Xinhua News Agency, Beijing, March 5-CPC Central Committee and State Council
Opinions on Deepening the Reform of the Medical Security System
(February 25, 2020)
Medical security is a major institutional arrangement to reduce the burden of medical treatment for the masses, improve the well-being of people's livelihood, and maintain social harmony and stability. The Party Central Committee and the State Council attach great importance to people's health and have established a basic medical security system covering the entire people. Since the 18th National Congress of the Communist Party of China, the reform of the national medical security system has continued to advance, and breakthroughs have been made in cracking down on difficult and expensive medical treatment. In order to thoroughly implement the 19th National Congress of the CPC's decision-making and deployment of a comprehensive medical security system with Chinese characteristics, and focus on solving the problem of imbalanced and inadequate medical security development, the following opinions are proposed on deepening the reform of the medical security system.
I. General requirements
(A) guiding ideology. Guided by Xi Jinping's ideology of socialism with Chinese characteristics in the new era, fully implement the spirit of the 19th National Congress of the CPC and the 2nd, 3rd, and 4th Plenary Sessions of the 19th CPC National Congress, adhere to the people's health as the center, and speed up the construction of coverage of the entire people, urban and rural coordination, power and responsibility A clear, appropriate and sustainable multi-level medical security system. Through unified systems, policies, mechanisms, and services, the fairness and coordination of medical security will be enhanced, the strategic purchase of medical insurance funds will be brought into play, and medical security and medicine will be promoted. Serve the high-quality and coordinated development of services, promote the implementation of a healthy China strategy, and make people feel more secure, happy, and secure.
(2) Basic principles. Insist that all guarantees are guaranteed and basic protection is provided. Basic medical insurance covers the entire population in accordance with the law. Do your best and do what you can. Determine the scope and standards of protection by seeking truth from facts. Adhere to stability and sustainability, prevent risks, scientifically determine the level of fundraising, balance the payment responsibilities of all parties, strengthen overall coordination and ensure the sustainability of the fund. We will continue to promote fairness, build a firm bottom line, strengthen institutional fairness, gradually reduce the disparity in benefits, and strengthen basic and bottom-line guarantees for the poor. Insist on governance innovation, improve quality and efficiency, give play to the decisive role of the market, better play the role of the government, and improve the level of socialization, rule of law, standardization and intelligence of medical insurance governance. Adhere to system integration, synergy and efficiency, enhance the integrity, systemicity, and synergy of medical insurance, medical treatment, and medical linkage reforms, and ensure that the masses have access to high-quality, efficient, and affordable medical services.
(3) Reform and development goals. By 2025, the medical security system will become more mature and finalized, and basic tasks such as the protection of benefits, fund-raising operations, medical insurance payments, and fund supervision, and the reform of key areas such as the provision of medical services and medical insurance management services will be basically completed. By 2030, a comprehensive medical insurance system with basic medical insurance as the main body and medical assistance as the foundation, supplementing the common development of medical insurance, commercial health insurance, charitable donations, and mutual medical assistance, with fair and moderate treatment guarantees, and stable and continuous fund operation, The management services are optimized and convenient, the modernization level of medical insurance management has been significantly improved, and the goal of better protection for diseases and medical treatment has been achieved.
Improving the fair and moderate treatment guarantee mechanism
Fair and moderate treatment guarantee is an inherent requirement for improving people's health and well-being. It is necessary to promote a more mature and statutory medical insurance system, improve the medical insurance and assistance system for major diseases, coordinate the planning of various types of high-quality medical insurance development, and steadily increase the level of medical insurance in accordance with the level of economic development and fund affordability.
(4) Improve the basic medical insurance system. Adhere to and improve the basic medical insurance system and policy system covering the entire population and participating in accordance with the law. Workers and urban and rural residents are classified and guaranteed. Treatment is linked to payment. Funds are established and accounted for separately. Unify the overall level of basic medical insurance, the catalog of medical insurance, and standardize the methods for determining medical insurance payment policies. Gradually incorporate outpatient medical expenses into the scope of payment of the basic medical insurance pool fund, reform the personal accounts of employees' basic medical insurance, and establish a sound outpatient mutual aid guarantee mechanism.
(5) Implementing a medical insurance benefit list system. Establish and improve the medical insurance benefit list system, regulate government decision-making authority, scientifically define the basic system, basic policies, fund payment items and standards, and promote the legalization of the medical security system, scientific decision-making, and standardized management. All regions must ensure that the decree is unblocked, and policies that do not exceed the authorized scope of the list cannot be obtained without approval. Strictly implement the basic payment scope and standards, implement fair and moderate guarantees, and correct excessive and insufficient guarantees.
(6) Improve the unified and standardized medical assistance system. Establish a timely and accurate identification mechanism for rescue targets, and scientifically determine the scope of rescue. Fully implement the policy of participating in the insurance payment for key aid recipients, and improve the medical assistance system for key aid recipients. Establish a long-term mechanism to prevent and resolve poverty caused by disease. Strengthen the support function of medical assistance support, reduce medical costs through clear diagnosis and treatment programs, and standardize referrals, increase the annual medical assistance limit, and rationally control the proportion of out-of-pocket expenses in the policy of the poor.
(7) Improve the guarantee mechanism for the cost of medical treatment of major epidemics. In emergencies, such as emergencies, ensure that medical institutions are treated first, and then charged. We will improve the payment policy for medical treatment of major outbreaks, improve the direct settlement system for out-of-town medical treatment, and ensure that patients will not be affected by medical expenses. Explore the establishment of a special group, specific disease medical fee waiver system, targeted exemption of medical insurance catalogs, payment limits, medication restrictions and other restrictive clauses, alleviate the worries of people in need of medical treatment. Coordinate the use of medical security funds and public health service funds, increase the proportion of payments to primary medical institutions, and achieve an effective connection between public health services and medical services.
(8) Promote the development of a multi-level medical security system. Strengthen the triple protection functions of basic medical insurance, critical illness insurance and medical assistance, promote the complementary connection of various types of medical insurance, and increase the level of protection for major and major diseases and multiple medical needs. Improve and standardize major illness insurance for residents, subsidy for large medical expenses for employees, subsidy for civil servants, and supplementary medical insurance for enterprises. Accelerate the development of commercial health insurance, enrich the supply of health insurance products, make full use of the personal income tax policy of commercial health insurance, and study and expand the scope of insurance products. Strengthen market behavior supervision, highlight key links in health insurance product design, sales, and compensation, and improve health protection service capabilities. Encourage social charitable donations, coordinate the mobilization of charitable medical assistance, and support the orderly development of mutual medical assistance. Exploring the drug protection mechanism for rare diseases.
Third, a sound and sustainable financing operation mechanism
Reasonable financing and stable operation are the basic guarantees for sustainable medical security system. It is necessary to establish a financing mechanism that is compatible with the basic national conditions of the initial stage of socialism, that matches the affordability of all parties, and that is coordinated with basic health needs, effectively strengthens fund operation management, strengthens risk early warning, and resolutely guards against the bottom line of systemic risks.
(9) Improve the fund sharing and adjustment mechanism. Employers and individuals shall jointly pay for the participation of employees in basic medical insurance. Non-employed persons participate in basic medical insurance by paying personally, and the government grants subsidies in accordance with regulations. The payment is linked to the level of economic and social development and the disposable income of residents. Adapt to the development of new business formats, and improve the flexible payment methods for employees to participate in insurance. Establish a basic medical insurance benchmark rate system, standardize the payment base policy, reasonably determine the rate, and implement dynamic adjustments. Balance the responsibilities of individuals, employers, and governments in financing and payment, optimize the structure of personal payments and government subsidies, and study multi-channel funding policies to address the burden of aging medical care. Strengthen financial investment in medical assistance and broaden the channels for financing medical assistance.
(10) Consolidate and improve the overall planning level. In accordance with the standards of unified system policies, unified fund collection and support, and management and service integration standards, the city-level coordination of basic medical insurance will be fully implemented. Explore and promote vertical management of medical security departments below the city level. The provinces (autonomous regions and municipalities) with conditions are encouraged to promote the overall planning at the provincial level in accordance with the ideas of hierarchical management, shared responsibility, overall adjustment and budget assessment. Strengthen the management of medical assistance funds, promote the coordination of the level of medical assistance and the level of basic medical insurance, improve the efficiency of the use of assistance funds, and benefit the poor as much as possible.
(11) Strengthening fund budget management and risk early warning. Scientifically compile the budget of the medical security fund, strengthen the budget implementation supervision, and comprehensively implement budget performance management. To meet the needs of the development of the direct settlement of medical treatment in different places, the "Internet + medical treatment" and the service model of medical institutions, explore the pilot project of cross-regional fund budgets. Strengthen the medium- and long-term actuarial calculation of the fund, establish a balance of payments mechanism, and improve the risk assessment and early warning mechanism for fund operations.
Establishing effective and efficient medical insurance payment mechanism
Medical insurance payment is the key mechanism to guarantee the masses' access to quality medical services and improve the efficiency of fund use. It is necessary to focus on clinical needs, reasonable diagnosis and treatment, appropriate technology, improve medical insurance catalogs, agreements, and settlement management, implement more efficient medical insurance payments, better protect the rights and interests of insured personnel, and strengthen the role of medical insurance in stimulating and restricting medical services.
(12) Improve the dynamic adjustment mechanism of the medical insurance catalog. Based on the affordability of the fund, to adapt to the basic medical needs of the masses, clinical technological progress, adjust and optimize the medical insurance catalogue, include drugs, diagnostic items, and medical consumables with high clinical value and excellent economic evaluation into the medical insurance payment scope, and regulate the payment scope of medical service facilities. We will improve the dynamic adjustment mechanism of the medical insurance catalog and improve the negotiation system for medical insurance access. Reasonably divide the central and local catalogue adjustment responsibilities and powers. All regions shall not make their own catalogues or adjust the scope of the limited payment of medical insurance medications, and gradually achieve a basically unified national scope of medical insurance medications. Establish evaluation rules and index systems for medical insurance drugs, diagnosis and treatment programs, and medical consumables, and improve the withdrawal mechanism.
(13) Innovative medical insurance agreement management. Improve the management of basic medical insurance agreements, and simplify and optimize the procedures for fixed-point applications, professional evaluations, and negotiation of medical institutions. Eligible medical institutions will be included in the scope of medical insurance agreement management to support the development of new service models such as "Internet + medical care". Establish and improve a cross-region medical agreement management mechanism. Formulate assessment methods for the performance of designated medical institutions to implement the agreement, highlight the evaluation and evaluation of norms of behavior, service quality and cost control, and improve the withdrawal mechanism of designated medical institutions.
(14) Continue to advance the reform of medical insurance payment methods. Improve the total budget of the medical insurance fund, improve the mechanism for consultation and negotiation between medical insurance agencies and medical institutions, promote collective consultations of medical institutions, scientifically formulate total budgets, and link them with the results of medical quality and performance of agreements. Vigorously promote the application of big data, implement a multi-compound medical insurance payment method based on disease type payment, promote payment by disease diagnosis related groups, medical rehabilitation, chronic mental illness and other long-term hospitalization are paid by bed day, and outpatient special chronic diseases are paid by head. . Explore paying for medical services separately from medicines. Adapt to the development and innovation of medical service models, and improve the payment method and settlement management mechanism of medical insurance funds. Explore the implementation of total payment for the close medical consortium, strengthen supervision and assessment, balance remaining, reasonable overspending, and areas with conditions can pre-pay some medical insurance funds to medical institutions in accordance with the agreement to ease the pressure on their fund operation.
Fifth, complete and strong fund supervision mechanism
The medical security fund is the "life-saving money" of the people, and it must always take the maintenance of fund safety as a top priority. It is necessary to tightly bind the institutional cage of medical insurance fund supervision, make great efforts to promote the reform of the regulatory system, establish and improve the medical insurance credit management system, and crack down on fraudulent and fraudulent insurance practices with a zero tolerance attitude to ensure the safe, efficient, and rational use of funds.
(15) Reform and improve the supervision system for medical insurance funds. Strengthen the supervision capacity building of medical insurance funds, further improve the fund supervision system and mechanism, and effectively maintain the safety of funds and improve the efficiency of fund use. Strengthen the construction of internal control institutions for medical security public service institutions, and implement the responsibilities of agreement management, cost monitoring, and auditing. Implement inter-departmental coordinated supervision, actively introduce third-party supervision forces, and strengthen social supervision.
(16) Improve the supervision of innovation funds. Establish a normal mechanism for supervision and inspection, and implement real-time dynamic intelligent monitoring of big data. Improve the monitoring mechanism for medical services, establish a mandatory information disclosure system, and disclose medical expenses, fee structure and other information to the society in accordance with laws and regulations. Implement the entire process performance management of fund operation, and establish a performance evaluation system for medical insurance funds. We will improve the social supervision and incentive mechanism for medical security and improve the system of reporting and rewarding fraud and fraud.
(17) To investigate liability for fraud and deceit in accordance with law. Formulate and improve laws and regulations related to the supervision of medical insurance funds, standardize regulatory authority, procedures, and punishment standards, and promote law-based administration. Establish a medical security credit system and implement joint incentives for trustworthiness and joint punishment for breach of trust. Strengthen joint departmental law enforcement, comprehensively use agreements, administration, and judicial methods to seriously investigate the liability of fraud and deception units and individuals, investigate criminal responsibility for suspected crimes according to law, and resolutely crack down on fraud and deception and endanger the rights and interests of the insured.
6. Promote the supply-side reform of pharmaceutical services in a coordinated manner
The supply of medical services is related to the realization of people's health and medical security functions. It is necessary to give full play to the leading role of centralized procurement of pharmaceuticals and medical consumables in deepening the reform of the supply side of medical services, promote the integration of the reform system of medical insurance, medical treatment, and pharmaceuticals, strengthen policy and management coordination, and ensure that the masses have access to quality and affordable medical services.
(18) Deepen the reform of the centralized procurement system for drugs and medical consumables. Adhere to the combination of recruitment and procurement, and price-to-price linkage, and comprehensively implement the centralized procurement of drugs and medical consumables. Based on medical insurance payment, establish a provincial-level bidding and procurement platform that integrates bidding, procurement, trading, settlement, and supervision, and promote the establishment of a regional and national alliance procurement mechanism to form a fully competitive, reasonable and orderly supply guarantee system . Promote the direct settlement of medical insurance funds and pharmaceutical companies, and improve the coordination mechanism of medical insurance payment standards and centralized procurement prices.
(19) Improve the price formation mechanism of medical services. Establish a market-led price formation mechanism for medicines and medical consumables, and establish a national transaction price information sharing mechanism. The prices of treatment medicines and high-value medical consumables are unrealistically high. Improve the medical service item access system, speed up the review of new medical service price items, establish a scientific price determination and dynamic adjustment mechanism, and continue to optimize the medical service price structure. Establish a mechanism for monitoring and disclosing pharmaceutical price information and industrial development index, establish a drug price and recruitment credit evaluation system, and improve the price inquiry and interview system.
(20) Enhance access to medical services. Improve the modern medical service system in the division of labor between general and specialist medical services, and strengthen basic general medical services. Strengthen the assessment of regional medical service capabilities, rationally plan the layout of various medical resources, promote the sharing and utilization of resources, accelerate the development of social medical services, and standardize the development of new Internet and medical service models. We will improve the management of medical equipment allocation in regional public hospitals, guide rational allocation, and strictly control oversize and overcapacity. Supplement shortfalls in medical services such as nursing, pediatrics, geriatrics, and psychiatry. Do a good job in accepting and reviewing the consistency and evaluation of the quality and efficacy of generic drugs, and support the development and use of high-quality generic drugs, and promote the substitution of generic drugs by improving medical insurance payment standards and drug bidding and procurement mechanisms. Improve the monitoring and early warning and grading response system for shortage drugs.
(21) Promote the improvement of medical service capabilities. Standardize medical institutions and medical personnel's diagnosis and treatment behavior, promote the prescription review system, and promote rational drug use. Strengthen internal professional and refined management of medical institutions, improve the scientific and reasonable assessment and evaluation system by classification, and link the assessment results to the payment of medical insurance funds. Reform the current accounting methods of departments and individuals, improve the incentive and compatible, flexible and efficient personnel compensation system consistent with the characteristics of the medical industry, and improve the performance appraisal and distribution system.
Optimizing public administration services for medical security
The medical insurance public management services are of vital interest to millions of people. It is necessary to improve the management and public service system, better provide precise and refined services, improve the level of information services, promote innovation in medical insurance governance, and provide the people with convenient and efficient medical security services.
(22) Optimizing public services for medical security. Promote the standardization and standardization of medical security public services, and realize one-stop medical security services, one-window processing, and one-unit settlement. To meet the needs of population movements, do a good job of transferring and joining cross-regional relations between various types of population insurance and medical insurance, and speed up the improvement of direct settlement services for medical treatment in different places. Deepen the style construction of the medical security system, establish a unified medical security service hotline, accelerate the online processing of service matters, and improve operational efficiency and service quality.
(23) High starting point to promote standardization and information construction. Unify medical security business standards and technical standards, establish a nationwide unified, efficient, compatible, convenient, and secure medical security information system, achieve national medical security information interconnectivity, and strengthen the orderly sharing of data. Standardize data management and application permissions, and protect the basic information and data security of insured personnel in accordance with the law. Strengthen the development of big data, highlight application orientation, strengthen service support functions, and promote equal access to medical security public services.
(24) Strengthen capacity building. Establish a unified national medical security handling management system, vigorously promote service sinking, and achieve full coverage of provinces, cities, counties, towns (streets), and villages (communities). Strengthen the construction of handling service teams, and build a professional team that meets the requirements of medical security public services in the new era. Strengthen the allocation of medical security public management service capabilities, and establish incentive and restraint mechanisms linked to management service performance. The government reasonably arranges the budget to ensure the normal operation of medical security public service agencies.
(25) Continue to promote innovation in medical insurance governance. Promote the legal person governance of medical security agencies, actively introduce social forces to participate in the agency services, and explore the establishment of a medical insurance governance structure that is co-established, co-managed and shared. Standardize and strengthen cooperation with commercial insurance institutions and social organizations, and improve incentive and restraint mechanisms. Explore the establishment of a cross-regional medical insurance management collaboration mechanism to achieve full-process, seamless public service and fund supervision. Make better use of the decision support and technical support of high-end think tanks and professional institutions.
Organizational security
(26) Strengthen Party leadership. Party committees and governments at all levels should take the reform of the medical security system as an important task and implement party leadership throughout the entire process of medical security reform and development. Strictly follow the unified deployment, improve the working mechanism, and formulate practical policies and measures in accordance with the actual situation. The implementation of the reform of the medical security system will be included in the key tasks of safeguarding and improving people's livelihood, and ensuring that the reform goals are achieved as scheduled.
(XXVII) Strengthen synergy. Strengthen the legislative work in the field of medical security, and accelerate the formation of a comprehensive legal and regulatory system that is conducive to medical security reform. Establish a departmental coordination mechanism to strengthen overall coordination and comprehensive support of medical insurance, medical treatment, and medical system policies. The department in charge of medical security under the State Council is responsible for coordinating and advancing the reform of the medical security system. It will work with relevant departments to study and solve major problems in the reform of cross-sectoral, cross-regional, and cross-industry, and guide the regulation of policies and the appropriate level of protection in each region.
(28) Create a good atmosphere. All regions and departments should take the initiative to do a good job in interpreting medical security policies and publicizing services, responding to social concerns in a timely manner, and reasonably guiding expectations. Fully mobilize all parties to support and cooperate with the enthusiasm and initiative of reform to build social consensus. Important reform issues should be widely heard, and risk assessments should be done well in advance. In case of major circumstances, report to the Party Central Committee and the State Council in a timely manner.