On December 6, the Hunan Provincial Medical Insurance Bureau issued the "Hunan Provincial Medical Security Credit Management Measures (Draft for Comments)", which included medical personnel and pharmacists in the "personal credit subjects", and the relevant personnel of designated medical institutions included in the negative list of medical insurance credit management can suspend or terminate their medical insurance payment qualifications and fee settlement in accordance with the regulations.
Previously, Hebei, Guangxi, Fujian and other places have also issued relevant regulations, making it clear that the object of medical insurance supervision is no longer limited to medical institutions, and will actively explore effective ways to extend medical insurance supervision to medical service behaviors, and the division of responsibilities is more specific and clear.
The medical insurance credit list is divided into "positive and negative", and punishment and reward are at the same time.
According to the above-mentioned draft for comments, Hunan will establish a medical insurance credit commitment system, and the relevant personnel of designated medical institutions shall make and fulfill credit commitments in accordance with the medical insurance service agreement to provide reasonable and necessary medical services for the insured;At the same time, they should also actively cooperate with the medical security department to provide relevant credit information, and be responsible for the authenticity and completeness of the information provided. In this system design, both rewards and punishments are equally important. For doctors included in the negative list for credit management, the medical insurance payment qualifications and fee settlement of the relevant responsible personnel may be suspended or terminated in accordance with regulations;Doctors who are included in the positive list of credit management will receive corresponding rewards, such as providing medical insurance credit payment.
In the "Hebei Provincial Medical Security Physician Assessment Measures (Solicitation of Opinions)" issued by the Hebei Medical Insurance Bureau on November 2, it is also clearly stated that medical insurance physicians will be comprehensively assessed through daily management, intelligent monitoring, special inspections, complaints and reports verification, etc., including the use of centralized procurement of drug consumables, reasonable diagnosis and treatment, etc. And implement a point deduction system, where a cumulative deduction of 21 points or more will be suspended for 1-5 years, depending on the severity of the circumstances.
In the view of many industry insiders, the refinement of the supervision of medical actors is the direction of medical insurance supervision. As early as October 8 this year, the National Health Insurance Administration issued the "Guiding Opinions on Strengthening the Management of Medical Insurance Payment Qualifications of Relevant Personnel in Designated Medical Institutions (Draft for Comments)", which emphasized that the supervision of medical insurance costs will be strengthened, and the supervision objects will be extended from medical institutions to medical personnel.
Judging from the previous cases of cracking down on medical insurance fraud, there are two weak links in the supervision of medical insurance, one is weak pre-supervision, and the second is that the supervision of individuals is not in place. On the one hand, it can standardize the diagnosis and treatment behavior of individual doctors, reduce excessive diagnosis and treatment, excessive medication, and improve the consciousness of medical staff's moral behavior, on the other hand, it can also strengthen the link of pre-supervision, so that the problem can be curbed in time before it expands, and the efficiency of supervision can be improved. Lawyer Daniel Zhang, founder of Medical Law Hui, who has long been concerned about the supervision of medical insurance, told the people's ** health client reporter that in order to ensure the good operation of this set of mechanisms, it is necessary to emphasize both rewards and punishments in order to fully mobilize the enthusiasm of medical institutions and medical personnel.
In the process of policy implementation, it is necessary to pay attention to the grasp of "degree".
However, during the interview, a number of clinicians also expressed concerns to reporters about the flexibility in the implementation of the policy.
Medical insurance has great guiding significance for medical behavior, and the responsibility for the standardized use of medical insurance is directly specific to doctors. However, in the actual landing process, we cannot ignore the particularity and complexity of the medical behavior itself, for example, for patients who come to remote areas for medical treatment, it may be a more economical and humane choice to prescribe a full 2 cycles of chronic disease drugs at a time, in this case, the definition criteria for excessive medication should be further refined. A number of clinicians from tertiary hospitals mentioned that how to determine the rational use ratio of centralized collection of drugs should also be further considered, so as not to dampen the enthusiasm of clinicians to explore clinical diversification.
In this regard, lawyer Daniel Zhang pointed out that in the process of extending medical insurance supervision to medical service behavior, special attention should be paid to the grasp of "degree", and in the process of policy formulation and landing, it is necessary to fully investigate and refine the identification of various assessment standards to avoid interfering with doctors' professional medical judgment.
In addition, in the course of our research, we found that medical staff in public hospitals and medical institutions do not have a high level of understanding of medical insurance regulatory policies. Daniel Zhang suggested that the medical insurance department and medical institutions should further strengthen the training and publicity of medical insurance ** regulatory laws and regulations and related policies, especially for clinicians, medical personnel's correct understanding of medical insurance ** regulatory laws and regulations and related policies, and understanding and support of medical insurance supervision activities, which is not only the premise for the smooth progress of medical insurance supervision, but also the basis for medical personnel to standardize diagnosis and treatment behavior.