Health Insurance Bureau: Keep an eye on hospital health insurance loopholes, flight inspection has been targeted

Following a special notice issued by the National Health Insurance Administration of the United Nations Health Care Commission in June this year, the two ministries deployed two rounds of nationwide flight inspections to standardize the use of medical insurance funds by designated medical institutions throughout the country. At present, the first round of flight inspection focus on the operators and contractors of medical insurance business, completed at the end of October. On November 15th, the State Health Insurance Administration held the second batch of fund supervision flight inspection shandong launch meeting in Jinan in 2020.The goal is clear: the focus is on large medical institutions, will be a nationwide inspection of some medical institutions of the use of funds violations. Jinan and Tai'an, Shandong Province, have been identified as the cities under inspection. Previously, a number of medical institutions in Beijing have been drawn to carry out flight inspections on outstanding issues such as hospital health insurance management loopholes, illegal acts and fraudulent insurance. Soon, a game of chess will be rolled out across the country.

three key points in the direction ofComprehensive Shandong, Beijing and other places have started the information transmitted by the flight inspection, the second round of medical insurance fund inspection is mainly reflected in three aspects:The inspection team will focus on checking whether large hospitals have established an internal management system for the use of medical security funds, set up specialized agencies or personnel to manage the use of medical security funds, keep financial accounts, accounting vouchers, prescriptions, medical records, medical examination records, expense details, records of access to medicines and medical supplies, etc. in accordance with the provisions, and whether to refuse medical security and other administrative departments to supervise and inspect or provide false information.Second, the general violation of the law. According to the actual situation of the hospital, the general violations of the hospital are cleared: such as decomposition of hospitalization, hospitalization, violation of the norms of diagnosis and treatment overdiagnosis, over-examination, decomposition of prescriptions, over-prescription, repeated prescription of drugs and other medical services;Third, the problem of serious fraud and insurance. Such as inducing, assisting others to seek medical treatment under false pretentious names, purchasing drugs, providing false supporting materials, colluding with others to falsely open expense documents, falsifying, altering, concealing, altering, destroying medical documents, medical certificates, accounting vouchers, electronic information and other relevant materials, fictitious medical services, etc.Unlike the first round of flight inspection, this time the focus will further guide medical institutions at all levels to standardize medical service behavior and comprehensively promote the safe, efficient and rational use of medical insurance funds. However, it is important to note that the practice of pharmaceutical prescriptions and the value chain extended by prescriptions will gradually be regulated in flight tests, which in turn will change the choice of drug use and market layout of hospital channels.

hospital channel metamorphosisThe window period left for pharmaceutical companies is very shortTake Beijing as an example, the State Health Insurance Administration from the city's use of health insurance funds in the first 30 hospitals on-site to carry out flight inspection, respectively, Beijing Hospital, Peking University Third Hospital, Xuanwu Hospital, Tiantan Hospital, Water Pool Hospital, Beijing Chinese Medicine Hospital, Civil Aviation General Hospital, Fangshan First Hospital and Century Temple Hospital.In fact, the State Health Insurance Administration recently in the 13th National People's Congress of the third session of the 13th recommendation No. 1319, also highlighted that as of the end of December 2019, the country's total inspection of fixed-point medical institutions (including village health rooms) 815,000 (99% of all fixed-point institutions), to deal with violations of the law 264,000 institutions, 336,000 individuals. At the same time, in 2019, the State Health Insurance Administration sent 69 flight inspection teams to 30 provinces across the country to carry out on-site inspections and interviews with 177 designated medical institutions, and found that the suspected illegal funds amounted to 2.232 billion yuan. To be sure, health-care funds will be used more transparently.The precise use of health insurance funds is also changing the pattern of hospital channels. According to Minenet data, in the first half of 2020 China's three major terminals in the six major markets drug sales reached 783.9 billion yuan, down 10.7% YoY. In terms of sales distribution of the three terminals that realize drug sales, public hospital terminals have the largest market share, accounting for 63.2% in the first half of 2020. Despite this, hospital terminals have experienced negative growth for the first time in recent years, with sales of 495.2 billion yuan in the first half of 2020, down 13.4% year-on-year, although there are epidemic factors, but the urban and county-level public hospital market is indeed changing.After combing, the reporter found that in 37 more than 1 billion local health insurance products, 14 were included in the national key monitoring directory - including thymus quinteptides, ICTs II. If the total regional health insurance budget and the point method are combined to achieve a multi-composite payment method based on the value of the disease, this "one-click" will be the largest number of hospital drug use convention circled out.Expert analysis, health insurance payment method reform not only directly affects hospital profitability, but also will also have an impact on doctors' drug habits. At present, left to pharmaceutical companies to change business ideas and product structure, to adapt to the requirements of the new market in the future window period has been very short, how to do a good job in the hospital market into a new test question. (Medical Economics)