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Schlagwort: ‘Reimbursement’

Shenzheng social security cards can be used at 307 hospitals in Guangzhou

March 21st, 2017 | by

Recently, the direct settlement platform for hospitalizing in Guangdong was expanded again. On the 21st February, already 354 medical institutions participate, including 47 hospitals in Shenzheng and 307 hospitals in other regions in Guangdong. All participants of Shenzheng basic health insurance can directly use the social security card for reimbursement when hospitalizing in the province of Guangdong. Then it is not necessary to come back to Shenzhen for the reimbursement. (Source: people.cn)

广东307家医院可直接刷深圳社保卡

来源:人民网 2017-02-28

核心提示:广东省异地就医直接结算平台近期再次扩容。截至2月21日,已有354家医疗机构加入,包括深圳本地医院47家、市外异地医院307家。只要是参加深圳基本医疗保险的参保人,在省内异地住院时,均可在307家医院直接刷社保卡记账报销住院费用,不必返回深圳社保局报销。

New national reimbursement drug list comes out – changes in 376 varieties

March 21st, 2017 | by

On 23rd February, Ministry of Human Resources and Social Security published the new national reimbursement drug list (Version 2017) for the national basis health insurance, occupational insurance and maternity insurance. (Source: Chinamsr)

新版医保目录正式出台!376品种有变

来源:中国医药联盟 2017-02-24

核心提示:2月23日,人社部网站发布《关于印发<国家基本医疗保险、工伤保险和生育保险药品目录(2017年版)>的通知》,公布了2017年版国家基本医疗保险、工伤保险和生育保险药品目录。

Paying by insurance card is suspended at 19 pharmacies in Xi’an due to the fraud

February 22nd, 2017 | by

Recently, the social security center of the Xi’an Human Resources and Social Security Bureau carried out the inspection at health-insurance-designated retail pharmacies. In the inspection, it has been found out that in some pharmacies, it was possible to buy household items paying by health insurance cards. According to relevant rules, 19 pharmacies with the fraud are punished with suspension of their businesses. (Source: cnwest.com)

西安市19家药店因违规被暂停医保卡刷卡业务

来源:西部网 2017-02-16

核心提示:近期,西安市人社局社保中心在对部分城镇职工基本医疗保险定点零售药店进行检查时,发现个别定点零售药店存在使用西安市医疗保险卡刷售生活用品等问题。根据相关规定,决定对存在违规行为的19家定点药店进行处罚,暂停执行定点医疗服务协议、暂停医保刷卡业务、扣除质量保证金、责令整改。

The State Council: accelerating to build up a direct settlement mechanism for hospitalizing in other regions

February 10th, 2017 | by

The State Council recently published the plan of deepening the health reform in the 13th Five-Year. The plan requires building up a national health insurance system, which can work efficiently. The direct settlement mechanism for hospitalizing in other regions should be accelerated to build up. The basic health insurance should be promoted to connect nationwide. The cooperation between the regions of participating health insurance and the regions of hospitalizing should be strengthened, so that people do not need to shuttle or pay in advance. (Source: China News)

国务院:加快建立异地就医直接结算机制

来源:中国新闻网 2017-01-10

核心提示:国务院近日印发《“十三五”深化医药卫生体制改革规划》。《规划》要求,建立高效运行的全民医疗保障制度,加快建立异地就医直接结算机制,推进基本医保全国联网和异地就医直接结算,加强参保地与就医地协作,方便群众结算,减少群众“跑腿”、“垫资”。

Unified management of physicians according to codes in Fujian

November 23rd, 2016 | by

On 11th November, Fujian Medical Security Management Committee published an announcement about the unified management of physicians according to codes. At the moment the codes of local physicians are being collected by medical security agencies in Fujian. After a review, the codes will be recorded in the physician database for the whole province of Fujian. This work is planned to be done by 31th December. After all codes will be recorded in the database, every unreasonable medical expense can be traced to the physician, so that the overall process management of medical treatments of doctors becomes possible. (Source: the 21th Century Economic Report)

福建医师代码统一管理 不合理医药费用责任追踪到个人

来源:21世纪经济报道 2016-11-15

核心提示:福建省医疗保障管理委员会办公室于本月11日正式发布《关于做好全省统一医保医师代码管理的通知》。现阶段福建省内各设区市医保经办机构正采集、汇总和审核本地区医保医师代码,审核通过的代码将录入全省医保医师代码库。相关工作将于12月31日前后结束。所有代码入库后,将全面实现每一笔不合理医药费用追踪到个人,进而实现对医生医疗行为的“事前、事中、事后”全过程管理。

Health reform in Fujian: “Three in one”– to break the profit chain

November 23rd, 2016 | by

Recently, Fujian Institutional Organization Commission published an announcement concerning the medical security management system in municipalities. All municipalities are required to integrate municipal medical security institutions including their functions. The establishment of medical security authority should speed up. The management system of medical security should be straightened up, and the management responsibilities should be gathered. It is said that before the end of November, municipal medical security authorities should be set up in Fujian, and take charge of the businesses of health insurance, medical assistance and etc. Those businesses used to pertain to Ministry of Human Resources and Social Security, Health and Family Planning Commission and other departments. (Source: The Time Weekly)

福建医改探路三医合一:拧成一股绳,斩断利益链

来源:时代周报 2016-11-8

核心提示:日前,福建省委机构编制委员会下发《关于设区市医保管理体制问题的意见》,要求各设区市整合市级医保机构和职能,加快成立市医疗保障管理局,理顺医疗保障管理体制,归拢管理职责。据悉,全省所有设区市本月底前将设立市级医疗保障管理局,统一管理原属于人社、卫计、物价和民政等部门管理的医疗保险、医疗救助等事务。

The health insurances for urban and rural residents will be integrated comprehensively in 2017

November 23rd, 2016 | by

Recently, the General Office of the government of Henan Province published the implementation opinions about the integration of basic health insurance systems for urban and rural residents. From next year, a unified health insurance system for urban and rural residents will be implemented in Henan Province. More than 80 million rural residents will have the same health insurance treatment as 11 million urban residents. (Source: Xinhua News Agency)

2017年河南将全面实现城乡居民医保“并轨”

来源:新华社 2016-10-25

核心提示:近日,河南省政府办公厅日前下发《关于整合城乡居民基本医疗保险制度的实施意见》。从明年起,河南省将全面实施统一的城乡居民医保制度,全省8000多万农村居民将与1100多万城镇居民一样,平等享受城乡居民医疗保障待遇。

New children’s drugs – the adjustment of health insurance category in 2016

October 18th, 2016 | by

Recently, the Ministry of Human Resources and Social Security published the work plan of the adjustment of drug category of the national basic health insurance, employment injury insurance and maternity insurance and asked for comments. New drugs, secondary drugs, children’s drugs, drugs for urgent rescue and special drugs for occupational diseases are listed as key points for the adjustment. After the adjustment, the reimbursement amount will be directly affected. (Source: Liaoning News)

2016年医保药品目录调整将新增儿童用药

来源:辽宁新闻网 2016-10-09

核心提示:日前,人社部发布了《2016年国家基本医疗保险、工伤保险和生育保险药品目录调整工作方案》的征求意见稿,新药、乙类药品、儿童用药、急抢救用药、职业病特殊用药等均在重点考虑的调入范围内。调整完成后,将直接影响参保人医药费的报销金额。

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日前,人社部发布了《2016年国家基本医疗保险、工伤保险和生育保险药品目录调整工作方案》的征求意见稿,新药、乙类药品、儿童用药、急抢救用药、职业病特殊用药等均在重点考虑的调入范围内。

今年年底前,与医保、工伤、生育险参保人密切相关的医保药品目录将完成调整。日前,人社部发布了《2016年国家基本医疗保险、工伤保险和生育保险药品目录调整工作方案》的征求意见稿,新药、乙类药品、儿童用药、急抢救用药、职业病特殊用药等均在重点考虑的调入范围内。调整完成后,将直接影响参保人医药费的报销金额。

本次调整与卫生体制改革相关,按照计划,2016年底前完成医保药品目录调整工作,进一步优化目录结构,适当扩大目录范围,支持鼓励医药创新,提高保障水平。

2017年修改完善基本医保用药管理办法,逐步建立规范的药品目录动态调整机制。药品目录与参保人的报销金额有多大的关系?

以沈阳市为例,沈阳医保报销依据辽宁省的药品目录,其中约15%的内容为辽宁省可调节的,其余均依据国家制定,沈阳市不能自行制定和调整。如今很多大病和怪病,使用的药物并不在药品目录中,无法用医保报销。本次调整医保、工伤和生育险的药品目录,将与城镇居民、城镇职工医保,生育险、工伤保险参保人的利益挂钩。

征求意见稿中提出,将根据基本医疗保险、工伤保险和生育保险基金承受能力和参保人负担水平,合理确定用药范围和水平。药品目录由专家按程序科学合理评审确定,行政部门不干涉专家评审。兼顾中西药,充分体现西药和我国传统医药各自优势,西药和中成药(含民族药)数量增幅基本平衡。调整就有药品调入和药品调出,调入药品重点考虑临床价值高的新药、地方乙类调整增加较多的药品以及重大疾病治疗用药、儿童用药、急抢救用药、职业病特殊用药等。完善药品分类,组织专家按类别进行评审。

对同类药品按照药物经济学原则进行比较,优先选择有充分证据证明其临床必需、安全有效、价格合理的品种。目录内原有的药品,如已被国家药品监管部门禁止生产、销售和使用的,应予调出目录;存在其他不符合医疗保险用药要求和条件的,经相应评审程序后可以被调出目录。现调整方案在公开征求意见阶段,截至10月12日,可通过登录人社部网站的方式提出意见。

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New step of smart social security in Weifang – doctors have smart secretaries

September 27th, 2016 | by

In June 2016, the localization application of the supervision system of health insurance has been realized in Weifang. The supervision system seems to be effective until now. The statistical result shows that the co-ordination fund reimbursement of August is 1.74 million yuan less than in July. The unreasonable reimbursement of the co-ordination fund is effectively controlled, so that the individual burden of insurance personnel could be reduced. (Source:  Qilu Evening News)

潍坊加快智慧社保步伐 医生有了“智能秘书”

来源:齐鲁晚报 2016-09-18

核心提示:今年6月,潍坊在全省率先实现了医保监管系统的本地化应用。目前,监管系统初现效果。据8月份的统计显示,统筹支付额度比7月份减少了174.1万元,有效控制了统筹基金的不合理支出,减轻了参保人员的个人负担。

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今年6月,潍坊在全省率先实现了医保监管系统的本地化应用。目前,监管系统初现效果。据8月份的统计显示,统筹支付额度比7月份减少了174.1万元,有效控制了统筹基金的不合理支出,减轻了参保人员的个人负担。

2013年潍坊成功创建“全国首批电子社保示范城市”以来,社会保险信息化建设向“智慧社保”目标迈进的步伐不断加快。今年6月,潍坊又在全省率先实现了医保监管系统的本地化应用。

据悉,该系统共分两个模块,一是事前提醒、事中预警模块,这个模块就像“智能秘书”,实时帮助医保医师掌握、了解用药、检查、治疗等的规范和规则,避免医保医师因对政策不了解、不熟悉而导致被扣费情况的发生,受到了医保医师的欢迎和支持。二是事后审核模块,该模块提高了医保监管质量和效率,基本实现了无纸化审核。仅8月份,5家试点医院的避光输液器、留置针、血清胱抑素等3个项目的统筹支付额度就比7月份减少了117万元,另对确定为直接违规的项目扣费近60万元。

目前,该监管系统已初现效果。先行上线运行的3家试点医院,监管信息系统平均每天上传住院费用明细30余万条、上传医嘱信息近10万条,上传病案首页信息近400条。系统审核的准确性有了较大提升,审核出的违规信息、违规费用占异常信息总量、异常费用总量的比例分别由5月份的6%、3%,提高到了8月份的52%、18%。对部分药品、治疗项目等的审核准确率达到了100%,对审核确认的违规费用予以直接扣除。对审核确认违规的信息,按照医保医师管理制度对责任医师进行追责处理。今年来,全市共对5家定点医疗机构的10名违规医保医师做出了扣减年度积分的处理。其中,2名医保医师因年度累计扣分达到12分,被给予了暂停医保医师处方权一年的处理。

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Selection of drugs for health insurance begins – the adjustment direction of new health insurance category is clear

September 12th, 2016 | by

At the end of July, the selection of health insurance medicine category (2015) started. According to the requirement, the health insurance category will be published at the end of the year. It is said that Ministry of Human Resources and Social Security has formulated specific documents for the conditions of medicines, the process of examination and adjustment mechanism. (Source: Eyaojingliren)

医保药品遴选开始,新版医保目录调整方向已明确

来源:E药经理人 2016-08-30

核心提示:7月底2015版医保药品目录遴选工作已经启动。按照要求,医保目录将于年底出台。据介绍,人社部已经制定了专门文件,对医疗保险药品纳入的条件、审评程序、调整机制等做了明确规定。

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近来,与医保目录相关的各类会议密集召开,其中有专业专家组会议,也有行业协会参与的讨论会议,之前在银川就举行过医保研究会会议。

7月底2015版医保药品目录遴选工作已经启动。按照要求,年底医保目录出台,虽然从时间上看比较紧张,但人社部对此已经是有的放矢。此前李忠也介绍说,人社部已经制定了专门文件,对医疗保险药品纳入的条件、审评程序、调整机制等做了明确规定。

产品谁来选?

此次主导2015版医保目录的筛选工作的是专家,但是与以往不同的是,这次的遴选专家分为“综合专家组”和“专业专家组”。

对于两者分工上,综合专家组主要负责大范围的筛选,确定2009版医保目录中哪些品种该剔除医保目录,进行划定;对于哪些品种应该进入医保目录,也要进行划定。总体来说,综合专家组的功能是确定医保目录范围和划定方向,但不掌握产品是否进入目录的生死大权。

谁出谁进?

对于2015版医保目录的筛选范围上,除了经常所说的“安全、有效、经济”外,此次筛选还会考虑是否具备以下三个条件:

第一,已经进入省级医保目录有15个以上省份的,自动进入遴选目录;

第二,已经被收载入各类循证医学指南、临床治疗指南的产品被纳入遴选目录;

第三,性价比是否具备优势(包括多竞品品种、国产自有自主知识产权的、上市时间较长临床认可的)。

OTC产品是否应该纳入医保目录,一直以来备受争议。

2015 版医保目录同样遇到这个问题,有专家建议这版医保目录应该像欧洲一些国家一样,OTC产品应该从医保目录中拿出来。但是也有一些专家认为,很多OTC产品 属于双跨品种,不应该被剔除医保目录。所以,从目前E药经理人获得的消息是,2015版医保目录不会剔除OTC产品,但也不会增补新的OTC产品进入医保 目录。

“辅助用药”在2015版目录中将会出局。

这两年很多地方已经开始出台限制“辅助 用药”的目录,但是由于“辅助用药”这一术语争议较大,所以此次医保目录修订,人社部将不会具体涉及“辅助用药”这一概念,但是将会以“疗效不确切”的名 义,剔除一批现在市面上大家颇为认同的“辅助用药”。在操作上,人社部将通过专业专家组做具体的甄别。而从企业的角度来说,自身是不是“辅助用药”,必须 提供具有循证医学的数据来印证其有效性。

在增加上,2015版医保目录的要求是遴选一批国产、具有自主知识产权、临床使用时间较长、临床广泛认可其疗效的产品,将会成为此次考虑进入医保目录的重点增选对象。

对创新药进入医保目录,行业早已达成共识。

无 论是国家层面的“十三五”规划,还是国务院发布的《关于促进医药建厂产业发展的指导意见》,抑或是发改委发布的《关于促进医药产业健康发展的指导意见重点 工作部门分工方案》,都明确提出,据医保基金承受能力,及时将符合条件、价格合理、具有自主知识产权的药品按规定纳入医保支付范围。

此次2015版医保目录修订,创新药成为最大的赢家。不过,至于创新药进入医保目录之后报销比例有多高,目前还没有考虑。但肯定是的,接下来创新药将不会被局限于地方医保目录,得去各省增补才能实现市场的放量。

5月份药价谈判结果出来后,其与医保部门衔接成为最受关注的问题。

截止目前也未在全国范围落地,只是部分省市在执行。但新版医保目录的调整将会配合国家药价谈判推进,将有可能被优先纳入医保目录中。

从整个新版医保目录修订来看,中国医药市场格局将会发生巨大变化,“辅助用药”出局,创新药进入,从国家引导的角度而言,医药行业将会回归到产业发展本质,研发会成为第一竞争力。而进入新一版的医保药品目录的药品,将会在目录发布一年后在市场有真实的体现,届时市场格局必然发生变化。

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