2020 Medical Insurance Statistics Bulletin released!

The 2020 National Medical Security Development Statistical Communiqué (hereinafter referred to as the "Communiqué") was officially announced on June 8

So what kind of response does the "Communiqué" give to the following four general concerns of medical institutions? Here I will discuss with you

30 cities carry out DRG payment pilot

71 cities carry out DIP payment pilot

In June 2017, the General Office of the State Council issued the "Guiding Opinions on Further Deepening the Reform of Basic Medical Insurance Payment Methods" (Guobanfa [2017] No.

The proposed goal is: by 2020, the reform of medical insurance payment methods will cover all medical institutions and medical services, and multiple and compound medical insurance payment methods adapted to different diseases and different service characteristics will be widely implemented nationwide, and the proportion of payment by item will be significantly reduced

In December 2018, the National Medical Insurance Administration issued a document to start reporting by disease diagnosis-related group (DRG) pilot cities.

On October 19, 2020, the National Medical Insurance Administration issued a pilot work plan for the total budget of the regional point method and the payment by disease point (DIP) (Medical Insurance Office [2020] No.

Therefore, the "Communiqué" has clearly and continuously promoted the reform of payment methods.

Medical insurance fund supervision is on the track of legalization

Medical insurance supervision is what everyone feels most in recent years

Since March 2018, the central and national institutional reform plans were passed, and since the establishment of the National Medical Insurance Bureau, the fight against fraudulent insurance has set off a new upsurge

On September 13, 2018, the National Medical Insurance Administration, the National Health Commission, the Ministry of Public Security and the Food and Drug Administration jointly held a video conference on the national special action against fraudulent insurance, which kicked off the first wave led by the National Medical Insurance Bureau since the establishment of the National Medical Insurance Bureau.

On November 28, 2018, the Office of the National Medical Security Administration issued a notice on strengthening the management of medical insurance agreements to ensure the safety of funds (Medical Insurance Office Fa [2018] No.

On February 26, 2019, the National Medical Security Administration issued a notice on the supervision of medical security funds in 2019 (Yibaofa [2019] No.

At the beginning of 2020, the fourth plenary meeting of the Central Commission for Discipline Inspection was held

On June 10, 2020, the National Medical Insurance Administration and the National Health Commission jointly issued a notice on the special management of the standardized use of medical insurance funds by medical insurance designated medical institutions (Medical Insurance Letter [2020] No.

On July 10, 2020, the General Office of the State Council issued the Guiding Opinions on Promoting the Reform of the Medical Security Fund Supervision System (Guobanfa [2020] No.

On December 18, 2020, in response to the induction of hospitalization and false hospitalization in some designated medical institutions in Taihe County, Anhui Province, the Office of the National Medical Security Administration and the General Office of the National Health Commission issued a "look back" on the development of special governance for designated medical institutions Notice (Medical Insurance Office Fa [2020] No.

The "Communiqué" reported this work in the section "Supervision of Medical Security Funds"
.
The “Communiqué” pointed out that in the whole year, medical insurance departments at all levels inspected 627,000 designated medical institutions, and investigated and dealt with 401,000 medical institutions that violated laws, regulations, and contracts.
Among them, 6,008 medical insurance agreements were cancelled, 5457 were administrative penalties, and 286 were transferred to judicial organs; 26,100 people insured who violated laws and regulations were handled, of which 3,162 were suspended for settlement and 2,062 were transferred to judicial organs; a total of 22.
31 billion yuan was recovered in the whole year
.

The National Medical Insurance Bureau organized a total of 61 unannounced inspection teams to conduct on-site inspections in various provinces across the country.
The unannounced inspection teams inspected 91 designated medical institutions (including integrated medical care institutions), 56 medical insurance agencies, and undertook medical insurance for urban and rural residents and major diseases.
Forty commercial insurance companies insured have found a total of 540 million yuan in funds suspected of violating laws and regulations
.

This information tells us that the use of medical insurance funds is still very irregular, and "medical institutions in violation of laws and regulations" account for more than 60%.
It is expected that all insurance-related institutions will use medical insurance funds in compliance with the law
.

This year’s crackdown on fraud and insurance has clearly stated that the focus of the crackdown is three fakes, namely "fake patients", "fake medical conditions" and "fake bills
.
"

Particularly worthy of attention is that on February 19, 2021, the State Council issued the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" and decided to implement it from May 1, 2021
.
This is the legalization of medical insurance fund supervision
.

Is the payment ratio of hospitals at all levels high or low?

The "Communiqué" shows that the hospitalization expenses fund within the scope of the employee medical insurance policy pays 85.
2%
.
The hospitalization expenses fund payment within the policy scope of secondary and lower-level medical institutions was 86.
9% and 88.
7%, respectively, which were 2.
6 and 4.
4 percentage points higher than those of tertiary medical institutions
.

In 2019, the National Medical Insurance Bureau bulletin showed that the hospitalization expense fund within the scope of the employee medical insurance policy paid 85.
8%, the actual hospitalization expense fund paid 75.
6%, and the personal burden was 24.
4%
.
The hospitalization expenses fund payment within the policy scope of secondary and lower-level medical institutions was 87.
2% and 89.
3%, respectively, which were 2.
2 and 4.
3 percentage points higher than those of tertiary medical institutions
.

Based on this, the "Communiqué" concluded that the hospital reimbursement level remained stable
.

The "Communiqué" shows that the hospitalization expense fund within the scope of the residents' medical insurance policy pays 70.
0%, an increase of 1.
2 percentage points over the previous year
.
According to the level of medical institutions, the hospitalization expense fund payment within the policy scope is: 65.
1% for the third level, 73.
0% for the second level, and 79.
8% for the first level and below
.
Among them, 74.
6% of the funds paid within the policy scope of secondary medical institutions and below are 9.
5 percentage points higher than that of tertiary medical institutions
.

To understand this communiqué, one must first understand a concept, that is, "hospital expenses within the scope of the medical insurance policy"
.
To clarify this concept, the premise is to figure out what out-of-pocket expenses are? What is self-care expenses? What is out-of-pocket expenses? The so-called out-of-pocket expenses refer to the medical expenses that are borne by the individual in proportion to the basic medical insurance provisions, the first out-of-pocket expenses of the transferred hospitalization individual, the hospitalization threshold, and the prescribed (special) disease threshold
.

The so-called self-care expenses refer to the basic medical insurance catalog for the category B items, category B drugs, etc.
, which need to be paid by the individual first
.
The so-called out-of-pocket expenses refer to the project expenses that are not included in the basic medical insurance coverage and are entirely borne by the insured person
.
The so-called "hospital expenses within the scope of the medical insurance policy" refers to the expenses that can be included in the scope of the medical insurance policy to be reimbursed in accordance with the prescribed proportion in addition to the above three types of expenses
.

Speaking of this, you may understand why the “hospital expenditure fund payment ratio within the scope of the medical insurance policy” mentioned by the medical insurance is usually not a small gap with the actual reimbursement ratio we feel, mainly because we are in the process of hospitalization.
There are always part of the expenses that are out-of-pocket, self-care expenses, and self-paid expenses, which must be paid or not included in the “medical insurance policy”
.

Another issue worth noting is that the gap in the reimbursement ratio of hospitals at all levels is actually not large.
This shows that the medical insurance policy is actually not effective enough to induce patients to stay at the grassroots level.
(Of course, the main reason why patients choose not to choose to stay at the grassroots level is Determined by the medical service capacity of the grassroots)
.

Judging from the actual situation of the tightening of medical insurance policies and strict management of medical insurance in some places, the actual out-of-pocket ratio of patients may increase significantly
.

Has the hospital's drug use increased or decreased after the purchase?

Everyone knows that the price of medicines has dropped drastically after mass purchase and negotiation
.
However, whether the burden on patients has been reduced or not is directly related to the average cost of medicines in hospitals and outpatients
.
Unfortunately, the "Communiqué" does not contain this type of information
.

However, the "Communiqué" has four sets of information: First, the number of hospitalizations has decreased: 50 million employees were hospitalized, a decrease of 12.
3% from the previous year; the hospitalization rate of residents covered by medical insurance was 15.
1%, a decrease of 1.
5% from the previous year
.

Second, the average hospitalization expenses per time continued to increase
.
In 2020, the average hospitalization cost per medical insurance for employees nationwide was 12,657 yuan, an increase of 6.
5% over the previous year
.
The average hospitalization expenses of urban and rural residents were 7,546 yuan per time, an increase of 7.
1% over the previous year
.

Among them, the average hospitalization expenses in tertiary, secondary, primary and lower medical institutions were 13,533 yuan, 6464 yuan, and 3237 yuan, respectively, an increase of 9.
6%, 6.
4%, and -1.
3% over the previous year
.

Third, after the 2020 National Medical Insurance Drug List was adjusted, a total of 119 new drugs were added to the list, and 29 drugs in the original list were removed from the list
.

Fourth, in 2020, the total amount of online procurement orders nationwide through the provincial centralized drug procurement platform is 931.
2 billion yuan, a decrease of 60.
1 billion yuan from 2019
.

From the side, after the adjustment of the medical insurance catalog, the catalog increased, which greatly restricted the grassroots (first-level and lower medical institutions), and reduced the hospitalization of mild patients (of course, the impact of the epidemic is also on the one hand), so it shows: the number of hospitalizations has decreased and the number of hospitalizations has been reduced.
The situation in which costs increase and the medical insurance catalogue increases, but the total amount of drug purchases declines
.
In the years when the prices of medical services were basically not adjusted, it showed that the use of drugs in second- and third-level hospitals did not significantly decrease
.

Note: The original text has been deleted