Promoting the quality of medical insurance by standardization

Medical insurance management service includes insurance registration, premium collection, information change, medical institution management, medical management and service, fund management and many other links and businesses It provides residents with "record life, management life and service life" services, and is one of the largest social public service management projects of the government Therefore, it is of great significance to carry out the construction of medical insurance standardization for promoting the healthy and sustainable development of medical insurance in China, standardizing the management and service behaviors of social insurance agencies at all levels and medical service behaviors of medical institutions, protecting the social insurance rights and interests of the insured, and improving the social insurance standard system in China Recently, the general office of the State Council issued the main work arrangement for deepening the reform of the medical and health system in 2013, which stressed that the management ability and service level of basic medical insurance should be improved We will make unified plans to promote the standardization of basic medical insurance and the construction of information systems Therefore, the author believes that the construction of medical insurance standardization in China will enter the track of rapid development The late start and slow development with the vigorous promotion of the "financial insurance project", China's medical insurance standardization management has made great progress However, due to the late start and slow development, there are some gaps between China's medical insurance standardization work and the overall requirements of the development of medical insurance and the growing service demand of the insured population, which need to be paid attention to 1 There is a lack of systematic planning at the national level First, there is a lack of systematicness in system construction Due to the lack of top-level design and unified standards at the national level and the lack of unified basis in practical work, the allocation of public service resources of medical insurance is restricted to a certain extent, which affects the capacity and quality of public service Secondly, there is a lack of overall planning in institutional management The current policy is not unified, the management mode is diversified, and the overall planning level is not high, which leads to difficulties in the promotion of standardized technology in the field of medical insurance public services However, the current local standards provide important basic information and preconditions for the system design and planning at the national level 2 The standardization of medical insurance is not clear The current social insurance standard system in China is mainly based on the service industry standard framework, but because the medical insurance service is more complex than the ordinary service, involving the relationship between the operator, the insured and the medical service provider, many works in the medical insurance cannot be carried out in accordance with the service industry standard framework, and some services in the medical insurance process are not It can find accurate positioning in the service industry framework 3 Lack of understanding of the importance of standardization At present, the construction of China's medical insurance system focuses on legislation, policy improvement, mechanism construction, operation management, specific measures, etc., while the standardization construction has not been paid enough attention Although the "social insurance law" has been promulgated and implemented, there is still a lack of relevant laws and regulations in the field of medical insurance Relevant departments and local governments do not know enough about the technical support role of standardization, and the degree of attention needs to be improved 4 The research and formulation of standards lack of relevant supporting medical insurance service standards and standard governance system, which is the technical support system of administrative legislation, administrative supervision and affairs office The establishment of this system is determined by the particularity that medical insurance must provide compensation to the insured in the form of medical services, and the formulation of standards must be guaranteed by corresponding organizations From the perspective of Germany's social medical insurance governance system, in addition to the administrative governance system and administrative governance system, the norms and standards system of medical insurance services and the judicial supervision system are also important parts of the medical insurance governance system However, in the current medical insurance governance system of our country, the norms and standards of medical insurance service are not formulated by special institutions, but are undertaken by administrative organs and agencies respectively This kind of organizational setup destroys the governance structure system of normal organizations, increases the workload of administrative agencies and agencies, and reduces the transparency and fairness of management In addition, at present, the medical insurance standard researchers in China are mostly engaged in administrative management and standardization research, lack of professional training of medical insurance and standardization knowledge, and lack of standardization professionals There is no special fund to support the development of medical insurance standards, and there is no reliable financing mechanism to guarantee the sustainability of the standard research 5 The research of medical insurance standardization theory is relatively backward in China The research work is not perfect, which restricts the scientific development of medical insurance standard The main performance is: the research content lacks depth, mostly focuses on the medical related document standards, such as medical service project coding standard, ICD10 standard, medical record standard, etc., and lacks the systematic framework of medical insurance standardization construction; the research of relevant local standards mainly stops publishing the standardization work in the form of work summary, and lacks the implementation of standardization construction In depth evaluation of the effect 6 The formulation and promotion of local standards are not in place The formulation of local standards for medical insurance lacks the overall arrangement and planning at the national level, and there is no effective mechanism to promote the formulation and promotion of local standards In most areas, the formulation of medical insurance standards only aims at some specific problems, and the awareness and strength of the formulation of local standards are weak At the same time, there is a lack of effective feedback mechanism In the process of standard promotion, the implementation of the work is not in place, it is just a formality, there is no effective incentive mechanism to make the agency actively learn and apply the standard, and the overall implementation progress of standardization is not ideal On the one hand, we should strengthen the construction of medical insurance standard system Establish the framework of medical insurance standard system from the national level, clarify all kinds of standard levels, determine the responsibilities of medical insurance departments at all levels, systematically improve relevant policies and regulations of medical insurance, and ensure the policy environment for the implementation of medical insurance standards; on the other hand, strengthen the overall management of medical insurance agencies It is suggested that the formulation, implementation and evaluation of the standards should be implemented on the basis of the overall planning at the prefecture (city) level, the implementation and supervision of the standards of the medical insurance institutions at the prefecture (city) level should be strengthened, the evaluation of the work of the agencies should be carried out with the prefecture (city) level as the unit, the relevant laws and regulations of the overall planning at the prefecture (city) level should be implemented, and the overall planning should be encouraged 2 Define the orientation of standardization work The standardization of medical insurance is not only based on the standard framework of traditional service industry, but also based on the particularity and complexity of "intangible products provided by medical insurance service" On the basis of the general standardization work guide of service industry, the specific principles and methods of medical insurance standardization should be clarified 3 We should pay more attention to the standardization First, we should strengthen the promotion of standards and further strengthen the awareness of medical insurance standardization Carry out systematic publicity and education by holding mobilization meetings, training courses, etc.; strengthen the promotion of standards in daily work by issuing learning manual of medical insurance management service standards and preparing standard briefing, etc.; use the publicity role of mass media to enhance the awareness of service objects on public service standardization, and understand their complaints on standardization work Please accept their reasonable suggestions and process supervision on standardization Second, the standardization work should be transformed into "normal management", and the specialized local standardization organizations such as "standardization office" should be implemented Their management and coordination functions should be fully exerted, so that the standardization and revision work can start from the actual work of the business departments, serve each link of the handling work, and further explore the transformation from administrative management to standardized management 4 Strengthen the guarantee and support related to the standardization First, make clear the system planning and organizational functions of the medical insurance standardization, establish the cooperation mechanism of relevant departments, and jointly complete the formulation, implementation, evaluation and feedback of the medical insurance standards Secondly, we should improve the funding guarantee of medical insurance standardization First, establish a subsidy mechanism for the preparation and revision of standards, and grant subsidies for the preparation and revision of major standards through scientific research projects; second, actively coordinate various resources, and establish a diversified fund-raising mechanism guided by government investment and supplemented by social investment; and finally, strengthen the construction of medical insurance standardized talent team Human resources and social security departments at all levels have Plan to recruit senior talents of standardization and other related specialties, increase talent reserve, and train standardized talents in the medical insurance system by establishing standardized expert database and improving standardized training system 5 Strengthen the theoretical research of standardization, on the one hand, focus on the basic theoretical research of standardization; on the other hand, explore the application practice research of standardization, strengthen the tracking research of pilot demonstration, information feedback and applicability evaluation 6 The deployment of standardization pilot and promotion of standardization work should adhere to the basic principles of "bottom-up, step-by-step" and "typical way leading, step-by-step promotion" The construction of grass-roots platform can play a role of typical demonstration to drive and improve the overall level of China's medical insurance standardization work We will guide local governments to actively participate in the research, formulation and pilot work of medical insurance standards, increase the experience summary and promotion after the pilot work, and expand the scale of the pilot work in a timely manner Related links: current situation of medical insurance standardization construction in China At the national level, the Ministry of human resources and social security, the National Standardization Management Committee and other departments attach great importance to the planning, formulation and application of medical insurance standards: since 2009, the following work has been carried out: the National Technical Committee for social insurance standardization has been established; the social insurance standard system and the construction plan for human resources and social security standardization (201 1-2015); proposed four standards that should be focused on in the field of medical insurance - social insurance terminology medical insurance part, national medical insurance service project code, basic medical insurance drug code, medical insurance treatment enjoying audit business standard, and determined the undertaking unit and schedule According to the unified planning of the Ministry of human resources and social security, local standards for medical insurance management services have been formulated and implemented Shanghai has established a standard system of medical insurance management services, including service standards and institutional standards, and formulated a standard system of medical insurance services in Shanghai, which is composed of general basic standards, measurement standards and provision standards There are 267 standards in the medical insurance service standard system, including 61 national standards, 7 industrial standards, and 199 local standards and enterprise standards Based on the establishment and improvement of ISO9000 standard system, Jiangsu price province starts with the promotion and maintenance of medical insurance standard from the perspective of service quality Based on the principle of seeking truth from facts, the province defines document preparation and process design as the process of standardization and continuous improvement; based on the guideline of standard work, the province comprehensively combs the relevant documents issued by the state, province and city, and sorts out the existing management documents, rules and regulations, work specifications and operation processes; with the provincial medical insurance center as the core, the province radiates Take ISO9000 certification system to medical insurance agencies of cities, counties and streets