The reform of medical insurance payment method has been carried out in most parts of the country.NbajamgameSome people are worried that there will be changes in medical insurance benefits. How to change the payment method of health insuranceNbajamgame? What is the impact on the insured? Around the questions of concern of the masses, the relevant responsible person of National Healthcare Security Administration gave an answer.
The purpose of the reform of payment method is by no means simple to "control fees".
Q: some people say that the reform of the payment method of health insurance is because the health insurance fund is out of money and it is necessary to control expenses. Is there any basis for this statement?
Answer: the payment method of medical insurance is a specific way for medical insurance agencies to pay fees to medical institutions, including payment by project, by disease, by bed, and so on. Different ways play a different role in guiding clinical diagnosis and treatment. China has successively launched the pilot payment mode of DRG (by disease group) and DIP (by disease score). By the end of last year, more than 90% of the overall planning areas had carried out DRG/DIP payment reform. After the reform, the proportion of medical insurance fund for hospitalization in the reformed areas has dropped to about 1x4 by project payment.
It should be noted that the purpose of the reform of the mode of payment is by no means a simple "fee control", but to guide medical institutions to focus on clinical needs, adopt appropriate technology for disease treatment, reasonable diagnosis and treatment, avoid excessive prescriptions and excessive examinations, and better protect the rights and interests of insured personnel. The payment standard after the reform is timely improved with the development of social economy and the change of price level. Every year, health insurance fund expenditure maintains a growth trend and is higher than the increase in GDP and prices.
There have never been restrictions such as "no more than 15 days in a single hospital".
Q: in recent years, in some areas, some patients have been required to be discharged after two weeks of hospitalization and then re-admitted to the hospital. It is said that after the reform of the payment method, there is a stipulation that "a single hospitalization shall not exceed 15 days." What's going on?
A: the national health insurance department has never issued restrictions such as "no more than 15 days in a single hospital". In 2022, National Healthcare Security Administration also issued a notice on Comprehensive investigation and abolition of unreasonable restrictions on Medical Insurance, requiring local health insurance departments to conduct a comprehensive and in-depth investigation of unreasonable restrictions on medical institutions, and the cleaning up of areas with problems has been completed.
The situation of "no more than 15 days in a single hospital" may be due to the relatively extensive management measures set by some medical institutions in order to complete the assessment indicators such as "average hospitalization days" and "average cost". With regard to changing the "average" of the health insurance payment standard into a "limit" and requiring patients to be discharged, transferred or hospitalized at their own expense on the ground of "the amount of medical insurance has reached," we firmly oppose and welcome reports from the public, and will be dealt with seriously.
Qualified new drugs and new technologies can be settled according to the actual costs incurred.
Q: under the disease-by-disease payment model, will medical institutions purchase new equipment or give patients new drugs with high prices, will there be cost pressure? If medical workers spend too much on new drugs and new technologies in the process of seeing a doctor, will their performance income be affected?
A: the emergence of such problems in individual medical institutions in individual areas is not the original intention of the reform of the mode of payment. On the contrary, in order to support the application of new clinical technologies and ensure that seriously ill patients are fully treated, relevant rules have also been introduced in the reform of payment methods. For example, new drugs and new technologies that meet the requirements may not be included in the "exception payment" rule of disease payment standards, and the "special case discussion" rules of severe cases, which are significantly higher than the average cost of disease types, can be settled according to the actual expenses, so that the broad masses of insured persons, medical institutions and medical personnel can rest assured.
The medical problem is very complex, and the technological progress in the medical field is also very fast. The medical insurance payment policy must not match with the medical practice and lag behind the clinical development. For this reason, National Healthcare Security Administration is establishing a mechanism for collecting opinions and adjusting DRG/DIP grouping rules for the vast number of medical institutions and medical personnel, based on the opinions and suggestions put forward by medical staff and the objective data of medical expenses, to adjust and improve the grouping dynamically and regularly, to update the optimized version regularly, to fully respond to the demands of medical institutions, and to ensure that the payment method of medical insurance is scientific and reasonable.
(article Source: People's Daily)