Medical insurance is divided into compulsory insurance and commercial insurance, and compulsory insurance must be paid.
Dai Songjing, 64, has suffered from diabetes and hypertension for many years. Before New Year's Day this year, her condition deteriorated and she needed hospitalization, but she was unexpectedly pushed off by the local hospital. The family sent her to two hospitals, and the doctors suggested bidding farewell to the hospital on the grounds of "uncertain illness".
According to the survey, it is not the surrogate mother-in-law who can't stay in the hospital because the doctor is uncertain about her condition, but because of the "contract system" of medical insurance quota, that is, some local medical insurance centers allocate the annual medical insurance payment quota to various hospitals, and the excess is borne by the hospitals; The hospital allocates the number of places to doctors, and if the number exceeds the quota, the doctors are deducted from the bonus. This problem puzzles not only patients, but also hospitals and medical staff. At this year's National People's Congress, it also caused a heated discussion among CPPCC members in the medical and health sector.
"Although our hospital has not implemented the medical insurance quota, some people have calculated that if it is implemented, it can be divided into 460 million yuan of medical insurance indicators a year. Some hospitals allocate the medical insurance quota to various departments, and some departments spend the medical insurance payment quota in five or six months. What should I do if I run out of flowers? Medical insurance patients dare not accept it. Therefore, many departments will give priority to foreign patients, at public expense and at their own expense, and medical insurance patients will find ways to squeeze them out. " Wang Jianye, Party Secretary of Beijing Hospital, pointed out the irrationality of the medical insurance quota system at this year's two sessions.
Ge Junbo, director of the Department of Cardiology, Zhongshan Hospital affiliated to Fudan University, felt the same way. He said: "It is true that some hospitals dare not accept medical insurance patients at the end of the year."
Why should hospitals implement medical insurance quota? Ma, Vice Minister of Health, pointed out at the China Hospital Forum last year that after the reform, the fixed prepayment system of medical insurance was linked to hospital income, and those exceeding the fixed amount were counted as hospital income.
It is understood that in 20 1 1 year, Ministry of Human Resources and Social Security issued the "Opinions on Further Promoting the Reform of Medical Insurance Payment Methods" and other documents, requiring medical insurance to explore a payment system that combines total prepayment, outpatient co-ordination and per capita payment, and hospitalization and outpatient serious illness payment by disease. At present, most provinces and cities in China have begun to implement this system.
Generally speaking, the reform of medical insurance payment is "fixed lump sum, cost capping and cost saving to maximize benefits", which is mainly aimed at the serious waste of medical service resources, even over-prescription, over-dose, fraudulent insurance and hedging, which are common in China's medical industry.
"The purpose of the medical insurance quota is actually to control fees, which is aimed at hospitals. However, in the absence of obvious reforms in the doctor's income mechanism, medical service supply mechanism, and medical care with medicine, although the medical insurance cost has been controlled, the pressure of medical insurance quota will eventually fall on doctors, who will take the initiative to reduce medical insurance drugs and refuse medical insurance patients to be admitted to hospital, which will ultimately affect the medical treatment effect of medical insurance patients. For hospital managers, it is a simple and lazy internal control method to implement a fixed contract for doctors. " A doctor in tongji hospital said.
The doctor also said that the new medical reform will focus on the goal of hospital cost control, and it is reasonable to strengthen the quality of hospital cost management, which has also achieved good results in pilot areas. However, under the total prepayment system, the regulatory authorities cannot control the medical expenses outside the medical insurance catalogue and the expenses of self-funded patients, and it is difficult to ensure that the hospital does not shirk the seriously ill patients.
Zhu Hengpeng, an expert on medical reform in China Academy of Social Sciences, believes that although the direction of medical insurance payment reform is in line with the international trend, it depends on the reform of public medical system to achieve the set goals in China.
"Now the reimbursement is not reimbursed, and the payment is not paid. One or two medical insurance institutions have the final say. The insured person cannot choose the insured institution, and the medical service institution cannot choose the payment institution. " Ye Lin, vice president of Peking University Stomatological College, expressed the helplessness behind the medical insurance quota. "It is recommended to diversify the medical insurance payment model and introduce market-oriented insurance institutions to participate in the medical insurance payment business."
The medical insurance quota makes it difficult for some primary hospitals to operate. Fang Laiying, director of the Beijing Municipal Health Bureau, said: "Medical security is a matter managed by the social security department. As far as the health department is concerned, medical service institutions cannot refuse to provide treatment for patients under any circumstances, but the basic operating costs of public hospitals should be guaranteed. If the medical insurance center can't give the excess expenses, it will have to be financially compensated, otherwise it will be paid by the people, otherwise the hospital will not be able to operate. "
"This problem is not a contradiction between hospitals and medical insurance, nor is it a contradiction between hospitals and patients. This is a question of internal balance of medical service supply funds and how to balance the tripartite relationship. " Fang Laiying finally stressed that "this should not be finally solved by hospitals and patients."