Shenyang opens outpatient clinic for chronic diseases
related Inter-provincial direct settlement service for treatment costs
hypertension, diabetes, etc. p>
5 outpatient chronic diseases related treatment costsuse< /strong>
No need to pay in advance and then go back to the insured place for reimbursement
< p>Can be billed directly for medical treatment in different places
In order to implement the spirit of the Sixth Plenary Session of the 19th Central Committee of the Communist Party of China and the relevant document requirements for national and provincial medical treatment in other places, and further solve the “urgent difficulties encountered by the people in the settlement of medical treatment in different places in different provinces” With the high attention of the Municipal Party Committee and Municipal Government, the Shenyang Municipal Medical Insurance Bureau, on the basis of accelerating the promotion of the direct settlement of general outpatient medical expenses across provinces, has carried out the pilot work of cross-provincial direct settlement of outpatient chronic and special disease-related treatment expenses in Shenyang.
< span>I. Background of the pilot
Chronic diseases in outpatient clinics generally refer to some chronic diseases with long treatment cycles, A disease that is highly damaging to health, has a high cost burden, and is suitable for outpatient treatment. At present, the number of people with hypertension and diabetes in my country has exceeded 400 million, and chronic diseases account for nearly 90% of the deaths caused by various factors every year. With the increasing burden of medical expenses for chronic diseases and the increasing frequency of population movement, the demand for direct settlement of outpatient clinics across provinces continues to increase. At the same time, due to the large differences in the policies of outpatient chronic and special diseases in different regions, it is difficult to directly settle the outpatient chronic and special diseases across provinces. It is urgent to solve the problem of cross-provincial direct settlement of outpatient chronic and special disease-related treatment costs. To this end, five outpatient chronic and special diseases were identified and pilot work was carried out.
In the past three years, the state has carried out three consecutive pilot projects in terms of direct settlement of medical care in other places , Shenyang has become a pilot city. In 2020, the self-service direct settlement service for off-site medical treatment will be opened; in 2021, the inter-provincial direct settlement service of outpatient expenses will be opened; in 2022, the inter-provincial direct settlement service of outpatient chronic and special disease-related treatment expenses will be opened. .
II. Overall situation
Shenyang City has overcome difficulties and actively innovated since the implementation of direct settlement services for basic medical insurance in different places. Under the guidance of the ideology of “in-province first, then cross-province”, various measures have been advanced rapidly, and the scope of services has been continuously expanded. Following the smooth and orderly operation of services such as off-site hospitalization, off-site general outpatient clinics (outpatient co-ordination), and off-site pharmacy purchases, our city, in accordance with the requirements of the national pilot, took the lead in opening hypertension on behalf of Liaoning Province. , diabetes and other five outpatient chronic diseases related treatment costs across provinces and different placesDirect medical settlement service, to further solve the problems of excessive manual reimbursement of chronic diseases in outpatient clinics, large advances, heavy burden, and long cycle.
In December 2021, the Shenyang Municipal Medical Insurance Bureau issued the “Regarding the development of outpatient chronic disease-related treatment costs in different places” The “Notice on the Pilot Work of Direct Medical Settlement” has clarified the scope of pilot personnel, standardized the process of direct settlement across provinces, unified the rules of medical settlement, and improved the construction of the information system and other pilot contents. In accordance with the national requirements, we have completed the system construction of the insured places and the medical treatment places respectively. After several rounds of repeated tests, it was officially launched on January 1 this year.
At present, there are a total of 44 types of chronic and special diseases in Shenyang outpatient clinics, and the first batch of outpatient chronic and special diseases have been identified. The diseases for which the treatment costs are directly settled for medical treatment in different provinces and different places are five kinds of diseases including hypertension and diabetes. As a place for medical treatment, 13 designated medical institutions have been opened. As of the end of July, 257 outpatient clinics for chronic and special diseases in our city have directly settled 257 outpatient visits.
span>Three, operating characteristics
In view of the outpatient clinic Due to the complexity, specificity and uncertainty of the treatment process for patients with chronic and special diseases, Shenyang Medical Insurance has carefully studied, repeatedly demonstrated, optimized the process, and formulated a treatment policy for outpatient chronic and special diseases with Shenyang characteristics. The policy has the following characteristics.
The first is to serve a wide range of people. After expert research, combined with the development situation in various parts of the country, the scope of 5 types of chronic and special diseases in the pilot outpatient clinic was determined, namely: hypertension, diabetes, outpatient radiotherapy and chemotherapy for malignant tumor, and dialysis for uremia , Anti-rejection therapy after organ transplantation. It basically meets the medical needs of nearly 50% of long-term expatriates in different places for outpatient chronic diseases.
Second, the settlement method is convenient. Shenyang Medical Insurance has adjusted the fixed payment method for hypertension and diabetes to a fixed payment method to support online settlement of insured persons. The insured person can realize the direct settlement of medical treatment in different places with the electronic medical insurance certificate or holding the resident ID card and the social security card, which avoids the trouble and burden caused by the patients in the past paying cash in advance and then returning to the insured place for reimbursement.
Third, the treatment is humanized. In principle, the direct settlement of outpatient chronic and special disease medical treatment in other places shall implement the “directory of medical treatment places and policy of insured places”, that is, when the medical expenses of the insured personnel for outpatient chronic special disease medical treatment in other places are settled, the settlement shall be carried out. The scope of payment and related regulations for basic medical insurance drugs, medical service items, and medical consumables stipulated by the place of medical treatment; implementation of policies such as the proportion of outpatient chronic and special disease payments and the maximum payment limit in the insured place.
Fourth, the filing methods are diversified. Insured persons in Shenyang can visit the window of the city’s medical insurance agency, the “Liao Shitong” App, Shenyang Smart Medical Insurance App, and the National Medical Insurance Service Platform A pp, the national off-site medical treatment filing mini-program, the State Council’s client mini-program or other designated processing channels, after completing the filing procedures for long-term foreigners in accordance with regulations, offline treatment of outpatient chronic and special diseases in selected designated hospitals. If this function has been activated in the insured area, people who come to Shenyang for medical treatment from different places can choose a designated hospital for treatment according to the type of disease, and the outpatient chronic and special disease expenses can enjoy direct settlement services. Insured persons can also inquire about the opening of pilot areas for cross-provincial direct settlement of outpatient chronic and special disease-related medical expenses through the National Medical Insurance Service Platform App.
First, the premise of realizing the cross-provincial direct settlement service for outpatient chronic and special diseases is that, the insured person must first be a long-term resident in a different place, and need to apply for a long-term settlement in another place. Residents who live outside the country file the record and select a local medical institution for medical treatment.
Second, the outpatient treatment for chronic and special diseases is still qualified< strong>The insured personnel are required to follow the regulations of the insured place before they can enjoy the outpatient treatment for chronic and special diseases. Currently, the insured persons in Shenyang need to complete the outpatient chronic and special disease treatment qualification certification in Shenyang.
In the next step, our city will resolutely implement the national and provincial decision-making and deployment, and further improve the outpatient clinic For the direct settlement of medical treatment in different places, firstly, while stabilizing the treatment, the outpatient chronic and special disease-related treatment expenses that are widely in demand by other people and widely carried out in various places are gradually included in the direct settlement; The ability to process collaborative business, dredge and solve the difficulties and blockages in the direct settlement of medical treatment in other places; the third is to comprehensively improve the service efficiency of direct settlement of outpatient treatment for chronic and special diseases in different places, so that the people seeking medical treatment in other places and insured can save worry, time and effort.
We will also continue to rely on the national off-site settlement platform, speed up the construction of the medical security information system, and actively participate in national and provincial The various reform work organized by the organization strives to play a leading role as a demonstration benchmark on the basis of the first pilot, promote the high-quality development of medical insurance from “is there” to “is it good or not”, so that the majority of insured personnel can share the results of the medical insurance reform.
< > The press conference also answered
Relevant questions from reporters
QWhat types of diseases are involved in the direct settlement of outpatient treatment for chronic and special diseases opened this time? Answer
Shenyang Municipal Medical Security Affairs Service Center appointed Minister of Service Department of Medical Institutions Ying: In accordance with the national pilot requirements, our city, as a place for insured and a place for medical treatment, has opened two-way services in our cityHypertension, diabetes, malignant tumor outpatient chemoradiotherapy, dialysis for uremia, organ Post-transplant anti-rejection treatment for 5 outpatient chronic diseasesRelated treatment costs are directly settled across provinces. These five diseases are chronic and special diseases commonly carried out in outpatient clinics across the country. Among them, hypertension and diabetes are common diseases with high incidence, and the masses have a great demand for medical treatment; outpatient radiotherapy and chemotherapy for malignant tumors, dialysis for uremia, and anti-drug after organ transplantation If there is no direct settlement, manual reimbursement will result in a large amount of funding and a heavy burden on the masses. In the future, in accordance with the unified deployment of the National Medical Insurance Bureau, we will gradually include other outpatient chronic and special disease-related treatment expenses that are in high demand and widely carried out in various places into the scope of direct settlement.
AskPlease tell us about the first phase of Shenyang’s pilot hospitals for outpatient chronic and special diseases to receive direct settlement for cross-province medical treatment. Can you inquire about the designated medical institutions that have opened this service in various places? AnswerRen Ying, Director of Service Department of Designated Medical Institutions of Shenyang Medical Security Affairs Service Center span>:As the first phase of the 13 outpatient chronic and special diseases opened in Shenyang City, the pilot hospital for direct settlement of cross-province medical treatment in different places, these 13 hospitals have super three-level first-class hospitals, There are also second-level hospitals. The establishment of hospitals of different levels not only meets the requirements of the state for hierarchical diagnosis and treatment, but also meets the medical needs of the masses at different levels. At the same time, the regional distribution of pilot hospitals is balanced, ensuring that each district/county (city) has one pilot hospital for outpatient chronic and special diseases to seek medical treatment in other places, so that the masses can seek medical treatment nearby. The insured can inquire about the various coordinators through the National Medical Insurance Service Platform Appremote filing items in the remote networked designated medical institutions. Regional designated medical institutions have opened outpatient chronic diseases related information on cross-provincial network medical institutions.
Source: Shenyang.com Published by ShenyangEditor: Wang PeixuanProducer: Shenyang.com span>
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