First, strengthen the economic security function of outpatient service. Establish and improve the overall security mechanism for general outpatient medical expenses, start with chronic outpatient diseases such as hypertension and diabetes, and gradually include the general outpatient medical expenses with frequently-occurring and common diseases into the scope of payment of the overall fund.
The general outpatient service covers all employees' medical insurance participants as a whole, and the payment ratio starts from 50%. With the strengthening of the fund's affordability, the level of protection is gradually improved, and the payment of benefits can be appropriately tilted towards retirees. According to the characteristics of outpatient medical service, scientifically calculate the minimum payment standard and the maximum payment limit, and make a good connection with the hospitalization payment policy.
According to the fund's affordability, all localities can explore and gradually expand the scope of payment of outpatient chronic diseases and special diseases, and include some outpatient medical expenses for chronic diseases and special diseases with long treatment cycle, great damage to health and heavy economic burden into the scope of payment of outpatient chronic diseases and special diseases. Some special treatments that need to be carried out in outpatient department and are more economical and convenient than hospitalization can be managed with reference to hospitalization. With the gradual improvement of outpatient economic security mechanism, explore the transition from disease security to cost security.
Second, improve the personal account counting method. Methods and levels for scientifically and reasonably determining personal accounts. Personal accounts of on-the-job employees are included in the basic medical insurance premiums paid by individuals, and the inclusion standard is controlled within 2% of the base of my insured payment in principle. The basic medical insurance premiums paid by the unit are all included in the overall fund; In principle, the individual accounts of retirees are allocated by the overall fund according to the quota, and the amount allocated is calculated at about 2% of the basic pension during the reform in this area, and will not be adjusted in the future.
The specific proportion or standard of individual accounts shall be determined by the provincial medical insurance department in accordance with the above principles, guiding the overall planning area to combine local conditions and making overall research. After the adjustment of the overall account structure, the funds allocated to individual accounts are mainly used to support and improve the economic security and treatment of outpatient services.
Third, standardize the scope of use of personal accounts. Personal accounts are mainly used to pay out-of-pocket expenses of insured employees within the policy scope of designated medical institutions or designated retail pharmacies. It can be used to pay the medical expenses incurred by employees themselves, their spouses, parents and children in designated medical institutions with medical insurance, as well as the expenses incurred by individuals in purchasing drugs and medical consumables in designated retail pharmacies.
Explore the personal accounts of spouses, parents and children participating in the basic medical insurance for urban and rural residents. Personal accounts shall not be used for public health expenses, physical fitness or health care consumption and other expenses that are not covered by the basic medical insurance. Improve the management measures for the use of personal accounts, and do a good job in revenue and expenditure information statistics.
Fourth, strengthen supervision and management. Improve the management service measures, innovate the system operation mechanism, guide the rational use of medical resources, and ensure the stable operation of medical insurance funds and the effect of system guarantee. Strictly implement the fund budget management system and strengthen the fund audit system and internal control system.
Establish a dynamic management mechanism for the whole process of personal accounts, and strengthen the audit of the use and settlement of personal accounts. Strengthen the supervision of outpatient medical behavior and medical expenses, establish a fund safety prevention and control mechanism, crack down on insurance fraud, and ensure the safe, efficient and rational use of funds.
Innovate the management mode of outpatient medical services, improve the monitoring, analysis and assessment system of medical services, and guide medical institutions to control the cost of medical services. According to the requirements of the national unified medical insurance information platform construction, accelerate the informatization construction and explore the realization path of outpatient medical settlement in different places.
Through concerted efforts to promote the construction of primary medical service system, improve the family doctor contract service and long-term prescription system. , guide the insured to the grassroots medical treatment. Combined with the improvement of outpatient chronic diseases and special diseases management measures, standardize the diagnosis and treatment and referral of primary medical institutions.
Fifth, improve the payment mechanism suitable for outpatient medical characteristics. Primary medical services are paid per head, and the combination of payment per head and chronic disease management is actively explored; For daytime surgery and eligible outpatient special diseases, payment shall be made according to the disease type and the population related to disease diagnosis; For outpatient expenses that are not suitable for package payment, they can be paid by project. Accelerate the formulation of payment standards for medical insurance drugs, and guide medical institutions and patients to take the initiative to use drugs with definite curative effects and reasonable prices.