"It's great to be able to use this medicine!"
In 2022, on the first day of the new year, in the inpatient department of neurology department of Henan Provincial Children's Hospital, a child less than 3 years old with congenital spinal muscular atrophy (SMA) is receiving nosinagen sodium injection.
From nearly 700,000 to tens of thousands of yuan, Nosinagen Sodium Injection is included in the medical insurance, which greatly reduces the burden of medical treatment for children.
"Now the disease can be cured, and there is hope for the child." The child's mother's words revealed a beautiful vision for the future.
And this is just a microcosm of how our country has made people more sense of gain in the field of medical insurance.
On March 6, 2021, General Secretary Xi Jinping visited the members of the medical and health sector and the education sector who participated in the fourth session of the 13th National Committee of the Chinese People's Political Consultative Conference, and participated in the joint group meeting to listen to opinions and suggestions.
He emphasized that it is necessary to continue to intensify the reform of medical insurance, normalize and institutionalize the centralized procurement of drugs with volume, improve the medical insurance and assistance system for major and serious diseases, deepen the reform of the medical insurance fund supervision system, and protect the people's "life-saving money", "" life-saving money".
In 2021, the reform of the medical insurance field will be unprecedented, the burden of drug consumption will be significantly reduced, the experience of medical treatment across provinces and other places will be steadily improved, and the "medical treatment money" and "life-saving money" will be safer.
In order to meet more expectations of the people, China is writing more heart-warming "health answers" with the "pen of innovation".
The effect of "combination price reduction" releases the public's drug burden and continues to reduce
"Every small group should not be abandoned"
"It's really hard, in fact, just now I felt like my tears were about to fall."
——Zhang Jinni, the negotiator of the National Medical Insurance Bureau and the Director of the Pharmaceutical Equipment Procurement Supervision Department of the Fujian Provincial Medical Insurance Bureau
At the end of 2021, a video of a drug negotiation scene on the National Medical Insurance List went viral on the Internet.
After two rounds of 9 negotiations with the medical insurance department, the price of Nosinagen Sodium Injection was finally sold at a price of tens of thousands of yuan per injection.
Previously, the reason why the drug was called a "high-priced drug" was that it was priced at 699,700 yuan per injection. The patient needed to inject 4 injections in the first 63 days and 1 injection every 4 months after that.
In order to allow ordinary people to use high-quality and low-cost good medicines, since the establishment of the National Medical Insurance Administration in 2018, the medical insurance drug catalogue has been dynamically adjusted every year for four consecutive years, and a total of 507 new and good drugs have been included in the catalogue. more and more secure.
In 2021, on the basis of adding innovative drugs and anti-tumor drugs, a "zero breakthrough" in the inclusion of high-value drugs for rare diseases in medical insurance will be achieved.
Li Tao, deputy director of the National Medical Security Administration, said that in 2021, a total of 7 rare disease drugs have been successfully negotiated, with an average price drop of 65%.
At the same time, the centralized procurement of medicines with quantity is gradually normalized and institutionalized.
Since the “4+7” pilot city centralized drug procurement opened in Shanghai in December 2018, the State Organization Drug Joint Procurement Office has organized 6 batches of 7 rounds of national centralized procurement.
The average price of "centralized procurement" of medicines has been reduced by more than 50%, and the average price of "centralized procurement" of consumables has been reduced by more than 80%, reducing the burden on the masses by more than 250 billion yuan.
In March this year, the collection of artificial total knee joints and artificial total hip joints will also be available nationwide, with an average price reduction of 82%.
It is expected to benefit nearly 11 million patients and reduce the burden by nearly 30 billion yuan per year.
"Under the principles of safety, effectiveness and economy, the 2021 medical insurance catalog adjustment will include more high-quality and cheap drugs, and at the same time, the centralized procurement of drugs with volume has become the norm. Through centralized procurement with volume and directory access negotiations" Combining boxing' has significantly reduced the public's drug burden." Wang Zhen, a researcher at the Institute of Economics of the Chinese Academy of Social Sciences, said in an interview with a reporter from People's Daily Online.
Direct settlement for medical treatment in different places makes reimbursement no longer "running"
"Normally, there is a headache, and you only need to click on your mobile phone to complete cross-province reimbursement."
In order to take care of her granddaughter, Aunt Han came to Beijing from Shanxi, which is more than 600 kilometers away.
She praises everyone, and it is really convenient to use the medical insurance service platform APP for medical reimbursement.
You can also switch the "care version", which is easier to operate.
The APP of the national medical insurance service platform has launched a "care version" to facilitate the elderly.
Screenshot of the National Medical Insurance Service Platform APP
In recent years, with the large increase in the number of people living in different places, retiring in different places, and working in different places, especially the group of elderly people who move with their children has become more and more large, and there is a higher demand for direct settlement of medical treatment in other places.
Focusing on the medical settlement needs of the 125 million inter-provincial floating population, we will further promote the reform of "decentralization, regulation and service" in the medical insurance field. Since 2021, the National Medical Insurance Administration will work with relevant departments to consolidate and expand the results of direct settlement of hospital expenses across provinces, and comprehensively promote inter-provincial direct settlement of outpatient expenses. Settlement work.
At present, the direct settlement service of inter-provincial and non-local hospitalization expenses has covered all provinces, all coordinating regions, all types of insured persons and major out-of-home personnel, and connected to 52,900 networked designated medical institutions, basically achieving full coverage of designated hospitals and every The county has a target of at least one networked designated hospital.
At the same time, the direct settlement of general outpatient expenses across provinces has been accelerated.
From fully opening up the pilot areas of Beijing-Tianjin-Hebei, Yangtze River Delta, and Southwest China, to adding 15 provinces such as Shanxi as pilot provinces, from regional pilot to full rollout, as of the end of November 2021, all provinces and Xinjiang Production and Construction Corps All of them have started the direct settlement of general outpatient expenses across provinces, covering 97.6% of the country's overall planning areas, with more than 120,000 networked designated medical institutions, and 91.7% of the country's counties have at least one networked designated medical institution.
"Judging from the current progress, whether it is outpatient or inpatient direct settlement for out-of-town medical treatment, there are no institutional and policy obstacles." Wang Zhen analyzed that from the management of medical insurance funds, there is no out-of-town medical treatment after direct settlement. The rapid rise in costs and the impact on the order of medical treatment are due to the refined management of direct settlement of medical treatment in different places and the construction of information systems.
Ying Yazhen, vice president of the National Medical Insurance Research Institute and vice president of the China Medical Insurance Research Association, said that the main progress in promoting the settlement of medical insurance in different places is reflected in: the nationwide direct settlement system for hospitalization expenses across the country is running smoothly and is becoming more and more mature; the national platform The number of valid filings has continued to increase, and the scope of benefits has continued to expand; by carrying out medical insurance settlement in different places, it is conducive to promoting the standardization of medical insurance; it is conducive to gradually improving the overall level of medical insurance.
"Looking at it now, there are still some technical problems. For example, the direct settlement of outpatient clinics is still blocked, and some medical institutions that have already been connected still have problems in the actual settlement process." Wang Zhen suggested that the information system should be further opened up, and at the same time Improve the flexibility and convenience of filing.
"It is also necessary to strengthen the connection and cooperation between the medical insurance policy and the handling management between the insured place and the medical place, and between the medical insurance departments, especially to strengthen joint supervision, prevent excessive medical treatment in the process of medical treatment in different places, and ensure that the medical insurance fund Safe." Ying Yazhen emphasized.
Payment method reform helps "medical insurance patients" win-win situation
In the medical reform experience speech competition held in Sanming City, a dean told a story of two invoices: "The same two invoices for hospitalization of 30,000 yuan, 10 years ago, 70% of their own expenses, 30% of reimbursement, and the patient spent 21,000 yuan; after 10 years, 30% will be paid by themselves, 70% will be reimbursed, and the patient will spend 9,000 yuan." - Sanming, Fujian, is known as one of the cheapest places for ordinary people in the country to see a doctor.
For a long time, the traditional payment method of medical insurance in my country is to pay by item, that is, according to all the drugs, medical service items, medical consumables, etc. used in the diagnosis and treatment process, and how much the hospital uses in the diagnosis and treatment process, the medical insurance and the patient pay according to the proportion.
Under this model, excessive medical behaviors such as "big prescriptions" and "big inspections" may occur, which not only causes a waste of medical resources, but also makes the insured spend more money and medical insurance funds spend more.
In 2017, Sanming was selected as one of the three pilot cities for the “Reform of Charges and Payments by Disease Diagnosis-Related Groups (C-DRG)” in the country. For the first time in the country, medical insurance and patients and hospitals are settled according to the fixed amount of the disease at the same time, and there is no minimum payment. The medical insurance fund reimburses 70% and 80% of the fixed amount according to the disease type, and the individual pays 30% and 20% respectively.
Through the reform, the "same disease, same treatment, same quality, same price" for medical institutions at the same level, urban workers and urban and rural residents have been realized.
The reform effect is obvious.
In 2020, 229,600 cases were discharged from medical institutions at or above the county level in Sanming, of which 187,300 were settled according to DRG, with an enrollment rate of 81.58%.
Summarizing the experience of Sanming, Fujian Province, based on its own actual situation, based on the reform of charging and paying according to DRG, and using big data technology to explore a reform path of "payment according to disease type (DIP)", to promote medical insurance along high-quality , refined track development.
On the basis of the previous pilot, the National Medical Insurance Administration launched two new payment models, DRG and DIP, at the end of 2019 and in 2020.
As of October 2021, the actual DRG payment in 30 pilot cities has covered 807 medical institutions.
"The reform of the DRG/DIP payment method highlights the value of medical care, which is bound to have an impact on hospitals, medical insurance and patients." Wang Zhen analyzed to reporters that in terms of hospitals, the previous operating mechanism under the payment by project has changed from "seeing a doctor" to "seeing a doctor". From the center to the patient's health, the more you see a doctor, the more money you make, and the more healthy the patient is, the more money you make.
In terms of medical insurance, from project management to "value" management, from post-supervision to pre-event, in-event, and post-event supervision at the same time.
In terms of patients, the burden of medical treatment has been reduced and the quality of diagnosis and treatment has been improved.
At the end of November 2021, the National Medical Security Administration issued the "Three-Year Action Plan for the Reform of DRG/DIP Payment Methods", with the goal of accelerating the establishment of an effective and efficient medical insurance payment mechanism, and accelerating the reform in stages and in batches.
According to the plan, by the end of 2025, the DRG/DIP payment method will cover all qualified medical institutions that provide inpatient services, and basically achieve full coverage of diseases and medical insurance funds.
"For the three parties of medical insurance and patients, this is a win-win and mutually beneficial reform." Ying Yazhen commented.
Find out the fraud and defraud the "shuo rat" and guard the people's "life-saving money"
From the elderly in their 70s to the children of 5 years old, why did more than 2,000 villagers in the village collectively "suffer" from stroke?
——In October last year, a report caused a public outcry.
Stroke is neither an infectious disease nor an endemic disease, but in Cuikou Village, Laihe Town, Shanxian County, Heze, Shandong, many villagers' medical insurance accounts have inexplicably recorded medical insurance settlement records of multiple strokes in the past five years.
Immediately, the National Medical Insurance Administration dispatched a working group to Shanxian County to conduct on-site supervision.
In fact, the case of medical insurance fraud in Shanxian County is not an isolated case.
There are still many "shuo rats" who are trying to "save money" for the common people.
Data from the National Medical Insurance Bureau shows that from 2018 to October 2021, the National Medical Insurance Bureau and other relevant departments recovered a total of about 50.6 billion yuan in medical insurance funds.
In 2021, the National Medical Insurance Bureau exposed 58 typical cases in batches. Only the latest batch of typical cases exposed involved defrauding medical insurance funds of more than 12 million yuan. The supervision situation is severe and urgent.
In order to strengthen the supervision of the use of medical insurance funds and effectively maintain the safety of medical insurance funds, in early 2021, the State Council promulgated my country's first regulation on medical insurance supervision, the Regulations on the Supervision and Administration of the Use of Medical Insurance Funds, which changed the lack of special laws in the field of medical insurance in my country.
Subsequently, the "Interim Measures for the Designated Management of Medical Insurance in Medical Institutions", "Interim Measures for the Designated Management of Medical Insurance in Retail Pharmacies", and "Measures on the Discretion of Administrative Penalty for Standardizing the Supervision and Administration of the Use of Medical Insurance Funds" were successively implemented, providing a basis for the medical insurance department to carry out fund supervision work. support.
In order to strengthen the connection between executions of medical insurance fund cases, in November 2021, the National Medical Insurance Administration and the Ministry of Public Security jointly issued the "Notice on Strengthening the Investigation and Punishment of Medical Insurance Fund Cases to Execution Connections", proposing specific requirements and practices.
By severely cracking down on violations of laws and regulations in the medical insurance field, in 2021, the national medical insurance department will inspect a total of 708,000 medical institutions, handle 414,000 times, recover more than 23 billion yuan in funds, and expose 70,000 cases.
What is the difficulty of rooting out medical insurance fraud and defrauding insurance?
Jin Weigang believes that it is mainly reflected in several aspects: the amount of medical insurance fund expenditure is huge, and the losses caused by fraud continue to expand; with the improvement of medical insurance benefits, the proportion of patients’ personal payment decreases, the sensitivity to medical expenses is reduced, and criminals commit fraud. The opportunities are increased; the number of insured persons has increased substantially, the composition of the personnel is complex, and it is difficult to monitor the medical treatment behavior of the insured persons; the management of primary medical institutions is loose, and it is difficult to supervise their medical service behaviors.
Faced with the above situation, how to maintain the safety of medical insurance funds?
Jin Weigang said that we must adhere to treating both the symptoms and root causes, and constantly improve the medical insurance anti-fraud mechanism.
Strengthen the construction of the medical insurance legal system, including improving the system of relevant laws and regulations, and clarifying the provisions on severe penalties for medical insurance fraud from the three levels of administrative punishment, civil liability, and criminal responsibility; take targeted anti-fraud measures, such as improving medical insurance information. system, develop and promote a professional medical insurance fraud identification system; establish a special medical insurance anti-fraud agency and equip corresponding professionals.
In addition, Wang Zhen also suggested that the regulatory means should be updated first.
"Magic is one foot taller", "Tao must be taller than one foot", especially for new types of fraud and insurance fraud, new high-tech supervision methods based on modern information technology are needed; secondly, the multi-departmental linkage mechanism must be improved to strengthen cooperation with the Commission for Discipline Inspection and Supervision The linkage mechanism of departments such as public security, public security, health and market management, etc.; it should also be combined with reform measures such as payment method reform and centralized drug procurement to improve supervision methods.
At present, the reform of my country's medical insurance system is still in progress.
Standing at the starting point of the new year, people are looking forward to the introduction of more reforms.
Focusing on enhancing security capabilities and reducing the burden on the masses, my country's medical security network is becoming more and more dense.
Yang Di Qiao Yeqiong