Liaoning medical insurance bureau Huitong

14 urban medical insurance departments and designated hospitals.

* * * With the development of

Notice on Standardizing the Security System for Chronic Diseases and Special Diseases in Outpatients in the Province

(Liao Medical Insurance [2022] 17, hereinafter referred to as 17)

The document 17 standardizes the medical insurance for employees and the security system for chronic diseases and special diseases in outpatient clinics of urban and rural residents in the whole province from five aspects, establishes the disease catalogue of the whole province, unifies the standards for disease identification in the whole province, clarifies the scope of cost protection, reasonably determines the treatment level and optimizes the handling services.

The treatment level of the insured in the province has generally improved, especially for patients with serious diseases such as dialysis, malignant tumors and severe mental disorders. In the context of the normalization of epidemic prevention and control, medical insurance services are more convenient. The new policy will be implemented in the whole province from 1 in 2023.

165438+2022 10/8

Medical insurance bureau, Liaoning Province

Fu Hailong, deputy director of the treatment and protection department, introduced

Five highlights of document 17:

First, it is conducive to the prevention and treatment of infectious diseases.

Taking AIDS as an example, AIDS will be included as a new disease in the province. The local medical insurance department will provide good outpatient medical security treatment for AIDS patients.

Since June 5438+ 10, 2023, the medical insurance for urban workers and medical insurance for urban and rural residents in the province has provided at least 2,000 yuan and10.8 million yuan for outpatient treatment for AIDS patients every quarter, and the total annual payment for individual co-ordination areas can reach10.0 million yuan.

There is no personal deductible for outpatient treatment, and the proportion of payment is not less than 85% for employees and 80% for residents, and it can reach more than 90% in some overall planning areas.

Second, it is conducive to solving the problem of poverty caused by illness.

Take dialysis as an example:

First, the minimum payment limit for outpatient dialysis has been greatly increased, and the residents' medical insurance is not less than 6,000 yuan/month, which is twice the current standard in some cities (increased by nearly 50%), which is conducive to the promotion of peritoneal dialysis.

The second is to promote the hospital to improve the effect of outpatient dialysis treatment. After the payment limit is raised, the number of outpatient dialysis can be increased from the current 12 to 13 times per month to 14 to 15 times. Designated hospitals are required to provide outpatient hemodialysis filtration at least once a month, and Qualcomm is encouraged to have dialysis, so the overall outpatient dialysis effect will be significantly improved.

The third is to expand the scope of protection. The auxiliary drugs, routine examination and laboratory items and medical consumables necessary for dialysis treatment will be included in the payment scope of medical insurance outpatient service, which will greatly reduce the burden of personal comprehensive expenses and avoid poverty caused by illness.

Third, it is conducive to the rational treatment of malignant tumors.

First, malignant tumors are subdivided into four categories, including outpatient radiotherapy and chemotherapy, analgesic therapy, endocrine therapy and adjuvant therapy, and different payment limits are set.

Second, the payment limit of outpatient chemotherapy medical insurance for malignant tumors is generally around 654.38+10,000 yuan, and the reimbursement rate of outpatient chemotherapy in some overall planning areas is higher than that of hospitalization, so as to guide insured patients to use outpatient treatment more and reduce unnecessary hospitalization.

Thirdly, the outpatient analgesic treatment for cancer patients has been increased. The annual medical insurance reimbursement amount exceeds 20,000 yuan, and there is no need for hospitalization analgesia.

Fourth, it is conducive to the treatment of serious diseases.

Take severe mental disorder as an example. Our province 17 is a concrete measure for the medical insurance department to implement the Regulations on Mental Health in Liaoning Province.

The disease has expanded from schizophrenia to all six serious mental disorders. The proportion of urban and rural residents' contributions is not less than 80%, and the amount of medical insurance reimbursement is not less than 1.200 yuan every quarter, with an annual total of nearly 5,000 yuan and corresponding medical expenses of nearly 7,000 yuan.

According to the calculation of the health department, the annual cost of commonly used drugs for patients is concentrated between 5000-6000 yuan. After the payment of medical insurance, the economic burden of illness of individuals and families will be greatly reduced.

Five, is conducive to the normal medical treatment and epidemic prevention and control of the insured.

Identification and reimbursement of medical insurance for long-term residents in different places

On the one hand, the scope of designated hospitals has been expanded. Cancel the current rule that insured patients can only go to one hospital a year, and allow patients to choose public hospitals or private hospitals voluntarily.

On the other hand, all co-ordination areas are required to carry out disease identification business on a monthly basis. Due to the identification of long-term residents in different places in the province, the insured place admits that this will greatly reduce the identification burden of residents in different places.

Dialogue: Liaoning Medical Insurance Bureau

Fu Hailong, Deputy Director of the Department of Treatment and Protection

Q:

Reporter: Document 17 is the first time to standardize outpatient chronic diseases and special diseases in our province. At present, 4 1 diseases have been detected in the whole province, which is of great concern to workers and urban and rural residents all over the country. How is the catalogue of diseases in the province formulated? How to deal with diseases that are not in the catalogue?

A:

Fu Hailong: At present, document 17 has identified 4 1 disease, and individual diseases are further refined. The establishment of the province's disease catalogue is determined after full consideration and demonstration in accordance with strict procedural requirements.

First, we defined the basic principles of disease selection. Dialysis, malignant tumor (radiotherapy and chemotherapy), severe mental disorder, rehabilitation treatment (minors), diabetes (complications), stroke, myocardial infarction and other diseases with long treatment cycle, great harm to health, heavy cost burden and suitable for outpatient treatment are included in the unified outpatient catalogue of chronic diseases and special diseases in the province. Secondly, based on nearly 150 diseases in the province, the catalogue uses the national disease identification scoring method to rank the existing medical insurance diseases of employees and residents in Liaoning after comprehensive scoring, and selects the diseases with the highest score.

Thirdly, according to the distribution of disease clinical departments, adjust and optimize the disease structure (type) and conduct expert argumentation, and delete the diseases with low outpatient expenses. For the 4 1 specific diseases determined by the provincial bureau, cities are allowed to determine the scope of diseases in the region according to the actual situation such as the number of local patients. At the same time, the provincial bureau encourages and supports all localities to explore the transition from disease protection to cost protection, and the provincial medical insurance will take the lead in exploring.

Q:

Reporter: After carrying out disease identification in various places, disease identification has become the primary link for insured people to enjoy the treatment of chronic diseases and special diseases in outpatient clinics. Before, there was a big gap between the identification standards in different places. Because of its strong professionalism, how did the provincial bureau unify the standards in the province?

A:

Fu Hailong: On the basis of learning from other provinces' accreditation standards and summarizing the practical experience of disease accreditation in various places, the accreditation standards of our province were determined by China Medical University, Dalian Medical University, Liaoning University of Traditional Chinese Medicine, Affiliated Hospital of Jinzhou Medical University and some central hospitals in some cities. 150 clinical experts studied and demonstrated them one by one.

In accordance with the principle of "adapting to local conditions and applying scientifically", clinical experts refine the conditions for disease access and strictly control the disease access.

Compared with the current identification standards of various co-ordination areas, the identification standards of diseases in the province are wide and strict, such as the inclusion of diabetic gangrene in the identification scope; Strictly speaking, such as quantifying the degree of vascular stenosis caused by hypertension and diabetic peripheral neuropathy, to avoid the waste of funds caused by low inclusion criteria.

After the drafting of the province's certification standards, opinions from all over the country were repeatedly solicited. More than 0/00 clinicians in the whole province gave positive opinions, and our bureau adopted some doctors' opinions on adjusting the details of individual disease identification standards.

The first unified certification standard in the province will be used as a trial version in various places. After a trial period, clinical experts will be organized to adjust and improve according to local conditions to ensure that the certification standards are scientific and reasonable.

In view of the long-term (24 months) problem that some certified personnel in various places have not incurred medical expenses, all cities are required to be retired to solve the problem that they can only enter but not leave.

Q:

Reporter: Document 17 standardizes the level of treatment by proposing minimum treatment guidelines. Excuse me, what factors have been considered in the formulation of the treatment standard guidelines in our province, and what specific contents have been included?

A:

Fu Hailong: According to the principles of basic guarantee, equal rights and responsibilities, and fund balance, after comprehensive analysis of current policies, field research, cost calculation and evaluation of the affordability of the city's overall fund, the guidelines for the payment ratio and payment limit of employee medical insurance and resident medical insurance in the province were determined respectively, that is, all localities should not be lower than this treatment standard, and they can rise appropriately. Specific security advantages include three aspects:

Except for AIDS, severe mental disorders and other special diseases 12, there is no deductible line in the province, and the others are determined by the municipalities themselves.

Payment ratio. We have fully considered the current actual payment level and widened the reasonable gap and the fund's affordability. On the one hand, according to the actual reimbursement level of the whole province, the minimum payment ratio is determined to be no less than 60%, and the basic principle of appropriately improving special diseases. On the other hand, the payment ratio keeps a reasonable gap, which is reflected in the three dimensions of disease, insurance and hospital.

Payment limit. This is the difficulty of unified standardization in the whole province. It is necessary to reflect the treatment gap caused by the difference in financing between employees and residents, and also consider the affordability of the fund to avoid the waste of the fund. Through repeated calculations by clinical departments and on-the-spot investigation and demonstration, according to the actual clinical diagnosis and treatment of various diseases, our bureau has determined the time limit (year, quarter and month) for enjoying the treatment, and on this basis, respectively determined the payment limit (lower limit) for medical insurance for employees and medical insurance for residents.

Judging from the actual guarantee effect, the standard of disease treatment in most areas of our province has been improved, especially for urban and rural residents. In some cities, the number of diseases has increased from more than 20 to more than 40, including 4 diseases for minors. From the point of view of diseases, the actual treatment level of patients who are prone to poverty due to illness, such as malignant tumor, dialysis (the lower limit of monthly medical insurance for employees is 6,600 yuan/resident is 6,000 yuan) and severe mental disorder (employees are not less than 65,438 yuan +0.600 yuan/quarter and residents are not less than 65,438 yuan +0.200 yuan/quarter), has been significantly improved.

All co-ordination areas will do everything possible to raise funds to ensure that treatment is in place. Conditional areas will appropriately raise the standard of treatment on the basis of the provincial guidelines, but the payment limit (payment ratio) should also be appropriately reduced for diseases that waste funds due to excessive personal treatment in some overall planning areas.