On December 18th, the “2018 Future Medical 100†forum hosted by the Arterial Network, Eggshell Research Institute, and Future Medical College, Junlian Capital, BV Baidu Ventures, KPMG China, and Health Zhigu was held in Beijing R&F Renaissance The grand opening of the hotel. This is the annual brand event hosted by Arterial Network. The innovative medical institutions and guests actively cooperated with more than 2,500 guests.
The conference set up a parallel forum on innovative health insurance, and discussed the hot issues of medical insurance and business protection with a number of heavy industry insiders.
Within the system, with the establishment of the National Medical Insurance Bureau, the management of medical insurance funds entered the era of super medical insurance, making full use of the "money bag" payment adjustment function, and reforming the medical payment method, which has far-reaching impact on the industry.
Outside the system, with a number of favorable policies, increased residents' awareness of insurance, and increased spending power, commercial health insurance has become the fastest growing segment of the insurance industry in the past few years.
At the same time, it should also be noted that the reform of medical payment methods is very difficult, and the system construction has a long way to go; health insurance has the status of low penetration rate, small market size and unbalanced product structure; service capacity is also lacking, which is reflected in the weak control of medical expenses. And the lack of health management services.
Opportunities and challenges coexist. In the future, what is the core point of medical insurance change, and how does commercial insurance break through barriers? The guests gave their thoughts and answers.
The participating guests and topics of the sub-forum are:
Hao Chunpeng, Deputy Secretary General of China Medical Insurance Research Association
Theme: Improve the construction of medical insurance system and promote innovation in health industry
Liu Chang, Director of Asia Pacific, Ai Kang
China's commercial health insurance innovation trends and challenges
Wu Yiyu, deputy general manager of Zhongan Technology
Using financial technology to create HMO with Chinese characteristics
Shi Mengmeng, General Manager of Meide Medical China
Theme: PBM localization, helping health insurance development
Elephant Insurance CEO Yang Wei
Topic: Customized development of insurance products based on big data analysis and artificial intelligence
Chairman of Jindou Data, Huoli Long
Topic: Technology-driven changes in medical payments
This article is organized according to the guests, there are deletions, the following is the text.
Hao Chunpeng, Deputy Secretary General of China Medical Insurance Research Association
Theme: Improve the construction of medical insurance system and promote innovation in health industry
Hao Chunpeng, Deputy Secretary General of China Medical Insurance Research Association
Let us first review the development process of the medical insurance system reform. In 1994, the two rivers piloted. In 1998, the "Decision on Establishing the Basic Medical Insurance System for Urban Employees" was issued. In 1999, the two reforms were carried out simultaneously. In 2000, the new rural cooperative medical care was launched. By the establishment of the National Health Insurance Bureau in 2018, the governance system has been strengthened, and a new chapter has been opened for the development of the medical insurance system.
After more than 20 years of development, China has established a multi-level medical security system with basic medical insurance for employees and basic medical insurance for urban and rural residents. In addition to civil service subsidies, enterprise supplementary insurance, special populations, Commercial insurance, etc.
From the perspective of the scope of protection, the total number of people participating in basic medical insurance and the new rural cooperative medical insurance is 1.35 billion, which is the largest medical insurance network in the world. The scale of insurance funds is also growing. In 2017, the annual income of urban basic medical insurance funds was 1793.2 billion yuan, and the expenditure was 144.2 billion yuan.
The level of treatment has been continuously improved. Among them, the per capita salary of employees in medical insurance is 5,240 yuan, the proportion of hospitalization expenses fund is 81.7%, the per capita subsidy of residents is 605 yuan, the financial assistance at all levels is 439 yuan, and the policy scope of medical institutions at the second level and below. The proportion of the internal hospitalization fund payment reached 71.0%.
The report of the 19th National Congress of the Communist Party of China also put forward some new requirements for the entire social security system including medical insurance, emphasizing the need to adhere to the protection and improvement of people's livelihood in development, the bottom line, the woven network, the construction mechanism, and the comprehensive construction. Covering all-level, urban-rural integration, clear rights and responsibilities, ensuring a moderate and sustainable multi-level social security system, comprehensively implementing the national insurance plan, improving the unified urban and rural residents' basic medical insurance system and the major illness insurance system, and establishing a national unified social insurance public Service Platform.
Related to medicines, the adjustment of payment scope supports the innovation of the pharmaceutical industry, including the focus of drug list adjustment in 2017, supporting new drugs with significant technological innovation value, and supporting evidence-based medical evidence to prove that drugs with clear therapeutic effects and advantages. There were 44 kinds of drugs involved in drug negotiations, and 36 kinds of negotiations were successful. In the 2018 cancer drug insurance negotiations, 18 drugs were involved, and 17 kinds of negotiations were successful. In the future, this mechanism will continue to establish a dynamic adjustment mechanism for drug catalogs.
Future commercial insurance will also play an important role, such as multi-level system planning to help commercial insurance achieve positioning, the scope and level of protection gradually increase to stimulate commercial insurance innovation, boost medical supply side reform to improve commercial insurance voice, and play "strategic purchase" The mechanism provides demonstrations for commercial insurance, procurement of commercial insurance services to promote the integration of medical insurance and business insurance, and the application of new technologies to promote the development of commercial insurance technology.
Of course, there are still some shortcomings and obstacles, such as insufficient supply of medical services, structural imbalances, long-term in the seller's market, and insufficient buyer's voice. Insufficient medical service regulations, unnecessary medical expenditures have occupied the development space of new drugs and new technologies. The positioning of commercial insurance is still not clear enough, and the direction of industrial development is not clear, and it has not yet been able to supplement the basic medical insurance.
The future direction is to promote the reform of the supply side of the medical service market, give play to the decisive role of the market in the allocation of medical resources, and play a "strategic purchase" mechanism to promote the complementarity and linkage of the multi-level medical security system.
Liu Chang, Director of Asia Pacific, Ai Kang
Theme: China's commercial health insurance innovation trends and challenges
Liu Chang, Director of Asia Pacific, Ai Kang
The sharing is divided into five parts, including the challenges of the current Asia-Pacific medical service and security system, the status quo and opportunities of China's commercial health insurance development, China's commercial health insurance innovation highlights and model examples, the future development trend and challenges of commercial health insurance, Ai Shekang Introduced with the Fudan Health Finance Research Office.
First of all, the challenge is that the population is aging, the aging of the population will bring different medical service needs from the past, which needs to be adjusted on the supply side; the second is the pressure that the medical system has already faced, overcrowding, structural imbalance, and Satisfy demand; third, the level of funding is still relatively low, health insurance is lower, and there is a very large room for improvement.
Next is the status quo of China's commercial health insurance. We first noticed the policy. There are many policies in this area, including the “Opinions on Accelerating the Business Health Insuranceâ€. This year, the National Medical Insurance Bureau and the National Banking Insurance Regulatory Commission were formally established, and multi-level medical care was established. The security system forms a new structure, fragmenting the effective medical security policy, and inefficiently connecting all levels of the medical insurance system.
Commercial health insurance is actually a hub, and it is closely related to all parties in the industry. For example, for social security, it can give full play to the advantages of commercial health insurance to meet people's multi-level and diversified health protection needs; for medical institutions, to pay The role of improving medical experience, building a harmonious relationship between doctors and patients, and improving the accessibility of medical services; for pharmaceutical companies, bringing in the sales of special drugs, patient management and other needs (effect tracking, patient behavior). Of course, the support of insurance technology companies is also needed.
In recent years, commercial health insurance has continued to climb the total national health expenditure, which was 1.86% in 2015, 2.2% in 2016, and jumped to 2.51% in 2017. From the perspective of insurance, it is mainly disease insurance and medical insurance. The development of nursing insurance is very slow, and there is almost no disability insurance. This also reflects the imbalance of health insurance structure.
Here are some highlights and models of China's commercial health insurance innovation. The first is the cooperation between commercial health insurance and basic medical insurance: including basic medical insurance. In 2017, commercial insurance institutions added 26.538 billion yuan of trust funds, covering 489 million yuan. People, a total of 46,901,700 people paid compensation and compensation of 63.11 billion yuan; contracted for major illness insurance, as of the end of 2017, the major illness insurance has achieved full coverage, commercial insurance institutions in 31 provinces and autonomous regions to undertake major illness insurance business, covering The population is 1.08 billion, and the premium scale is 39.6 billion yuan. Information interconnection and intercommunication. At present, China has established a policy registration management information platform and a commercial health insurance information platform.
At the same time, various insurance companies have developed health insurance business systems based on the health insurance business situation, and the informationization construction has achieved remarkable results.
More non-traditional participants enter the commercial health insurance field, bringing a variety of “new†insurance institutions, Internet insurance companies, insurance brokers, insurance technology companies, technology companies BAT, big data companies, drug distribution platforms, medical services Group, etc.; also has a variety of upstream and downstream cooperation institutions, insurance brokerage companies, insurance technology companies, medical big data companies, patient communities and other third-party platforms, drug distribution platforms, medical service groups, pharmaceutical companies, health management companies, technology Company, etc.
Of course, the new model also includes data connection and control fees. Currently, insurance institutions or third-party medical finance technology platforms try to use the financial technology technologies such as big data, artificial intelligence, cloud computing, and blockchain to build a network of commercial insurance hospitals. Through the efficient connection and effective coordination with the participants of the medical health service, we will continue to create a new ecosystem that is accurate, reasonable and convenient.
As well as realizing the insurance business operation automation and online medical insurance business insurance settlement payment, optimizing the medical experience, this can reduce the insurance company's operational burden. Overcoming the shortcomings of traditional post-nuomasurance claims, participation, participation in the design and operation of different disease diagnosis and treatment methods in advance, and achieving effective control fees.
There are also innovative types of insurance that can serve more people and develop products in an innovative way for people who already have patients, those who need treatment, and those who are at risk. The operation mechanism is also brand new. It is aimed at the needs of chronic disease management, encourages its own health management, cross-border integration of health management services and insurance protection, and “pays by efficacy†to alleviate economic worries and enhance patient confidence. Insured patients provide insurance benefits, combined with early screening, accurate insurance, according to gender, age, living environment, eating habits, physical discomfort, etc., the major illness is generally guaranteed within a certain period of time, while the single product Health insurance is a lifelong system.
From the perspective of the future development trend of commercial health insurance, there are four directions. One is to break away from the traditional business model, break away from the traditional life insurance and production line business development model, and form an ecological linkage with medical related parties. The second is to assist the government to promote medical reform. Actively cooperate with various government departments, participate in the reform of the medical system, better realize medical insurance control fees, and optimize the medical experience.
The third is to open up the upstream and downstream information data, and open up links with data, systems and customers of hospitals, pharmaceutical companies, health service organizations, etc., and develop synergistically. In order to improve customer experience, ease the relationship between doctors and patients, optimize insurance actuarial and product design, control medical costs, improve medical quality; Fourth, actively promote cooperation with high-tech, combined with innovative high-tech, actively promote chronic disease management, early screening Technology such as investigation and intelligent auxiliary diagnosis realizes leap-forward development.
Innovation also faces challenges, such as convergence and integration with social security, scale and risk pool building, real-time data links, and true cost-effectiveness.
Wu Yiyu, deputy general manager of Zhongan Technology
Theme: Using financial technology to create HMO with Chinese characteristics
Wu Yiyu, deputy general manager of Zhongan Technology
First introduce what is HMO, the full name is HealthMaintenance Organization (HMO). The core feature is the demand for control fees. The insurance institutions and medical institutions are one. There is a strict level-by-level referral system: general-specialty, special attention to prevention, and perfect health management closed-loop. There are three elements: comprehensive insurance, a prepayment system, and a medical organization that guarantees high quality services.
The US HMO is relatively mature and develops year by year. In 1988, the traditional model insurance was 73%, HMO was 27%, and by 2007 HMO had accounted for 92%.
Why do we say that HMO is imperative in China? In the past, domestic medical insurance coverage was extensive, public medical institutions developed independently, medical institutions were in an absolutely strong position in the medical and health market, and China’s medical environment was targeted at maximizing revenue. Medical resources are uneven, the level of primary medical care is poor, the number of general practitioners is small, the informationization of medical institutions is weak, and there are information islands in medical data.
As a result of the pressure on domestic medical insurance funds, the state encourages the development of commercial insurance, the government is increasingly focusing on the overall improvement of medical quality and health management, the development of Internet hospitals and health management industry has accumulated a large number of professionals, the rise of financial technology companies, become medical and business A natural bridge that is connected.
As of May 2018, there were 12,145 public hospitals and 19,461 private hospitals. The high acceptance of commercial hospitals by private hospitals provided accelerated conditions for the deep integration of medical and commercial insurance.
After so many years of practice, gradually accumulate the foundation of managed care, data access + standardization, and accelerate the deep integration of medical and commercial insurance. It is reflected in the opening of medical information channels for medical institutions and commercial insurance, breaking information barriers; providing medical information structure and standardization services to improve data governance capabilities; reducing costs and efficiency for commercial insurance operations, improving insurance customer experience; and accelerating medical + insurance + Deep integration of technology and other aspects.
Breaking the island of medical data information is a necessary task at present, which is good for hospitals, insurance companies, and patients. The hospital can attract high-quality commercial insurance users, optimize hospital patient structure, reduce window operation pressure, improve hospital operation efficiency, improve hospital social influence and patient satisfaction; commercial insurance companies improve the accuracy of claims information through direct connection of medical data lines Reduce the cost of information collection (artificial electronic, adjustment), speed up the account to improve customer satisfaction; users do not need to collect and organize paper materials, reduce reimbursement troubles, quickly obtain claims, reduce patient economic pressure, avoid invoice loss and omission To reduce patient losses.
Data interconnection and interoperability are also the functions of Zhongan Technology. We cover all aspects of health care data required by business insurance. Now Zhong'an Technology has covered more than 700 hospitals nationwide; regional data platform (connecting 3 district health platforms); physical examination platform covers more than 90% of private stereo inspection institutions, and public hospitals are connected in physical examination.
Zhongan Technology is based on medical data insurance for big data analysis, perfecting the patient's medical insurance + comprehensive insurance protection, while reducing doctor-patient disputes. Data collection, modeling analysis, product design, and fee model support for insurance companies; insurance companies design insurance products for hospitals, underwriting insurance, security customer service, insurance claims; hospitals conduct demand research, review historical data, evaluate cost requirements, Carry out quantity estimation, etc.
Zhongan Technology also developed a data visualization management system for medical institutions. It can see the real-time monitoring of the hospital's overall traffic in the hospital cockpit, and analyze the emergency and hospitalization information, including patient information, bed use, income, cost, service quality, drug supervision, High-risk and major diseases, infectious diseases, etc., to achieve refined management of the hospital; department management personnel see the resource load status of the undergraduate room from the medical data big screen, the real-time status of the operation screen visualizes the progress of the operation, let the patients and their families know the whole surgical procedure . Then there is a reasonable control system to identify abuse and fraud, a risk control engine to visualize risk warnings, and AI+ medical assistance for clinical diagnosis and decision making and research.
The closed loop of managed medical ecology has been initially established. We believe that the spring of managed medical care is coming soon. One is to effectively alleviate the pressure of medical insurance and gradually realize medical control fees; the other is to guide high-net-worth customers and optimize the structure of patients in medical institutions; It is a managed medical system that integrates prevention, treatment, rehabilitation and commercial insurance payment; the fourth is to achieve a win-win mechanism for patients, hospitals, commercial insurance and society.
This also depends on the further development of the environment, such as further clarifying the policy of sharing health care data sharing, encouraging innovation in data and technology companies, enhancing supply-side strength, and greatly enhancing the contribution of social security systems.
Shi Mengmeng, General Manager of Meide Medical China
Theme: PBM localization, helping health insurance development
Shi Mengmeng, General Manager of Meide Medical China
First, what is PBM, Pharmacy Benefit Management (PBM), which is a management coordination agency between insurance institutions, hospitals, pharmacies and pharmaceutical companies. Can improve clinical efficacy, optimize drug costs, and improve operational efficiency.
PBM's core responsibilities are very high. For example, PBM creates a retail pharmacy network. Members of insurance companies can enjoy discounts in PBM's designated pharmacies. For chronically ill patients, PBM provides mail-order pharmacy services because the prescription is relatively stable. Consulting can provide prescription drug delivery services; PBM uses a group of independent doctors, pharmacists and other clinical experts to develop a list of approved reimbursement drugs to encourage the use of clinically necessary, reasonable and cost-effective drugs.
And PBM integrates all purchasing power, negotiates substantial discounts with drug manufacturers, thereby reducing the cost of benefits for customers and consumers; or timely follow-up and updates with FDA drug information to provide users with the latest drug advice; PBM uses a variety of tools, Such as drug use assessment, disease management, PA audit, ladder treatment, standardizing doctors' treatment behavior, encourage the adoption of the most cost-effective drug treatment program.
PBM provides insurance companies with consulting services for insurance product design; when a doctor prescribes a prescription, the PBM engine recommends the safest, most effective, and most economical medication plan to the doctor through a unified electronic prescription platform; through the system settings and engine of the insurance product. And the necessary labor to achieve insurance direct compensation.
Virtue is the largest independent PBM company in the United States and the only global PBM company. Founded in 1989 by professionals such as pharmacists, Meide is the largest unlisted drug benefit management company in the United States that does not sell any drugs. Eight of the top ten insurance companies in the United States choose Virtue as their drug welfare manager. Mead Medical Services serves more than 50 million insurance members, manages $18 billion in drug costs, and handles more than 4 claims reviewed annually. Billion single.
In 2011, Virtue and Medicine began preparations for entering the Chinese market. After that, it took more than three years for Virtue doctors to set up a database involving diagnosis, prescriptions, and more than 170,000 drug data, and explored with insurance companies, medical institutions, and dental organizations to conduct pilot projects for PBM business.
At present, there are four main parts of Virtue's domestic business: hospital reasonable compliance medical solutions, dental welfare solutions, localized PBM, and Chinese one-stop service for overseas drug benefits. The localized PBM services mainly include modules such as cost control, quality and safety supervision, and report analysis.
The following is a case in which the US and German doctors explored the FWA audit. The purpose of the warning is to identify the amount of prescribed drug that exceeds the medical insurance regulations or exceed the reasonable use range. According to the situation, it is judged as a suspicious document that the medical insurance policy is illegal or fraudulent, wasted or abused. Judgment by drug name, specification, number of prescriptions, usage and dosage.
The other is a pre-authorization review for the detailed review process for applying for high prices, high toxic side effects, controlled drugs or medical devices; the core of the review is the diagnosis of the patient, past medication history, physical condition, test report and other details. , whether to support the judgment of the application, and give specific guidance or reasons for rejection.
After several years of exploration, the current virtues have become the pioneer of the localized PBM business. From pharmacy network management, drug catalog development and pre-authorization review, drug rationality, FWA, insurance rules review, to help health management.
Elephant Insurance CEO Yang Wei
Topic: Customized development of insurance products based on big data analysis and artificial intelligence
Elephant Insurance CEO Yang Wei
Let's take a brief look at Elephant Insurance. The positioning of the Elephant Insurance Platform is an Internet insurance advisory platform driven by big data and artificial intelligence. The vision of the Elephant Insurance is that every sense of security is within reach. Elephant Insurance provides "insurance technology services" to China's middle class users with a family-based insurance coverage solution.
Elephant Insurance has a unique big data model and rapid technical skills. The insurance team is from the traditional insurance companies in the industry. It has rich experience in insurance products, and deepens the research and operation capabilities of the Internet business and the innovation ability of insurance business.
Then we review the development of Internet insurance and the chaos of the industry: it began to sprout in 1997. At the end of the year, China’s first professional Chinese website for the insurance market and the internal information management needs of insurance companies, the Internet Insurance Company Information Network was born; Entering the comprehensive development period, during this period, various insurance enterprise trust official websites, insurance supermarkets, portal websites, offline business platforms, third-party e-commerce platforms and other methods to carry out Internet business, and gradually explore the Internet business management model.
2015-2017 is a full-blown period. The mobile exhibition industry has set off a new round of Internet insurance. It will carry out a full range of insurance business around mobile terminals, including product sales, premium payment, mobile marketing and customer maintenance services.
At this time, there are also some chaos: financial products are promised by high commissions, and they are separated from the original insurance attributes. Internet insurance is basically equivalent to agent tools. A large number of offline to online guidance, stealing, and volume change, the overall market chaos .
After entering a period of stable development in 2018, after a series of strong supervision and policy adjustments, the chaos of the Internet insurance industry was well controlled, and some of the industrial models operated by extensive offline gradually moved toward refined and planned operations. Enterprises that have settled down and truly do industry model application of compliance innovation can achieve greater space development.
The problem to be solved is the chaotic agent platform policy, as well as the platform cashback that exacerbates bad competition, and the discount activity makes the industry become a vicious circle of subsidies.
Internet health insurance ushered in a new "outbreak window", the Internet's largest life insurance, the second largest insurance annuity insurance fell year-on-year, while health insurance premiums increased by 85.9%.
Then introduce some practices of elephant insurance. First, elephant has 2C product system, facing C-end product matrix: three-dimensional product matrix, fully serving online users, efficient and personalized access guarantee; integrating all online insurance stocks: Objective and neutral way to provide users with product optimization, comparison, customized services; content-driven: insurance services such as insurance education / evaluation / strategy, to build user reputation and stickiness.
In addition to the technology-enabled insurance service, AI & Big Data Lab was established in 2016, and it has formed a series of application products in the fields of actuarial model optimization, big data risk control, intelligent customer service, intelligent underwriting, precision marketing, etc., forming a unique insurance technology capability. And product system.
And the "health health + insurance service" big health ecology, based on medical big data, deep integration with medical health scenes, customized development of health insurance products, medical insurance products and services for specific people, specific scenarios, deepen the health of large health Industry chain.
We have also seen some new opportunities, such as insurance-enabled hospitals and pharmacies. In recent years, with the penetration of Internet technology in the insurance industry, health insurance has developed rapidly. In the first nine months of 2018, health insurance premiums exceeded 400 billion. A large number of new business scenarios and opportunities combined with insurance and medicine, through health integration ecology, medical care, health management, and pension as a service provider.
The overall growth rate of non-prescription drugs slowed down. Based on the value-added service platform of the pharmaceutical retail scene, insurance services were introduced through joint scene innovation to bring incremental business to pharmacies.
Big data technology plus new retail empowerment industry to enhance business ceilings. The elephant intelligent pharmacy management platform integrates the drug operation, sales, storage, statistical analysis and marketing management integrated operation and management platform, through the big data operation precision marketing, increase user stickiness, increase customer unit price, and deeply explore the business value of the big health field.
Elephant Insurance also works with insurance companies to innovate products. For example, the first insurance for hepatitis C drugs - liver recovery; the first diabetes intensive treatment insurance - diabetes intensive treatment allowance insurance; drug overdue insurance, drug reimbursement insurance, medication safety insurance.
Chairman of Jindou Data, Huoli Long
Topic: Technology-driven changes in medical payments
Chairman of Jindou Data, Huoli Long
Talking about the change of medical payment driven by technology, we first analyze from the macro environment to see the evolution trend of medical payment policy and social environment: from multi-pay to three-guarantee, from post-payment to pre-payment, from basic protection to Consumer medical care.
The first problem to be solved in the medical payment industry chain is where the money comes from – national medical insurance, patient pays, commercial insurance, and then how the money is paid – paying by project or packaged, indirectly involving the payment of – - Whether there is fraud, medical quality and safety.
The change in payment methods has instigated the reform of the medical and health system. In the past, the hospital was a service provider, and its core position was relatively strong. Medical insurance was the main payer; in the future, the Health and Family Planning Committee set the standard of diagnosis and treatment, and the drug manufacturers became the product suppliers, and the patients became users.
The change in payment method has a significant impact on hospital management. Before 2014, it was a post-payment system. The treatment process was: patient visit - admission - doctor diagnosis - medical record filing - discharge payment / commercial insurance reimbursement; 2014-2020 is Prepayment system, the treatment process is: patient visit - admission - doctor diagnosis / medical record group - discharge payment / commercial insurance reimbursement. With the reform of payment methods, the medical treatment process will also change accordingly.
The impact of changes in payment methods on hospital management is also reflected in income. In the past, it was “medical supplementationâ€, insufficient compensation for medical services, government pricing for medical service charges, and the use of pharmaceutical medical supplies. There is no clear application management mechanism, which will lead to hospital induced consumption, large prescriptions, abuse of high-value consumables, over-examination and inspection. So that the hospital will have high income.
After the reform of the payment method, the payment compensation pricing is based on the DRG cost. The diagnosis and treatment specification is based on the clinical path. The hospital must carry out refined cost accounting and refined performance appraisal, so as to improve efficiency and increase competitiveness and profit.
The change in payment methods also has an impact on the management of the Health Care Committee, such as the standard writing of the medical record, the disease classification code, the surgical operation code, and the medical terminology.
Correspondingly, for the payer itself, the reform of payment methods also brings changes, requiring macro-micro combination, medical service behavior and cost, medical quality and medical expenses, online services and offline services. Medical insurance and commercial insurance are combined.
With the establishment of the National Health Insurance Bureau, entering the era of big medical insurance, there are opportunities and challenges in the era of big medical insurance. The policy is to restore the four rights, the National Medical Insurance Bureau becomes the largest medical payment party; the opportunity is that the functions of medical insurance become comprehensive and diverse, and the universal medical insurance system can not only spread the risk of disease, but also affect the allocation of health resources and improve the performance of health systems. To promote the health of the whole people; the challenge is how to deal with the fraud, waste, unreasonable expenditure and inefficient expenditure of the medical insurance fund.
There are also many cases in the reform of medical payment methods. Here we look at the exploration of Sanming: Since 2012, Sanming City has implemented a comprehensive reform of “three medical linkages†between medicine, medical insurance and medical care. First of all, we have straightened out the leadership system, centralized management of medical, medical insurance, medicine and other fields, breaking the situation of long-term co-management, and truly achieving the linkage of three medical systems from the institutional mechanism.
“Three Guarantees†(urban workers' medical insurance, urban residents' medical insurance, and new rural cooperative medical care) are united to form a medical insurance bureau to strengthen the supervision function of medical insurance. Sanming became the first demonstration city for comprehensive reform of public hospitals in the country. It was reported at the 21st meeting of the Central Deep Reform Group and was fully affirmed by the 27th and 33rd meetings of the Central Deep Reform Group.
The reform of medical payment method is an advanced process. The first stage is to pay according to the project; the second and third stages are gradually explored to implement different forms of package charges, such as paying by head, paying by inpatient unit, paying by hospital bed, from simple Single disease
Payment becomes a complex single-patient payment; in the fifth stage, it really becomes a payment by DRG.
The problems that need to be solved in the reform of medical payment methods are the standardization of medical data, the localization of payment standards, the controllability of medical quality, the standardization of clinical management, and the rationalization of medical behavior. The core responsibility of DRG is medical coding standardization and medical service standardization.
DRG itself is a standardized tool. In the same DRG group, the clinical process is similar (disease diagnosis, diagnosis process, individual characteristics), resource consumption is similar, and the same group of cases has good comparability; in different DRG groups, each group has different weights. , "risk adjustment", a reasonable comparison between different groups of cases. To sum it up, the essence of “homogeneity†+ “risk adjustment†makes DRG “scientific†and “fairâ€.
The business focus of Jindou Data is also on the reform of medical payment methods. As one of the earliest teams in China to focus on medical big data technology and industry experience, Jindou has ten years of medical data analysis and disease coding application and conversion product development. Experience, eight years of experience in product research and development in the field of medical insurance control fees and payment methods reform. A total of more than 120 data analysis models and related algorithms have been accumulated, and some core technologies have been patented.
The Golden Bean Code Conversion System unifies the medical code and docks the national standard. This system is the only product on the market that can realize 12-version disease diagnosis/operation coding one-key conversion. And the DRG performance evaluation system, a scientific and comprehensive performance evaluation system, can standardize the indicators evaluated by the case (DRG group), fully consider the clinical practice and resource consumption, and achieve horizontal comparison between different cases, so as to reasonably evaluate the medical output. .
It can also present performance analysis results to the hospital leadership in the form of a chart, providing management decision-making basis intuitively and clearly; the analysis dimension mainly covers MDC (major diagnostic classification), department and doctor's comprehensive performance index, medical service ability, medical service efficiency, and number of cases. , medical insurance profit and surgical grading, etc.; from the medical professional and specialist construction aspects of the evaluation unit performance operation evaluation, and make management decisions and resource allocation.
Jindou also has an independent surgical grading system that can reflect clinical practice and evaluate the surgical capabilities of various medical institutions, clinical departments, and doctors. Surgery can be divided into one to four levels, the proportion of hospitals in the third and fourth grades, representing the strength of surgical ability.
It also includes the DRG cost analysis system, which together with the National Health and Family Planning Commission Health Development Research Center holds a national training course on medical service price and cost monitoring, covering 1300+ medical institutions nationwide and 70% tertiary hospitals. Jindou is also exploring the application of commercial insurance big data, such as underwriting, security, claims, and secondary sales.
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