1、 What is the background of the promulgation of the Interim Measures for the designated management of medical security in medical institutions and the Interim Measures for the designated management of medical security in retail pharmacies (hereinafter referred to as the "two measures")?
In 1998, the State Council issued the "decision on establishing the basic medical insurance system for urban employees" (GF [1998] No. 44, hereinafter referred to as the "decision"), which determined that the basic medical insurance should be managed by designated medical institutions and designated pharmacies. The administrative department should formulate the methods for examining and approving the qualification of designated medical institutions. The agency should be responsible for determining the designated medical institutions and designated pharmacies, and cooperate with the designated medical institutions Sign a contract with a designated drugstore. In 1999, in order to implement the requirements of the "decision", the former Ministry of labor and social security, the former Ministry of health and the State Administration of traditional Chinese medicine jointly issued the "Interim Measures for the administration of designated medical institutions of basic medical insurance for urban workers" (LSBF [1999] No. 14) and "Interim Measures for the administration of designated retail pharmacies of basic medical insurance for urban workers" (LSBF [1999] No. 16), which determined the implementation of the "decision" The basic framework of the management of designated medical institutions and designated retail pharmacies was established. In 2003, the state began to establish a new rural cooperative medical system, and each region chose the best service institutions according to the situation. After the integration of the new rural cooperative medical system and the medical insurance for urban residents, it shall be implemented in accordance with the relevant measures of employee medical insurance. Article 31 of the social insurance law promulgated in 2011 stipulates that "according to the needs of management services, social insurance agencies can sign service agreements with medical institutions and drug trading units to regulate medical service behaviors." Since then, the system has been constantly improved, and the fixed-point management work has been constantly promoted in breadth and depth.
In 2015, the State Council issued the "decision on the first batch of cancelling 62 items of administrative examination and approval in central designated areas" (GF [2015] No. 57), cancelling the "two fixed" (designated medical institutions and designated retail pharmacies) qualification examination implemented by social insurance administrative departments. In order to implement the requirements of "release, management and service", the Ministry of human resources and social security issued the "guidance on improving the agreement management of designated medical institutions of basic medical insurance" (No. 98 [2015] of the Ministry of human resources and social security), cancelled the "two fixed" qualification examination and improved the agreement management.
With the deepening of the medical and health system, the basic medical insurance system in urban and rural areas has been continuously integrated. The medical and health service system has developed rapidly, and the number of medical institutions has increased significantly. Especially the demand for new medical services such as medical care and integration, Internet plus medical care has springing up rapidly. The two management work is facing new situation and new environment. In June 2019, the opinions on promoting the sustainable and healthy development of community run hospitals (gwyf [2019] No. 42) jointly issued by multiple departments put forward new requirements for simplifying the application conditions and optimizing the evaluation process. According to the relevant requirements of the opinions of the CPC Central Committee and the State Council on deepening the reform of the medical security system, we have studied and formulated a new "two determination method".
2、 What is the significance of "two fixed methods" in strengthening the management of designated medical institutions and designated retail pharmacies?
The "two measures" fully embodies the spirit of "release, management and service". Qualified medical institutions and retail pharmacies can apply for signing medical insurance agreement to be included in the designated management of medical insurance, and the basic conditions and process of signing the agreement are clarified. The relationship of rights and responsibilities among medical insurance administrative departments, medical insurance agencies, designated medical institutions and designated retail pharmacies is clearer. Medical insurance agencies, medical institutions and retail pharmacies are the main body of the agreement. The administrative department of medical insurance supervises the process of fixed-point application, professional evaluation, agreement signing, agreement performance and termination.
The "two regulations" also specifies the rights, obligations and responsibilities of the subject of the agreement. It is clear that designated medical institutions and designated retail pharmacies should provide services in accordance with the agreement, implement the relevant policies and regulations of medical insurance, submit information to the medical insurance agency as required, and serve the insured. At the same time, it is necessary to cooperate with the medical insurance agency to carry out medical insurance expense audit and performance appraisal. According to the agreement, medical insurance agencies provide agency services, carry out cost audit, performance appraisal, etc. At the same time, it clarifies the liability of the main body of the agreement for breach of contract, and puts forward the specific circumstances of the termination and dissolution of the agreement, which is equivalent to listing a "negative list", which is conducive to promoting the standardization of medical service behavior, ensuring the safety of medical insurance funds, and promoting the standardization and legalization of the designated management of medical institutions and retail pharmacies.
3、 What are the conditions for medical institutions and retail pharmacies to apply for inclusion in the designated medical insurance?
Medical institutions and retail pharmacies need to meet several basic conditions to apply for inclusion in the designated medical insurance, including that the operating time of the institutions should not be less than 3 months, that the institutions should have certain business license qualifications and that the personnel should provide services. We believe that these are the basic conditions for medical institutions and retail pharmacies to provide services for the insured normally. In the Interim Measures for the management of designated medical insurance institutions, we also defined the scope of institutions that can be included in the designated medical insurance institutions, so as to make the designated application more specific. In addition, in terms of application conditions, we also put forward several aspects related to medical insurance work from the perspective of strengthening medical insurance management. One is the requirements of medical insurance management system, including the allocation of corresponding medical insurance management personnel. Second, medical insurance related financial system requirements. Truly record the "purchase, sale and inventory" of drugs and consumables in the medical insurance catalog. Third, improve the management of statistical information, and submit relevant information and data of medical insurance settlement as required. Fourth, it effectively connects with the medical insurance information system to provide direct online settlement for the insured. Set up basic databases of medical insurance drugs, diagnosis and treatment projects, medical service facilities, medical consumables, disease types, etc., and use national unified medical insurance code according to regulations. Fifthly, strictly implement the medical insurance drugs, consumables, medical service items and other catalogues, control the proportion of patients at their own expense, and improve the use efficiency of medical insurance funds.
4、 What is the positive impact of the "two fixed methods" on expanding the coverage of designated medical insurance and facilitating the masses to seek medical treatment and purchase drugs?
The starting point of the "two fixed methods" is to meet the health needs of the people. The purpose is to strengthen and standardize the fixed-point management of medical security in medical institutions and retail pharmacies, improve the efficiency of the use of medical security funds, and better protect the rights and interests of the majority of insured persons. According to statistics, in 2019, about 200000 medical institutions (excluding village clinics with integrated management) and 390000 retail pharmacies have been included in the designated medical insurance, basically meeting the medical and drug service needs of the insured. In order to implement the requirements of "release, management and service", medical institutions and retail pharmacies can apply for fixed points after three months of formal operation, and the time limit for the evaluation of medical insurance agencies shall not exceed three months. The regional medical insurance agencies, qualified medical institutions and retail pharmacies shall negotiate with each other. If they reach an agreement, both parties shall sign a service agreement voluntarily. By simplifying the application conditions, optimizing the evaluation process and improving the negotiation mechanism, it is helpful to expand the supply of medical resources and provide more suitable and high-quality medical and drug services for the masses.
5、 Under what circumstances does the medical insurance agency have the right to terminate or terminate the medical insurance agreement?
The "two fixed methods" have made it clear that the designated medical institutions should implement territorial management. The medical insurance agency or the third party agency entrusted by it shall carry out performance appraisal on the designated medical institutions, and strengthen the supervision on the designated medical institutions and the designated retail pharmacies. The method also gives a clear definition of the situation of termination and rescission of the agreement. The termination of the designated medical insurance agreement means that the medical insurance agency, the designated medical institution and the designated retail drugstore suspend the performance of the agreement, and the medical insurance expenses incurred during the termination period will not be settled. At the end of the suspension period, if the validity period of the agreement is not exceeded, the agreement may continue to be performed; if the validity period of the agreement is exceeded, the agreement shall be terminated. The termination of the agreement mainly includes four situations: first, according to the daily inspection and performance appraisal, it is found that the safety of the medical security fund and the rights and interests of the insured may cause major risks; second, it fails to provide the relevant data to the medical insurance agency and the medical security administrative department according to the provisions or the data is untrue; third, it should terminate the agreement according to the agreement; Fourth, other circumstances that should be suspended according to laws, regulations and rules.
The termination of the designated medical insurance agreement refers to the termination of the medical insurance agreement between the medical insurance agency, the designated medical institution and the designated retail drugstore. The agreement relationship no longer exists, and the medical expenses generated after the termination of the agreement will no longer be settled by the medical insurance fund. Among them, the "Interim Measures for the designated management of medical security in medical institutions" put forward 14 cases to terminate the agreement, and the "Interim Measures for the designated management of medical security in retail pharmacies" put forward 17 cases to terminate the agreement, mainly focusing on the implementation of medical insurance agreement, strengthening medical insurance management, ensuring the safety of medical insurance funds, practicing according to law and standardizing medical service behavior.
6、 How to bring internet hospital into designated management?
At present, there are many forms of Internet hospitals, such as the information platform built by the entity medical institutions themselves, the information platform built by the entity medical institutions and the third-party institutions. Internet hospitals should rely on entity medical institutions to apply for practice license. Therefore, the "two regulations" stipulates that Internet hospitals can sign an agreement with the entity designated medical institutions they rely on and report it to the health insurance agency of the coordinating region for the record, and the relevant expenses incurred in providing services in line with the regulations shall be settled by the health insurance agency of the coordinating region and the designated medical institutions.
7、 How to understand that "designated retail drugstores can sell drugs with electronic external prescriptions issued by designated medical institutions", does it mean that medical insurance allows and supports online selling of prescription drugs?
During the novel coronavirus pneumonia epidemic situation, to facilitate the non new crown pneumonia chronic disease patients to take a medicine again, the local Health Insurance Bureau actively supports the "Internet plus" medical service, some local medical insurance departments also explore the Internet hospital prescription, prescription transfer to slow point disease designated retail pharmacies, patients in the retail pharmacy drug collection mode. In October 2020, the guidance issued by our bureau on promoting the medical insurance payment of Internet plus medical service (No. 2020) was put forward. The prescription was transferred to the designated retail drugstore in the same area, and the insured purchased medicine at the designated retail drugstore, and explored the coordinated planning of the prescription in the conditional overall planning area relying on the national unified medical insurance information platform. The plan was to implement the prescription in the area with the overall planning of the whole area. This is the 45 step in the plan. Regional circulation. All localities can directly deploy and use the relevant functional modules of the medical insurance information platform business platform, prescription circulation center, etc., to realize the circulation of Internet hospital prescriptions to the designated retail pharmacies in the overall planning area, which provides convenience for cross planning area drug collection, and realizes "more information and prescriptions, less patients running errands". However, prescription circulation and online sale of prescription drugs are not the same. At present, the standard of the method is that the prescription that meets the requirements can be transferred to the entity drugstore or distributed by the entity drugstore, and the relevant policies of online sale of prescription drugs need to be studied and clarified by the relevant authorities.
