What does it affect the direct settlement of water medical insurance funds and enterprises in many places?

The 21st Century Economic Herald reporter Wei Xiao Shenzhen reported that with the continuous reform of the "three medical" linkage reforms of medical, medical insurance, and medicine, the three parties of medical insurance, medical institutions and enterprises are changing.

On August 12, the Ningxia Medical Insurance Bureau issued the "Announcement on the Implementation Plan for the Protection Purchase of Pharmaceutical Medical Consumption and Medical Consumption Alliance for the Ningxia Hui Autonomous Region Medical Institutions (Trial) Opinions". The plan proposes that according to the direct settlement of the medical insurance fund and the enterprise, it is explored to incorporate the pharmaceutical medical consumables in the alliance to purchase the medical insurance directory in a timely manner into the direct settlement range.

In August 10, the Xiamen Medical Insurance Bureau issued the "Notice on Implementing the Procurement Plan for the Procurement Plan for the Procurement of General Medical Consumption of General Medical Consumption Institutions in Xiamen". The notice clearly proposes that in order to ensure the timely settlement of the payment, the selected product payment in the general consumption collection is included in the scope of the medical insurance payment.

In addition, Shandong, Shaanxi, Guizhou, Tianjin, Liaoning, Henan and other provinces have also opened pilots to promote direct settlement of medical insurance funds and enterprises.

It is reported that in the traditional settlement model, the settlement cycle of the hospital and the pharmaceutical enterprise is relatively long. The direct settlement of the medical insurance fund with the enterprise and the efficiency of the repayment can be greatly improved, which can reduce the pressure of corporate capital turnover, and also help enterprises to invest more funds and energy into innovative research and development.

In addition, it can also reduce the interests between enterprises and medical institutions from the settlement session, and promote the solution of rebates and false invoices from the source; on the other hand, it is also conducive to strengthening the medical insurance department's management and control of medical insurance funds, reducing the medical insurance funds, reducing Fund is risk of unreasonable use.

In this regard, many people in the industry believe that the implementation of medical insurance funds and enterprises direct settlement is not a good thing for hospitals, which may mean that the hospital has lost its right to conclude. Because the new settlement method will make the funds no longer pass through the hospital, or it will cause its cash flow to be more tense.

However, Zhao Heng, the founder of the medical strategy consulting company Latitude Health, pointed out in an interview with the 21st Century Business Herald that although it will have a certain impact on the three -way relations of medical insurance, medical institutions and enterprises, it will not be great. After all, the hospital decides what brand and how much. It is impossible for all products to settle directly.

As for whether the direct settlement pilot will be fully promoted in the future, and whether the scope of the settlement will cover the pharmaceutical and medical consumables outside the medical insurance directory, Zhao Heng believes, "In the future, it is necessary to look at the specific pilot situation, and it is not easy to judge now."

Why do pilot medical insurance funds and enterprises settle directly?

On August 12, the Ningxia Medical Insurance Bureau issued the "Announcement on the Implementation Plan for the Protection Purchase of Pharmaceutical Medical Consumption and Medical Consumption Alliance (Trial)> Opinions of the" Ningxia Hui Autonomous Region Medical Institutional Medical Institutional Medical Institutional Medical Institutional Medical Institutional Medical Institutional Medical Institutional Medical Institutions' Medical Institutions ", which strictly settled.

It is pointed out that according to the direct settlement of the medical insurance fund and the enterprise, it explores that the pharmaceutical medical consumables in the alliance purchase of the medical insurance directory will be incorporated into the direct settlement range. For pharmaceuticals and medical consumables outside the medical insurance directory, medical institutions assume the responsibility of the procurement and settlement of the product procurement and settlement of the product, and set the goods in a timely manner according to the procurement contract. The settlement time must not exceed the end of the month after the delivery acceptance.

Earlier on August 10, the Xiamen Medical Insurance Bureau also issued the "Notice on Implementing the Procurement Procurement Procurement Procurement Procurement Procurement Procurement Procurement Procurement Procurement Procurement Procurement Procurement Procurement Procurement Plan for the Implementation of Xiamen Public Medical Institutions." Carry out the procurement and use of concentrated bands of ordinary medical consumables.

The notice requires all public medical institutions in Xiamen to form a general consumption collection alliance to participate in the general consumption collection work. Encourage medical insurance Social Office medical institutions to further improve the management of general consumption and deposit and ensure the timely settlement of freight consumption. It is worth noting that the notice clearly states that in order to ensure the timely settlement of the payment, the selected product payment in the general consumption collection is included in the scope of the medical insurance payment. Generally consuming the payment of related products. The product payment paid by the medical insurance fund is deducted from the medical insurance settlement model of medical institutions.

On June 10, the Shandong Provincial Medical Insurance Bureau said that at present, 8 cities and other 8 cities in Texas have achieved direct settlement of collecting consumables in 221 medical institutions. Essence

In addition, Shaanxi, Guizhou, Tianjin, Liaoning, Henan, etc. have previously opened pilots to promote direct settlement of medical insurance funds and enterprises.

Although the policy of "direct settlement of medical insurance and pharmaceutical companies" has not been mentioned repeatedly in the past two years, relevant departments have been committed to solving the problem of unable to settle on time in the goods of pharmaceuticals; Regarding the guidance of improving the centralized procurement of public hospitals "(Guo Office [2015] No. 7), which clearly proposes to improve the method of medicine for medicine. Clarify the time limit for the settlement of the medicine and strengthen the contract constraint. Encourage pharmaceutical manufacturers and hospitals to settle the payment of drugs directly, settle the delivery costs with the distribution enterprise, and further reduce the intermediate links.

At that time, the state hoped to promote the "direct settlement of hospitals and drug production enterprises", and at this time, they were trying to promote the "direct settlement of medical insurance funds and pharmaceutical companies". cycle.

It is understood that the traditional settlement model is that the medical insurance agency will allocate medical expenses to each designated medical institution every month. Medical institutions will regularly call the drug funds to the enterprise in accordance with the contract with the pharmaceutical enterprise. It is worth noting that in this drug procurement settlement model, the problem of the cost of the hospital's arrears of the cost of pharmaceutical companies exists for a long time. One year. Some people in the industry pointed out that before the collection, the sales of medicine and equipment belonged to the high -margin industry. Even if the hospital's payment was slow, the enterprise could afford it; Model is important to enterprises.

At present, the direct settlement of medical insurance funds and enterprises can skip medical institutions. Medical insurance funds can be settled directly with pharmaceutical enterprises. Medical institutions only need to verify with pharmaceutical enterprises and agencies. This settlement model can not only alleviate the slow return speed, liberate this part of the corporate funds occupied by the hospital, reduce the pressure on corporate funds, and help enterprises invest more funds and energy into innovative research and development.

It is worth noting that the payment party and the supplier directly settle the payment and shorten the payment chain of the medical funds. On the other hand, it is also conducive to strengthening the management and control of the medical insurance department and reducing the risk of unreasonable use of the fund.

With the normalization of the national drug concentrated volume procurement, the right to speak in the medical service market gradually increases, and the continuous optimization and improvement of the internal medical insurance system, the working mode of the payment party and the supplier will be further explored and explorated and and offered. Promotion.

How will it affect the hospital?

As the main body of purchasing, how does the new settlement method affect medical institutions such as hospitals?

Some people in the industry pointed out that it is not a good thing for hospitals. In July 2022, the National Health and Health Commission announced the work opinions of the national second and third -level public hospitals in 2020. A total of 508 three-level public hospitals across the country participated in the assessment. The medical surplus rate was -0.6%, and 43.5%of the hospital's surplus was negative, an increase of 25.89 percentage points from 2019. The new settlement method will make the funds from passing through the hospital. It may be more nervous.

Why is the hospital's funding pressure so much? It is reported that the income of public hospitals is mainly derived from medical service income and government financial subsidies.

Under the epidemic, due to the needs of the epidemic prevention and control, public hospitals increased expenses; while public hospitals spent huge spending, business volume and income shrank sharply. According to the statistical bulletin of the development of my country's health and health undertakings, in 2020, the total number of diagnosis and treatment of national medical and health institutions reached 7.74 billion, a decrease of 980 million people over the previous year, a year -on -year decrease of 11.2%; The annual decrease of 35.83 million people, a year -on -year decrease of 13.5%, and an annual hospital hospitalization rate of 16.3%.

It is worth noting that in fact, in addition to the epidemic, the debt of public hospitals has more complicated factors. In 2016, in order to reduce the burden of medical treatment, the state carried out pilots in medical price reform, implemented a zero -addition policy of drugs, and broke the long -term situation of "supporting medicine with medicine".

After zero drugs, the National Development and Reform Commission issued another announcement to cancel the bonus of medical consumables in 2017. According to statistics from industry institutions, in 2012, public hospital's drug revenue accounted for 44.3%of total income, and medical service income accounted for 25.6%. After the cancellation of drug bonuses and compression circulation channels in 2020, the proportion of drugs dropped to 30.6%. However, the proportion of medical service income increased to only 28.5%, and the operating income of hospitals decreased significantly.

Relevant industry insiders also pointed out that in the zero plus drug consumption and the hospital's financial losses, according to relevant documents of the State Council, the "loss" of public hospitals will be "filled" by three parts, 10%of the financial subsidies, and the hospital digests 10%by itself. Another 80%will be compensated by increasing the price of medical services.

But in fact, the current adjustment of medical service price has not been fully made up for the loss. Therefore, in the case of the short -term adjustment of the price of medical services, the medical institution has to rely on the supply chain of drugs and consumables to get compensation; with the advancement of the new settlement method, the hospital's cash flow may be more tense.

How much will the direct settlement of medical insurance funds and enterprises on the medical institution will have a large impact on medical institutions? In this regard, Zhao Heng pointed out to the 21st Century Business Herald that the impact may not be great. This does not mean that the hospital has no effect, because after all, the hospital decides what brand and amount.

Chen Hao, director of the Drug Policy and Management Research Center of Tongji Medical College of Huazhong University of Science and Technology, also pointed out to the media that under the current transaction structure, the main body of market transactions is medical institutions and drug suppliers, not the medical insurance fund management department and drug supplier; The direct settlement of the Medical Insurance Bureau should be the direct settlement of the Medical Insurance Bureau of the Medical Institution.

In this regard, the 21st Century Business Herald also noticed that the notice of the Xiamen Medical Insurance Bureau also clearly mentioned that it was "medical insurance payment": In order to ensure the timely settlement of the payment, the selected product payment in the general collection of collections was incorporated into the scope of the medical insurance payment. Essence

- END -