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1.
Acta bioeth ; 30(1)jun. 2024.
Article in English | LILACS-Express | LILACS | ID: biblio-1556627

ABSTRACT

Objective: To evaluate the implementation effect of serious illness medical insurance in Guang Xi Zhuang Autonomous Region of western China. Study design: Through the collection of 2017-2021 Guang Xi serious illness medical insurance specific policy making such as fund usage, serious illness compensation, medical expenses data, and data analysis of a serious illness medical insurance effect. Method: Literature research, Policy text analysis, quantitative data collection method, using Excel and SPSS 19.0 data descriptive statistical analysis and comparative analysis. Results: Serious illness medical insurance has had some effect, e.g., from 2017 to 2021, the utilization rate of serious illness medical insurance fund in Guang Xi was 109.49% and 103.87% respectively, the fund balance rate was -9.45% and -8.54% respectively, and the accumulated balance was -2.3871 million CNY and -70.7955 million CNY. Conclusion: The serious illness medical insurance has reduced the burden of large medical expenses of patients to a certain extent, but the fund is under too much pressure, and there is a payment deficit. The coverage and security of serious illness medical insurance need to be expanded and strengthened, and the cooperation mechanism with commercial insurance institutions should be gradually explored to improve the serious illness medical insurance.


Objetivo: evaluar el efecto de la implementación de seguros médicos para enfermedades graves en la Región Autónoma Guang Xi Zhuang, al oeste de China. Diseño del estudio: a través de la recopilación de pólizas de seguro médico específicas para enfermedades graves de la región de Guang Xi entre 2017-2021, como por ejemplo: uso de fondos, compensación por enfermedades graves, datos de gastos médicos y análisis de datos del efecto de seguros médicos para enfermedades graves. Método: investigación de literatura, análisis de textos de políticas públicas, metodología de recolección de datos cuantitativos utilizando Excel y SPSS 19.0, análisis estadístico descriptivo de datos y análisis comparativo. Resultados: el seguro médico para enfermedades graves ha demostrado tener efectos, tales como: entre 2017 y 2021, la tasa de utilización de fondos de seguros médicos para enfermedades graves en Guang Xi fue de 109,49 % y 103,87 % respectivamente, las tasas de saldo del fondo fue de -9,45 % y -8,54 % respectivamente y el saldo acumulado fue de -2,3871 millones de CNY y -70,7955 millones de CNY. Conclusión: El seguro médico para enfermedades graves ha reducido en cierta medida la carga de los grandes gastos médicos de los pacientes, pero al existir un déficit de pagos está bajo demasiada presión. Por ello, es necesario ampliar y fortalecer la cobertura y seguridad del seguro médico para enfermedades graves, y explorar gradualmente mecanismos de cooperación con instituciones de seguros comerciales.


Objetivo: Avaliar o efeito da implementação de seguro médico para doenças graves na Região Autônoma de Guang Xi Zhuang da China Ocidental. Desenho do Estudo: Através da coleta de políticas específicas de seguro médico para doenças graves de Guang Xi 2017-2021, uso de fundos, compensação por doenças graves, dados de despesas médicas e análise de dados de um efeito de seguro médico para doenças graves. Método: Pesquisa na literatura, análise do texto da política, método de coleta de dados quantitativos usando Excel e SPSS 19.0, análise estatística descritiva de dados e análise comparativa. Resultados: Seguro médico de doenças graves teve um certo efeito. Em 2017 e 2021, a taxa de utilização do fundo de seguro médico para doenças graves em Guang Xi foi 109,49% e 103,87% respectivamente, a taxa de saldo do fundo foi -9,45% e -8,54% respectivamente e o saldo acumulado foi -2,3871 milhões de yuans e -70,7955 milhões de yuans. Conclusão: O seguro médico para doenças graves reduziu o ônus de grandes despesas médicas dos pacientes até certo ponto mas o fundo está sob demasiada pressão e há um déficit de pagamentos. A cobertura e segurança do seguro médico de doenças graves necessitam ser expandidas e fortalecidas, e o mecanismo de cooperação com instituições de seguros comerciais deve ser gradualmente explorado para melhorar o seguro médico para doenças graves.

2.
Modern Hospital ; (6): 178-180, 2024.
Article in Chinese | WPRIM | ID: wpr-1022231

ABSTRACT

As the medical insurance system continually evolves,the sustainable development of hospitals necessitates the establishment of an intelligent medical supervision system.With this system,hospitals can strengthen the management of specific outpatient diseases,achieve intelligent,standardized medical insurance management,and enable real-time supervision throughout the entire process.This article first outlines the background for applying the intelligent medical insurance supervision system in the management of specific outpatient diseases.It then delves into the problems in the application of this system and proposes strategies for solving the problem.These strategies include continuation of effective medical insurance cost control and decision-making management,improvement of a payment supervision system for specific diseases,establishment of an intelligent evaluation and review system for specific outpatient diseases,and development of a financial management system for specific diseases.

3.
Modern Hospital ; (6): 258-262, 2024.
Article in Chinese | WPRIM | ID: wpr-1022252

ABSTRACT

Objective This study aimed to investigate the factors influencing the personal burden rate incerebral ische-mic patients,compare the difference in the burden rate among the patients with varying degrees of cerebral ischemia,provide a reference for establishing a personal burden rate evaluation,and propose suggestions for control its increase.Methods The medi-cal insurance data were collected from 8164 discharged patients in a tertiary hospital in Tianjin between January and December 2022.With the data,the Generalized Linear Model was utilized to analyze the factors affecting the personal burden rate across different Diagnosis Related Groups(DRGs).Results Statistically significant differences were observed in the cost structure a-mong different DRGs.Age,length of hospital stays,total hospitalization cost,hospital admission mode,number of hospitaliza-tions,and type of medical insurance significantly impacted the personal burden rate.The personal burden rate was inversely cor-related with age and length of hospital stays,but directly correlated with the total hospitalization cost.The patients admitted from emergency,first-time hospitalization,and those covered by the basic medical insurance program for urban employees had a lower personal burden rate.Conclusion Hospitals should establish diverse personal burden rate performance evaluation standards for patients with different types of medical insurance,incorporating factors such as average length of hospital stays and average hospi-talization cost.A more equitable hospital internal assessment plan should be developed by considering patients admitted to differ-ent departments and aligning with the characteristics of clinical pathways.Medical institutions should minimize self-funded pro-jects under declared medical insurance,increase the enrollment of cases in DRGs,and promote tiered diagnosis and treatment to reduce the personal burden rate for patients.

4.
Herald of Medicine ; (12): 470-476, 2024.
Article in Chinese | WPRIM | ID: wpr-1023736

ABSTRACT

Payment by diagnosis related groups(DRG)is an important research direction in China's current medical insurance payment reform.However,it limits the clinical development and utilization of innovative medicines to a certain extent.Additional payments for innovative medicines have been thoroughly studied in many countries.This paper conducted an analysis and summary of the global experience regarding additional payment for innovative medicines under the DRG payment system.U-sing the United States,France,and Germany as case studies,this paper also examined the current state of medical insurance pay-ment for innovative medicines in China and the influence of DRG payment on the development of such medicine.In addition,it has put forward explicit policy recommendations,including the establishment of inclusion criteria,the selection of appropriate payment modes,the implementation of dynamic adjustment mechanisms,the enhancement of payment methods,etc.This paper aims to provide references to comprehensively promote DRG payment reform while further establishing and enhancing medical in-surance payment mechanisms related to innovative medicines in the context of China's national conditions.

5.
Article in Chinese | WPRIM | ID: wpr-1030124

ABSTRACT

The rational use of medical insurance fund(MIF) plays an important role in promoting the high-quality development of public hospitals, and the supervision of MIF is in a trend of under the rule of law, normalization, professionalization and standardization, and unannounced inspection will become the norm. The authors systematically analyzed three main trends of MIF unannounced inspections, namely, gradually increasing intensity, constantly innovating methods, and increasingly serious consequences. The problems exposed in unannounced inspections were sorted out from five dimensions: form of results, severity, scope of attribution, subjective intention, and regulatory screening ideas. The enlightenment of MIF unannounced inspections to hospital management was explored from four aspects: compliance awareness, organizational system, fine management, and daily supervision. It was proposed that public hospitals should transform their roles and positions, improve the working mechanism of departmental collaboration, and achieve fine management in policy understanding, system formulation, process design, information support, data governance, regulatory implementation, personnel training, and performance matching. At the same time, internal simulated unannounced inspections in hospitals should be regarded as a routine work.

6.
Article in Chinese | WPRIM | ID: wpr-1030125

ABSTRACT

Medical insurance fund is the foundation for the healthy operation of the medical insurance system, which is related to the well-being of the people and social stability. Medical institutions, as important entities in the implementation of medical insurance policies and the use of medical insurance funds, should continuously improve and optimize their self-management, and strengthen the prevention and control of clean risks in the use of medical insurance funds. This is not only a necessary response measure in the context of strict supervision of national medical insurance funds, but also an inevitable choice for hospitals under the trend of high-quality development. This article took a certain hospital as an example to illustrate the practice of sorting out the relevant authority directory for the use of medical insurance funds, analyze the integrity risk points of doctors, patients, and medical insurance reimbursement auditors; And introduced the practice of using a clean risk prevention and control grid to strengthen the hospital′s medical insurance fund, including improving the medical insurance management system, cultivating a sustainable culture of integrity, optimizing process design, improving information system construction, and improving medical insurance service modes, so as to provide reference for other medical institutions.

7.
China Pharmacy ; (12): 1552-1557, 2024.
Article in Chinese | WPRIM | ID: wpr-1036541

ABSTRACT

OBJECTIVE To learn the practical experience of medical insurance payment standards adjustment in Japan and South Korea, which will serve as a reference for the improvement of simple renewal mechanism in China. METHODS Retrieving relevant literature from CNKI and related policy documents from official websites of Japan and South Korea, the medical insurance payment standards adjustment practice in Japan and South Korea would be elucidated from 2 perspectives of adjustment criteria and formulas, and then were compared with the current simple renewal mechanism in China to clarify the areas where simple renewal mechanism in China can be optimized and propose several suggestions. RESULTS & CONCLUSIONS In terms of adjustment methods, Japan and South Korea were similar to China. For excessive drugs, the reduction rate of drugs was calculated based on the situation of excess and adjustments were implemented; however, there were differences in the specific adjustment criteria and formulas. Japan and South Korea adopted a linear price reduction approach for drugs with significant oversupply, while China adopted a gradient price reduction approach for drugs with both current and expected oversupply. The results of the comparative analysis show that China has initially established simple renewal mechanisms that are in line with the national conditions and the actual medical insurance situation, and has taken some innovative measures, including considering the current and expected oversupply of drugs and introducing a halving mechanism in the adjustment formula. However, there are also certain shortcomings, such as a relatively single set of indicators for adjusting conditions and a too broad range of gradient price reduction in adjustment formulas, which fail to fully reflect the market-oriented mechanism of “volume for price”. It is recommended that China’s medical insurance department increase consideration of drug fund expenditures, refine the gradient price reduction range of adjustment formulas, increase policy preferences for special category drugs when adding new indications, and further improve the mechanism for simple renewal.

8.
China Pharmacy ; (12): 906-911, 2024.
Article in Chinese | WPRIM | ID: wpr-1016710

ABSTRACT

OBJECTIVE To provide reference for the smooth implementation of the “dual channel” management policy for China’s medical insurance negotiated drugs. METHODS Based on Smith policy implementation process model, the dilemmas for the implementation of “dual channel” policy for medical insurance negotiated drugs were analyzed from four aspects: implementation details and regulatory system, drug selection, drug provision and quality control, the situation of medical insurance funds and information technology capabilities. The corresponding promotion strategies were put forward. RESULTS & CONCLUSIONS The “dual channel” policy for medical insurance negotiated drugs in China might face implementation difficulties such as a lack of clear implementation rules and a full process supervision system, the suitability and operability of some medical insurance negotiated drugs need to be considered in the “dual channel” management, difficulties in drug allocation and quality control, differences in the management and operation of medical insurance funds in different regions, and insufficient informatization capability. In this regard, this study suggests that measures, such as improving the implementation rules of the “dual channel” policy, enhancing the rationality of the “dual channel” drug catalog, establishing a dynamic exit mechanism for “dual channel” pharmacies, promoting professional delivery services, and improving the electronic prescription circulation platform, which can be taken to enhance the implementation effect of the “dual channel” policy.

9.
Chinese Health Economics ; (12): 34-37, 2024.
Article in Chinese | WPRIM | ID: wpr-1025219

ABSTRACT

Objective:To analyze the basic medical insurance fund balance status in China and the risk warning since the new medical reform,in order to provide decision-making references for the sustainable development of basic medical insurance fund in China.Methods:Collecting the data on the basic medical insurance fund in China from 2009 to 2022 for descriptive statistical analysis,and conduct fund balance risk warning analysis based on the risk warning interval.Results:During 2009-2021,the percentage of retirees enrolled in UEBMI has continued to increase,and there will still be a certain accumulated balance in the integrated fund.The number of participants in the URBMI has been decreased since 2020,the growth rate of fund expenditures became higher than the growth rate of fund revenues,the fund balance showed a decreasing trend.Conclusion:There are certain risks to the long-term balance of the basic medical insurance fund,which may caused by factors such as aging population,funding mechanisms,and treatment levels.

10.
Chinese Health Economics ; (12): 92-96, 2024.
Article in Chinese | WPRIM | ID: wpr-1025232

ABSTRACT

The payment methods,such as Diagnosis Related Group(DRG)for hospitalization and capitation for outpatient treat-ment,have achieved positive results in protecting the rights and interests of insured persons and improving the efficiency of the use of medical insurance funds.However,for patients with chronic diseases and rehabilitation nursing,the hospitalization period is long and the conditions complicated,and the payment method of DRGs is not reasonable.It analyzes the experiences of paying for long-term hospital cases in the US.and Germany from the aspect of reform process,payment method and regulatory measures.In order to pro-vide references for the reform of per-diem payment in rehabilitation nursing and other long-term hospitalized cases,it puts forward suggestions from aspects of realizing value care,reflecting individual differences,exploring complex payment methods,improving data quality and establishing constraint mechanism.

11.
Chinese Health Economics ; (12): 7-9, 2024.
Article in Chinese | WPRIM | ID: wpr-1025256

ABSTRACT

The process of establishing and improving the Employee Health Insurance Outpatient Co-payment Protection Mecha-nism is one of the major livelihood projects to deepen the reform of China's medical insurance system.The implementation of the mu-tual-aid mechanism for covering outpatient bills in each coordinating region is accompanied by the risks of squeezing outpatient medi-cal resources,the prevalence of fraud and deception,the increase of the government s economic burden and the lack of public ac-ceptance.In this regard,suggestions are made to improve the policy:open source and cut costs to make up for the shortage of funds,linkage of three medical institutions to build a medical security pattem,coordinated supervision to maintain the stability of medical insurance funds,and optimized policies to promote the reform of medical insurance payment methods.

12.
Chinese Health Economics ; (12): 10-15, 2024.
Article in Chinese | WPRIM | ID: wpr-1025257

ABSTRACT

Objective:Efficiency is a key factor in the sustainable operation of the medical insurance system.By measuring the current efficiency of the urban employee basic medical insurance system in 31 provinces in China from 2020 to 2021,it discovers possible problems,and provides reference suggestions for improving the efficiency of the system.Methods:Using the super efficiency SBM model based on unexpected output and the Malmquist index to measure the static and dynamic efficiency of employee medical in-surance in 31 provinces in China,and using Tobit regression analysis to analyze its influencing factors.Results:The overall compre-hensive efficiency of the national employee medical insurance operation is 0.826 in 2020 and 0.827 in 2021 respectively.The efficien-cy of employee medical insurance operation in the eastern region is significantly higher than that in the central and westem regions.Over 60%of provinces have inefficient operation of employee medical insurance.The overall total factor productivity of employee medical insurance operation is showing a downward trend,and the decline in technological progress is the main limiting factor.The level of economic development has a significant promotion effect on the efficiency of employee medical insurance operation,and the degree of population aging has a significant inhibitory effect on it.Conclusion:The efficiency of employee medical insurance opera-tion in China still needs to be improved,and there is a significant efficiency gap among different regions.Therefore,investment and attention should be increased in the central and western regions to bridge regional gaps and promote the equity development of medi-cal insurance.Therefore,the reform efforts should be continuously intensified to achieve technological progress.In addition,attention should also be paid to the driving role of economic development in the efficiency of employee medical insurance operation and the for-mulation of positive policies on population aging.

13.
Chinese Health Economics ; (12): 16-19, 2024.
Article in Chinese | WPRIM | ID: wpr-1025258

ABSTRACT

Objective:To evaluate the effect of urban-rural integrated medical insurance on rural households'catastrophic health expenditure(CHE),thereby proposing targeted optimization strategies for the integration.Methods:Based on the five tracking data of the China Household Tracking Survey(CFPS)from 2010 to 2018,Process Specification Model-Dynamic Integrity Dimension(PSM-DID)was used to empirically test the impact of urban-rural integrated medical insurance on rural households'catastrophic health expenditures.Results:The urban-rural integrated medical insurance system significantly reduces the incidence of CHE in ru-ral households.Mechanism testing indicates that health levels,human capital expenditures,and household asset accumulation are important channels of action.Conclusion:It is suggested to continuously promote the urban-rural integrated medical insurance sys-tem,formulate comprehensive policies for medical insurance according to local conditions,and incorporate catastrophic health indi-cators into the detection and warning indicator system for rural residents returning to poverty.

14.
Chinese Health Economics ; (12): 92-96, 2024.
Article in Chinese | WPRIM | ID: wpr-1025276

ABSTRACT

It summarizes the practical experience of medical insurance payment methods for medical services provided by Canadian medical staff,covering payment methods for medical services and alternative payment methods.Taking into account the current situation and conditions of the medical insurance payment method for medical services provided by medical personnel in China,it proposes policy recommendations for exploring diversified payment models,introducing direct settlement of health insurance,optimizing payment methods,considering regional differences,and ensuring the long-term sustainability of healthcare personnel health insurance payment methods.

15.
Article in Chinese | WPRIM | ID: wpr-1025318

ABSTRACT

Objective:This study aims to analyze the provincial policy text of separate payment for National medical insurance negotiated drugs,summarize the key measures and characteristics,and provide reference for the formulation and improvement of separate payment policies in various provinces.Methods:The retrieved policy texts were analyzed by searching the websites of the medical security bureaus of various provinces,municipalities,and autonomous regions.Results:There are differences in the separate payment policies of different provinces in terms of catalogue publishing,catalogue selection,drug management,policy treatment level and policy cohesion.Conclusion:The separate payment policy is the key driver of Joint Reformation for Public Health Services,Medical Insurance,and Medical Production-Circulation.And all provinces should balance the various policy elements of the separate payment catalogue,deal with the control of medical insurance funds and patients'sense of gain,and clarify the relationship between the separate payment policy and support the development of innovative drugs,so as to reduce the obstacles of Joint Reformation for Public Health Services,Medical Insurance,and Medical Production-Circulation.

16.
Article in Chinese | WPRIM | ID: wpr-1025319

ABSTRACT

Objective:To analyze the release and distribution characteristics of Chinese medical insurance payment policies,and to provide reference for future policy formulation in the field of medical insurance payment construction.Methods: Content analysis method was used to construct a two-dimensional framework of "policy goals-policy tools",and text analysis was carried out according to 63 policy documents.Results: A total of 493 policy codes were completed.From the perspective of policy goals,the policy objectives of Chinese medical insurance payment mainly focused on three aspects: improving the payment level,optimizing the medical insurance environment,and standardizing the supervision regulations.From the perspective of policy tools,environmental policy tools are the most used policy tools,followed by supply and demand tools.There is a shortage of financial input and talent training in all policy objectives,so more attention should be paid to demonstration and Category of payment.Conclusion: Our country puts forth effort to build a perfect medical insurance payment system,but should further strengthen policy content supplement,optimize the structure of policy tools,and give full play to the payment ability of medical insurance when pulling the demand of medical insurance payment and driving the supply of medical insurance payment.

17.
Article in Chinese | WPRIM | ID: wpr-1025324

ABSTRACT

Objective:Operational efficiency and influencing factors of China's basic medical insurance system from 2020 to 2021 is conducted to provide reference for improving the operational efficiency and optimizing the input-output relationship.Methods:The super-efficiency SBM model based on unexpected output and the Malmquist index are used to measure the static and dynamic efficiency of resident medical insurance in 31 provinces in China,and Tobit regression analysis is employed to analyze the influencing factors.Results:The overall operational efficiency of resident medical insurance still needs improvement.The operational efficiency of resident medical insurance in the central and western regions is lower than that in the eastern region,and the gap is significant.Different levels and regions have differentiated main constraints on the operational efficiency of resident medical insurance.In terms of dynamic efficiency,the total factor productivity of resident medical insurance operation shows an increasing trend,mainly due to technological progress.In terms of influencing factors,the degree of aging,the level of medical expenses and the level of medical insurance supervision have a significant impact on the operational efficiency.Suggestions:Efforts should be made to bridge regional disparities,promote the equitable development of medical insurance,reasonably control the level of medical expenses,strengthen the supervision of medical insurance funds,and implement active aging policies.

18.
Article in Chinese | WPRIM | ID: wpr-1025327

ABSTRACT

Taking the aging population of Nanjing as an example,through the method of constructing actuarial models,this paper predicts and analyzes the impact of the reform of outpatient mutual aid security mechanism on the income and expenditure of the overall planning funds of workers'medical insurance in Nanjing during 2021-2035,and simulates the impact of policies such as delaying retirement,expanding financing and reforming payment methods on improving the sustainability of medical insurance funds.Based on this,it proposes policy suggestions.The study finds that under the current outpatient mutual aid security plan,by 2032,the overall planning funds of workers'medical insurance in Nanjing will face the risk of running out;compared with the current policy,implementing the same retirement age for men and women will delay the time point of accumulated deficits by one year;implementing the policy of expanding financing,after both employed and retired workers pay contributions to the overall planning funds,the overall planning funds will eliminate the risk of deficits in the medium term;implementing the policy of reforming payment methods can also make the overall planning funds sustainable in the medium term.Therefore,it is concluded that the reform of outpatient mutual aid security implemented in the context of aging population may lead to payment pressure on the overall planning funds.In the long run,a combination of various supporting policies is needed to achieve sustainable development of the overall planning funds.

19.
Article in Chinese | WPRIM | ID: wpr-1025332

ABSTRACT

The present analysis was based on the iteration of the 2023 WHO Essential Medicines Model List(23rd list)and Essential Medicines Model List for Children(9th list).In a methodological fashion,the adjustment procedure of the basic drug list and the materials required to submit the application were sorted out.Subsequently,a comprehensive synthesis of predominant features characterizing the 2023 edition of the EML and EMLc are summarized(offered).Notably,this edition boasts the highest count of medicines ever included featuring extensive inclusion of innovative drugs to fill the gap,select medicines for children carefully,and the emphasizing on clinical benefit evidence and public health affordability.It is suggested that China should update the NEML according to the national conditions and the experience of WHO as soon as possible,pay attention to the difference and connection between the list of essential medicines and the list of medical insurance,and play a meticulous role for establishing effective linkages between two lists.Such measures are envisaged to meet the basic drug needs,and ensure the accessibility and affordability of drugs,thereby optimizing the allocation of health resources.

20.
Chinese Hospital Management ; (12): 78-82, 2024.
Article in Chinese | WPRIM | ID: wpr-1026594

ABSTRACT

It collected relative policy documents systematically and analyzed the development process and policy objective evolution of Chinese basic medical insurance system.Based on this,it determined the performance assessment objectives of the designated medical institutions of basic medical insurance and constructed the assessment framework guided by the goal realization.Then,from the perspective of contract management and performance management,it determined the assessment elements of contract enforcement assessment system of designated medical institutions and the logical relationship between the elements,and to construct a conceptual model,which provides a reference for guiding the research of the contract enforcement assessment of the designated medical institutions of basic medical insurance.

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