Smart medical insurance is one of the five development goals proposed in the "14th Five-Year Plan" for universal medical security, and it is one of the main focuses to improve the modernization of medical insurance governance capabilities. At the same time, smart medical insurance is also very much in line with the general trend of the world's scientific and technological revolution and new technological and industrial organization changes. At present, new technological innovations and industrial organization innovations represented by big data, artificial intelligence, platform economy, and "Internet +" are constantly advancing. **Attach great importance to the new technological revolution with big data as the main feature. The report of the 20th National Congress of the Communist Party of China proposed to accelerate the development of the digital economy and promote the deep integration of the digital economy and the real economy. **The General Secretary has emphasized the important role of big data in safeguarding and improving people's livelihood on many occasions. In 2021, the general secretary pointed out in the 28th collective learning speech of the 19th Political Bureau that it is necessary to make full use of the Internet, big data, cloud computing and other information technology innovation service models to further promote the digital transformation of social security management. This puts forward new requirements for the operation and governance capacity of the medical security system. It can be said that the construction of smart medical insurance is a major strategic measure to respond to this requirement.
Since the establishment of the National Health Insurance Administration, it has built a unified national medical insurance information platform with informatization and standardization as the starting point, laying a good foundation for the construction of smart medical insurance. In terms of handling, management, supervision, public services and other aspects, we have made full use of big data and information systems to expand and enrich the content of smart medical insurance, improve the operational efficiency of the medical insurance system, and greatly improve the accessibility and convenience of medical security for the insured people. The author intends to summarize and analyze the construction of smart medical insurance in China around the policy connotation, practical development and challenges faced by smart medical insurance, in order to provide reference for smart medical insurance to play a greater role in the modernization of medical insurance governance capabilities.
The policy connotation of smart medical insurance
As one of the five development goals of the "14th Five-Year Plan" for universal medical security, the policy connotation of smart medical insurance has a process of continuous development, deepening and improvement in practice, which is both related to and different from the concepts of informatization, big data, and "Internet +". From the perspective of the modernization of medical insurance governance capabilities, smart medical insurance should be a governance concept, which is the application of modern information technology, mobile technology and Internet thinking in the construction of medical security system, management, fee payment, public services and many other links.
First of all, smart medical insurance, as a concept of modern governance, runs through all aspects of medical security operation. Smart medical insurance should not be independent of specific medical insurance affairs, but run through the specific operation of various medical insurance, and play an active role in all aspects such as insurance payment, fee payment, drug procurement, management, and supervision, so as to improve the operation efficiency of medical insurance as a whole. From this perspective, smart medical insurance is a catalyst for the efficiency improvement of various operating elements of medical insurance. In the process of insurance payment, through big data and intelligent data analysis, the redundant links of insurance payment are reduced and the accuracy of insurance payment is improved; In the process of fee payment and drug procurement, the goal of transparency, comparability and standardization is achieved through the information communication of designated medical institutions and production enterprises, so as to improve the efficiency of fee payment and procurement; In the first supervision link, precise supervision is achieved through big data models, and at the same time, the organic connection of before, during and after supervision is realized through big data early warning.
Secondly, the main way for smart medical insurance to improve the efficiency of public services is technology substitution and interconnection. Technology substitution refers to the use of new information technology and mobile technology to replace the work that was previously done manually to achieve intelligence; Interconnection refers to the timely or even instant exchange of information between various participants. The work of medical insurance involves a number of participants, including individual insureds, institutionalized medical service providers, and a large number of drugs and equipment production and marketing enterprises. Through the substitution of information technology, the original manual work can be completed by a large number of information technology, reducing the dependence on labor; The interconnection of information reduces many unnecessary obstacles and improves operational efficiency. A common problem faced by modern public services is "Baumol's cost disease", that is, in the field of public services, due to the difficulty of achieving technology substitution, labor costs will grow rapidly, resulting in cost inflation. However, the development of modern information technology, especially "Internet +", has become an important breakthrough in solving the "Baumol's cost disease". In this regard, smart medical insurance has grasped the trend of modern technological progress and is an important part of realizing the modernization of medical insurance governance capabilities.
Thirdly, smart medical insurance is both related and different from the concepts of medical insurance big data, informatization, and the Internet. Big data, informatization and the Internet are the material foundation of smart medical insurance and the prerequisite for the realization of smart medical insurance, but they are by no means smart medical insurance itself. Smart medical insurance is built on the basis of big data, informatization and the Internet, but it is also a governance concept and "total factor productivity". Of course, the development of smart medical insurance is inseparable from big data, informatization and the Internet. From the perspective of the concept of smart medical insurance, the emergence of a unified national medical insurance information platform and a large medical insurance database is a prerequisite for the emergence of smart medical insurance; Smart medical insurance is a comprehensive application of big data, informatization and the Internet in all aspects of medical insurance operation.
Progress in the practice of smart medical insurance
Since the establishment of the National Health Insurance Administration, many major measures have been taken in the construction of smart medical insurance, the intelligent level of the medical insurance system has been continuously improved, and the modernization level of medical insurance governance has been significantly improved.
The first is to establish a unified national medical insurance information platformIt has realized the standardization of medical insurance information, accumulated a large amount of medical insurance data, and consolidated the material foundation for the construction of smart medical insurance. The national unified medical insurance information platform has realized the national unification of the medical insurance information system, accessing about 400,000 medical institutions and 400,000 designated retail pharmacies, covering 13400 million insured people. In the process of building the medical insurance information platform, a unified medical insurance information business code has been realized. On the basis of a unified information platform and a unified information business code, a large amount of standardized data has been accumulated to form a large database of medical insurance. This is the prerequisite and material basis for smart medical insurance to function.
The second is to comprehensively improve the quality of insurance. In terms of insurance payment, with the launch of the national unified medical insurance information platform, the problem of duplicate insurance between regions and systems has been effectively managed through data comparison and other means, and the quality of insurance has been improved. At the same time, with the improvement of data application capabilities, precise positioning and accurate insurance participation are also gradually realized. Not only that, on the basis of informatization, the accessibility of insurance payment has been greatly improved, and online and face-to-face insurance payment have been realized in most areas.
The third is to help the reform of medical insurance payment methods. The Three-Year Action Plan for DRG DIP Payment Methods is a major measure for the reform of the medical insurance operating mechanism. Whether it is DRG or DIP payment, it relies on standardized medical treatment and cost data. In this regard, with the improvement of the medical insurance information system, especially the extensive use of tools such as the medical insurance settlement list, it has strongly promoted the reform of DRG DIP payment methods. The reform of DRG DIP payment method has further promoted the standardization of medical record management and information and data in medical institutions, which in turn has further improved the operational efficiency of medical insurance.
Fourth, promote the coordinated development and governance of the "three medicines". The unification of the medical insurance information system and information business coding also provides an important entry point for the medical service supply side to solve the problems of "information islands". With the completion of the medical insurance information system and access to the designated medical institutions, the information standardization between medical institutions has been improved to a certain extent, which is conducive to improving the informatization level of medical institutions. Some medical institutions have taken the opportunity of accessing the medical insurance information platform to improve their own information systems and promote the construction of smart hospitals.
Fifth, improve the ability to supervise the use of medical insurance. The construction of smart medical insurance is mainly reflected in the formation and improvement of the intelligent supervision system in the supervision of the use of medical insurance. Supervising and managing the use of medical insurance is the last "fence" to improve the efficiency of medical insurance. * The use of supervision has high professional requirements, involves many subjects, and the illegal means are highly concealed and complex, and it is difficult to adapt to the high-intensity regulatory requirements of the previous manual supervision method. With the construction of smart medical insurance, the intelligent supervision system is also constantly improving, using big data to establish different types of supervision models and depict the behavioral characteristics of various fraud and insurance fraud, so as to achieve accurate and efficient supervision. The early warning mechanism established through big data analysis in daily supervision is an organic combination of before, during and after supervision.
Sixth, help the service sinkIn a relatively short period of time, the full coverage of medical insurance services has been realized, which has greatly improved the accessibility of medical insurance public services to the masses. The medical insurance service is a "window unit", directly facing the insured people, and the service needs to sink quickly. In this regard, if you rely on manual labor alone, it is costly and inefficient. However, with the support of smart medical insurance, the service can quickly sink in a short period of time and directly reach the insured individuals. At present, there are not only national-level medical insurance service platforms, but also local medical insurance departments have basically opened local medical insurance service platforms to directly connect with the insured people. Not only that, the electronic voucher of medical insurance is also constantly enriching the application scenarios, not only realizing the full use of appointments, sign-in, diagnosis and treatment, report inquiry, pharmacy pick-up, etc., but also providing first-class consultation, one-click prescription renewal, follow-up dispensing, online settlement, delivery of medicines, etc., to better meet the needs of the masses to enjoy medical insurance services in seeing a doctor and buying medicines.
Challenges in the construction of smart medical insurance
As one of the main goals of medical security development during the 14th Five-Year Plan period, smart medical insurance should be said to have made great progress and achieved major breakthroughs in many fields, especially the construction of smart medical insurance infrastructure. However, from the perspective of long-term development, there is still a long way to go to modernize the medical insurance governance capacity, and there are many challenges.
First of all, in terms of big data applications and use,At present, the system and mechanism have not been completely straightened out, and the big data of medical insurance has not been fully utilized. The premise and material basis of smart medical insurance is big data; But there is still a process from big data to smart medical insurance. At present, the amount of medical insurance data and the daily increment are very large, and there is already a foundation for realizing smart medical insurance, but there are still many obstacles in the use of data. The first is the issue of the confirmation of data as an element. The ownership, right to use, and management of medical insurance data need to be clearly defined in the process of data use, and the responsibilities, rights, and interests in the process of data use should be clearly demarcated. The second is the relationship between data use and data security. Medical insurance data involves personal privacy at the individual level, and national and social security issues at the macro level. How to maximize the use of data under the premise of ensuring security needs to be solved from the institutional point of view. Third, the standardization of data needs to be further standardized and improved.
Second, there are still certain obstacles to the interconnection of medical insurance information. The comprehensive completion of the national unified medical insurance information platform and the national unification of medical insurance business coding have laid an important foundation for the realization of the interconnection and interoperability of medical insurance information. However, from the perspective of the construction requirements of smart medical insurance, there are still some problems that need to be solved. First, there are still blockages in the circulation and use of data within the medical insurance information system, and some areas are unable to obtain the required return data. Second, the connection between the medical insurance information system and the medical institution information system is not very smooth. At present, the information system of China's medical institutions is basically built by each institution, and the system architecture and basic coding are different, and it is difficult to stably connect between medical institutions and between medical institutions and medical insurance information systems. Although the designated medical institutions have realized the interconnection of information to a certain extent through access to the medical insurance information system, the information is still relatively fragmented on the whole. Third, there is still a "silo phenomenon" between the medical insurance information system and the information system of other relevant departments. The medical insurance system has a very close relationship with other departments in terms of insurance payment, payment management, and supervision, and needs close cooperation with the financial department, health department, civil affairs department, rural revitalization department, drug regulatory department, public security department, discipline inspection and supervision department, etc. However, at present, it seems that the medical insurance departments in many regions and the information systems between these departments are not horizontally interconnected, and they are still "islands" with each other.
Thirdly, the application capability of smart medical insurance needs to be improved, and the application scenarios still need to be expanded. Judging from the "five medical insurance" construction goals proposed in the "14th Five-Year Plan" for universal medical security, smart medical insurance has the highest requirements for talents, and it is very much in need of more professional talent team support. In recent years, China's medical insurance team has made great progress in governance ability, and its business ability has been significantly improved, but smart medical insurance not only involves medical insurance business content, but also has high requirements for professional skills such as information technology and statistical technology, as well as legal, economic, commercial, social and other content, which puts forward new requirements for the medical insurance work team, especially the construction of the smart medical insurance work team. In addition, the current application scenarios of smart medical insurance are not rich enough. At present, although intelligence has played a certain role in supervision, the application scenarios in payment, drug procurement, and monitoring need to be further enriched.
Prospects for the development of smart medical insurance in 2024 and in the coming period
The modernization of governance capacity is an intrinsic requirement for the high-quality development of the medical security system, and smart medical insurance is one of the main means to realize the modernization of governance capacity. As a governance concept, smart medical insurance should run through all aspects of medical insurance work to improve the overall efficiency of the operation of the medical insurance system. China's smart medical insurance construction has made great progress, the national unified medical insurance information platform and unified medical insurance business code has accumulated a large amount of medical insurance data, smart medical insurance has played an important role in insurance payment, payment method reform, promoting the coordinated development and governance of the "three medicines", the use of supervision, medical insurance public services, etc.
As a new thing, smart medical insurance can play more and more functions in improving the modernization of medical insurance governance capabilities, and there will be more and more application scenarios. To comprehensively promote the construction of smart medical insurance, it is necessary to realize the transformation from the "artificial era" to the "intelligent era" in terms of governance concept, and integrate the concept of smart medical insurance into the whole process of medical insurance operation.
In terms of specific focus points,One isIt is necessary to focus on the mining and use of big data, coordinate security and development, and improve the system and mechanism for the use of big data in medical insurance as soon as possible. The second isIn order to truly get through the blocking points of information interconnection, the first thing is to open up the internal blocking points of the medical insurance information system as soon as possible and realize the upper and lower connections; The second is to break through the blockages between them and medical institutions, and realize the barrier-free interconnection of information between them and medical institutions. The third isEstablish the connection and collaboration of information systems with other departments to achieve effective information exchange and communication between departments. Fourth, it is necessary to improve and master the ability of smart medical insurance, and comprehensively improve the level of medical insurance data collection, governance and application by continuously strengthening the construction of talent team, so as to better promote the construction of smart medical insurance, so as to truly realize the modernization of medical insurance governance capabilities.
Author |He is a researcher at the Institute of Economics of the Chinese Academy of Social Sciences and the director of the Public Economics Research Office.
* |China Medical Insurance.
Edit |Fu Meiru Zhang Wenqing.
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