China News Service, Fuzhou, January 25th (Yiu Yihan) How to curb the excessive growth of medical expenses and ease the difficulty of seeing a doctor and expensive for the common people?
How to prevent passive payment of medical insurance and fraudulent insurance?
In this regard, Xiamen City has made useful explorations and has taken the lead in establishing a "three-in-one" medical insurance modern governance model.
According to Xiamen officials on the 25th, Xiamen continued to promote payment innovation, drug procurement innovation, and regulatory innovation, saving and recovering nearly 1 billion yuan in medical insurance funds every year. In the past three years, it has levied nearly 5 billion yuan in medical insurance premiums for enterprises.
Aiming at the problems of mild hospitalization, major treatment of minor illnesses, decomposition of hospitalizations, prevarication of serious illnesses, and fund abuse, Xiamen, based on the national medical insurance coding standards, uses big data to create a disease catalogue and a set of classifications in the entire field of hospitalization and outpatient services. Value-based payment standards, a set of payment evaluation system, and the first to establish an effective and efficient "point method under the total budget" payment mechanism.
In the past, the settlement between medical insurance and hospitals mainly adopted the “fixed amount as the mainstay, with a single disease as the supplement”, which played a role in cost control to a certain extent, but did not consider different factors such as disease difficulty and treatment methods, which were out of touch with clinical reality.
To this end, Xiamen has objectively classified more than 1 million cases from 706 medical institutions in the city into 4473 disease types in the past three years, realizing information conversion between clinical medical records and disease-based payment methods.
Relevant people said that the "score" of serious diseases is high, and the "score" of minor diseases is low, realizing the quantitative determination of disease types.
Remind and interview hospitals with high scores and abnormal cost growth. Those with serious violations will be handed over to the audit department for inspection and processing, and the medical insurance funds obtained from violations will be deducted at the end of the year.
Up to now, the number of local insured persons in Xiamen who transferred for medical treatment has dropped by 27%. The problems of patients being discharged from hospitals and hospitalization have been significantly improved, and the number of complaints has dropped by 90%.
In order to solve the dilemma of falsely high drug prices, Xiamen has created a new mechanism for centralized drug procurement by the three departments of medical care, medical insurance, and medicine, and promoted the implementation of centralized drug procurement policies; facilitated the effective connection of Fujian Province’s pharmaceutical equipment joint procurement platform, electronic settlement system and electronic payment system. Realize the direct settlement of drug payment between the medical insurance department and the distribution company; the country’s first national organization of centralized drug procurement and use supervision platform, realize the connection of production companies, distribution companies and hospital-end system data, and apply big data to drug distribution, procurement, settlement, and inventory , Use the whole-process integrated supervision and integration.
In addition, Xiamen has taken the lead in establishing a medical insurance big data monitoring system in the country in response to the problems of “multiple points, wide coverage, long chain”, false medical treatment, and drug reselling in medical insurance management, and has cracked a total of 8 cases of insurance fraud across 8 cities across the country12 Up.
At present, Xiamen has taken the lead in establishing an intelligent identity authentication system and an intelligent video monitoring system, and has taken the lead in innovating drug packaging disposal methods. Among them, the smart identity authentication system applies the face recognition core technology to the field of medical insurance supervision to ensure medical authenticity; the smart video surveillance system has covered all the city's more than 300 medical institutions below the first level, cracking the difficulty of obtaining evidence. (Finish)