Chinanews.com, August 26. According to the website of the National Medical Insurance Administration, on August 26, the National Medical Insurance Administration issued the "Guiding Opinions on Establishing and Improving the Employee Basic Medical Insurance Outpatient Mutual Aid Guarantee Mechanism (Draft for Comment)" for public consultation opinion. The opinion proposes to stipulate that general outpatient clinics shall cover all employees insured by medical insurance, and the payment ratio shall start from 50%.
Data map: Citizens line up for registration in the outpatient hall of the hospital. Photo by China News Agency reporter Yang Di
The opinion pointed out that the outpatient mutual aid protection function should be enhanced. Establish and improve the general outpatient medical expenses overall guarantee mechanism, starting from the outpatient chronic diseases with heavy burdens such as hypertension and diabetes, and gradually including the general outpatient medical expenses of frequently-occurring and common diseases into the scope of the overall planning fund. General outpatient clinics cover all employees’ medical insurance insured persons, and the payment ratio starts from 50%. As the affordability of the fund increases, the level of protection is gradually increased, and treatment payments can be appropriately tilted to retirees. According to the characteristics of outpatient medical services, scientifically calculate the minimum payment standard and maximum payment limit, and do a good job of linking up with the hospitalization payment policy.
According to the fund's bearing capacity, all localities can explore to gradually expand the scope of outpatient chronic diseases and special diseases paid by the overall fund, and include some outpatient chronic diseases and special diseases that have long treatment cycles, great health damage, and heavy economic burdens into the overall fund payment scope . Some special treatments that need to be carried out in outpatient clinics and are more economical and convenient than hospitalization can be managed with reference to hospitalization benefits. With the gradual improvement of the outpatient mutual aid protection mechanism, the transition from disease protection to cost protection is explored.
Opinion requests to improve the method of personal account credit. Scientifically and reasonably determine the crediting method and crediting level of individual accounts. The personal accounts of employees are credited by the basic medical insurance premiums paid by individuals, and the crediting standard is controlled within 2% of the insurance payment base of the individual. The basic medical care paid by the unit All insurance premiums are included in the pooled fund; in principle, the individual accounts of retirees are allocated from the pooled fund at a fixed amount, and the amount allocated is estimated at about 2% of the basic pension at the time of the reform of the region, and will not be adjusted in future years. The specific allocation ratio or standard of the personal account shall be determined by the provincial medical insurance department in accordance with the above principles, instructing the overall planning area in combination with the local reality. After the adjustment of the unified account structure, the reduction of funds allocated to personal accounts is mainly used to support and improve the mutual aid protection of outpatient clinics and improve outpatient benefits.
Opinions put forward to regulate the use of personal accounts. Personal accounts are mainly used to pay for out-of-pocket expenses incurred by insured employees in designated medical institutions or designated retail pharmacies. It can be used to pay for the medical expenses incurred by the employees themselves, their spouses, parents, and children in medical insurance designated medical institutions for medical treatment, and the expenses incurred by individuals for purchasing drugs and medical consumables in designated retail pharmacies. Explore personal accounts for personal payment for spouses, parents, and children participating in basic medical insurance for urban and rural residents. Personal accounts shall not be used for other expenditures that are not covered by basic medical insurance, such as public health expenses, sports fitness or health care consumption. Improve and improve the management methods for the use of personal accounts, and do a good job of statistics on income and expenditure information.
Opinion requests, strengthen supervision and management. Improve the management and service measures, innovate the system operation mechanism, guide the rational use of medical resources, and ensure the stable operation of the medical insurance fund and the effect of the system guarantee. Strictly implement the fund budget management system, strengthen the fund audit system and internal control system construction. Establish a dynamic management mechanism for the entire process of personal accounts, and strengthen the review of the use and settlement of personal accounts. Strengthen the supervision of outpatient medical activities and medical expenses, establish a fund security prevention and control mechanism, severely crack down on fraudulent insurance activities, and ensure the safe, efficient and reasonable use of funds. Innovate the management methods for outpatient services, improve the monitoring, analysis and assessment system of medical services, and guide medical institutions to control the cost of medical services. Accelerate the development of informatization in accordance with the requirements for the construction of a unified national medical insurance information platform, and explore the path to achieve settlement for outpatient medical treatment in different places. By cooperating to promote the construction of the grassroots medical service system, improving the family doctor's contracted services, and the long-term prescription system, etc., insured persons are guided to seek medical treatment in the first consultation at the grassroots level. Integrate and improve the management measures for chronic diseases and special diseases in outpatient clinics, and standardize the diagnosis, treatment and referral behavior of primary medical institutions.
The opinion also pointed out that the payment mechanism that suits the characteristics of outpatient services should be improved. Pay per capita for primary medical services, and actively explore the combination of per capita payment with chronic disease management; for day surgery and qualified outpatient special diseases, implement payment by disease type and group according to disease diagnosis; if it is not appropriate to pay in packages The outpatient fee can be paid per item. Speed up the formulation of medical insurance drug payment standards, and guide medical institutions and patients to actively use drugs with definite efficacy and reasonable prices.