About the development of the basic medical insurance for the opinions of the total amount control

The ministry of health of the People's Republic of China www.moh.gov.cn 2012-12-05 14:43:14

People club department is sent [2012] no. 70

        All provinces, autonomous regions, municipalities directly under the central government and the xinjiang production and construction corps human resources social security department (bureau), the provincial department of finance (bureau), health department (bureau) :

        At present, our country covering both urban and rural residents of the basic medical insurance system has been set up preliminarily, and increasing the number of ginseng, safeguard level gradually improve, according to the state council "" 1025" during deepening medical health system reform plan and implementation plan (guo fa [2012] 11) about give full play to the basic role of the basic medical insurance, key by extending the scope to improve quality requirements, should further deepen the reform of the medical insurance payment methods, combined with the fund of insurance of primary medical treatment of the comprehensive budget management and development, the basic medical insurance pay total amount control (hereinafter referred to as the "total amount control"). As a guide to all the work, we put forward the following opinions:

        A goal, task

        CPC central committee and the state council on deepening the reform of the medical and health system file spirit as the guidance, in accordance with the "combined with fund budget management to strengthen the control of total amount, and, on this basis, combining with the development of the outpatient service as a whole to explore head pay, combined with be in hospital, outpatient service a serious illness safeguard explore press disease to pay" reform direction, with two years time, in all as a whole the area within the scope of work in total control. Combined with the medical insurance fund budget management, reasonably determine the total amount control target as a whole area, and according to the classification of medical service system functional division and basic medical and health institutions and hospitals two-way referral requirements, the total amount control target refining decomposition at various levels to nod medical establishment. Gradually establish to ensure quality, cost control and standardize the diagnosis and treatment is the core of the medical service evaluation and supervision system, and control medical cost too fast growth, improve the basic medical insurance security performance and better protecting the people's basic medical rights and interests, and give full play to the basic medical insurance in public hospital reform, as well as to support and promote the role.

        Second, the basic principles

        One is the basic guarantee. Adhere to the set branch, balance of payments and somewhat balance, ginseng protect personnel to ensure the basic medical needs, to improve medical and health resources reasonable use and control medical cost too fast growth.

        2 it is scientific and reasonable. Total amount control objectives to nod medical establishment historical cost data and medical insurance fund budget as the foundation, considering the rising medical costs and fund and medical service, scientific measurement changes, reasonably determine the.

        The third is transparent. Total amount control program to open transparent, total amount control management to the society regularly to report. Establish orgnaization of agency of medical treatment insurance to nod medical establishment and the consultation mechanism, give play to the medical staff and industry learn (association) will participate in such as the role of management.

        The fourth is incentive constraint. Establish reasonable moderate "balance continue to employ, overspend share" of incentive and constraint mechanism, improve the medical institutions to strengthen management, cost control and improve the quality of the enthusiasm and initiative.

        Five is to strengthen the management. To strengthen the coordination between departments, use a combination of means, and give full play to the role of insurance of medical treatment of monitoring to ensure implementation of the total amount control and the medical service level is not reduced, the quality is guaranteed.

        Three, the main content

        (a) to strengthen and improve the fund budget management. Improve the basic medical insurance fund budget management system, the establishment of the basic medical insurance serious budget income on the basis of further strengthen spending budget, and will fund budget management and payment management, combining strengthen budget enforcement. Each plan as a whole according to region in recent years the region fund of medical treatment insurance to pay the actual situation, combined with the contributors, age structure and disease patterns change and policy adjustment and treatment level and other factors, the scientific establishment fund spending budget. The realization of the region as a whole and in establishing municipal fund budget management system based on the city, district (county) two levels of orgnaization of agency of medical treatment insurance classification management authority, the fund budget for refining and decomposition.

        (2) as a whole the area reasonably determine the total amount control target. As a whole the area according to the set with the branch and the balance of payments and somewhat balance principle, the basic medical insurance fund in the annual budget as the foundation, after deducting ginseng protect unit and individual one-time pay insurance cost, the plan as a whole to regional medical treatment, medical treatment and retires personnel designated retail pharmacy spending and other fees, and comprehensive consideration of the various spending risk, considering the overall price level, ginseng protect personnel to medical consumption level and other factors so as to determine the fund of medical treatment insurance as a whole area designated medical institutions pay annual total amount control target. In the development of total amount control at the same time, to guarantee the basic rights and interests, ginseng protect personnel to control ginseng protect personnel individual responsibility.

        (3) refining decomposition amount control indicators. The recent three years to nod medical establishment service conditions and actual medical expense as the foundation, will be as a whole the area annual total amount control objectives, in accordance with the designated medical institutions at different levels, class, designated service scope, and effective services for the first diagnosis, referral tasks, and to distinguish factors such as outpatient service and hospitalization expenses implement further refined to the designated medical institutions. According to the basic medical insurance for different categories and levels of medical institutions pay policy difference, pay attention to to grassroots tilt, make point basic medical and health institutions of reasonable proportion index, in order to adapt to the classification of medical service system construction and basic medical and health institutions and hospitals two-way referral system, support the establishment of a reasonable and orderly pattern of medical treatment of the formation.

        (4) pay attention to communication and consultation. As a whole the area should abide by the principle of transparency, the implementation of the total amount control procedures and methods, and to the public. To establish orgnaization of agency of medical treatment insurance to nod medical establishment and between effective consultation mechanism, in the decomposition of the total area control goal, should be asked for a wide range of medical institutions, relevant industry associations and ginseng protect personnel representative opinions. Conditional area according to grade, class will be divided into several groups to nod medical establishment, through the designated medical institutions held up representative or play industry learn (association) will effect etc, between group and group in consultation, determine the specific amount to nod medical establishment control indicators, promote fair competition between to nod medical establishment.

        (5) establish incentive and restraint mechanism. According to "balance continue to employ, overspend share" principle, reasonably determine the fund of insurance of primary medical treatment and medical institutions to balance funds and overspend cost sharing method, give full play to the designated medical institutions control medical cost of enthusiasm. Ensure that medical treatment in quantity, quality and safety and strengthen the basis of assessment, and gradually form the cost overruns to nod medical establishment reasonable sharing, balance funds to nod medical establishment by reasonable mechanism of continue to employ. More than the total index of medical institutions, we should analysis the reason, improve management, puts forward the opinion of rectification. Orgnaization of agency of medical treatment insurance fund according to the budget implementation, to nod medical establishment go to a doctor because of ginseng protect personnel to the increase of the number of the formation of reasonable compensation overruns. Orgnaization of agency of medical treatment insurance shall be in accordance with the designated medical institutions consultation related specific situation, and in the designated service agreement clearly.

        (6) into the designated service agreement. To control the total contents into the designated service agreement, and according to the total amount control management requirements adjust and improve the content of the agreement. To control the total for the possible conditions, gradually switch are cost, return visit rate, hospitalization rate, people head ratio, ginseng protect personnel to burden level, referral hospital rate, the rate of surgery, and elective surgical procedures rate, severe patient proportion and so on, into the designated service agreement evaluation indicator system, and strengthening management.

        (7) perfect cost settlement management. As a whole the area orgnaization of agency of medical treatment insurance to pay the total control indicators and specific ways and standards, combining reasonable reserve a certain proportion of quality security and year-end settlement fund, will control the total index decomposition to the settlement period (in principle on cycle), in accordance with the terms of the designated service agreement on time full specified amount settlement to nod medical establishment, to ensure the normal operation of the medical service. To nod medical establishment settlement period not more than the total control index of medical costs, medical insurance agencies according to the agreement shall be allocated on time full specified amount; More than the total control index part of the medical costs, can defer to the end of the fund, liquidation to review again. To orgnaization of agency of medical treatment insurance is not in accordance with the agreement on time full specified amount settlement medical expenses, as a whole the area government administrative departments should strengthen the supervision, shall be ordered to correct illegal and irregular to deal with according to law.

        Orgnaization of agency of medical treatment insurance can according to a certain proportion of total amount control indicators established revolving fund, according to the agreement to allocated to nod medical establishment, to alleviate the capital operation pressure. Orgnaization of agency of medical treatment insurance and point between medical institutions shall establish regular information communication mechanism, and publicize the medical cost dynamic situation. In the reform process of medical institutions effective workload or cost structure of substantial change, as a whole the area orgnaization of agency of medical treatment insurance can be according to the actual, in the middle of the designated medical institutions to adjust the total control indicators.

        (8) to enhance the medical service supervision. As a whole the area health, human resources and social security departments to implement according to the total amount control may appear after the shuffle rejection patients, reduce service standard, any behavior such as services, to strengthen the medical behavior to nod medical establishment of supervision. For the medical service quantity or quality does not comply with the requirements of the designated medical institutions, should according to agreement proper deduction quality margin. To perfect the medical insurance information system, clear reporting and complaint channels, clear monitoring indicators, to strengthen the key risk prevention. To establish department linkage mechanism, strengthen the breach of contract, illegal medical behavior investigation dynamics.

        (9) advance payment reform. To carry out the total amount control at the same time, actively promote on a per head, such as press disease to payment reform. To adjust measures to local conditions selection and local medical insurance and health management situation of the phase matching ways of paying for it, and constantly improve the medical insurance payment methods, improve the scientific nature of the fund performance and management efficiency.

        Four, organize the implementation

        (a) strengthen organization and leadership. Total amount control is to deepen the reform of medical insurance system is an important task, and advancing the reform of public hospitals have an important role in promoting, each district should attach great importance, strengthen leadership, will this work as one of the most important medical insurance work grasp, emphasizing, pay special attention to. The provinces (autonomous regions and municipalities) to strengthen research and guidance, carries on the overall arrangement; As a whole the area to formulate specific work plan, earnestly implement.

        (2) make coordination. Departments to strengthen coordination, clear departments responsibility, form work force. Financial departments shall jointly with the human resources social security departments to implement the basic medical insurance fund budget management the related work, the common perfect fund of medical treatment insurance budget management system and measures, strengthen the orgnaization of agency of medical treatment insurance executive budget, cost settlement supervision. Health departments should strengthen the medical institutions and medical personnel behavior of the supervision to the medical insurance payment reform as an opportunity to explore the effective way of public hospital reform. According to the regional health planning and program of the establishment of medical institutions, strictly control the number of hospital and scale, it is strictly prohibited to public hospital construction of debt. To conform to the situation to strengthen the medical service of fine management, and promote the hospital total cost accounting and standardized diagnosis and treatment work. To take various measures to control the medical cost, and guide the medical staff strengthen cost control consciousness, the standard medical service behavior. Regions to establish the human resources social security, financial and health departments, with participation of coordination mechanism, and timely solve the total control of the major problem.

        (3) pay attention to the risk prevention and control. The orgnaization of agency of medical treatment insurance as a whole the area in total amount control management process, it is necessary to adhere to the "open, fair and justice" principle, strengthen and negotiation to nod medical establishment, and to realize the transparency of program. Orgnaization of agency of medical treatment insurance to nod medical establishment and consultation does not have "a school talk about", and resolutely put an end to black case work, negotiate and confirm the total amount control of indicators to the public in time. The total amount control management should take the initiative to accept disciplinary inspection and supervision departments and social supervision of all parties. Orgnaization of agency of medical treatment insurance and medical institutions in total amount control management in the process of dispute, according to the service agreement and related laws and regulations processing.

        (4) provide policy propaganda. Pay great attention to the importance of publicity work, to do a policy propaganda and reading, make broad medical personnel and ginseng protect personnel to understand the significance of the total amount control, understanding support reform. Total amount control work in case of major issues or problems, to timely report, properly handle.

        The opinions are applicable to the human resources department is responsible for the social security of the basic medical insurance.

        Human resources social security ministry of finance ministry of health

        On November 14, 2012