What will the unified national medical insurance information platform bring?
Interview with Wang Wenjun, Director of the Planning, Finance and Regulations Department of the National Medical Security Administration
Recently, the national unified medical insurance information platform has been fully completed and launched in 31 provinces across the country and the Xinjiang Production and Construction Corps.
The platform covers 14 subsystems, including payment methods, cross-provincial medical treatment, public services, and procurement of drugs and medical consumables, effectively covering about 400,000 designated medical institutions and about 400,000 designated retail pharmacies, providing 1.36 billion insured High-quality medical insurance services.
Since the 18th National Congress of the Communist Party of China, under the strong leadership of the Party Central Committee with Comrade Xi Jinping at its core, we have established the world's largest basic medical security network for all in a relatively short period of time.
At present, the number of insured people exceeds 1.36 billion, and the insured rate is stable at over 95%. The proportion of hospitalization expenses within the scope of employee medical insurance and resident medical insurance policies is about 80% and 70%, respectively. The annual income and expenditure of the fund exceeds 2 trillion yuan. It has benefited more than 4 billion people seeking medical treatment, and played an important role in solving the problem of difficult and expensive medical treatment for the masses, supporting the development of medical and health services, maintaining social stability, and promoting common prosperity.
What changes will the establishment and operation of the unified national medical insurance information platform bring to the people's medical treatment?
What role will the platform play in strengthening the supervision of medical insurance funds and guarding the "life-saving money" of the masses?
The reporter interviewed Wang Wenjun, director of the Department of Planning, Finance and Regulations of the National Medical Security Administration.
Based on the "four needs", the national unified medical insurance information platform was built and operated in 2 years and 11 months
Reporter: What is the purpose, process, main functions and significance of the construction of the national unified medical insurance information platform?
Wang Wenjun: General Secretary Xi Jinping pointed out that "without informatization, there will be no modernization", "we must be keen to seize the historical opportunity of informatization development", "play the leading role of informatization in economic and social development", "use big data to promote security and improvement." people's livelihood".
As an important part of people's livelihood security, medical security is closely related to people's life and health, the development of medical and health services, and economic and social stability. In particular, it is necessary to play the role of informatization to support and lead medical insurance governance and services, promote the digital transformation of medical insurance services, and provide better services. Accurate public services, promote the modernization of the medical insurance governance system and governance capabilities, and empower the high-quality development of medical insurance.
Specifically, the construction of a unified national medical insurance information platform mainly has "four needs".
The need for a unified system.
my country's medical insurance system started as a local pilot program. After more than 20 years of reform and development, it is now gradually moving towards standardization and unification.
Before the establishment of the National Medical Insurance Bureau, employee medical insurance, resident medical insurance, new rural cooperative medical care, medical assistance, price management, and drug procurement were managed by different departments. Data is not mutually recognized, and the information system is seriously fragmented, which is not conducive to the unification of policy norms.
Moreover, the information systems of the original departments were developed according to their own functional business, and the system coupling degree was high, and the data resources and application systems could not be simply disassembled and used.
To solve these problems such as system segmentation, regional closure, chimneys, information islands, etc., it is urgent to seize the opportunity of institutional reform, build a national unified medical insurance information platform, and release reform dividends, thereby further helping the system to unify and standardize.
The need to improve the level of medical insurance services.
Medical insurance directly targets the 1.36 billion people insured, and improving service levels is our original intention and mission.
The old information system does not communicate with each other and the data does not recognize each other directly, which directly affects the settlement efficiency, causing the masses to “run multiple times, run back and forth”, “cannot do things online, and cannot do things in different places”, “doing things difficult, slow, and complicated”.
To this end, great efforts must be made to build a unified national medical insurance information platform, strengthen hardware support, improve service functions, and allow the masses to share the dividends of informatization and digital development.
The need to improve the management level.
Medical insurance has always been a "three-point policy and seven-point management".
To protect the people's "medical money" and "life-saving money", we must continue to make efforts in fine management.
Due to problems such as inconsistent data standards and non-communication of information, the "running and leaking" in the operation of funds in the past cannot be ignored.
Only by building a nationally unified platform and centralized management can we continuously improve data quality and provide solid support for achieving benefits from management.
The need to coordinately promote the reform of the three medical linkages.
At present, medical reform has entered the deep water area, and every reform is a deep adjustment of interests.
The theory of health economics believes that the biggest feature of the medical service market is information asymmetry. Relying on information construction, we can better link the stakeholders of medical insurance, medical care and medicine, which will help effectively solve the information asymmetry of all parties. The reform of public hospitals, the reform of payment methods, the reform of drug prices, the reform of medical service prices and other difficult areas have formed a force-back mechanism to play a guiding role and better promote the linkage of the three medical services.
The National Medical Insurance Bureau seized the window period of institutional reform, and made scientific plans since its establishment, clarified the overall work idea of medical insurance informatization, and made solid progress in the construction of medical insurance information platform as a "top-ranking project".
The platform construction has mainly gone through two stages: one is the demonstration start-up stage.
In August 2018, the National Medical Insurance Bureau held a symposium of experts on medical insurance standardization research to study and deploy the formulation of medical insurance business standards, and officially launched the medical insurance informatization work.
In March 2019, the "Preliminary Design Plan for the Construction of the Medical Security Information Platform" was approved, which marked the basic end of the preliminary preparations for the platform.
The second is the platform construction stage.
In April 2019, the bidding work of the national medical insurance information platform was officially launched; in October 2020, the main body construction of the national medical insurance information platform was completed, and the focus of platform construction began to shift to local applications.
As of the end of March 2022, the national medical insurance information platform has been launched in 31 provinces across the country and the Xinjiang Production and Construction Corps.
This marks that, after 2 years and 11 months, the national unified medical insurance information platform has been fully completed.
The new platform covers four major types of medical insurance business, including public services, handling management, intelligent monitoring, and macro-decision-making. It has specifically designed 14 subsystems, including settlement for medical treatment in different places, payment management, price procurement, fund supervision, basic information and application support, and has realized Nationally unified standards, two-level data centralization, platform-level deployment, comprehensive network coverage, and system security and controllability have achieved national, provincial, municipal, and county-level medical insurance information interconnection, orderly sharing of data, medical insurance and multiple departments and medical institutions. , pharmacies and other units for information sharing, for real-time settlement, handling services, medical treatment in other places, treatment formulation, list specification, rural revitalization, catalog adjustment, payment reform, fixed-point management, drug consumption and procurement, price management, fund supervision, internal control , statistical analysis and other medical insurance business to provide strong support and guidance.
The average daily settlement on the platform exceeds 18 million person-times, the average response time for hospitalization expenses settlement is 0.8 seconds, the "inter-provincial handling" and other services are more efficient, and the centralized drug procurement is more transparent
Reporter: It is understood that the national unified medical insurance information platform has effectively covered about 400,000 designated medical institutions and about 400,000 designated retail pharmacies. What changes will the platform bring to medical treatment for the masses?
What role will it play in the centralized procurement of medicines?
Wang Wenjun: As a livelihood cause closely related to the people, medical security needs to play an informatization role in particular. Relying on a unified national medical insurance information platform, we will continuously improve the level of medical insurance convenience services and meet the people's higher-level medical security needs.
The completion of the new platform will bring the following changes to the public’s medical treatment:
Improve settlement efficiency.
The average daily settlement of the new platform exceeds 18 million, the average response time for hospitalization bill settlement is 0.8 seconds, and the performance is improved by an average of 3 to 5 times. Prevention and control of the new crown pneumonia epidemic.
Improved service experience.
The cumulative number of active users of medical insurance electronic vouchers exceeded 1.17 billion, promoting medical insurance services into the "code era".
Continue to optimize and improve the medical insurance service online hall and APP, set up family accounts, and provide the masses with "medical insurance service points that move to their homes" and "medical insurance service halls in their pockets".
At present, there are more than 200 million real-name users of the medical insurance service online hall and APP, and more than 100 million family accounts, which greatly improves the processing efficiency and improves the medical insurance service experience of the masses.
Realized "cross-province handling".
In May 2020, it took the lead in launching the remote medical treatment management subsystem, realizing the direct settlement and online filing of inter-provincial and remote medical treatment.
In 2021, there will be more than 100 million direct settlements for out-of-town medical treatment across the country, of which 4.4059 million are directly settled across provinces for hospitalization expenses, a year-on-year increase of 46.8%.
In addition, relying on the national unified medical insurance information platform, we have also realized the "cross-province handling" of medical insurance business such as change of insurance information, relationship transfer and continuation.
Enhanced security capabilities.
The national unified medical insurance information platform must meet the medical insurance reimbursement needs of each overall planning area. By comprehensively sorting out the medical insurance policies of various regions and setting corresponding parameters, we can timely find and clear the regulations that do not meet the requirements of the treatment list and the development direction of medical insurance, and promote appropriate protection. , reflecting the principle of doing your best and doing what you can.
In terms of fund supervision, by connecting more designated medical institutions to the platform, through dynamic monitoring, intelligent monitoring and big data analysis, abnormal situations can be detected in a timely manner, and fraudulent insurance frauds can be precisely cracked down, so as to protect the people's "life-saving money".
After the national unified medical insurance information platform is completed, it will accelerate the standardization of the national coding of pharmaceutical consumables, and promote "bidding with codes, purchasing with codes, and settlement with codes", which will facilitate the mutual recognition, transfer and sharing of data nationwide, and promote inter-provincial prices. Information is interconnected and more transparent.
In the process of centralized procurement in various places, the price information on the platform can be more conveniently used to grasp the real price of products, so as to better guide enterprises to form a reasonable selection price and squeeze out the water of artificially high prices.
With the gradual improvement of the functions of the drug consumption recruitment and procurement subsystem of the National Medical Insurance Information Platform, it can also provide more technical support in the aspects of bidding and procurement, implementation monitoring of the selection results, etc., to ensure the better implementation of the selection results, and the masses will really use after the price reduction. The product.
At the same time, the interconnection of purchasing price information can also restrict the unreasonable phenomenon of “purchasing more high-priced drugs and less low-priced drugs” by medical institutions, forcing medical institutions to actively regulate their procurement behavior.
It can directly monitor medical institutions and pharmacies at all levels, accurately crack down on large prescriptions, drug abuse, illegal insurance fraud and other behaviors, and protect the people's "life-saving money"
Reporter: The medical insurance fund is the "life-saving money" for the people. In reality, the problem of fraudulent insurance frequently appears.
What role will the National Medical Insurance Information Platform play in strengthening the supervision of medical insurance funds, avoiding and combating insurance fraud?
What changes did it bring?
Wang Wenjun: Relying on the national unified medical insurance information platform, we have designed an intelligent supervision subsystem to empower and increase the efficiency of supervision work.
Improve supervision capabilities and change the past problems of single supervision means and weak supervision capabilities.
Relying on the national unified medical insurance information platform, it dynamically collects and analyzes business data, can screen abnormal medical insurance settlements in real time, accurately locate fraudulent insurance fraud such as fictitious medical records, and achieve all-round, full-process, and all-link intelligent monitoring to help advance reminders , Early warning during the event, and post-event review, to effectively create "electronic eyes" and "sunwind ears" to protect the safety of medical insurance funds, improve the ability and efficiency of intelligent supervision of medical insurance, and promote the effective use of funds.
Improve analysis capabilities, change the past data scattered, difficult to effectively mine application problems.
Medical insurance big data has a wide coverage and a fast iteration speed, and can comprehensively record and collect medical behaviors. By strengthening data analysis, it can effectively improve the intelligence of medical insurance fund supervision, the precision of decision-making analysis, and the precise crackdown on over-prescription, drug abuse, and violations. Insurance fraud and other behaviors will promote the supervision of medical insurance expenses from a single limit and control fee to the review of clinical diagnosis and treatment plans, and the supervision of medical insurance funds will be more scientific and reasonable, further promote the standardization and transparency of the use of medical insurance funds, and effectively protect the people. "Medical money", "Life-saving money".
Improve coordination ability and change the past situation of weak supervision and relying solely on the active supervision of the medical insurance department.
The medical insurance information platform realizes the unification of national medical insurance business coding standards, data standards, and handling services. The data interconnection and orderly sharing of units makes all data "traceable and well documented", enabling direct monitoring of medical institutions and pharmacies at all levels.
Through data sharing with the public security department, a joint effort is formed to crack down on fraud and insurance fraud.
By deploying various intelligent supervision rule bases such as medical insurance management rule bases, clinical diagnosis rule bases, drug rule bases, and diagnosis and treatment project rule bases, medical institutions are forced to strengthen fund security management and control, and effectively promote the coordinated supervision of medical insurance funds.
From 2018 to 2021, more than 2.4 million designated medical institutions were inspected nationwide, nearly 1.15 million were processed, and a total of 58.3 billion medical insurance funds were recovered.
Adhere to the party's overall leadership, keep the people first, use reform to overcome difficulties and challenges, and take the path of medical security with Chinese characteristics
Reporter: Since the 18th National Congress of the Communist Party of China, we have built the world's largest universal basic medical security network in a relatively short period of time.
What inspiration and experience?
Wang Wenjun: From 2012 to 2021, the number of people covered by basic medical insurance in my country will increase to 1.36 billion.
Looking back on the past ten years, it should be said that our insurance coverage is wider and the insurance efficiency is higher, helping to successfully win the battle against poverty, effectively playing the role of medical insurance in major epidemics, fully supporting the new crown virus vaccine and vaccination cost protection, more accurate and efficient. .
Our experience and inspiration are:
One is the strong leadership of the Party Central Committee.
Since the 18th National Congress of the Communist Party of China, the medical security work has made historic achievements and undergone historic changes. The fundamental reason is the strong leadership of the CPC Central Committee with Comrade Xi Jinping at the core, and the leadership of General Secretary Xi Jinping at the helm.
General Secretary Xi Jinping has personally researched, planned and deployed major reforms in the field of medical insurance, pointing out the direction for the high-quality development of medical insurance.
The second is to always keep the people first and stick to the original mission of medical insurance.
It is our original intention and mission to establish universal medical security to strive to relieve all people's worries about medical treatment of diseases.
Over the past ten years, medical insurers have always kept their original mission in mind, continuously improved the basic medical insurance system, optimized the financing treatment policy, insisted on ensuring basic, multi-level, reform-promoting, and sustainable, and effectively reduced the public's disease burden.
In 2020, the proportion of personal hygiene expenditure in total health expenditure has dropped to 27.7%.
This year, the financial subsidy standard for urban and rural residents' medical insurance per capita has been raised to 610 yuan.
The third is to insist on reform and innovation.
The Medical Insurance Bureau is the product of reform, and reform is the brightest background on the medical insurance banner, and it is also the most effective means to overcome difficulties and challenges.
Comprehensively and strictly governing the party has also created a good atmosphere and provided a strong guarantee for us to deepen reform and break down the barriers of interests.
Whether it is the reform of centralized procurement of drugs and medical consumables organized by the state, or the construction of information technology, the reform of medical service prices, the adjustment of medical insurance drug catalogues, and the reform of payment methods, medical insurers insist on opening roads in the mountains, building bridges in the water, and forging ahead. Not only continued to increase reform efforts to open up new roads, but also continued to optimize management to consolidate and expand reform achievements.
Fourth, adhere to common prosperity.
Promoting the high-quality development of medical security is an important aspect of achieving common prosperity.
We have always insisted on doing our best and doing what we can. We not only pay close attention to improving quality and efficiency, and maximize the guarantee efficiency of limited medical insurance funds, but also take a clear stand against "welfareism", govern excessive guarantees, and ensure the sustainability of the system. We have developed a Chinese characteristic. road to health care.
Reporter Wu Jing Xue Peng