Medical security is a major institutional arrangement for reducing the burden of medical care, improving the well-being of the people, and maintaining social harmony and stability. The Party Central Committee and the State Council attach great importance to people's health and have established a basic medical security system that covers the entire population. Since the 18th National Congress of the Communist Party of China, the reform of the universal medical security system has continued to advance, and breakthroughs have been made in solving the problems of difficulty and expensive medical treatment. In order to thoroughly implement the decision and deployment of the 19th National Congress of the Communist Party of China on the comprehensive establishment of a medical security system with Chinese characteristics, and strive to solve the problem of unbalanced and insufficient development of medical security, the following opinions are proposed on deepening the reform of the medical security system.
1. General requirements
(1) Guiding ideology. Guided by Xi Jinping ’s socialist ideology with Chinese characteristics in the new era, fully implement the spirit of the 19th National Congress of the Communist Party of China and the Second, Third, and Fourth Plenary Sessions of the 19th National Congress, adhere to the people ’s health as the center, and accelerate the construction of the whole people, urban and rural coordination, powers and responsibilities A clear, moderate, and sustainable multi-level medical security system, through a unified system, improved policies, sound mechanisms, and improved services, to enhance the fairness and coordination of medical security, to play a strategic purchasing role for medical insurance funds, and to promote medical security and medicine Serve for high quality and coordinated development, promote the implementation of the Healthy China strategy, and make the people feel more attained, happy, and safe.
(2) Basic principles. Adhere to the principle of ensuring full coverage and basic protection, basic medical security covers all people in accordance with the law, do what you can and do what you can, and determine the scope and standard of protection by seeking truth from facts. Adhere to a steady and sustainable, prevent risks, scientifically determine the level of funding, balance the payment responsibilities of all parties, strengthen overall coordination and mutual assistance to ensure the sustainability of the fund. Adhere to promote fairness, build a solid bottom line, strengthen institutional fairness, gradually narrow the treatment gap, and strengthen the basic and bottom-line guarantee for the poor. Adhere to governance innovation, improve quality and efficiency, play a decisive role in the market, better play the role of the government, and improve the level of socialization, rule of law, standardization and intelligence of medical insurance governance. Adhere to system integration, coordination and efficiency, enhance the integrity, systematization, and coordination of the reform of medical insurance, medical care, and medical linkage, and ensure that the masses have access to high-quality, efficient, and affordable medical services.
(3) Reform and development goals. By 2025, the medical security system will be more mature and finalized, and it will basically complete important mechanisms such as treatment guarantee, financing operation, medical insurance payment, and fund supervision, as well as reform tasks in key areas such as medical service supply and medical insurance management services. By 2030, fully build a medical security system with basic medical insurance as the main body and medical assistance as the foundation, supplemental medical insurance, commercial health insurance, charitable donations, and mutual medical development. The treatment guarantees fairness and fairness, and the fund operates steadily and sustainably. The management service is optimized and convenient, the modernization level of medical insurance governance has been significantly improved, and the goal of better protecting the sick with medical treatment has been achieved.
Second, improve the fair and appropriate treatment guarantee mechanism
Fair and appropriate treatment guarantee is an inherent requirement for improving people's health and well-being. It is necessary to promote the statutory medical security system to become more mature and complete, improve the medical insurance and relief system for serious diseases, coordinate the planning of high-quality development of various types of medical security, and steadily increase the level of medical security according to the level of economic development and the affordability of funds.
(4) Improve the basic medical insurance system. Adhere to and improve the basic medical insurance system and policy system covering all people and participating in accordance with the law, the classification protection of employees and urban and rural residents, the treatment is linked to payment, and the fund is separately accounted and accounted. Unify the basic medical insurance co-ordination level, medical insurance catalogue, and standardize medical insurance payment policy determination methods. Gradually incorporate outpatient medical expenses into the scope of the basic medical insurance co-ordination fund, reform the personal accounts of employees' basic medical insurance, and establish and improve outpatient outpatient mutual aid guarantee mechanisms.
(5) Implement a medical security treatment list system. Establish and improve the medical security treatment list system, standardize the government ’s decision-making authority, scientifically define the basic system, basic policies, fund payment items and standards, and promote the legalization of medical security system, scientific decision-making, and standardized management. All regions must ensure that the government orders are unblocked, and that no policies that exceed the scope of the list ’s authorization cannot be introduced without approval. Strictly implement the basic payment scope and standards, implement fair and appropriate guarantees, and correct the problems of excessive and insufficient guarantees.
(6) Improve the unified and standardized medical assistance system. Establish a timely and accurate identification mechanism for rescue objects, and scientifically determine the scope of rescue. Fully implement the policy of subsidizing key relief targets to participate in insurance payment, and improve the medical assistance mechanism for key relief targets. Establish a long-term mechanism for preventing and resolving poverty caused by illness and returning to poverty. Strengthen the support function of medical relief support, reduce medical costs through clear diagnosis and treatment plans, standardize referrals and other measures, increase the annual medical relief limit, and reasonably control the proportion of out-of-pocket expenses within the policy range of the poor.
(7) Improve the cost guarantee mechanism for medical treatment of major epidemics. In emergencies, such as emergencies, ensure that medical institutions first treat and charge later. Improve the medical insurance payment policy for medical treatment of major epidemic situations, improve the direct settlement system for medical treatment in other places, and ensure that patients do not affect medical treatment due to cost problems. Explore the establishment of a system for exempting medical expenses for special groups and specific diseases, and specifically exempt restrictive clauses such as medical insurance catalogs, payment limits, and dosage, so as to alleviate the worries of people in difficulty after seeking medical treatment. Coordinate the use of medical security funds and public health service funds, increase the proportion of payments to grassroots medical institutions, and achieve an effective connection between public health services and medical services.
(8) Promote the development of a multi-level medical security system. Strengthen the triple protection functions of basic medical insurance, critical illness insurance and medical assistance, promote the complementary connection of various types of medical insurance, and improve the level of protection for serious and serious diseases and multiple medical needs. Improve and standardize residents' serious illness insurance, employees' large medical expenses subsidies, civil servants' medical subsidies and enterprise supplementary medical insurance. Accelerate the development of commercial health insurance, enrich the supply of health insurance products, make full use of commercial health insurance personal income tax policy, and study to expand the scope of insurance products. Strengthen the supervision of market behavior, highlight the supervision of key links such as health insurance product design, sales, and compensation, and improve the ability of health protection services. Encourage social charitable donations, coordinate and mobilize charity medical assistance, and support the orderly development of mutual medical assistance. Explore the mechanism of drug protection for rare diseases.
3. Sound and sustainable financing operation mechanism
Reasonable financing and stable operation are the basic guarantees for the sustainability of the medical security system. It is necessary to establish a fund-raising mechanism that is compatible with the basic national conditions of the primary stage of socialism, compatible with the affordability of all parties, and coordinated with basic health needs, effectively strengthen fund operation management, strengthen risk early warning, and firmly adhere to the bottom line that no systemic risks occur.
(9) Improve the financing sharing and adjustment mechanism. Employed persons participating in basic medical insurance are paid jointly by employers and individuals. Non-employed persons participating in basic medical insurance are paid by individuals, and the government provides subsidies in accordance with regulations. The payment is linked to the level of economic and social development and the per capita disposable income of residents. Adapt to the development of new business forms, and improve the way in which flexible employment personnel participate in insurance payment. Establish a basic medical insurance benchmark rate system, standardize the payment base policy, reasonably determine the rate, and implement dynamic adjustments. Balance the responsibility for fund-raising and payment by individuals, employers and the government, optimize the structure of personal payment and government subsidies, and study multi-channel financing policies to deal with the burden of aging medical care. Strengthen financial investment in medical assistance and broaden the channels for financing medical assistance.
(10) Consolidate and improve the overall planning level. According to the standards of unified system policies, unified fund collection, unification and management, and management services, comprehensively implement prefecture-level coordination of the basic medical insurance market. Explore and promote the vertical management of medical security departments below the municipal level. Encourage qualified provinces (autonomous regions and municipalities directly under the Central Government) to promote provincial-level overall planning in accordance with the ideas of hierarchical management, shared responsibility, overall planning and adjustment, and budget assessment. Strengthen the management of the medical assistance fund, promote coordination between the level of medical assistance co-ordination and the level of basic medical insurance co-ordination, improve the efficiency of the use of aid funds, and maximize the benefits to the poor.
(11) Strengthen fund budget management and risk early warning. Scientifically compile budgets for income and expenditure of the medical security fund, strengthen budget execution supervision, and fully implement budget performance management. To meet the needs of direct medical settlement in different places, "Internet + medical" and the service model development of medical institutions, explore the pilot of cross-regional fund budget. Strengthen the fund's medium- and long-term actuarial calculations, build a revenue and expenditure balance mechanism, and improve the fund's operational risk assessment and early warning mechanism.
4. Establish an effective medical insurance payment mechanism
Medical insurance payment is a key mechanism to guarantee the public access to quality medical services and improve the efficiency of fund use. It is necessary to focus on clinical needs, reasonable diagnosis and treatment, and appropriate technology, improve the medical insurance catalogue, agreement, and settlement management, implement more efficient medical insurance payment, better protect the rights and interests of insured persons, and enhance the incentive and restrictive effect of medical insurance on the medical service field.
(12) Improve the dynamic adjustment mechanism of the medical insurance catalogue. Based on the fund's affordability, adapting to the basic medical needs of the masses and the advancement of clinical technology, adjusting and optimizing the medical insurance catalogue, including medicines, diagnosis and treatment items and medical consumables with high clinical value and excellent economic evaluation into the scope of medical insurance payment, and standardizing the payment scope of medical service facilities. Improve the dynamic adjustment mechanism of the medical insurance catalogue and improve the medical insurance access negotiation system. Reasonably divide the central and local catalogue adjustment responsibilities and authorities. Each region shall not make its own catalogue or adjust the limited payment range of medical insurance medicines, and gradually realize the basic unification of the national medical insurance medicines. Establish medical insurance drugs, diagnosis and treatment items, medical consumables evaluation rules and indicator systems, and improve the exit mechanism.
(13) Innovative medical insurance agreement management. Improve the management of basic medical insurance agreements, simplify and optimize the procedures for designated applications, professional evaluation, and negotiation of medical institutions. Incorporate eligible medical institutions into the scope of medical insurance agreement management and support the development of new service models such as "Internet + medical". Establish and improve a cross-region medical treatment agreement management mechanism. Formulate assessment methods for designated medical institutions to perform agreements, highlight the assessment of conduct standards, service quality and cost control, and improve the withdrawal mechanism of designated medical institutions.
(14) Continue to promote the reform of payment methods for medical insurance. Improve the total budget for medical insurance funds, improve the consultation and negotiation mechanism between medical insurance agencies and medical institutions, promote the collective consultation of medical institutions, scientifically formulate total budgets, and be linked to the results of medical quality and performance evaluation of agreement performance. Vigorously promote the application of big data, implement a multi-compound medical insurance payment method based on disease-based payment, promote payment based on grouping of disease diagnosis, pay for bedtime for medical rehabilitation, chronic mental illness and other long-term hospitalization, and pay for per capita for special chronic diseases . Explore the separate payment of medical services and medicines. Adapt to the development and innovation of the medical service model, and improve the payment method and settlement management mechanism of the medical insurance fund. Explore the implementation of total payment for the compact medical consortium, strengthen supervision and evaluation, balance retention, reasonable overspending, and areas with conditions can pre-pay medical insurance funds to medical institutions in accordance with the agreement to alleviate the pressure on their funds.
5. Improve the strict and powerful fund supervision mechanism
The medical security fund is the "life-saving money" of the people, and the maintenance of the fund's safety must always be the primary task. We must firmly organize the system cage for the supervision of the medical insurance fund, focus on advancing the reform of the regulatory system, establish and improve the medical security credit management system, severely crack down on fraud and insurance fraud with a zero tolerance attitude, and ensure the safe, efficient and reasonable use of the fund.
(15) Reform and improve the medical insurance fund supervision system. Strengthen the medical insurance fund supervision capacity building, further improve the fund supervision system mechanism, earnestly maintain fund safety, improve fund use efficiency. Strengthen the construction of internal control institutions for medical security public service institutions, and implement the responsibilities of agreement management, cost monitoring, and auditing. Implement cross-departmental coordination supervision, actively introduce third-party supervision forces, and strengthen social supervision.
(16) Improve innovation fund supervision methods. Establish a normal mechanism of supervision and inspection, and implement real-time dynamic intelligent monitoring of big data. Improve the monitoring mechanism for medical services, establish a mandatory information disclosure system, and disclose medical expenses, fee structure and other information to the society according to law and regulations. Implement the performance management of the entire process of fund operation and establish a medical insurance fund performance evaluation system. Improve the social supervision and incentive mechanism for medical security, and improve the reward system for fraud and fraud reporting.
(17) Investigate the responsibility for fraudulent and fraudulent insurance according to law. Formulate and improve relevant laws and regulations for the supervision of medical insurance funds, standardize the regulatory authority, procedures, and punishment standards, etc., and promote the administration by law. Establish a medical security credit system, and implement joint incentives for trustworthiness and joint disciplinary action for dishonesty. Strengthen joint law enforcement by departments, comprehensively use agreements, administration, justice and other means to seriously investigate the liability of fraud and fraud insurance units and individuals, investigate criminal responsibility for suspected crimes according to law, and resolutely combat fraud and fraud, and endanger the rights of insured people.
Sixth, coordinate the promotion of the reform of the medical service supply side
The provision of medical services is related to the realization of people's health and medical security functions. It is necessary to give full play to the leading role of centralized procurement of drugs and medical consumables in deepening the reform of the supply side of medical services, promote the integration of medical insurance, medical and pharmaceutical linkage reform systems, strengthen policy and management coordination, and ensure that the masses receive quality and affordable medical services.
(18) Deepen the reform of the centralized procurement system for drugs and medical consumables. Adhere to the integration of recruitment and procurement, linking volume and price, and fully implement centralized procurement of drugs and medical consumables. Based on medical insurance payment, establish a provincial bidding and procurement platform that integrates bidding, procurement, trading, settlement, and supervision, promote the establishment of a regional and national alliance procurement mechanism, and form a supply security system with full competition, reasonable prices, and orderly regulation . Promote the direct settlement of medical insurance funds and pharmaceutical companies, and improve the coordination mechanism of medical insurance payment standards and centralized purchase prices.
(19) Improve the pricing mechanism of medical services. Establish a market-led price formation mechanism for pharmaceuticals and medical consumables, and establish a national transaction price information sharing mechanism. The prices of treatment medicines and high-value medical consumables are artificially high. Improve the access system for medical service items, speed up the review of new medical service price items, establish a scientific price determination and dynamic adjustment mechanism, and continue to optimize the price structure of medical services. Establish monitoring and disclosure mechanisms for pharmaceutical price information and industrial development indexes, establish drug price and recruitment credit evaluation systems, and improve the price inquiry and interview system.
(20) Enhance access to medical services. Improve the modern medical service system of the division of labor between general practice and specialty medical services, and strengthen the basic general medical services. Strengthen the assessment of regional medical service capabilities, rationally plan the layout of various medical resources, promote the sharing and utilization of resources, accelerate the development of social medical services, and regulate the development of new service models such as "Internet + medical". Improve the management of medical equipment configuration in regional public hospitals, guide the rational configuration, and strictly control the excessive and excessive equipment. Make up for shortcomings in medical services such as nursing, pediatrics, geriatrics, and psychiatry. Do well in accepting and reviewing the consistency evaluation of the quality and efficacy of generic drugs, supporting the development and use of high-quality generic drugs and improving the substitution of generic drugs by improving medical insurance payment standards and drug bidding and procurement mechanisms. Improve the monitoring and early warning and hierarchical response system of shortage medicines.
(21) Promote the improvement of medical service capacity. Regulate the diagnosis and treatment behaviors of medical institutions and medical personnel, implement prescription review system, and promote the rational use of drugs. Strengthen the internal professional and refined management of medical institutions, classify and improve the scientific and reasonable assessment and evaluation system, and link the assessment results with the medical insurance fund payment. Reform the current department and individual accounting methods, improve the incentives compatible, flexible and efficient personnel compensation system that meets the characteristics of the medical industry, and improve the performance assessment and distribution system.
7. Optimizing medical security public management services
Medical security public management services are of vital interest to hundreds of millions of people. It is necessary to improve the management and public service system, provide better and more precise services, improve the level of information services, promote innovation in medical insurance governance, and provide the people with convenient and efficient medical security services.
(22) Optimize public services for medical security. Promote the standardization and standardization of public services for medical security and realize one-stop medical security