The "14th Five-Year Plan" for Universal Medical Security (hereinafter referred to as the "14th Five-Year Plan") draws an action plan for the high-quality development of medical security, and "building collaborative medical insurance" is one of the "five medical insurance" development goals proposed in the "14th Five-Year Plan", to achieve "high-quality coordinated development of medical security and pharmaceutical services, more effective and efficient medical insurance payment mechanism, more market-oriented pharmaceutical and procurement mechanisms, and more sensitive adjustment of medical services".
2023 is a crucial year for the implementation of the 14th Five-Year Plan. Despite facing many challenges, various key tasks and reforms have been steadily advanced, among which the construction of "coordinated medical insurance" has made significant progress and achieved remarkable results in phases.
Actively implement the "14th Five-Year Plan" and promote the construction of "coordinated medical insurance".
The reform of medical insurance payment methods has been comprehensively promoted across the country. 11 provinces (autonomous regions and municipalities directly under the central government) and the Xinjiang Production and Construction Corps have achieved full coverage of DRG DIP payment method reform in all coordinated areas; 282 co-ordinated regions have carried out DRG DIP payment method reform, accounting for 71% of all co-ordinated regions in the country; In the overall planning area where the reform was initiated, 70% of eligible medical institutions that provide inpatient services have started DRG DIP payment, and the coverage rate of disease types and ** has reached 80% and 50% respectively.
Medical insurance payment is a key mechanism to ensure that the masses have access to high-quality medical services and improve the efficiency of use. The reform of payment methods can fundamentally change the operation mechanism of public hospitals, establish a cost control mechanism under the premise of ensuring quality, and promote the transformation of public hospitals to transform their development mode, from the extension development of focusing on scale, quantity and the pursuit of income to the connotative construction and refined management of efficiency, quality and internal structure optimization on the basis of clarifying the positioning, development strategy and operation strategy of the hospital, which not only standardizes the provision of medical services, but also provides the most suitable services for the insured to improve their health. It can also guide and regulate the rational allocation of medical resources. With the advancement of reform, the results of the reform have begun to take shape, and an effective and efficient medical insurance payment mechanism has been initially formed.
Centralized procurement of pharmaceutical consumables is normalized and institutionalized. The National Health Insurance Administration conscientiously implements the first-class decision-making and deployment, and carries out centralized procurement of drugs and medical consumables in a normalized and institutionalized manner. As of 2022, 7 batches of 294 kinds of drugs have been purchased at the national level, with an average price reduction of more than 50%, and 3 batches of 4 types of consumables have been purchased, with an average price reduction of more than 80%. In 2023, the state will organize the eighth and ninth batches of centralized procurement of drugs and the fourth batch of consumables. Among them, the results of the eighth batch of drug centralized procurement have been implemented nationwide in July, and a total of 39 drugs have been successfully procured, with an average price reduction of 56%; A total of 41 kinds of drugs were successfully procured in the ninth batch of centralized drug procurement, with an average price reduction of 58%; The fourth batch of consumables was procured to cover intraocular lenses and high-value medical consumables related to sports medicine, with an average price reduction of 60% for intraocular lenses and 74% for sports medicine consumables.
The centralized procurement of drug consumables not only significantly reduces the economic burden of the masses for medical treatment, but also changes the competition model of the pharmaceutical industry, from the original "rebate" competition to the first-class, cost, and quality competition, improves the industry ecology, promotes effective competition, and forms a more in line with the laws of the market economy The formation mechanism of the pharmaceutical industry has promoted the supply-side reform of the pharmaceutical industry, seeking development with quality, efficiency and differentiation strategies, and forming a market environment that encourages innovation. At the same time, due to the squeezing out of the first "water", the mechanism has changed the behavior of medical service provision, created favorable conditions for promoting the reform of payment methods, the establishment of a cost control mechanism and the adjustment of medical services, and helped to solve the difficult problems accumulated for a long time in the pharmaceutical field.
Promote the reform of the medical service mechanism. In August 2021, eight departments including the National Health Insurance Administration issued the "Pilot Plan for Deepening the Reform of Medical Services", proposing to carry out pilot work in 5 cities and systematically explore five mechanisms, including total regulation and control, classification formation, dynamic adjustment, project management, and monitoring and assessment. In the past two years, the reform has been running smoothly and has provided experience for other regions to promote the reform of medical services**. In 2023, many regions across the country have promoted the reform of medical services**.
Through the first adjustment, the problem of unreasonable medical expenses caused by the alienation of medical service provision behavior and unreasonable allocation of medical resources caused by the unreasonable deviation of cost and price comparison relationship will be gradually solved, and the value of technical labor of medical personnel will also be reflected. At the same time, at present, medical expenses are used as the basis for DRG DIP grouping and determining payment standards, which is conducive to reducing the behavioral alienation of medical institutions and helping to better achieve the goal of payment method reform.
Actively promote the coordinated development of the "three medicines" and build a high-quality and efficient medical service supply system
Promoting the coordinated development of the "three medicines" under the premise of grasping the respective development laws of medical insurance, medical care and medicine is the key to promoting supply-side reform and building an efficient pharmaceutical service supply system. Among them, the medical insurance payment has formed a simulated market purchase service mechanism, coupled with administrative supervision such as unannounced inspections, which helps to control the behavior of doing large-scale, expanding business income and excessive service provision, which not only standardizes the provision of medical services, but also guides the rational allocation of medical resources, which is the core mechanism to promote the reform of the medical service system.
The centralized procurement of pharmaceutical consumables directly reduces the cost of medical institutions through full market competition under the effect of **, and helps standardize service delivery behavior by eliminating the negative incentive of "rebates", which creates conditions for promoting the reform of payment methods to achieve the goal of cost control. At the same time, part of the medical insurance fund space vacated by the collection of drug consumables can be used to adjust medical services, and part of it can also be used to incorporate new medical technologies with high clinical value that are needed by more patients. The adjustment of medical services** reduces unreasonable medical expenses and resource allocation, and also helps to better achieve the established goals of payment method reform.
From the perspective of the reform design of the "three medicines", through the reform of medical insurance payment methods and centralized procurement of drug consumables, the operation mechanism of public hospitals can be fundamentally changed, and the conditions for promoting effective competition of public hospitals can be established, and public hospitals can be encouraged to form competition in technology, quality, service quality and effect on the basis of controlling unreasonable expenditures. If the reform of the "three medicines" can be promoted in a coordinated manner, supporting the adjustment mechanism of the medical insurance drug catalog, the medical insurance supervision mechanism, the centralized procurement product quality supervision mechanism, etc., coupled with the reform of the medical alliance to promote hierarchical diagnosis and treatment according to capitation payment, on the one hand, it can promote the benign operation of public hospitals and promote the high-quality development of public hospitals; On the other hand, the changes in the operation mechanism of public hospitals can also be transmitted to the pharmaceutical market, coupled with the reform of centralized procurement of drug consumables that directly affects the pharmaceutical market, which not only changes the competition mode of the pharmaceutical market, promotes effective competition, promotes the quality and efficiency of the pharmaceutical supply side, and stimulates innovation. In short, the organic combination of promising and market mechanisms can promote the coordinated development of the "three medicines" and help build a high-quality and efficient pharmaceutical service supply system.
Strengthen the construction of coordination mechanisms and actively respond to challenges
While the construction of "collaborative medical insurance" has achieved phased results, the practice of reform also faces some challenges, mainly at the level of policy implementation, the progress of various regions is different, some reforms are not fully implemented in place or lag behind, and the effectiveness of reform is different.
One isThe reform of payment methods has not yet been widely implemented in the country, and public hospitals in some areas still focus on the extension development of scale and quantity, and if it is too advanced, it will increase unnecessary costs.
The second isIn some areas, the rules related to the reform of payment methods need to be improved, and some hospitals have changed their behaviors such as passing the buck to serious cases, transferring patients, and under-provisioning, cost shifting, excessive medical treatment, and passively increasing income and reducing costs.
The third isCentralized procurement varieties have not yet covered all competitive drug consumables, and in the case that there is still an inflated number of non-centralized procurement varieties, there may also be "rebate" incentives, and the coverage needs to be expanded as soon as possible.
Four areThe reform of medical services is relatively lagging behind, and the unreasonable medical expenses and resource allocation problems caused by unreasonable medical services have not been fully corrected in a timely manner, which also affects the rationality of DRG DIP grouping and payment standards based on medical expenses.
On the whole, the reform design of the "three medicines" is constantly improving in the direction of "three medicines" coordination, but it is not fully coordinated at the implementation level, coupled with the management ability and adaptability of public hospitals in some areas to be improved, and the management ability and service level of local medical insurance departments still have room for improvement, which also aggravates the lack of coordination at the implementation level of the "three medicines", and it is necessary to promote the effective implementation of the "three medicines" policy on the basis of further improving the policy.
One isResearch and promote the path and mechanism of the formation of multiple co-governance entities of the "three medicines", change the current situation that relevant departments pay more attention to their own goals and the coordination of departments still needs to be strengthened, and improve the synergy of the measures of "coordinated medical insurance" in the "14th Five-Year Plan" in the implementation process.
The second isIntensify the coordination of the "three medicines" and promote the construction of "collaborative medical insurance", including accelerating the reform of medical services; Promote the experience of medical insurance payment reform in pilot areas as soon as possible, especially the adjustment and improvement of medical insurance payment standards and relevant rules, and reduce the problem of "primary exploration" and increased reform costs in some areas in the process of promoting the reform of medical insurance payment methods nationwide; Improve the ability of local medical insurance departments to understand policies, improve rules and manage them, increase the guidance, guidance and supervision of public hospitals, and reduce the problem of alienation of service delivery behavior; Improve the management ability, policy understanding ability and adaptability of public hospitals in the context of medical reform, and ensure that the policy can be effectively implemented.
The third isUnder the condition of ensuring the smooth transmission chain of reform incentives and the implementation of incentive measures, we should increase supervision and accountability, and ensure the effective implementation of reform policies through the two-wheel drive of incentives and constraints.