[Society] Repair the burden on patients in different places

Author:China Well -off Time:2022.06.15

China Well -off Network Exclusive Specialty

Text | "Well -off" · China Well -off reporter Guo Yan

Photography/Guo Yan

Making the masses "can see a doctor" and "optimistic" in different places is the original intention of direct settlement of cross -provinces and other places. However, in actual operations, due to different policy treatments in various overall planning areas, such as the paid line, the cap, the proportion of reimbursement, the scope of the disease, etc., the policy differences are dazzling.

The original intention of the direct settlement policy for medical treatment is to solve the problem of "running legs" in the insured. Since the official launch in 2016, it has been step by step in accordance with the idea of ​​"first hospitalization, re -outpatient clinic; first province, and then across provinces". Implementation has continued to expand. Data show that the cumulative direct settlement of hospitalization and outpatient expenses across the country has exceeded 10 million.

This year's government work report proposes to improve the direct settlement method of cross -provincial medical treatment, and to achieve basically unified scope of medical insurance for medical insurance.

At present, my country has built a basic medical security network covering the people. Cross -provincial medical treatment expenses are fully pushed open for direct settlement, outpatient costs are steadily piloted by direct settlement of provinces, and medical records for medical treatment are being promoted.

Settlement of medical treatment at a different place is convenient and fast

With economic development and convenient transportation, more and more personnel flow. But once you get sick, the insured is not convenient to return to his own insurance place to see the doctor. What should I do if the medical insurance reimbursement of medical treatment in a different place is? Not long ago, Xi'an, Shaanxi Province, launched a national medical security information platform. The direct settlement of the "highway" has also been repaired. The insured person's medical expenses hand -reimbursement of the "running legs" burden and long reimbursement cycle and other issues have been resolved.

What are the benefits of direct settlement for hospital hospitalization in different places? Save, time, time, effort, and money. When the insured person is hospitalized in a different place, the medical expenses are required to pay the medical expenses burden of personal burden.

Coincidentally, the Changsha Medical Insurance Bureau of Hunan Province has optimized the management procedures for registering for registered medical insurance participants in the province of Changsha for medical insurance participants in the province of Changsha in order to improve the service efficiency of the medical and economic officers in different places and facilitate the direct settlement.

From the beginning of April this year, the insured persons in Changsha have a designated medical institution in the provincial medical network of fixed medical institutions. Essence

According to relevant regulations, when the insured persons in Changsha are discharged and settled in different places in the province, in principle, the designated medical institution of a designated medical institution should be settled in a different place. It only needs to pay the personal payment part. The treatment standards are implemented with reference to the medical policy policy, and the proportion of reimbursement is not reduced. If the case is not settled directly in the medical area, the insured person may be able to stay in the hospital for medical expenses, and return to the CIMC for settlement for reimbursement, and will not reduce the reimbursement ratio. At present, direct settlement for hospitalization and hospitalization in different places has covered all provinces, all regions, all kinds of insured personnel, and major out -of -person personnel in all provinces in the country. Cross -provincial medical treatment mainly covers retirees, long -term residents, resident staff, and referred persons in different places.

Sanhe City, Hebei Province is located in the junction of Beijing and Tianjin. It is separated from Beijing and only one river. The continuous development and improvement of Sanhe Hebei Hospital is a microcosm of the Beijing -Tianjin -Hebei coordinated development strategy in medical and health services.

In Sanhe City, there are many residents with Beijing Medical Insurance. In January 2017, the Beijing Human Resources and Social Security Bureau issued a document to use Hebei Yanda Hospital as the "Beijing insured person to settle directly to settle medical institutions." Hebei Yanda Hospital and Beijing Medical Insurance System successfully connected to become the first unique settlement unit in Beijing Medical Insurance.

When you see a doctor at Yanda Hospital, you can reimburse the medical insurance card in Beijing in real time and enjoy the equal reimbursement ratio of Beijing. This measure has lifted the worries of the permanent population who participated in medical insurance but lived in Yanjiao in Yanjiao.

The mother -in -law's mother -in -law's mother -in -law was from Beijing. After retiring, they lived in Yanjiao. Because they had chronic diseases such as hypertension, they had to go to Beijing to see a doctor often. "It's not easy to go to Beijing once, at least four or five hours back and forth. Now, at Yanda Hospital, you can use Beijing's medical insurance card to report actual sales. It feels particularly convenient." And because of often Beijing experts come to the clinic, this is this. Let their family feel very assured.

The number of migrants in China is huge, and many of them are the elderly. For elderly patients with chronic diseases, the demand for medical treatment for different places is urgent. In February 2017, the National Development and Reform Commission issued a document to use Yanda Hospital as "a fixed -point medical institution directly settled in the Beijing -Hebei provinces." In May 2017, the Ministry of Human Resources and Social Affairs issued a document to use Yanda Hospital as "the first basic medical insurance cross -provincial medical expenses directly settled the designated medical institution". This innovative road to Beijing -Hebei Medical integration is mainly due to the introduction of related policies of Beijing -Tianjin -Hebei Medical Coordinated Development and the innovation of ideas.

Multiple obstacle barriers need to be cracked

According to the "well -off" magazine and China Xiaokang.com, the medical treatment is mostly settled for developed areas to developed regions. It is also to prevent the "small illness" and disrupt the order of medical treatment. "This concern has its reasonableness, but it is not completely in line with reality." Zhu Fengmei, assistant researcher at the Institute of Economics of the Chinese Academy of Social Sciences, has evaluated the medical cost and medical insurance fund expenditure in different places. From the results The pressure of the land protection fund. "The diagnosis and treatment process of large hospitals is more standardized. In order to improve the circulation rate of the bed, there will be no over -medical phenomena. The number of hospitals, the number of times, and the cost will be less than the local hospital."

"The medical insurance department should change their minds. While guiding the hierarchical diagnosis and treatment, restrictions on patients with severe diseases, and realize‘ should be turned around ’.” Zhu Fengmei said.

Wang Yongxia was a girl who worked in Beijing. After her father found lung cancer last year, she decided to receive her father's surgery. However, the road of medical treatment in a different place was twists and turns. Although she was finally reimbursed successfully, she had repeatedly encountered a stuck shell. After receiving surgery in Beijing, Wang Yongxia's father was discharged from early October 2021. From November to early December, they tried to settle directly. The system could not read patient information, and the staff could not find the crux of the symptoms.

Wang Yongxia communicated with the Hometown Medical Insurance Bureau. After inquiring, the other party said, "During the system update, the record for admission has been deleted by the Beijing Medical Insurance Information Department." After the coordination of the two places re -entered the information, the problem was finally resolved on December 27, 2021.

Zhang Li (pseudonym), an employee of Taiyuan City, Shanxi Province, was also inconvenient to seek medical treatment for different places. Zhang Li believes that her disease cannot be effectively treated in the local area. I want to go to Beijing for medical treatment. The unit where the unit is located cannot issue the medical insurance "red -headed document" required by the Taiyuan Medical Insurance Bureau. smoothly. In the end, Zhang Li chose to go to Beijing for medical treatment.

Zhang Xinglong, deputy head of the medical institution service department of Taiyuan Medical Insurance Management Service Center, said that according to the current medical insurance policy of Taiyuan City, only three special groups of medical insurance for medical insurance for medical insurance are limited to three types of special groups: remote resettlement retirees, long -term residential retirees, and residents in different places staff. Zhang Li's "red -headed document" is a material that can prove that the employees of Taiyuan City needed to be resident due to their work.

Zhang Xinglong said that if the patient has begun to seek medical treatment in different places and paid it by himself, it is really critical, and it will be reimbursed at 70%of the scope of the report. If it does not belong to, it will also be reimbursed in accordance with the relevant provisions of the "non -emergency consultation", according to 50%of the scope of the reportable range.

Li Xingxing, Chief of the Medical Service Management and Treatment Security Division of the Taiyuan Medical Security Bureau, said that the online self -service filing of medical insurance for medical insurance is expected to be gradually liberalized this year.

In the "Leadership Message Board" column of the People's Daily Online, the reporter found that many netizens in many places have reported that "medical treatment cannot be settled." Judging from the response of the relevant departments, the reasons are "unstable information platforms" and "system interfaces have problems", but more often cannot confirm the error links, and can only revoke the registration and resume the filing and settlement process.

Han Qinghua, deputy dean of the First Hospital of Shanxi Medical University, said that the above -mentioned blocking point lies in the implementation of medical insurance for medical settlement and class diagnosis and treatment. It still needs to be further improved and coordinated. Han Qinghua suggested that the priority is to let the "rigid" crowds such as "rigid" and other "rigid" people in different places in other places in other places in other places; at the same time, we must reasonably guide the public expectations to meet the necessary needs, but also not waste medical resources to prevent first -tier cities from first -tier cities Medical resources formation is formed.

Since September 2021, the National Medical Insurance Administration has promoted the construction of a unified national medical insurance information platform, requiring localities to carry out conversion and docking one after another. Due to the large differences in medical insurance policies and settlement standards in various coordinated areas, the names and codes of drugs, consumables, and diagnosis and treatment projects are also inconsistent, and they cannot be compatible with the national platform.

Zhu Fengmei believes that the current medical insurance fund is mainly based on cities and counties. In the future, even if there are national platforms as intermediaries, they still need to settle the "point -to -point" settlement between the regions and departments. A coordination mechanism shall be established between medical institutions and medical insurance technology departments.

Explore refined management guarantee for reimbursement in different places

Earlier this year, Chen Sheng, a resident of Shenzhen, was planned to seek medical treatment in the local outpatient clinic during his abdominal discomfort during his business trip in Shijiazhuang, Hebei. He learned about the "National Different Place Medical File" applet through an online inquiry. He submitted a medical treatment for the filing of the medical treatment on January 6. The system prompts that you need to wait for 2 to 3 working days to apply until January 11.

At present, according to relevant national requirements, medical insurance referral personnel need to provide a referral certificate issued by a fixed -point medical institution for referral qualifications. The same disease process has been hospitalized in the same designated medical institution many times. The second and afterwards will not issue a referral certificate. With valid identity documents, original referral transfer certification materials (referral forms), or disease diagnostic certification, the filing procedures. All localities are combined with local actual adjustments.

Wu Ming, a professor at the School of Public Health of Peking University, believes that under the conditions of policy, relevant departments must adhere to the people -oriented, considering the actual difficulties of the diseased group, make the information "run more" and let the people "run less legs". Under the requirements of national policies, local regions should be adapted to local conditions, simplifying the processing process, and effectively solving the blocking points such as "material complexity" and "procedures" for medical insurance applications in different places. "Promoting the direct settlement of basic medical insurance cross -provincial medical treatment expenses is an important measure to improve the medical insurance system and solve the outstanding concerns of the masses." Long Xuewen, the person in charge of the Medical Insurance Administration's Medical Insurance Management Center. Cross -provincial medical settlement for hospitalization and outpatient expenses are "grasped" to reduce the burden of medical treatment for insured personnel.

In order to reduce the masses' "running legs", the State Medical Insurance Bureau has repeatedly simplified the filing materials, standardized the filing process, and optimized the filing channels, and successively launched services such as personal commitment systems and relatives on behalf of relatives. Self -service filing services that have been approved for review, instant opening, and instant enjoyment "to achieve" cross -provincial generalization "for medical online registration.

As of the end of 2021, all the national unified online filing services have been opened, of which 90 coordinated areas of 17 provinces have opened "real -time processing and instant enjoyment" self -service filing services.

Making the masses "can see a doctor" and "optimistic" in different places is the original intention of direct settlement of cross -provinces and other places. However, with the continuous development of the economy and society and the continuous increase in the people's demand for higher levels, the demands for medical treatment in different places for participants have continued to increase.

At present, cross -provincial medical insurance settlement uses the reimbursement principle of "medical land catalog, place of participation in the place of insurance, and medical management". However, in actual reimbursement, different policy treatments are implemented in various overall plans, such as paying lines, ceiling lines, reimbursement ratios, and scope of diseases. The differences in policy are dazzling.

A number of scholars who are concerned about medical insurance reform believe that the deeper reason is that the medical insurance overall level is low and the policy is fragmented.

Some experts analyze that the key problem for outpatient settlement is difficult to promote the management of medical insurance funds, and the differences in various places in this area are huge. "Policy implementation will also have a successful problem. To consider coordinated. For example, if you seek medical treatment in different places, it is not a problem of medical treatment in isolated. You may also consider personal account reform first."

The "hard bone" of the outpatient slow special disease is particularly difficult to settle in different places. According to Long Xuewen, the outpatient clinic has a high frequency, strong timeliness, and relatively high proportion of reimbursement in the outpatient disease. At the same time, there are still large differences in the number of diseased diseases, identification standards, and treatment standards in various outpatient diseases in various places. Essence

However, "no matter how difficult it is to go away." Long Xuewen said that the National Medical Insurance Bureau is starting from a slow special disease involved in the people involved in many people and generally developed. Go to the nation's pilot. As of the end of 2021, 31 provinces nationwide and Xinjiang Production and Construction Corps have launched pilots in overall planning regions as a place of insurance and medical treatment. Direct settlement services for 5 kinds of outpatient treatment of 5 kinds of outpatient clinics.

("Well -off" · China Well -off Exclusive Draft)

This article was published in "Well -off" in late May 2022

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