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Notice from the National Medical Insurance Administration on the issuance of guidelines for the standardization of medical insurance work
Author:
Notice from the National Medical Security Administration on the Issuance of Guidelines for Medical Security Standardization Work
Medical Insurance Document [2019] No. 39
Medical Security Bureaus of all provinces, autonomous regions, municipalities directly under the central government, and the Xinjiang Production and Construction Corps:
In order to accelerate the promotion of medical security standardization construction, our bureau has drafted the 'Guidelines for Medical Security Standardization Work', which is now issued to you. Please earnestly implement it in conjunction with actual conditions.
National Medical Security Administration
June 20, 2019
Guidelines for Medical Security Standardization Work
In order to deeply implement the national standardization strategy and accelerate the formation of a nationally unified medical security standardization system, based on the requirements of documents such as the 'State Council Notice on Issuing the Reform Plan for Deepening Standardization Work' (Guo Fa [2015] No. 13) and the 'National Standardization System Construction Development Plan (2016-2020)', and in conjunction with the needs of medical security reform and development, these guidelines are formulated.
1. Fully recognize the importance and urgency of medical security standardization work
Standardization is a basic element of modern society, reflecting the Party's governance philosophy and ruling strategy. General Secretary Xi Jinping pointed out that China will actively implement the standardization strategy to promote innovation development, coordinated development, green development, open development, and shared development through standards. Medical security is a major livelihood project related to the health and well-being of the people, and its standardization work will affect the improvement of the medical security system. After more than 20 years of operation of the medical security system in our country, a unified standardization system has not yet been formed, making it difficult to meet the requirements of modernizing medical security governance. All regions should fully recognize the importance and urgency of medical security standardization work, further unify thoughts, clarify goals, use scientific means, take effective measures, and solidly promote medical security standardization work.
2. Accurately grasp the overall requirements of medical security standardization work
(1) Guiding ideology.
Guided by Xi Jinping's Thought on Socialism with Chinese Characteristics for a New Era, fully implement the spirit of the 19th National Congress of the Communist Party of China and the second and third plenary sessions of the 19th Central Committee, adhere to the people-centered development philosophy, actively adapt to the needs of medical security reform and development, unify planning, classification, publication, and management, formulate various medical security standards, promote standard implementation, and form a nationally unified medical security standardization system to support the high-quality development of medical security in the new era.
(2) Basic principles.
1. Adhere to top-level design and overall planning. Centered on the goal of modernizing medical security governance, play the leading role of the National Medical Security Administration in policy guidance, system construction, and organizational coordination, and promote the national medical security standardization work in a coordinated manner.
2. Adhere to scientific authority and people-oriented principles. Referencing existing international, national, and industry standards, widely solicit opinions, gather consensus from all sectors, and scientifically formulate standards. Starting from standardized management and service enhancement, increase the applicability and accessibility of standards.
3. Adhere to demand orientation and prioritize urgent needs. Based on the needs of medical security reform and development, highlight key points, prioritize urgent needs, and formulate and implement various medical security standards in batches. Supported by the national medical security information construction, gradually form a nationally unified standard specification.
4. Adhere to pilot first and promote steadily. Based on the needs of standardization construction, implement medical security standards first in pilot areas for information technology, strengthen dynamic maintenance, continuously improve and revise, promote the smooth implementation of standards, and ensure that the public's medical settlement is not affected.
(3) Main goals.
Establish a standardization work mechanism led by the National Medical Security Administration, recognized by relevant departments, and collaboratively promoted by localities, forming a standardization system that is compatible with the reform and development of medical security. By 2020, based on the construction of a unified national medical security information system, gradually achieve the implementation of coding standards for 15 information business items such as disease diagnosis and surgical operations. During the '14th Five-Year Plan' period, form a national medical security standard list and initiate the research, formulation, and trial improvement of some medical security standards.
3. Establish and improve the medical security standardization system in the new era
(1) Improve the foundation of standardization work.
1. Conduct basic research. Adhere to goal-oriented and problem-oriented approaches, strengthen basic research on medical security standardization within the framework of the national standardization strategy, and provide theoretical basis and practical support for the construction of the medical security standardization system. Conduct comparative studies on foreign medical security standardization and related industry standardization to enhance the quality of standardization work and promote the connection between medical security standards and other industry standards.
2. Establish a working mechanism. Establish a medical security standardization working mechanism with clear responsibilities, systematic synergy, and upward and downward linkage. The National Medical Security Administration will manage and organize the research and formulation of various standards, carry out dynamic maintenance and improvement work. Local medical security departments will actively participate in standard formulation according to national arrangements, implement various standards, and formulate local standards based on actual needs and regional characteristics.
(2) Strengthen standardization work in key areas.
1. Basic common standards. Establish a nationally unified basic common standard for medical security, forming a 'common language' for the co-construction and sharing of the national medical security system and the connection and exchange of relevant departments and units. This includes medical security information business coding standards, unified identification, file management specifications, and technical standards related to network security, data exchange, and operation maintenance involved in medical security information construction.
2. Management work specifications. Improve work specifications covering medical security fund management, business operation management, medical price and bidding procurement management, etc. This includes fund management and operation business specifications such as review, settlement, payment, transfer, continuity, cross-regional settlement, and payment method management, as well as specifications for the construction of operating institutions and the behavior of operating personnel, and specifications for the management of medical service items and prices, as well as the bidding procurement management of drugs and medical consumables.
3. Public service standards. Optimize public service standards for medical security that are quick, efficient, convenient, and practical. This includes public service specifications for basic medical insurance enrollment, information disclosure, personal information inquiry, etc., agreement management specifications between medical security operating departments and designated medical institutions and other third-party organizations, long-term care insurance disability assessment standards, service item standards, etc.
4. Evaluation and supervision standards. Establish performance evaluation and service evaluation standards for medical security. This includes credit evaluation standards for insured individuals, insured units, designated medical institutions, and their staff, as well as monitoring and management specifications for the operation of medical security funds and medical service price monitoring specifications.
(3) Ensure the implementation of standards.
1. Organize pilot use. Following the approach of first piloting and perfecting, then promoting and popularizing, steadily advance the implementation of various medical security standards. Initially focus on testing the use of coding standards for four information business items: medical insurance disease diagnosis and surgical operations, medical service items, drugs, and medical consumables, and promptly summarize experiences and practices to provide feasible experiences and demonstration guidance for the comprehensive implementation of the remaining 11 information business coding standards.
2. Strengthen dynamic maintenance. Form a dynamic maintenance team, build a dynamic maintenance platform, and carry out dynamic maintenance of medical security standards. Coordinate and link national and provincial dynamic maintenance work, strengthen communication and collaboration between the maintenance team and relevant business departments, and improve the efficiency of standard maintenance. Form various standard consulting expert teams to assist in solving key and difficult problems.
3. Promote the integration of standardization and information technology. Strengthen the foundational support for information technology construction through standardization, and leverage information technology to enhance and lead standardization work. Integrate information technology throughout the entire standardization process to improve the efficiency of data collection, analysis, and organization. Utilize information technology platforms for event management and implement comprehensive traceability.
4. Ensure effective supervision and evaluation of standard implementation. Establish a supervision mechanism for the implementation of medical security standards, forming scientific and reasonable assessment indicators and evaluation methods. Create mechanisms for standard incentives, constraints, and optimization improvements, implement follow-up surveys and inspections, and establish a virtuous cycle of standard formulation, implementation, supervision, evaluation, and revision to enhance the effectiveness of medical security standardization work.
4. Strengthen the supporting measures for medical security standardization work.
(1) Strengthen organizational leadership.
Medical security departments at all levels should strengthen the organizational leadership and overall coordination of medical security standardization work, establish corresponding working mechanisms, consolidate workforces, prioritize standardization work on the agenda, scientifically and reasonably formulate work plans, and meticulously organize the implementation of standardization work.
(2) Gather forces from all sides.
Establish a high-level think tank for medical security standardization, inviting experts from relevant fields to participate, strengthening theoretical research on standardization, and enhancing the level of standardization work. Establish collaborative mechanisms with relevant departments, higher education institutions, social organizations, and other units to fully leverage the role of experts in supporting the formulation and implementation of standards.
(3) Strengthen business training.
Increase the intensity of training on medical security standards, compile training materials, innovate training methods, and improve training efficiency. Focus on enhancing the quality of standardization practitioners, optimizing knowledge structures, and cultivating a team of standardized professionals with solid expertise and rich experience.
(4) Strengthen publicity and guidance.
Utilize various media to comprehensively and multi-dimensionally promote and interpret medical security standards and implementation results, enhancing the influence and credibility of the standards. Guide relevant institutions to accurately grasp the content of the standards, understand the requirements, and improve the level of standardization implementation. Promote the standards within the medical security system to create a strong atmosphere of learning, understanding, and applying the standards.
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