Guiding Opinions of the Ministry of Health, the National Development and Reform Commission and the Ministry of Finance on Promoting the Reform of Payment Methods under New Rural Cooperative Medical Insurance

卫生部、国家发展改革委、财政部关于推进新型农村合作医疗支付方式改革工作的指导意见

Promulgating Institution: Ministry of Health; National Development and Reform Commission; Ministry of Finance

Document Number: Wei Nong Wei Fa [2012] No.28

Promulgating Date: 04/12/2012

Effective Date: 04/12/2012

颁布机关: 卫生部; 国家发展和改革委员会; 财政部

文      号: 卫农卫发[2012]28号

颁布时间: 04/12/2012

实施时间: 04/12/2012

To health departments (bureaus), development and reform commissions, price bureaus, and finance departments (bureaus) of all provinces, autonomous regions and municipalities directly under the Central Government,

With a view to enforcing the requirements of the CPC Central Committee and the State Council on deepening the reform of the medical and health care system, guiding local departments to actively explore the application of fee per disease, fee per bed-day, fee per patient, prepayment of total fees and other payment methods, and further improving the payment system under new rural cooperative medical insurance (hereinafter referred to as the “New Rural Cooperative Insurance”), these Opinions are hereby put forward as follows on actively yet steadily pushing forward the reform of payment methods under New Rural Cooperative Insurance pursuant to the Opinions of the CPC Central Committee and the State Council on Deepening the Reform of the Medical and Health Care System (Zhong Fa [2009] No. 6) and the Planning and Implementation Proposals for Deepening the Reform of the Medical and Health Care System during the “Twelfth Five-Year Plan” Period (Guo Fa [2012] No. 11):

    各省、自治区、直辖市卫生厅局、发展改革委、物价局、财政厅局:

    为贯彻落实中共中央、国务院关于深化医药卫生体制改革精神,指导各地积极探索实行按病种付费、按床日付费、按人头付费、总额预付等付费方式,进一步完善新型农村合作医疗(以下简称新农合)支付制度,根据《中共中央、国务院关于深化医药卫生体制改革的意见》(中发〔2009〕6号)和《“十二五”期间深化医药卫生体制改革规划暨实施方案》(国发〔2012〕11号),现就积极、稳妥推进新农合支付方式改革提出以下意见:

1. Fully appreciate the significance in promoting the reform of payment methods.

The reform of payment methods under New Rural Cooperative Insurance aims to, through the application of payment methods such as fee per disease, fee per bed-day, fee per patient and prepayment of total fees, transform the payment methods under New Rural Cooperative Insurance from a simple option of fee per item to a mixture of different methods. The core of the reform is to change the payment system from post-payment to pre-payment, so as to give full play to the fundamental role of basic medical insurance, and realize the conversion of the compensation mechanism and the incentive mechanism of medical institutions. The reform of payment methods is conducive to consolidating and improving New Rural Cooperative Insurance, raising the use efficiency of the New Rural Cooperative Insurance fund, and increasing the benefits to which insurance participants are entitled. It also serves to promote the rational use of health care resources, regulate the services of medical institutions, and control the unreasonable hike in medical bills. Therefore, such a reform is significant in terms of ensuring the sustainable, healthy and stable development of New Rural Cooperative Insurance, letting rural residents truly enjoy the fruits of health care reform, and protecting the rights and interests of participating farmers.

       一、充分认识推进支付方式改革的重要意义

    新农合支付方式改革,是通过推行按病种付费、按床日付费、按人头付费、总额预付等支付方式,将新农合的支付方式由单纯的按项目付费向混合支付方式转变,其核心是由后付制转向预付制,充分发挥基本医保的基础性作用,实现医疗机构补偿机制和激励机制的转换。实行支付方式改革,有利于巩固完善新农合制度,增进新农合基金使用效益,提高参合人员的受益水平;有利于合理利用卫生资源,规范医疗机构服务行为,控制医药费用不合理上涨,对于新农合制度持续、健康、稳定发展,让农村居民切实享受医改成果,保障参合农民权益具有重要意义。

2. Guiding thoughts and basic principles

(1) Guiding thoughts for promoting the reform of payment methods under New Rural Cooperative Insurance. Guided by the Scientific Outlook on Development, it is imperative to take the reform of payment methods under New Rural Cooperative Insurance as an important starting point for the development of the New Rural Cooperative Insurance system in the present stage, fully mobilize the enthusiasm of various parties, and gradually establish a fee payment system under New Rural Cooperative Insurance that is conducive to reasonably controlling medical bills, increasing the benefits to which insurance participants are entitled, and ensuring the safe and efficient operation of the insurance fund. Moreover, the reform of payment methods shall be adopted as an important means to push forward the comprehensive reform of grassroots medical care institutions and the reform of county-level public hospitals and to get rid of the practice of using pharmacy profits to subsidize medical services, so as to realize management innovation and change of incentive mechanisms.

(2) Basic principles for promoting the reform of payment methods under New Rural Cooperative Insurance.

-- The principle of full insurance coverage over medical institutions and disease types within regions subject to coordinated planning. The reform of payment methods shall gradually apply to all designated medical institutions and all disease types treated thereby within the regions subject to coordinated planning, so as to prevent medical institutions from avoiding new payment methods, and effectively exert the comprehensive effects of the reform.

-- The principle of dynamic adjustment to payment standards in light of actual situations. According to baseline survey data, clinical pathways or standardized treatment programs, it is imperative to scientifically calculate and determine payment standards by giving sufficient consideration to the average level of disease-specific costs and charging rates for medical services in the past three years. The payment standards determined for medical institutions at different levels shall help guide insurance participants to get common diseases treated at grassroots medical institutions and push medical institutions to offer multi-level medical services. Moreover, payment standards shall be dynamically adjusted according to economic and social development, compensation plan adjustments, changes in the costs of medical services, the application of high-tech medical technologies, the growing health care demands of residents and other factors.

-- The principle of giving consideration to the interests of multiple parties and ensuring sustainable development. The amount of fees payable by the insurance fund shall be rationally determined according to both its tolerance capability and the principle of determining expenditure based on revenue. The percentage of payments to be shared by insurance participants shall also be scientifically determined, without increasing their financial burden. It is important to pay equal attention to incentives and restraints, determine reasonable fee payment standards through the establishment of a negotiation and consultation mechanism between New Rural Cooperative Insurance processing agencies and designated medical institutions, fully mobilize the enthusiasm of medical practitioners, and ensure reasonable compensation for, and the normal operation and sustainable development of, medical institutions. At the same time, efforts shall be made to control the unreasonable hike of medical expenses.

-- The principle of reinforcing quality regulation to ensure service levels. It is necessary to play the concerted regulatory role against medical services of health departments and other departments concerned, adopt administrative, economic, management and other means, establish and improve the regulatory system, concurrently engage medical institutions, industry players and the general public in supervision, and reinforce the regulation over service quality, so as to make sure that the implementation of the reform of payment methods will not lead to a reduction of service items and a decrease in service levels of medical institutions, the dual goals of guaranteeing service quality while controlling unreasonable fee increase are achieved, and the interests of insurance participants are earnestly safeguarded.

       二、指导思想和基本原则

    (一)推进新农合支付方式改革的指导思想。以科学发展观为指导,将新农合支付方式改革作为当前新农合制度建设的重要抓手,充分调动多方面的积极性,逐步建立有利于合理控制医疗费用、提高参合人员受益水平、确保基金安全高效运行的新农合费用支付制度。同时将支付方式改革作为推动基层医疗卫生机构综合改革和县级公立医院改革、破除以药补医机制的重要手段,实现管理创新和激励机制转换。

    (二)推进新农合支付方式改革的基本原则。

    ——统筹区域内机构、病种全覆盖。逐步对统筹区域内所有定点医疗机构及其所有病种全面实行支付方式改革,防范医疗机构规避新的支付方式的行为,有效发挥支付方式改革的综合作用。

    ——结合实际,动态调整支付标准。要根据基线调查数据、临床路径或标准化诊疗方案,充分考虑前三年病种费用平均水平和医疗服务收费标准等,科学测算、确定支付标准,对不同级别医疗机构确定的支付标准应当有利于引导参合人员常见疾病在基层就医和推进医疗机构实行分级医疗。要根据经济社会发展、补偿方案调整、医疗服务成本变化、高新医疗技术应用以及居民卫生服务需求增长等因素对支付标准进行动态调整。

    ——兼顾多方利益,确保持续发展。要以收定支,根据基金承受能力合理确定基金支付水平。科学确定参合人员的费用分担比例,不增加参合人员个人负担。要坚持激励与约束并重,通过建立新农合经办机构与定点医疗机构的谈判协商机制确定合理的费用支付标准,充分调动医务人员的积极性,使医疗机构获得合理的补偿,保证医疗机构正常运转和持续发展。同时,控制医药费用不合理增长。

    ——强化质量监管,保证服务水平。要发挥卫生等多部门对医疗服务的协同监管作用,运用行政、经济、管理等多手段,建立健全监管体系,实行组织、行业监管和社会监督并举,强化服务质量监管,确保实施支付方式改革后医疗机构服务内容不减少,服务水平不降低,实现保证服务质量和控制费用不合理上涨的双重目标,切实维护参合人员利益。

3. Main contents of the reform of payment methods

 (1) Reform of payment for outpatient fees. The reform of payment methods, which focuses on prepayment for the total amount of outpatient fees, shall be actively promoted in medical care institutions at the township (town) and village levels. Prepayment for the total amount of outpatient fees is a method of payment to determine the total annual outpatient fee budget based on scientific calculations after consultation between New Rural Cooperative Insurance processing agencies and designated medical institutions. The total budget shall be used for purchase of the outpatient services for general diseases from medical care institutions at the township (town) and village levels. The total outpatient fee budget shall be calculated and determined according to the regional service recipients, clinical visit rate, average outpatient fee per visit and service capability of each medical care institution at the township (town) and village levels in the past two to three years, and shall, in principle, be adjusted once a year upon consultation by taking into account economic growth, prices changes, geographical environment, population growth, population mobility and other factors. New Rural Insurance Cooperative processing agencies shall disburse the total outpatient fee budget to service institutions in light of the assessment of the volume and quality of services agreed upon annually, to avoid the situation whereby medical care institutions at the township (town) and village levels unreasonably refer patients to other medical institutions after the method of prepayment for the total amount of outpatient fees has been adopted.

During the reform of payment methods for outpatient fees, the way of purchasing services from rural (general) doctors on per-patient basis may also be explored. The method of fixed lump-sum payment may be explored for large outpatient fees for special diseases. In regions where vertical county-township-village technological cooperation or integrated management is carried out, efforts may be made to explore per-patient payment for outpatient services within the cooperation system, and the standards of per-patient payment shall be determined according to the prevalence rate of diseases among the service population, the classified outpatient treatment, the average outpatient fee per visit in the past three years, etc.

(2) Reform of payment for inpatient charges. Relevant departments shall actively promote the reform of payment methods for inpatient charges, such as the method of fee per disease and fee per bed-day. Fee-per-disease is a payment method whereby payment standards are determined according to the disease contracted by a hospitalized patient. New Rural Cooperative Insurance processing agencies and medical institutions shall, through negotiations and consultations, reasonably determine the payment standards based on the average disease-specific costs in the past three years and the existing disease-specific charges, and may allow for a certain floating range depending on the abnormal situations of a disease during diagnosis and treatment. Payment standards under fee per disease shall cover all expenses incurred by a patient from being admitted to a hospital for treatment to being discharged according to the hospital discharge standards, and in principle no other fee may be charged. Active efforts shall be made to properly connect the reform of fee payment methods and collection methods under fee per disease. Where the method of fee per disease applies to the payment and collection of fees, the portion of fees in excess shall, in principle, be borne by medical institutions, while any remaining balance shall also belong to medical institutions. Diseases eligible for fee-per-disease collection and payment shall be selected in line with the principles of standardized diagnosis and treatment, and relatively simple cost calculation, and priority may be given to the diseases to which the Ministry of Health has decided to apply clinical pathways. The types of diseases to be included under fee per disease may also be screened and adjusted according to the order of the disease spectrum of insurance participants who are hospitalized in medical institutions at different levels, so as to gradually increase the types of diseases eligible for fee-per-disease payment and expand the coverage of such payment to hospitalized patients. The percentage of exceptional diseases among all diseases under fee-per-disease collection and payment shall be reasonably controlled.

Payment under fee per bed-day is to divide all hospitalized diseases into several categories, reasonably determine their average length of hospitalization, and calculate and determine the payment standards under fee per bed-day for different periods of hospitalization for various types of diseases requiring hospitalization. This payment method serves to reflect the daily clinical activities and resource consumption during disease diagnosis and treatment, and calculates the amount payable by each hospitalized patient according to the accumulated number of bed days. Rigorous quality control and evaluation indicators shall be set for payment under fee per bed-day to prevent medical institutions from shortening or lengthening the hospitalized period in violation of relevant provisions or shifting the duties of patient care among each other.

Local departments concerned are encouraged to explore and improve the existing fee-per-disease models with reference to DRGs payment, and control the cases where medical institutions avoid fee-per-disease payment during the treatment and diagnosis process.

       三、支付方式改革的主要内容

    (一)门诊费用支付改革。在乡(镇)、村两级医疗卫生机构要积极推行以门诊费用总额预付为主的支付方式改革。门诊总额预付是新农合经办机构与定点医疗机构在科学测算的基础上协商确定年度门诊费用预算总额的一种付费方式。预算总额用于购买乡(镇)、村级医疗卫生机构提供的一般性疾病门诊服务。门诊预算总额的确定,要根据每一个乡(镇)、村级医疗卫生机构近2至3年区域服务人口、就诊率、次均门诊费用、服务能力等分别测算确定,同时考虑经济增长、物价变动以及地理环境、人口增长、流动等因素,对预算总额原则上每年协商调整一次。门诊预算总额的支付必须结合新农合经办机构对服务机构年度约定服务数量和质量的考核情况,避免乡(镇)、村级医疗卫生机构实行门诊总额预付后病人不合理转诊分流。

    在实施门诊费用支付方式改革中,也可探索实行按人头付费向乡村(全科)医生购买服务的方式。对于特殊病种大额门诊费用,可探索实行定额包干的支付方式。在开展县、乡、村纵向技术合作或一体化管理的地方,可探索在协作体系内对门诊服务按人头付费,要根据服务人口患病率、门诊分级诊疗、前三年门诊次均费用等情况,综合确定人头付费标准。

    (二)住院费用支付改革。积极推进按病种付费、按床日付费等住院费用支付方式改革。按病种付费是指根据住院病人所患病种确定相应付费标准的费用支付方式。新农合经办机构和医疗机构通过谈判协商,根据前三年病种费用平均水平和现行病种收费标准等,合理确定付费标准,并可根据疾病诊疗过程中病情的异常变化给予一定的费用浮动空间。按病种收费标准应包括患者从诊断入院到按出院标准出院期间所发生的各项费用支出,原则上不得另行收费。要积极做好按病种付费方式和收费方式改革的衔接。按病种收付费,原则上费用超出部分由医疗机构承担,结余部分归医疗机构所有。按病种收付费病种的选择,应当本着诊疗规范、费用测算相对简单的原则,可优先在卫生部已经确定实施临床路径的病种中选择。也可按照在不同级别医疗机构住院参合人员的疾病谱排序,对拟纳入按病种付费的病种进行筛选和调整,逐步扩大按病种付费的病种数量和住院患者按病种付费的覆盖面。要合理控制按病种收付费疾病的例外病例的比例。

    按床日付费是将所有住院疾病分为若干类,合理确定平均住院日,经过测算确定各类住院疾病不同床日段的床日付费标准,体现疾病诊疗每日临床活动及资源消耗情况,并按住院床日累计计算每例住院病人的付费额。实行按床日付费要制定严格的质量控制和评价指标,避免违规缩短或延长住院时间、推诿病人的行为。

    鼓励各地参照疾病诊断相关组(DRGs)付费,探索完善现行按病种付费的模式,控制诊疗过程中规避按病种付费的行为。

4. Establishing and improving the evaluation and regulatory measures relating to payment methods.

According to the characteristics of different payment methods under New Rural Cooperative Insurance, it is important to improve and fine-tune the evaluation indicators, assessment methods and supervision and administration measures in response to key aspects, and establish a payment method evaluation system. Relevant supporting restraint and incentive measures may be formulated in light of the actual conditions, and performance assessment methods shall be effectively implemented.

During the application of prepayment for the total amount of outpatient fees, New Rural Cooperative Insurance processing agencies shall conduct regular assessment of the volume and quality of outpatient services, the referral rates and patient satisfaction level of designated medical institutions, improve the system of public announcement, and pay attention to preventing medical institutions from issuing separate prescriptions unnecessarily, trying to avoid certain patients, unreasonably reducing medical services or lowering the quality of services.

In terms of the payment for inpatient charges, New Rural Cooperative Insurance processing agencies shall strengthen the regulation over the diagnosis and treatment process of designated medical institutions to push them to make rational diagnosis and treatment and improve service quality and efficiency. Designated medical institutions shall strictly implement the corresponding standards of hospital admission and discharge, and New Rural Cooperative Insurance processing agencies shall conduct monitoring of, and pay random return visits to, the discharged patients, so as to prevent the designated medical institutions from shifting costs to the outpatient sector, upgrading the level of diagnosis, dividing the hospitalization period, shortening patients’ hospitalization period without justification, or lowering service quality. Where multi-level medical care is practiced, the primary-level diagnosis accountability system shall be rigorously enforced, and the level-by-level referral system shall be improved, so as to prevent medical institutions from shifting among one another the responsibilities towards critically-ill patients. Medical service monitoring and evaluation results shall be taken as important bases for New Rural Cooperative Insurance to disburse final payments.

       四、建立并完善支付方式的评价和监管措施

    要根据不同的新农合支付方式特点,针对重点环节,完善细化评价指标、考核办法以及监督管理措施,建立支付方式评价体系。可结合实际配套制定相应的约束和激励措施,落实绩效考核办法。

    在实施门诊总额预付中,新农合经办机构要对定点医疗机构门诊服务数量、质量、转诊率以及患者满意度定期进行考核,完善公示制度,注意防范医疗机构分解处方、推诿病人、不合理减少医疗服务、降低服务质量的行为。

    对住院费用的支付,新农合经办机构要加强对定点医疗机构诊疗过程的监管,促进合理诊疗,提高服务质量和效率。定点医疗机构应严格执行相应的入出院标准,由新农合经办机构对患者出院状态进行监测和抽查回访,避免发生向门诊转嫁费用、诊断升级、分解住院、无故缩短患者住院时间、降低服务质量等现象。实行分级医疗,严格执行首诊负责制,完善逐级转诊制度,避免医疗机构推诿重症患者。应当将医疗服务监测评价结果作为新农合最终支付费用的重要依据。

5. Earnestly organizing and executing the reform of payment methods.

Health departments of all provinces (autonomous regions and municipalities directly under the Central Government) shall enhance cooperation and coordination with development and reform commissions, finance departments and other relevant departments, effectively provide more guidance for the reform of payment methods under New Rural Cooperative Insurance, and shall, on the basis of earnestly summarizing local work experience, formulate or fine-tune, as soon as possible, their respective opinions on or measures for promoting the reform of payment methods under New Rural Cooperative Insurance pursuant to relevant principles herein and in light of local realities. Local departments shall, from the year 2012 onwards, actively push forward the pilot implementation of the reform of payment methods that cover all designated medical institutions and disease types within regions subject to coordinated planning as required, and gradually expand the scope of application, so that the reform can be carried out in all regions subject to coordinated planning by 2015.

Departments concerned shall pay attention to fine-tuning relevant supporting policy measures while pressing ahead with the reform of payment methods under New Rural Cooperative Insurance. They shall speed up the information technology development of New Rural Cooperative Insurance, and improve the detailed rules of implementation of the accounting and financial systems applicable to hospitals and grassroots medical care institutions so that they can reflect the income and expenditure status of the schemes of fee per disease and fee per bed-day, and provide necessary basic conditions for the application of new payment methods. They shall do a good job of linking the reform of payment methods with the reform of public hospitals, give full play to the important role of the reform of payment methods in adjusting the structure of medical expenses in line with the work requirements of total amount control and structural adjustment, strive for a reasonable decrease in the use of drugs and supplies, raise medical technology service incomes, closely integrate the reform of payment methods with the implementation of clinical pathway management and standardized treatment, and achieve the expected objectives of controlling costs and standardizing diagnosis and treatment. Moreover, the departments shall properly connect the reform of payment methods with the implementation of the essential drug system, and work with other parties to promote the transformation of the operating mechanisms of grassroots medical institutions. The departments shall also connect the reform of payment methods with the work of promoting the equalization of basic public health services, and collaborate with other parties concerned to jointly display the role of the basic public health service fund and the medical insurance fund in supporting the comprehensive reform of grassroots medical care institutions.

It is a must to step up publicity efforts to raise relevant departments' awareness of the significance of pushing forward the reform of payment methods, and provide proper training on relevant policies, so as to ensure the smooth progress of the reform.

Ministry of Health

National Development and Reform Commission

Ministry of Finance

April 12, 2012

       五、认真做好支付方式改革的组织实施工作

    各省（区、市）卫生部门要加强同发展改革、财政等相关部门的配合协调，切实加强对推进新农合支付方式改革工作的指导，在认真总结各地工作经验的基础上，根据本意见的相关原则结合实际抓紧出台或完善本省（区、市）推进新农合支付方式改革的意见或办法。各地要按照要求从2012年开始积极推进统筹区域内定点医疗机构和病种全覆盖的支付方式改革试点工作，并逐步扩大实施范围，争取到2015年实现在所有的统筹地区全面实施的目标。

    在推进新农合支付方式改革中，要注意完善相关配套政策措施。要加快新农合信息化建设，完善医院、基层医疗卫生机构财务会计制度实施细则，体现按病种、按床日等收支情况，为推行新的支付方式提供必要的基础条件。要做好支付方式改革与公立医院改革的衔接，按照总额控制、结构调整的工作思路，充分发挥支付方式改革调整医药费用结构的重要作用，合理减少药品、耗材使用，提高医疗技术劳务收入，把支付方式改革与推行临床路径管理、标准化诊疗密切结合，实现控制费用、规范诊疗的预期目标;要做好与基本药物制度实施工作的衔接，协同推动基层医疗卫生机构运行机制转变;要做好与促进基本公共卫生服务均等化工作的衔接，协同发挥基本公共卫生服务经费与医疗保障基金对基层医疗卫生机构综合改革的支撑作用。

    要加强宣传，提高相关部门对推进支付方式改革重要性的认识，做好相关政策培训，保证支付方式改革工作的顺利推进。

    卫生部

国家发展改革委

财政部

    二〇一二年四月十二日