The "National Hospital Medical Insurance Service Regulations" was recently released, and comprehensively announced that the fine management of medical insurance from the hospital level has been fully opened. Correspondingly, the medical insurance control business of medical IT companies represented by Weining Software, Wanda Information, Haihong Holdings and Donghua Software also kicked off. For example, Weining Software first strengthened the layout of the medical and social security business in the Sichuan-Yunnan region, and then won the construction contract for the provincial medical insurance control fee platform of the Shanxi Medical Insurance Center.

Hospital active control fee

In the past, the hospital’s management attitude towards the medical insurance fund was relatively passive. With the implementation of the “Regulations”, hospitals that were forced by the medical insurance management department to passively control fees will change their attitudes and actively carry out medical insurance control fees.

For the first time, the "Specifications" clearly raised the medical insurance management to the height of hospital administration. It required the designated medical institutions to establish a medical insurance management committee under the leadership of the hospital, establish a sound medical insurance management system, and form a three-level medical insurance for hospitals, competent departments and departments. Manage the network and set up an independent medical insurance management department that is compatible with the medical insurance management tasks and parallel with the medical administrative department of the unit.

The "Code" emphasizes that the use of medical insurance expenses management and medical insurance funds should be based on a reasonable basis, advocating reasonable inspection, rational use of drugs, reasonable treatment and reasonable fees. Optimize the allocation of health resources on the premise of ensuring medical quality. In the medical management system of the hospital, it is necessary to use the clinical diagnosis and treatment norms and the evidence of health economics as the starting point, supervise the medical quality and medical insurance expenses, and continuously improve the quality and management level of medical insurance management. While not increasing the overall medical expenses, patients are given more standardized and more reasonable treatment, and the use of limited medical resources allows the people to enjoy better medical services.

Yao Hong, director of the Department of Health Insurance of the Ministry of Human Resources and Social Security, pointed out that the "good days" of medical insurance have ended. With the gradual realization of the goal of universal health insurance, there has been no room for large-scale and extensive expansion, and the increase in fund income has fallen sharply, but the expenditure on medical insurance funds has continued to increase. This requires medical insurance fund management to promote connotative construction and development.

According to industry insiders, if hospitals and doctors are consciously conducting cost control, the hospital drug structure will actually have a major earthquake, and the impact on various products may be more intense than the impact of the “limited resistance” policy on antibacterial drugs, especially Diabetes, hypertension and other areas of chronic disease medication. The impact of this process will slowly advance with the construction of hospital fee regulations, but time is extremely urgent for enterprise product structure adjustment or product development.

Informatization adds wings to the control fee

The use of information technology to conduct medical insurance control fees is generally considered to be a major trend in the future. Under the background of the tightening of the national health insurance fund, the fee-based platform based on the HIS system database of major hospitals will bring more refined management capabilities to the medical insurance fund.

According to industry insiders, the control of the information system can check the standardization of each treatment process and the rationality of the prescription, so as to ensure the reasonableness of expenses. In addition, due to the limited manpower of medical insurance agencies, it is impossible to conduct a detailed review of each single treatment process. It is an inevitable trend in the future to pass informationization control fees. The construction of information system is the real market for domestic medical insurance control fees.

According to Zhao Yongchao, a securities researcher, from the perspective of the informationization development process of medical insurance system, medical insurance informationization can be roughly divided into four stages: the first stage is the establishment period of medical insurance system, generally from 1998 to 2003. During this period, all localities began to gradually establish their respective regional medical insurance systems according to the urban workers' medical insurance policy, and completed the initial medical insurance system from the organizational structure and fund pooling. This period is still in its infancy, and it is still not informatization. The second phase is the construction period of the Jinbao project, generally from 2003 to 2007. With the establishment of social security systems throughout China, management requires a top-down information system. In August 2003, the State Council officially approved the establishment of the Jinbao Project, and the construction of medical insurance informationization began. The third stage is the period of phased success of the medical insurance system, generally from 2007 to 2012. During this period, with the advancement of “new medical reform”, the coverage of medical insurance and the gradual improvement of payment standards, medical insurance gradually assumed the role of important third-party payment in China's medical system, and the proportion of medical insurance payments in total medical expenses gradually increased from 20%. Increased to 35%, the proportion of hospital income and medical insurance has gradually increased from about 20% to about 50%. This stage prepares objective conditions for informatization construction. The fourth phase is the establishment of the medical insurance control system, which may be from 2013 to 2015.

"The construction of medical insurance control informationization has an important significance. The direction of China's next medical and health reform is the way of medical, medical and medical insurance 'three medical linkages', and 'medical insurance' is a lever to incite the reform of the overall medical system. Zhao Yongchao introduced that the establishment of medical insurance control information system as an entry point can effectively analyze and monitor all aspects of hospital fees, doctors' treatment behaviors, doctor prescription behaviors, etc., and provide data foundation for various medical system reforms.

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