The filing and issuance of referral certificates are blocked, and the information platform is not connected smoothly, resulting in the card settlement stuck——
When will the "highway" for medical settlement in different places be unimpeded?
Experts suggest that for patients who just need to be "turned to the end", optimize the construction of information platforms, and promote the standardization of medical insurance handling services
Our reporter Chen Xi
Chu Ting (pseudonym) is a Heilongjiang girl working in Beijing.
After her father was diagnosed with lung cancer last year, she decided to take him to Beijing for surgery.
However, the road to seeking medical treatment in other places has twists and turns: the issuance of referral certificates for filing was blocked, the system for swiping credit cards for discharge from the hospital was upgraded, and the admission filing was mistakenly deleted by the handling agency... Although the reimbursement was finally successful, the repeated encounters with stuck cases also made Chu Ting feel tired. .
The original intention of the direct settlement policy for out-of-town medical treatment is to solve the problem of "running errands" for the insured.
Since its official launch in 2016, it has been implemented step by step in accordance with the idea of "inpatient first, then outpatient; first within the province, and then across the province", and the benefits continue to expand.
The data shows that the accumulative total of cross-provincial direct settlement of inpatient and outpatient expenses across the country has exceeded 10 million person-times.
The reporter found that the "highway" for direct settlement of medical treatment in different places has been paved, but due to differences in medical insurance policies, fund revenue and expenditure, and platform construction in different places, there are still obstacles in the actual treatment and settlement process for medical treatment in different places.
Issuing a referral certificate has twists and turns
At the end of August 2021, Chu Ting's father was diagnosed with left lung squamous cell carcinoma at the local county hospital.
Chu Ting immediately began to go through the formalities for medical treatment in Beijing, but encountered resistance during the referral and filing.
"The county hospital was transferred to the city hospital, and the city hospital was transferred to the provincial tertiary hospital. The tertiary hospital insisted that the hospital could accept treatment, but did not agree to transfer to the hospital in Beijing."
According to the current system design, the insured generally follows the process of "filing first, selecting a point, and using the card code to seek medical treatment" when handling direct settlement for medical treatment in other places.
For people who are referred from other places, the first filing needs to be submitted by a local designated medical institution with the qualifications for referral and referral, and the referral must be registered.
After consulting the Heilongjiang Provincial Medical Insurance Bureau, Chu Ting got a reply, "The hospital will comprehensively judge whether it is necessary to continue referral based on the patient's condition and the medical technology level of the hospital."
After Chu Ting's understanding, local hospitals are not good at lung cancer treatment, and "seeking a doctor in another place is just needed."
In desperation, she had to return to her hometown, and took her father to several hospitals to try, and finally completed the record through the relationship.
Why is the hospital "not very enthusiastic" about referrals from other places?
Liao Zangyi, an associate professor at the School of Politics and Public Administration of China University of Political Science and Law, believes that medical treatment in other places is mostly settled from underdeveloped areas to developed areas. The reason why insured places strictly review and refer referrals is to consider the pressure of medical insurance fund revenue and expenditure and the safety of operation after the fund flows out. It is also to prevent "minor illnesses and big problems" and disrupt the order of medical treatment.
"This kind of worry is reasonable, but it's not completely in line with reality." Zhu Fengmei, an assistant researcher at the Institute of Economics, Chinese Academy of Social Sciences, once evaluated the cost of medical care in other places and the expenditure of medical insurance funds. From the results, medical treatment in other places will not increase participation. Guarantee Fund pressure.
"The diagnosis and treatment process in large hospitals is more standardized. In order to improve the turnover rate of hospital beds, there will be basically no excessive medical treatment, and the number of hospitalization days, times, and expenses will be less than local hospitals."
"The medical insurance department should change its thinking. While guiding hierarchical diagnosis and treatment, it will release restrictions on patients suffering from serious and serious diseases, so as to realize 'turn all the time'." Zhu Fengmei said.
Off-site settlement encounters stuck
After undergoing surgery in Beijing, Chu Ting's father was discharged from the hospital in early October 2021, but due to a system failure, the card was not settled on the same day.
Chu Ting was told that this was due to the upgrade of the medical insurance system in Heilongjiang Province, and the out-of-town business would be reopened from October 31.
From November to the beginning of December, they tried to make direct settlement several times, but the system could not read the patient information, and the handling staff could not find the crux.
Chu Ting communicated with the hometown medical insurance bureau again, and the other party said after inquiry, "During the system update, the admission record has been deleted by the Beijing medical insurance information department." After the two places coordinated and re-entered the information, the problem was finally resolved on December 27.
It is not an isolated case of “difficulty swiping a card” for direct settlement of medical treatment in other places.
In the "Leadership Message Board" column of People's Daily Online, the reporter found that netizens in many places had reported that "medical treatment in other places cannot be settled."
Judging from the replies from the relevant departments, the reasons include "instability of the information platform" and "problems with the system interface", etc. However, in most cases, the error link cannot be confirmed, and the registration can only be cancelled, and the filing and settlement process can be repeated.
"This is related to the poor connection between the local handling systems and the national medical insurance information platform." Liao Zangyi said.
Liao Zangyi analyzed that since September 2021, the National Medical Insurance Administration has promoted the construction of a national unified medical insurance information platform, requiring localities to carry out conversion and docking one after another.
Due to the large differences in the medical insurance policies and settlement standards of each overall planning area, the names and codes of medicines, consumables, and diagnosis and treatment items are also inconsistent, and they cannot be immediately interoperable with the national platform.
Zhu Fengmei believes that the current coordination of medical insurance funds is mainly based on cities and counties. In the future, even if there is a national platform as an intermediary, it is still necessary to coordinate the "point-to-point" settlement between districts. Therefore, the coordination ability between regions and departments needs to be strengthened urgently.
A coordination mechanism should be established between medical institutions and medical insurance technical departments.
Liao Zangyi suggested that the construction of the national medical insurance information platform should be further optimized, and the standardization of medical insurance handling services should be promoted; designated medical institutions and handling institutions should ensure operation and maintenance, improve the stability of the settlement system, and regularly train staff.
There is "poor treatment" in the two reimbursement methods
After getting the settlement details, Chu Ting found that the reimbursement amount was higher than her expectations.
After consulting the doctor, Chu Ting learned that the staplers and other instruments used in the operation were imported, and some of them could not be reported in Heilongjiang, but they could be used in Beijing.
Since the implementation of the policy, inter-provincial medical treatment in different places has been settled according to the principle of "the directory of medical treatment places and the policy of insured places".
Liao Zangyi explained that "direct settlement" is reimbursed according to the scope and standard of payment for medical treatment, while "manual reimbursement" is subject to the catalogue of the insured place. Because there may be differences in the catalogues of the two places, the two settlement methods will also cause "poor treatment". .
Unlike Chu Ting, who has benefited from "catalog differences", some netizens also raised questions in the "Leadership Message Board" column of People's Daily Online, believing that the reimbursement ratio of direct settlement is low.
In a complaint case received by the Hainan Provincial Medical Insurance Service Center, the Hainan patient Li had an operation in Sichuan, and the total medical expenses were 49,000 yuan. The medical insurance reimbursed only 19,000 yuan, and the remaining 30,000 yuan had to be paid by individuals.
Checked by the Hainan Provincial Medical Insurance Center, the high out-of-pocket ratio is due to the patient's use of many medical consumables outside the Sichuan Provincial Medical Insurance Catalogue, but according to the Hainan Provincial Catalogue, these consumables can be reimbursed by more than 10,000 yuan.
After learning about it, Li said that if he knew in advance that the reimbursement treatment between the two places was so different, he would prefer to go back to the place where the insurance was insured for sporadic "manual reimbursement".
It is understood that in order to enhance the sense of gain of the insured, Anhui, Hainan and other provinces have carried out pilot explorations of "treatment compensation".
For those who do have obvious "poor treatment", start treatment calculation and provide compensation for compensation to ensure that the treatment level after compensation is not lower than or close to the treatment level of "manual reimbursement".
In August 2021, the National Medical Insurance Administration and the Ministry of Finance issued the "Opinions on Establishing a List of Medical Insurance Benefits".
This year's government work report also made it clear that the direct settlement method for cross-provincial medical treatment in different places will be improved, and the scope of medical insurance drugs will be basically unified across the country.
Zhu Fengmei believes that these measures will effectively promote the equalization of medical insurance public services and further reduce the "poor treatment".
In addition, Zhu Fengmei said that, on the one hand, it is possible to strengthen the management of high-value medical consumables, and squeeze out the price “moisture” through centralized procurement, making it possible to establish a unified national catalog of medical consumables; See, most of the needs can be met through "remote medical treatment within the province". With the improvement of the level of medical insurance co-ordination and the implementation of provincial-level co-ordination, the problem of "inversion of treatment" will be greatly alleviated.