The total amount control of basic medical insurance payment is one of the common means to curb the unreasonable growth of medical expenses. At present, most regions in China adopt the total amount control method that the total amount of fund expenditure according to the budget is decomposed into designated medical institutions at the beginning according to certain rules, but there are some negative effects and problems in the implementation process, and the total amount control method that some regions try to settle the total amount of fund expenditure according to the disease score after the period has better avoided these problems. Through the comparison and analysis of these two typical total amount control methods, this paper puts forward ways to improve the total amount control of medical insurance payment.

Keywords medical insurance; Total amount control; Perfect; think

Total amount control of basic medical insurance payment (hereinafter referred to as total amount control) is one of the common means used by many countries in the world to control the excessive growth of medical expenses. It effectively inhibits the impulse of medical service providers to increase medical expenses rapidly through budget management of medical insurance funds to achieve stable and sustained operation of medical insurance funds. In recent years, with the initial formation of China's universal medical insurance system, the coverage population has been expanding, the level of protection has been steadily improved, and the establishment and improvement of the protection mechanism for serious and serious diseases, direct settlement, medical treatment in different places and other convenience measures have been introduced one after another, which has enabled the people to quickly release their medical needs, greatly increased the number of medical visits and rapidly increased medical expenses. In order to ensure the steady and sustainable development of medical insurance, the Ministry of Human Resources and Social Security, the Ministry of Finance and the Ministry of Health issued the Opinions on Carrying out Total Payment Control of Basic Medical Insurance, deepening the reform of payment methods of medical insurance nationwide, carrying out total payment control, and controlling the excessive and unreasonable growth of medical expenses. However, judging from the trial of total amount control in some areas (such as Baoding, Hebei) in recent years, some medical institutions have shirked medical insurance patients for various reasons to avoid overspending, and some even refused medical insurance patients altogether; However, in order to increase the budget in the following year, some medical institutions also require some mild patients to be hospitalized or give them a big prescription, and then implicitly take some discordant notes such as medical insurance funds. How to improve the total medical insurance cost control is a realistic problem that needs to be solved urgently.

First, the connotation of total payment control of basic medical insurance

The total payment control of basic medical insurance refers to the behavior and process that medical insurance institutions determine the total medical expenses that should be paid by the basic medical insurance fund in a period of time according to the income and expenditure budget of the medical insurance fund through consultation with designated medical institutions, and take corresponding settlement methods and incentive and restraint control measures to control unreasonable or excessive growth of medical expenses, improve medical security performance and safeguard the rights and interests of insured patients.

In a broad sense, the total medical insurance payment control includes controlling the total medical expenses incurred by the insured in designated medical institutions and the insured in non-designated medical institutions (referring to medical treatment in different places outside the insured place) that should be paid by the basic medical insurance fund; In a narrow sense, total amount control only means that the basic medical insurance institutions control the total medical expenses of designated medical institutions. The total amount control in the practice of medical insurance management mainly refers to the total amount control in a narrow sense.

The total payment control of basic medical insurance is not a payment and settlement method for the medical service expenses incurred by the insured patients, but after the insured patients pay the corresponding medical service expenses according to the medical insurance policy, the medical service is controlled within the corresponding scope according to the expenditure budget on the basis of consultation and negotiation. The total payment control of basic medical insurance includes several meanings:

First, determine the control target according to the income and expenditure budget of the medical insurance fund. On the basis of the income and expenditure budget of the basic medical insurance fund, the actual payment situation of the medical insurance fund in the overall planning area in recent years is comprehensively considered, and the expenditure budget is scientifically compiled in combination with factors such as economic development, number of participants, age structure and disease spectrum changes, policy adjustment and treatment level. After consultation with designated medical institutions and comprehensive consideration of all kinds of expenditure risks, the annual total payment control target of medical insurance fund to medical institutions is determined.

The second is to produce corresponding incentive and restraint effects. In order to effectively control medical expenses and standardize the behavior of medical institutions, the key is to establish a scientific incentive and restraint mechanism, so that medical institutions can truly become the managers and responsibility bearers of total amount control, so as to fully mobilize the enthusiasm and initiative of medical institutions to control medical expenses.

Third, the purpose of total amount control is to improve the performance of basic medical insurance. Through the total amount control, medical institutions can be promoted to make rational diagnosis and treatment, conduct self-management and cost control, better protect the basic medical rights and interests of the insured, and control their personal burden. Corresponding measures should be taken to prevent some medical institutions from refusing patients, lowering service standards, falsely reporting service volume and other supporting measures and assessment means in order to avoid overspending or obtaining surplus, so as to continuously improve the scientificity of medical insurance payment methods and improve fund performance and management efficiency.

Two, the comparison of two typical models of total payment control of basic medical insurance

At present, many medical insurance co-ordination areas in China have implemented the total amount control of medical insurance payment. There are two typical ways to carry out the total amount control in various places: one is to decompose the total amount of fund expenditure according to the budget into designated medical institutions at the beginning according to certain rules, and the other is to settle on schedule according to the disease score according to the total amount of fund expenditure.

(1) Decompose the total budgeted fund expenditure into designated medical institutions according to certain rules at the beginning.

Most areas, such as Shanghai, Hangzhou, Zhejiang, Baoding, Hebei, etc., have adopted the practice of decomposing the total budget fund expenditure into designated medical institutions according to certain rules, with Shanghai being the most typical and the earliest implementation. Its basic process is as follows:

1. Fund budget. At the end of each year, the medical insurance agency will draw up the budget of the medical insurance fund for the next year based on the actual income of the medical insurance fund in the current year and the expected growth of the income of the medical insurance fund in the next year after retaining the necessary risk reserves and other funds in accordance with the principle of fixed income. On the basis of the next year's medical insurance fund budget, according to the situation of medical insurance fund payment projects, the total hospital budget control index is drawn up and implemented after approval.

2. Negotiate and determine the total budget control index of each hospital. On the basis of disclosing the annual fund revenue and expenditure budget and the total hospital budget control index, the total hospital budget control index and the actual implementation situation, through the representatives recommended by the hospitals (the hospital representatives who participated in the consultation were elected), and combining the opinions and situations of different hospitals, the total hospital budget index was determined through independent consultation ("three rounds of consultation") (the basis of hospital consultation is mainly the situation of hospital expenses in recent years).

3. Monthly disbursement and deferred disbursement. Medical insurance agencies shall allocate funds equally on a monthly basis according to the control indicators of the total annual budget of each hospital, and according to the declaration and settlement of medical expenses of the hospital in the current month, and according to the hospitals with rapid growth of actual expenses and high proportion of exceeding indicators, the full or partial suspension of allocation shall be implemented in the current month. After the year-end assessment, the part of the actual declared expenses that is lower than the prepaid amount due to strengthening management and controlling unreasonable expenses is retained by the hospital.

4. Adjust the total budget control indicators in the middle of the year. Medical insurance agencies organize district and county medical insurance departments and hospitals to adjust the annual budget indicators of hospitals in the middle of the year to cope with possible changes that affect the budget indicators.

5. Share the year-end assessment. At the end of each year, the municipal medical insurance department shall formulate a budget to manage the year-end liquidation plan according to the opinions of hospital representatives. In principle, the year-end assessment will not be deducted or shared for hospitals whose actual reporting expenses do not exceed the annual budget targets. For hospitals whose actual annual reporting expenses exceed the annual budget targets, on the basis of assessing the standardization of hospital diagnosis and treatment behavior and the rationality of medical expenses, and taking into account the affordability of the medical insurance fund and the hospital, the medical insurance fund and the hospital will share the over-budget part reasonably in proportion.

6. Practices in other cities. Compared with Shanghai, the difference of total amount control in other regions lies in the determination of hospital quotas, which is not in the form of consultation as in Shanghai, but in the determination of total budget according to the occurrence of medical expenses in medical institutions last year (most cities adopt this approach). For example, Baoding City, Hebei Province, based on the total overall income of the previous natural year, set aside 10% of the risk adjustment fund, then set aside 10% as the funds used for transfer, off-site reimbursement and outpatient chronic disease reimbursement, and the rest is the total amount in advance. The total amount of advance payment multiplied by the hospital weight [the' proportion' calculated according to the factors of overall payment (80%), hospitalization expenses (6.67%), number of beds (6.67%) and registered medical staff (6.67%) in each hospital in the previous three years] is taken as the annual advance payment index of this hospital. Redistribute the annual prepayment index of the hospital to each month. When the overall cost of the hospital in that month is equal to or less than the prepayment index, the overall fund will be settled according to the facts, and the balance index will be transferred to the prepayment index in the next month; When the overall cost of the hospital is greater than the prepayment index in the month, the overall fund will be settled according to the prepayment index in the month. At the end of the year, 50% of the balance funds will be used as the hospital development fund to reward hospitals with prepaid indicators and hospitals that have completed more than 80% of the assessment indicators; Hospitals that exceed the prepayment index meet the requirements of medical insurance, and the part that exceeds the annual prepayment index 10% shall be borne by the hospital and the overall fund respectively; More than 10% (including 10%) shall be borne by the hospital.

For another example, the total amount of hospitals in Hangzhou, Zhejiang Province is determined according to the final accounts of medical expenses of medical institutions in the previous year and the adjustment coefficient (the adjustment coefficient is determined according to the changes of medical expenses in the previous year and the level of economic and social development in this city), and the total budget proposal for that year is put forward, which will be issued after consulting the opinions of relevant medical institutions. On the basis of the total budget at the beginning of the year, the medical insurance agency will decompose it into hospitals on a monthly basis. If the monthly expenses are below the budget, it will be pre-drawn according to the actual expenses; If it exceeds the monthly budget, it will be pre-drawn according to the budget. At the end of the year, the annual expenses will be liquidated. For hospitals whose actual expenses are lower than the budget, the savings will be shared by hospitals and medical insurance funds. For hospitals whose actual expenses exceed the budget, the overspent part shall be shared by the hospital and the medical insurance fund. During the period, the medical insurance agency can adjust the budget according to the service volume of the hospital, and the incremental cost of the service will be added to the budget.

(two) according to the budget of the total fund expenditure according to the disease score settlement.

Huai 'an City, Jiangsu Province, Zhongshan City, Guangdong Province, Nanchang City, Jiangxi Province, Wuhu City, Anhui Province and other places have implemented the payment method of "fixed expenditure by income, total amount control, and monthly settlement by disease score". Huai 'an City, Jiangsu Province is the earliest city to implement. Its basic idea is to determine the corresponding score for each disease according to the proportional relationship between different medical expenses required by different diseases, and each designated hospital will settle the expenses with the distributable medical insurance fund of the medical insurance agency according to the budget.

1. Screening diseases. According to the "International Classification of Diseases" (ICD- 10), the diseases that actually occurred in designated hospitals in recent three years were extensively investigated and counted, and the diseases that actually occurred in more than 10 every year were selected as common diseases for classification and summary, and 892 diseases in different departments covering more than 90% of the cases in the city were screened out.

2. Determine the score. In the past three years, the disease types and expense data of all discharged patients (including non-employee medical insurance patients) were classified and summarized. According to the different treatment requirements and the historical average level of expenses of each disease, the preliminary scores were determined for each disease. After the experts corrected the deviation and integrated the feedback from various hospitals, the scores of each disease were determined (the "score" of serious illness was high, and the "score" of minor illness was low). Determine the hospital grade coefficient (i.e., the conversion coefficient when calculating the score) according to the proportion of the average expenses of various diseases in hospitals of different grades, and determine the settlement score according to the corresponding grade coefficient when each hospital settles (the grade coefficients of tertiary, secondary and primary hospitals are 1.0, 0.85 and 0.6 respectively).

3. Total budget. At the beginning of each year, according to the factors such as the number of insured persons and the payment base, and referring to the use of funds in previous years, the total amount of funds available for distribution in that year is calculated. After extracting 5% of the comprehensive adjustment fund (for year-end final accounts adjustment), then 15% of the total amount extracted is used for specific outpatient items and medical expenses of personnel transferred abroad, and the remaining 70% is used as the total distributable medical expenses of designated hospitals, which are distributed monthly.

4. Prepaid expenses. At the beginning of the year, according to the actual expenses of the designated hospitals in the previous year, combined with the grades assessed by the hierarchical management of medical institutions, the working capital was prepaid in accordance with the proportion of 8- 12%.

5. Monthly settlement. Calculate the specific price of the monthly score based on the sum of the disease scores of the insured patients discharged from each designated hospital (the score converted by the corresponding grade coefficient), and settle the medical insurance expenses respectively according to the cumulative scores of the discharged patients in each hospital.

6. Budget adjustment. In July every year, according to the adjustment of payment base and the expansion of insurance coverage, the distributable overall fund is re-calculated and adjusted to make the monthly distribution fund more consistent with the actual income and expenditure of the fund.

7. year-end accounts. At the end of the year, according to the actual income of the year's overall fund, the specific outpatient items, the over-expenditure or surplus of medical expenses of overseas and transferred personnel, the use of critical cases, long-term inpatients and special materials admitted to hospitals throughout the year, and combined with the implementation of the agreement, the final accounts were made with the designated hospitals.

8. Corresponding supporting mechanisms are also adopted in the specific settlement process. Including: first, the special case single discussion mechanism. In view of the obvious special condition and complicated treatment, if the score determined by the first diagnosis of discharge is obviously deviated, the hospital representatives and experts will be organized to discuss with each other to determine a reasonable score. The second is the collegial mechanism of critical cases. For cases of similar diseases with critical illness, high cost of treatment and large difference in settlement by score, the experts will re-determine the appropriate score before the year-end final accounts. The third is the compensation mechanism for long-term inpatients. For long-term hospitalized mental patients and other cases, experts will review and confirm the reasonable subsidy standard at the time of final accounts. The fourth is the deferred payment mechanism for special materials. Medical materials such as cardiovascular stents, cardiac pacemakers, and orthopedic special materials, which are expensive, easy to abuse and difficult to control, should be studied and solved according to the fund balance at the end of the year, so that the use of special materials can meet the needs of the disease. The fifth is the score control integrity mechanism. Incorporate the disease score into the fixed-point agreement for daily management, and take corresponding punishment measures for "diagnosis upgrade" and "high score" at the time of settlement.

(C) Analysis and comparison of two total amount control methods

Judging from the implementation of the total payment control of basic medical insurance in some overall planning areas, the total payment control of medical insurance has a high degree of control over the service volume and expenses of medical service institutions, which is the most reliable and effective way to control medical expenses, and also an easy-to-operate way to control expenses. Although there are some differences in the specific scope of implementation and settlement methods, they have achieved results in controlling the growth rate of medical insurance expenditure, standardizing the behavior of hospital medical services, reducing excessive consumption of medical expenses and rationally using health resources.

Compared with the above two total amount control methods, the first control method is relatively simple, and the overall planning area used in the handling practice is more and more common. But there are:

First, it is difficult to determine the scientific and reasonable total amount control quota for each specific designated medical institution. Due to the ever-changing medical technology, the introduction and use of frequently updated drugs and medical equipment, and the convenience and accessibility of medical services, it is difficult for the medical insurance department to accurately predict the amount of medical treatment in each medical institution, and it is also difficult to determine a reasonable quota for medical institutions. If the budget is too high, it will lead to unreasonable growth of medical supply; If the budget is insufficient, it will affect the enthusiasm of designated hospitals and the interests of medical insurance patients.

Second, the way to determine the quota at the beginning is not conducive to the competition among medical institutions, but also affects the enthusiasm of designated hospitals to provide medical services and the potential motivation to develop new technologies. Once the total quota is determined, medical service institutions will no longer compete for the market through competition. On the contrary, because the quota is set too tightly, their service attitude and quality will be affected, and the use of high and new technologies will be restricted, which is not conducive to the improvement of medical technology level. As a result, the enthusiasm of medical institutions will be suppressed and the pace of technological development will be limited.

Third, medical service providers may blindly save costs and restrain the reasonable medical needs of the demanders. Medical service providers may artificially cut services, shirk patients, and artificially delay medical treatment in order to save costs, resulting in the insured not being able to enjoy the basic medical security they deserve, the rights and interests of the insured being damaged, and the reasonable needs of the demander not being met, resulting in contradictions between the supply and demand sides. In some hospitals, taking into account the medical insurance handling department's assessment of the number of inpatients and the average cost, there are phenomena such as decomposing services, restricting services, shirking serious illness, etc. (limiting the amount of prescriptions, increasing the number of outpatient visits, shirking patients with high medical expenses, etc.), or shifting the cost burden to the insured (requiring patients to pay for themselves). In the internal management of the hospital, the hospital simply decomposes the total amount into departments, and turns the "average cost" and "average hospitalization days" originally calculated according to the law of large numbers into mandatory implementation standards, which infringes on the legitimate interests of the insured.

Compared with the method of decomposing quota, the second total amount control method has the following characteristics:

First, the total amount index is relatively scientific and reasonable to coordinate regional control. How to make scientific and reasonable allocation among hospitals under a certain total amount is the key and difficult point in the process of implementing total amount control. When the settlement is based on the disease score, under the total budget that can be allocated, it is not distributed in the designated medical institutions at the beginning, and the insured people's medical treatment in the designated hospitals presents a changing relationship, thus breaking the distribution pattern of the first control mode and creating a fair competition atmosphere.

Second, medical service behavior is encouraged and restrained. The disease score is based on the relationship between the treatment costs of different diseases, and the score is given according to the diagnosis, which embodies the principle of "the same disease and the same fee". When there are differences between medical institutions (or diagnosis and treatment groups) in reasonable treatment or overtreatment, reasonable treatment can get a relatively more distribution than the actual cost; However, those who are overtreated can only get a distribution that is relatively less than the actual cost, which reflects the incentive to reasonable treatment and the constraint to overtreatment.

The third is to establish a special case discussion mechanism for special medical service behavior. Due to the complexity and uncertainty of disease treatment, there will be special cases in which some cases in the same disease are in critical condition and the treatment cost is obviously high. If the channel cannot be provided for this case at the time of settlement, even if the hospital carries out necessary treatment from the perspective of saving lives, it will also have dissatisfaction and resistance to the payment system. In view of this situation, we can solve it by organizing experts' special case discussion every month and holding collegial discussion on critical cases every year, which not only relieves doctors' worries when treating critical patients, but also effectively solves the occurrence of shirking patients and decomposing hospitalization.

Three, improve the basic medical insurance payment control measures

Through the analysis and comparison of the above two typical total amount control methods, it can be seen that the total amount control of basic medical insurance is to determine the total amount of funds that can be distributed in the overall planning area according to the principle of "fixed income and expenditure, balance of payments and slight balance", and the difference lies in how to decompose the total amount of budget into designated medical institutions. The first way is to determine the quota of each designated medical institution this year through certain forms (negotiation or according to the corresponding indicators and parameters of previous years) after the total amount of funds that can be allocated in the overall planning area is determined, and then pay it after assessment according to different situations at the time of monthly settlement; The second way is to allocate funds according to the budget according to the number of patients discharged from hospitals and the disease types every month. Take the first way as a whole area, no matter how the number of discharged patients in each hospital changes every month, there are so many quotas, and hospitals usually follow the practice of medical insurance departments to further implement the total budget indicators to departments, and some departments further implement them to doctors, and even limit the unit price of prescriptions. In this way, the principle of "law of large numbers" has a high rationality at the level of overall planning, but the rationality is often reduced when it is allocated to each smaller part. Especially when the method of average distribution is simply adopted, its rationality is even lower. Designated hospitals will inevitably weaken competition, restrict medical care, and pass on expenses, which will have a considerable negative impact on the reform of medical insurance payment system. The second way is to give each inpatient disease a corresponding score according to the proportional relationship between the medical expenses of different diseases treated by discharged patients, so as to objectively reflect the level and amount of medical expenses, and calculate the total score according to the composition of monthly discharged diseases and the number of people discharged from each disease, which represents the service volume of each hospital and serves as the basis for reimbursement and settlement of expenses. Because there is no quota limit in hospitals and corresponding departments, there is no reason to restrict medical treatment, such as shirking patients. At the same time, due to the mechanism of special case discussion, there are also solutions for patients with high medical expenses. Moreover, the score does not directly represent the "cost", but only the "weight" used for weighted distribution. The unit price of the monthly score changes dynamically with the number of discharged patients and the severity of the disease, thus eliminating the direct correspondence between diseases and expenses, not only effectively controlling the total amount, but also forming a cost sharing mechanism more easily when the total amount is insufficient. Therefore, the total payment control of basic medical insurance should consider the following aspects to improve:

(1) Strengthen communication and coordination with designated medical institutions, and enhance understanding and recognition of total amount control.

Medical insurance agencies should strengthen communication, consultation and negotiation with designated hospitals on total amount control, and improve the initiative of designated hospitals to implement total amount payment. Through communication and consultation, it is beneficial for designated hospitals to fully accept the management requirements of total payment and stimulate their enthusiasm for internal management; It is beneficial to reflect the fairness and scientificity of the budget allocation process of designated hospitals and the rationality of year-end assessment and liquidation; It is helpful to realize the "win-win" effect of the insured, the medical insurance agency and the designated hospital. Consultation and negotiation should follow the principles of openness, fairness and impartiality, disclose the annual medical insurance fund revenue and expenditure budget and total payment plan to designated hospitals, and fully consult the opinions of designated hospitals. Through consultation and negotiation with designated hospitals, the standards such as cost standard, service content and assessment index are reasonably determined.

(two) scientific design to determine the parameters of the hospital quota, and increase the range of reasonable adjustment in the settlement.

In order to ensure that medical institutions can implement the basic medical insurance policy and protect the rights and interests of the insured when implementing medical services, it is necessary to have a reliable and true basis when settling expenses, change the extensive management currently existing in some areas into refined management, and implement flexible payment. It is necessary to popularize the method of disease score settlement in conditional areas, and change the focus of total control from specific decomposition quota to medical institutions to total distribution according to the amount of medical services provided by medical institutions in a certain period of time, so as to realize the scientific and reasonable quota of designated institutions; Temporarily do not have the conditions, to determine the total amount of medical institutions, should leave enough room to better adjust the index system. Specific parameters and indicators should include: the total fund expenditure, the number and age structure of the insured, the expenditure level of different types and levels of medical institutions, and the service quality and quantity requirements.

(2) Strengthen incentives and constraints and guide orderly competition.

The key to total amount control is to establish a scientific incentive and restraint mechanism in order to effectively control medical expenses and standardize the behavior of medical institutions. Because the key point of medical expense control lies in the hospital's self-management, only by fully introducing the competition mechanism can medical institutions truly become the managers and responsibility bearers of total amount control, can an incentive and restraint mechanism be effectively formed, and an atmosphere of reasonable treatment, rational drug use and "excellent work and excellent income" be created. It is necessary to reasonably determine the sharing ratio between the medical insurance fund and the designated medical institutions for the surplus funds and the overspending medical expenses, so as to fully mobilize the enthusiasm and initiative of medical institutions to control medical expenses. At the same time, a positive incentive mechanism should be established to fully mobilize the enthusiasm of doctors to actively participate in fee control, and strive to seek "the same disease and the same fee" so that the interests of medical insurance, hospitals, doctors and patients tend to be consistent.

(4) Improve supervision and management and provide quality services.

Sound supervision service is the key link to standardize medical behavior. In view of the possible problems in the quality and quantity of medical services caused by total amount control, we can't just prevent them by auditing expenses afterwards. We must formulate a set of guarantee indicators to realize the quality and quantity of medical services when determining the total budget, so as to prevent medical institutions from reducing the necessary medical services to reduce medical costs and damage the rights and interests of insured persons to obtain basic medical security through the audit of these service guarantee indicators and the cash of rewards and punishments. Specifically, it includes: establishing and perfecting the standards and management norms for doctors' medical service behavior, scientifically determining monitoring indicators (such as average cost, follow-up rate, hospitalization rate, person-to-person ratio, out-of-pocket expenses of the insured, referral rate, operation rate, elective operation rate, proportion of severe patients, etc.), improving the medical insurance information system, improving evaluation methods, and encouraging the society to participate in supervision from multiple channels and directions. At the same time, it is necessary to strengthen services for designated institutions and insured patients, strive to meet their reasonable requirements, especially smooth channels of appeal, properly handle exceptional disputes, and establish long-term and sustainable adjustment mechanisms and supporting mechanisms according to the problems found in daily management and the reasonable demands of both doctors and patients, so as to make the settlement model more reasonable and perfect.

;