Discussion on the reform of medical insurance payment mode by provincial medical insurance center

　　In November, 2011, according to the overall requirements of the national medical reform, the four departments of human society, development and reform, finance and health of our province jointly issued the Opinions on Further Promoting the Reform of Medical Insurance Payment Methods. It is understood that over the past year or so since the reform, 16 provincial cities in the province have carried out the reform of payment methods according to the deployment. What is the significance of this work to the sustained and healthy development of medical insurance? After the reform of the payment system, what new measures have the medical insurance handling department taken in supervision and management? What achievements have been made in the reform of payment system? In addition, can the insured use the funds in the medical insurance card at will? What are the penalties for hospitals and pharmacies that illegally swipe their cards? In response to these social concerns, Guo Zhenlan, director of the provincial social medical insurance center, was invited by the provincial government portal website in conjunction with Dahe.com and Henan Daily’s Focus Network Talk to participate in this exclusive interview to talk about the reform of medical insurance payment methods.

　　Theme:On the reform of payment mode of medical insurance

　　Time:Friday, April 26th, 2013 at 15:00.

　　Location:He ‘nan Daily Newspaper Building

　　Guest:Guo Zhenlan, Director of Provincial Social Medical Insurance Center

　　On the afternoon of April 26th, Guo Zhenlan, the director of Henan Social Medical Insurance Center, was interviewed on the "Online Interview" section of the portal website of the provincial government on the related situation of "the reform of payment mode of provincial medical insurance". In the interview, Guo Zhenlan also answered questions about the hospital’s illegal use of medical insurance cards reflected by the media recently.

　　[Meaning]

　　Reform of payment system to protect the medical insurance rights and interests of insured persons

　　Talking about the significance of the reform of the payment system, Guo Zhenlan said: First, curb the rapid rise of medical expenses, reduce the burden of medical expenses for insured persons, alleviate the problem of "expensive medical treatment" for the masses, and further protect the medical insurance rights and interests of insured persons; The second is to urge medical institutions to strengthen internal management, establish and improve self-restraint and self-management mechanisms, change development models, and achieve sustainable and benign development; The third is to achieve accurate management of medical insurance, ensure the balance of medical insurance funds and ensure the healthy and sustainable development of medical insurance.

　　[Content]

　　It mainly includes "changing the post-payment system to the budget system" and so on.

　　Regarding the content of the reform of medical insurance payment method, Guo Zhenlan said that there are three main contents: First, the post-payment system is changed to the budget system, and the total amount of hospitals is controlled according to the fund income and expenditure budget, and the budget is made for each hospital, and "budget management, flexible settlement, balance reward and overspending sharing" are implemented. The second is to break the previous way of paying by project, and implement different payment methods according to the level, type, characteristics and service volume of different designated medical institutions. In principle, the hospitalization expenses of non-profit medical institutions at or above the second level are mainly paid in advance, supplemented by payment by disease and payment by project; Pay by project for critically ill patients; Pay by bed for psychiatric specialized medical institutions; For-profit medical institutions and first-class medical institutions, the payment is based on the average limit under the total amount control. The third is to establish a negotiation mechanism, and the budget quota is determined and the year-end settlement is negotiated with the hospital.

　　[Measures]

　　Establish a provincial medical insurance expert database

　　Guo Zhenlan said that after the reform of the payment system, the medical insurance department made some new attempts in supervision and management. For example, in order to improve the scientific, standardized and professional level of medical insurance management, 2,171 experts with both ability and political integrity were hired from designated hospitals to form a medical insurance expert database. Experts are responsible for providing professional technical guidance and consultation for policy formulation, and assisting in the corresponding research and demonstration work. Organize experts to audit medical records regularly, and change the audit of medical insurance managers into expert audit, which improves the authority and scientificity of medical record audit.

　　[Effect]

　　Last year, the province achieved the balance of payments of the overall fund in the current period.

　　Guo Zhenlan said that in 2012, the current balance of the overall fund was achieved throughout the province, and the rapid growth of medical expenses was effectively curbed. Taking the provincial medical insurance as an example, in 2012, when the reimbursement ratio increased by 5% (from 80% to 85% for employees and from 85% to 90% for retirees), the growth of the overall fund expenditure decreased from 46% to 11% annually, which reversed the situation that the overall fund failed to meet its expenses for two consecutive years and achieved a balance of payments, with a balance of 54.95 million yuan in that year. The average hospitalization expenses decreased from 12,900 yuan in 2011 to 11,400 yuan; The average hospitalization days decreased from 20.97 days to 18.45 days.

　　[Explanation]

　　Question 1: Can the insured use the funds in the medical insurance card at will?

　　Guo Zhenlan made it clear that he could not. She explained that although the funds in the medical insurance card (that is, the personal account IC card) are owned by individuals, they are part of the basic medical insurance fund, and the scope of use should be strictly implemented in accordance with the provisions of the Social Insurance Law (Article 28 of the Social Insurance Law stipulates that medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency and rescue should be paid from the basic medical insurance fund in accordance with state regulations). The medical insurance card is only used by the card owner himself, and may not be lent to others for use, and may not pay medical expenses for others.

　　Question 2: If the owner of the medical insurance card is inconvenient to move, can’t his family use the medical insurance card to buy medicines for him?

　　Guo Zhenlan said that in this case, the medical insurance agency stipulates that if someone else swipes the card to buy medicine or pay medical expenses, the designated hospitals and pharmacies should check the ID card of the cardholder and record his name and ID number on the statement. As long as the above regulations are followed, it is ok for others to pay the medical expenses that meet the basic medical insurance coverage by swiping the card.

　　Question 3: What are the penalties for hospitals and pharmacies that illegally swipe their cards?

　　Guo Zhenlan said that according to the agreement, assessment methods and relevant regulations, hospitals and pharmacies that illegally swipe their cards were given penalties such as refusing to pay fees, informed criticism, suspending designated services and dissolving service agreements according to the nature of violations. From January to March this year, two designated hospitals that use IC cards to pay fees other than medicine and medicine have suspended the outpatient credit card service; And for more than a dozen designated pharmacies that illegally swiped daily necessities, the designated services were suspended or the agreement was lifted.

　　Question 4: Recently, some media reported that hospitals used medical insurance cards illegally. What measures did the provincial medical insurance center take?

　　In this regard, Guo Zhenlan said that we have taken the following three measures. First, we issued the Notice on Further Strengthening the Use and Management of Personal Account IC Card, reaffirming that personal account funds are an integral part of medical insurance funds, and their scope of use should be strictly implemented in accordance with the provisions of the Social Insurance Law. People and certificates must be consistent. If someone else swipes the card to buy medicine or pay medical expenses, the cardholder’s identity card should be checked, and his name and certificate number should be recorded on the statement. Second, the field supervision has been strengthened. The third is to interview nine designated hospitals involved in illegal card swiping in the report, and issued a notice of self-examination, requiring them to conduct self-examination and report the results to the provincial center. (Reporter Huang Liang graphic)