressure of normalized management of grassroots management institutions, and achieve improved management quality and efficiency.
According to reports, Hebei Province is making every effort to build a medical insurance intelligent monitoring system, combined with embedded regulatory rules, to conduct automatic real-time monitoring and analysis of all data related to the use of medical insurance funds such as medical institutions, insured personnel, diagnosis and treatment items, and medical information, and regularly Push and review the doubtful points in the use of medical insurance funds, forming a closed loop of doubtful point review, so as to establish the whole-process monitoring of designated medical institutions by medical insurance agencies.
At the same time, the Provincial Medical Insurance Bureau, in conjunction with the Provincial Department of Finance, formulated the "Implementation Rules for Reporting and Rewarding of Fraudulent Obtaining of Medical Security Funds", which announced the telephone number of the report to the public and rewarded those who met the conditions.
In addition, for certain hospitals or clinics with serious circumstances, their medical insurance qualifications should be suspended, and the relevant responsible persons should be held accountable for administrative and even legal responsibilities. Only by increasing the “high pressure” of supervision can the hand extended to the medical insurance fund be retracted.
It can be seen from this that grasping technological upgrading on the one hand, activating the enthusiasm of public information reporting on the other hand, and grasping accountability in place are effective ways to control the phenomenon of "false hospitalization" in primary medical institutions.
Other places, including Anhui, should also speed up the construction of these two systems, so as to improve the level of informatization and intelligent supervision, realize real-time monitoring of the whole process of medical services, block various management gaps, and let the medical insurance "life-saving money" truly play a role effect.
□Bi Ge (financial commentator)