It is imperative to improve the system of patients' prevarication caused by prepayment of total medical insurance

At her own expense, she can be hospitalized, and her medical insurance can't live in her home -- the experience of Yu Guiying, a Changchun patient three months ago, has made her family angry Reporters learned that some places implemented the total medical insurance prepayment system, the hospital declined, shuffle the phenomenon of patients occurred more In the game of hospital medical insurance, patients are victims At her own expense, she can be hospitalized Not long ago, Yu Guiying, a 69 year old Changchun citizen, was in a coma Her family called 120 and rushed her to a top three hospital in Changchun "Before CT, emergency doctors have determined that it is cerebral hemorrhage according to symptoms," Yu's daughter said Yu Guiying holds the employee medical insurance card, and his family wants to go through the hospitalization formalities as soon as possible Unexpectedly, the doctor on duty told them that if they wanted to be hospitalized, they would have to pay their own expenses "There are regulations in the hospital, and the provincial and municipal medical insurance patients are not accepted." Yu's daughter said that at that time, her mother was unconscious and in critical condition It was too late to transfer to another hospital, so her family had to pay for hospitalization at their own expense Yu spent more than 20 days in the hospital and 18000 yuan "My mother's bleeding volume was only 9 ml, and she was treated conservatively If it is more than 10 ml, it will cost more " Yu Guiying's daughter said, "it's unreasonable to have to pay for medical insurance." After Yu Guiying was hospitalized, her family found that two other patients in the ward, like her, had medical insurance cards and could not only be hospitalized at their own expense "It's said that medical insurance owes the hospital money, so the hospital doesn't accept medical insurance patients." It is understood that after the prepayment of the total amount of medical insurance in China, hospitals in Beijing, Shanghai, Anhui, Hebei, Shandong and other places have declined and prevaricated patients Total prepayment is a system to control the excessive growth of medical insurance expenses For a long time, the payment method of medical insurance in our country has implemented the project payment system, and the amount of medical insurance spent by hospitals has been reported Under this kind of payment mechanism, the behaviors such as excessive examination, drug abuse and over treatment are more prominent, and the medical expenses are increasing too fast It is in this context that China has begun to implement the total prepayment system of medical insurance fund Generally speaking, the total prepayment is usually based on the annual fund income of the above medical insurance Considering a certain growth rate, the total payment plate of the annual fund of the current medical insurance is determined by "revenue and expenditure", and then the total plate is distributed among all designated hospitals according to a certain proportion The total prepayment effectively prevented the fund risk In the past, if there was a bed in a large hospital, it would induce hospitalization, and even reduce blood sugar It is understood that before the implementation of total prepayment, the hospitalization rate of medical insurance in Changchun in 2011 was as high as 40%, which means that the city's 1 million insured employees lived in the hospital once in three months After the implementation of total prepayment last year, the hospitalization rate of medical insurance in Changchun has been controlled below 10% "Total prepayment controls the growth of medical expenses, reduces the risk of medical insurance fund, but pushes the contradiction to the hospital," said Hua Shucheng, President of the first hospital of Jilin University The first hospital of Jilin University is the largest top three hospital in Jilin Province, with an annual outpatient capacity of 2.7 million and inpatient capacity of 100000 The number of patients is still growing at a rate of more than 10% per year But the increase in the amount of health care funds paid did not keep up with the increase in patients and medical expenses According to Hua Shucheng, in the past three years, the first hospital of Jilin University has been refused to pay 150 million yuan by provincial and municipal level medical insurance institutions for exceeding the medical insurance quota, with an average of 50 million yuan per year "This number was crushed in a small hospital," Hua said The 150 million yuan that was refused to be paid could only be digested by the hospital itself "The hospital pays for the patients." Not long ago, Yu Ying, the chief physician in the emergency department of Peking Union Medical College Hospital, tweeted that a hospital with a colleague from a foreign hospital issued an order to all doctors If there is a surplus in the fixed consumption of medical insurance for patients, the doctor's money will be rewarded, and if it exceeds the consumption, the doctor's money will be deducted It is understood that in order to resolve the risk, many hospitals across the country have taken the way of decomposing the indicators layer by layer to distribute the medical insurance quota to each department The Department then breaks down the indicators to the doctor "The same is true for us If the quota exceeds in the first half of the month, we will not be admitted to the hospital in the second half of the month After that, we have to take the money ourselves." Said the head nurse of a top three hospital in Changchun "It's not surprising that patients are shuffled under the total prepayment system," said Zhu hengpeng, director of the microeconomic Research Office of the Institute of economics, Chinese Academy of social sciences According to Zhu hengpeng's analysis, when the annual total is set, the fewer patients the hospital receives, especially the less heavy patients who spend more, the more savings the hospital generates, and the greater the hospital's revenue Therefore, under the total prepayment system, the hospital has the incentive to shirk the responsibility of patients, especially the important patients According to the relevant person in charge of Changchun social medical insurance bureau, the quota given to the hospital by the medical insurance agency is a comprehensive quota, which does not advocate the hospital to divide the indicators into the following departments; in addition, the medical insurance also has strict regulations, forbidding to shift the responsibility of patients, and if a certain proportion of patients shift the responsibility, the medical insurance fixed-point qualification will be cancelled "It's actually hard to do that," Zhu said In most parts of the country, public hospitals are "the only one", and medical insurance institutions and patients have no choice According to the reporter, Changchun medical insurance plate more than 3 billion yuan, Jilin University under the three top three hospitals each year to nearly half "On the surface, it seems that the medical insurance agency is in charge of the power of designated qualification In fact, due to the social influence and monopoly status of some top three hospitals, even if patients are rejected, it is hard to say whether the medical insurance agency can really cancel its designated qualification and whether the masses will be satisfied after the cancellation of designated qualification." Han Junjiang, a social security expert at Northeast Normal University, said What's more, most hospitals don't blatantly shirk patients The reporter learned in the interview that the majority of hospitals adopt the "declined" way to the medical insurance patients, for example, there is no bed, there is no way for the patients The total amount prepayment system should be improved "The total amount prepayment system should be a good system, but a good system may not achieve good results in inappropriate places," said Liu Guoen, a professor at Guanghua School of management, Peking University The premise of total prepayment should be that the patients and diseases in the hospital are relatively stable, but in fact, due to the mobility of population and policy variability, it is difficult for some large-scale top three hospitals to maintain this stability As a result, the total prepayment may be thick line and not fine enough "There is no problem with the total prepayment from the perspective of policy direction, and the fund expenditure is more stable; however, new things need time to adjust," said the relevant person of Changchun social medical insurance bureau "To some extent, prepayment of the total amount of medical insurance forces hospitals to strengthen management and control medical costs Now many hospitals do not adapt to it and still need time to break in." Hua Shucheng said that the total amount of medical insurance can be prepaid, but it should be more scientific and precise rather than extensive cutting First of all, the medical insurance quota should be different for different hospitals "For a heart patient in five counties outside Changchun City, yuan per capita can come down; for those who come to the top three hospital, they are all serious patients, with more than 10000 yuan for a stent, and more than 20000 yuan for examination and operation Let's see how much we can pay for each one Secondly, for the overspending part of the hospital, the medical insurance agency can strengthen the examination The overspending caused by excessive medical treatment can be deducted in proportion, and the part belonging to proper medical treatment should be paid normally " Hua Shucheng suggested that a negotiation mechanism should be established between medical insurance and hospitals to make the quota of medical insurance more reasonable "China's medical insurance system lacks actuarial science and accurate assessment of risk and sustainability, especially the total prepayment," said Han Junjiang, a social security expert at Northeast Normal University Group payment by disease is considered to be a more scientific way of payment, but it is still difficult to implement at present because it requires a lot of preparation and complex calculation According to Han Junjiang, we can consider such hybrid payment methods as total prepayment, payment by disease type and payment by head However, Hua Shucheng is worried that under the current system and mechanism, it is very difficult to control medical expenses solely by relying on medical insurance and solve the problem of expensive medical treatment "It's hard for hospitals not to exceed the medical insurance quota." He said, "a hospital should pay 25% of its income to its employees, and now the state only gives 10% of it The rest of it should be earned by the hospital itself How can the hospital not pursue profits?"? Under the current income distribution mechanism, the salary of medical staff is still linked to the medical income, and the phenomenon of excessive medical treatment is even more difficult to avoid "