Hands-on experience | Information-based assistance to hospital medical insurance cost management of 4 initiatives

Case provided: Chen Junqiang, Liang Bing, First Affiliated Hospital of Guangxi Medical University; Comment Experts: Lin Seoul, Wu Ming, Expert Committee on Capacity Building for Modern Hospital Management; Fu Hongpeng, Director of the Medical Policy Research Office of the Health Development Center of the National Health and Health Commission, has been strengthening the supervision of medical insurance funds as a top priority of medical insurance since its establishment.
health insurance departments around the country have introduced an intelligent audit system for health insurance, focusing on strengthening the supervision of health insurance funds.
in order to meet the requirements of hospital medical insurance management under the new situation, it is necessary to explore the establishment of hospital medical insurance fine management mode, with the help of hospital information system, strengthen the fine management of the whole process of medical services, and continuously improve the patient's medical experience.
this paper, taking a hospital in Guangxi as an example, introduces the practical experience of promoting the fine management of hospital medical insurance through the construction of information systems, and puts forward some suggestions for perfection.
Case study analyzes the development of new needs, explores the new mode of management according to the new situation of medical insurance regulatory requirements and the hospital's own development needs, analyzes the current hospital medical insurance management situation, systematically combs the management system and operation process, finds loopholes and weak links to form a list of improvements;
to change the "blocking"-based administrative "set of way" to achieve the "dredging"-based service-oriented medical insurance fine management model.
the establishment of pre-warning, effective implementation of the rules of the medical insurance information system embedded in the hospital information system, the establishment of pre-warning, effective implementation of the rules of health insurance.
Pre-rule settings: 1. Medical insurance binding of the consultation card, confirmation of medical insurance identity when the patient builds the card for later identification, realization of multi-directional correlation between diagnosis and treatment and settlement; The corresponding medical insurance rules shall be implemented in the catalogue and settlement methods of the diseases, 3. The types of admission shall be distinguished, the types of hospitalization shall be automatically distinguished upon admission, and treatment shall be determined (e.g. common diseases, single diseases, day surgery, etc., different types of admission and different treatment).
Previous reminders include: 1. Medical insurance authentication, setting up hospital information system and medical insurance system authentication to prevent the theft of health insurance funds; 2. self-funded project reminder; 3. Control drug use reminder, for the key control drugs, graded use of drugs, control reminders when the doctor's orders are confirmed, avoid unreasonable use; 4. Special examination special treatment of adaptive diseases reminder, in the "large-scale diagnosis and treatment project" confirmation, to carry out the allergy reminder, avoid unreasonable use; 5. Special examination and treatment approval reminder, according to medical insurance provisions, more than 200 yuan of examination and treatment items need to be approved before they can be included in the overall payment, in the doctor to prescribe tips, and inform patients.
in-process monitoring, strengthening process management based on hospital information systems, intervening in the process of restricted service items and key monitoring projects, and strengthening the process management of medical insurance.
specifically include: 1. Special drug monitoring.
the relevant provisions of medical insurance, the use of state-negotiated drugs, medical insurance approval can be reimbursed, restricted drugs must meet the conditions of use before reimbursement.
2. Repeated medication monitoring.
if the last prescription of the drug is still in the course of treatment, "in-course drug treatment reminder" to avoid repeated administration.
3. Prescription maximum course limit.
the relevant regulations, patients with outpatient chronic disease treatment card, a single course of medication does not exceed 14 days.
4. Independent single-disease settlement system.
automatic warning that you are exceeding the upper limit of the cost of health insurance for the disease.
5. A single hospital stay of more than 90 days for medical restrictions.
medical insurance provisions of the hospital settlement period of 90 days, the system in 85 days began to remind, overdue discharge, refused to issue new medical advice.
6. Violation of the rules settlement restrictions.
if the total number of items denominated by day (day) is greater than the number of days d'odd, settlement is limited.
improve after-the-fact evaluation, regularly evaluate and summarize the use of hospital information system, establish a multi-dimensional comprehensive analysis system, improve after-the-fact evaluation.
specifically include: 1. Health care cost analysis.
Using the target management method, the year-on-year and month-on-month analysis of various types of medical insurance costs, the average cost of each disease area, the cost of large cases, the single-disease data report, etc., and the construction of an independent functional department and clinical department evaluation system.
2. Drug supplies management.
Drug management includes hospital-wide drug ranking, disease area drug ranking and auxiliary drug use evaluation, as well as the use of information systems for auxiliary, antibacterial, anti-tumor, nutritional and other key control drugs for real-time monitoring and post-assessment, timely detection of fluctuations in the use of fluctuations and intervention;
3. Management of medical services.
regularly carry out quality control of outpatient prescriptions, medical insurance medical records and clinical pathways, strengthen the assessment of inpatient days, average costs, drug costs, supplies costs, etc., to prevent unnecessary examination and eliminate overuse of drugs.
4.DRG assessment evaluation.
the DRG management model into the evaluation and assessment system, more scientific assessment of the difficult factors of the work, with the CMI value of each section as the basis for marking, the same medical insurance category and clinical departments of the per capita discharge costs, drug costs, supplies, the hospital-wide drug, disease area drugs ranking, evaluation of the use of auxiliary drugs, etc. , more objective measurement of cost changes.
case effectiveness through the hospital medical insurance fine management, the hospital's various medical insurance management indicators run well, the key quality data of medical insurance in the past years in the formulation of standards smoothly run.
Taking 2019 data as an example, the average cost of hospitalization for local health insurance increased by 3.96%, which did not exceed the total control target, of which the provincial medical insurance balance of more than 5 million yuan; Check more than 16,000 prescriptions for medical insurance, the pass rate is 99.83 percent, spot check in-patient medical records and medical insurance intelligent monitoring platform feedback medical records more than 2400 copies, pass rate 98.02 percent, in the past three years at all levels of medical insurance costs were paid in full, for many years to obtain fixed-point medical institutions medical insurance service agreement annual assessment of "excellent units."
This case takes information as the grasping hand, takes the medical insurance agency assessment rules as the basis, realizes the management closed loop with the help of the hospital information system, and continuously strengthens the supervision and control of the medical quality, medical behavior and medical expenses, promotes the fine management of the medical process, and shows the role of the information technology in the fine management of medical insurance in the hospital.
features are as follows.
is through information technology to better integrate management into the service, changed the past to "block" the main hospital health insurance management concept, began to change to service-oriented management.
Such as through the introduction of PDCA concepts and tools, so that the formulation and implementation of management measures can be continuously improved, improve the full-time, multi-directional fine management level, through the establishment of pre-alert, strengthen process management, as well as multi-dimensional comprehensive analysis based on the after-the-fact evaluation, the formation of a management closed loop, reflecting the "prevention (violations)"-based management concept.
These concepts conform to the dynamic and systematic management of modern hospitals, correct errors in time in the process of system rule-making, achieve the goal of promoting rational drug use, reasonable examination and rational treatment, and provide continuous, dynamic and systematic protection for the fine management of hospital medical insurance.
is to standardize, information technology to promote the hospital medical insurance management and medical service management, drug supplies management and other business coordination, improve the level of fine management of medical insurance.
If through fine data analysis, it provides the basis for clinical diagnosis and treatment decision-making and medical insurance decision-making, establishes an information system platform with electronic medical records as the core, increases the modules of comprehensive medical insurance inquiry, project maintenance, project approval, quality control, integrates statistical analysis caliber, realizes the sharing of medical security information resources, promotes the interconnection of various data in hospitals, attaches importance to data management and data analysis, realizes real-time, multi-dimensional and all-round statistical report analysis, and makes hospital medical insurance management more scientific, systematic and data-based.
From the effect point of view, the fine management mechanism of medical insurance throughout the hospital effectively guides the improvement of the specialized level, plays an effective role in supervising medical behavior and controlling medical expenses, and combines medical insurance management with hospital management and clinical diagnosis and treatment through informationization to form an integrated operation, avoid the two skins of medical insurance, and promote the further improvement of medical insurance and medical management.
Three is to make full use of the relevant data to find problems and short boards, objectively reflect the cost control of each department and doctor, service quality, service difficulty, department management efficiency, etc., not only for hospital decision-making and effective management to provide a basis, but also promote health insurance policies, management concepts and measures in-depth departments and clinical.