Real-time medical insurance settlement: convenience behind the game

March 15, 2010, Social Security card in the Beijing platform site, the Beijing Bureau of Human Resources and Social Security Office released the sixth installment of the implementation of the Beijing "card for medical treatment, real-time settlement," the list of designated medical institutions. In the list, both the Chinese Academy of Medical Sciences Cancer Hospital such a top three hospital, but also South Mills, Chaoyang District, community health services such as community health service centers. It is understood that before the end of June 2010, more than 1,800 designated medical institutions in Beijing will all open out-patient card clearing functions.

Operations throughout the city convenient measures

In fact, from the start of 2009, the "card health care, real-time settlement," the pilot had a number of medical institutions in Beijing to start.

Peking University, Beijing Xicheng District People's Hospital is the medical insurance card for medical treatment, real-time settlement of the first pilot. January 2009, People's Hospital received a mandate to prepare before the trial began. September 2009, the acceptance by the relevant departments, to become one of the Western District pilot hospitals.

Reporters in Beijing Yuquan Hospital, Tsinghua University affiliated Department charges that a notice, the above reads, from September 4, 2009, the start of this two hospitals with social security card billing medical expenses.

Local districts and counties from the pilot to start in the past six months have been a lot of time, the people of this measure reflects how convenient it? In March of a morning, the reporters came Yuquan Hospital, in the registration process, the reporter observed that the registration of people, nearly half of the people holding the social security card.

A middle-aged man told reporters he was with children to see the doctor, the child's hand was injured when playing basketball, registration fee is 3.5 yuan, and now with "real-time settlement" paid 2 yuan medical insurance co-ordinate themselves today only the actual cash paid 1.5 yuan.

The parents said that in the past, different hospitals have different doctor each card, now have social security card, medical card people, the social security card to become a "card" can replace the hospital's attendance card on no longer appears a person to bring it to the hospital several more cards situation.

It is understood that card for medical treatment, patients in the payment burden on individuals should only pay the medical expenses, medical expenses should be reimbursed by the health insurance sector medical institutions and the direct settlement of insured claims for medical expenses to shorten the time from several months to tens of seconds. Moreover, the individual should be reimbursed for medical expenses be zero advance, and will not appear as in the past, "claims a long cycle, personal advances and more" situation.

In the Yuquan Hospital, a gentleman with chronic diseases, told reporters he wanted to go to a hospital a week and open a number of commonly used drugs in the past may be more than a month for reimbursement of time to wait even longer, but also a variety of instruments not less, is now fully completed by the computer system, for him is registered and the time to show what social security card settlement on the line, very convenient.

According to the Social Security card service platform, Beijing public information site, to the end of February 2010, Beijing Xuanwu only one area of the 43 designated medical institutions, have taken place card transaction data 186 000 pen, out-patient medical costs occur 3312.95 million, the work of medical institutions to run properly.

Action needs to step up efforts

In the interview, reporter friends around a small area of the social security card to receive surveys. Mr. Tang at the Haidian District, the Taiwan-funded enterprises, he told reporters he had received a social security card, but has not been used. Mr. Xue, Ms. Lu, Chaoyang District, respectively, private and foreign work, they did not receive to their own social security card. Reporter after another asked around then About ten friends, of which more than half do not get social security card.

According to the Social Security card service platform in Beijing website publicly available information, eight urban districts of Beijing have issued more than 300 million social security card, some of the district has completed the issuance of social security card insured work, over 99% of the insured have been given a social security card, Fangshan and some suburban districts and counties have already started.

Information, social security card works in accordance with the progress of Beijing demands, social security card issued in the order in line with Beijing's first "urban workers" after "urban residents" of the principle that the first payment of medical insurance for urban workers to participate in the staff, and then release medical insurance for urban residents to participate in personnel. Urban workers and social security card for payment of time divided into four phases: the end of December 2009, before the completion of Shijingshan District Xicheng District, two pilot areas and the release of social security card work; 1st quarter of 2010, began issuing Dongcheng District, Xuanwu District, and Chongwen District's social security card; in 2010 Q2, to Haidian District, Fengtai District, Chaoyang District, and the release of social security card work; second half of 2010, social security card for payment of other county work.

It is understood that the Beijing Municipal social security card service system mainly service outlets by the social security card, social security card hotline, web site and social security card social security card services, self-service terminals in four parts. In which social security card hotline "96102" is the 24-hour service, social security card services self-service terminals also have social security card service network and the city's designated medical institutions for more than two to install. However, reporters found the whole service system is still there to be improvement.

Interview with reporters call the "96102" hotline card which hospitals can be real-time settlement, the operator told us that his hand only the first three to implement "medical card, real-time settlement," the list of designated medical institutions, The fourth, fifth, sixth list also need to press their own online searching. This reporter familiar with the network and Internet conditions to facilitate access by people, This is not any problem, but for some special insured, such as some elderly people, online searching is not easy, the hotline should be the most convenient one query methods.

In the Yuquan Hospital, the reporter saw a social security card self-service terminals have been installed in place, side by side is a self-service payment terminals, but the former appears to be no power on, the screen is also off a layer of ash.

March 24, in Beijing, Human Resources and Social Security Bureau and the Internet users in online communication activities, the council responded to the relevant person in charge users for medical treatment on the social security card real-time settlement of various issues. Some netizens suggested that the current card to the hospital after medical treatment point of view the documents can not reimburse individuals how much money that year, hoping to solve. City Social Council responsible persons who respond, the council has to provide documentation of hospital-related content on the changes, an increase of at their own expense, from the pay line, the year accumulated large medical expenses paid and the balance of mutual funds and other related content. Among them, the "large medical expenses during the year the balance of mutual funds" is also the year the amount of money reimbursed. The revised cost of documents will be May 1, 2010 opening.

There are two sides behind the game

As a convenience and benefit of "livelihood projects", "social security card real-time settlement for medical treatment" behind the need for good information systems as a support system through information and linking hospitals and healthcare centers. And information technology within the organization compared to information technology across the organization are often particularly difficult. To make the city more than 1,800 medical institutions designated open out card clearing functions can imagine the work behind the difficulty of the workload and how great - not only the application of IT technologies, IT system implementation, but also on the original management system, work patterns and business process reform and innovation.

During the interview, the capital of the CIO over the hospital to "Computer World" newspaper reporters that the medical treatment in promoting social security card real-time settlement process, the Health Insurance Center has played a strong role. Undeniable that a strong, overall hospital information technology in promoting the rapid development of construction played a positive role, many hospitals and the medical insurance system for docking, are actively improve or upgrade the existing hospital information systems.

"Even if 0:00, health care centers If people call me to let me go check out, I definitely do not dare." An industry source said, "are afraid to offend any hospital health insurance."

Why should Medicare Centre Hospital so deferential? The industry gave away the secret, on the one hand to grasp a lot of money because of Medicare. In general, for an ordinary two hospitals, health care centers reimbursement amount paid to hospitals around the 100 million yuan, three hospitals, medical insurance amount is even greater, any one president is not such a big healthcare ignore groups. On the other hand, universal health care is a major national policy is an important part of the new medical reform, which the President did not dare go against the theme of this era.

At the same time, the CIO who frankly, medical insurance information system building in the hospital for standard medical procedures also played a very active role. Regulation and promotion through health insurance, the hospital management more scientific: from extensive to elaborate, from vague to precise, from fragments to full control. For example, patient 10 in the morning if you want surgery, but the 8 am opening the medicine has been out since 8 am still in the implementation of preoperative medical advice, after your doctor has not prescribed. In accordance with regulations ban water to fast before surgery, 8 am therefore not in patients taking the medicine. That is, although not in patients taking the drug at 8 am, but hospital charges Shique count this drug. Once found that Medicare does not eat the medicine been charging problems, may have to impose hefty fines on hospitals. Hospital course, very odd, because the hospital information system processes is so developed. So the hospital and medical insurance system when docked, it must begin the process of information systems to optimize.

Practical work, this positive effect has also brought some "side effects." In Beijing, "social security card real-time settlement for medical treatment," the construction of medical institutions, health insurance center feels like a strong "mother," like a bullied his "little wife." The face of strong "mother" of the stringent requirements, "Lady" only orders the implementation of envy, but not with the "mother" equal exchange and dialogue, the "Lady" is nowhere to complain complaining.

Beijing Hospital is a subsidiary of institutions of higher learning in Beijing for medical treatment medical insurance card, real-time settlement of the first trial, received a mandate from, to acceptance by the relevant department, before and after the experience of eight months. "In the last eight months of the implementation process, we always feel very Wohuo." Assistant dean, told reporters Wohuo reason is that hospitals feel relevant agencies and real-time billing technology program is unreasonable.

According to the technical program, medical insurance as a center, in the hospital to install front-end (single), all the front desk to use the front-end exchange. And front-end are all single, no hot standby program, switching between the two front-end server to 15 minutes. This means that the hospital become the healthcare data network can upload the key to successful real-time, less stable.

"We all know, our hospital's network or when the switch will certainly be problems, but if there are problems, Medicare will all liability, all risks are all pushed to the hospital's head." According to information of a hospital in Beijing, director introduced "If a health insurance network or front end problems, the service will be responsible for; if the problem is elsewhere, not only to the reimbursement of medical insurance, but also punish the hospital."

"Looks like a clear distinction in responsibility, in fact, if there are problems after the responsibility is blurred. For example, in the pilot stage, a renowned Orthopedic Hospital of Beijing Medical Insurance from the server be a 'black' the. Hard to say hospital or system's responsibility?, as it is in the design itself can be remotely controlled. "one insider said:" Prime Machine is an extension of health insurance center network, if there are problems, health care centers do not review issues its own structure , do not review their own security, but to push all the responsibility to the hospital. "

All the parties to hear different voices, journalists feel that all is normal. Even as the United States carried out nearly a hundred years of national health insurance system, Obama health care reform have given rise to controversy, argument, and even extremists clamoring to "rise up and overthrow this country."

Medicare reform is definitely a trend, an inevitable development, but also from the Government's original intention and policy of the designer's perspective, certainly hope that the first benefit for the people to ensure that all the improvements in health, followed by the interests of all parties to achieve balance, or to find a coordinated mechanism. Now China is in the initial stage of building universal health insurance, the policy certainly imperfect, supporting local, the parties certainly biased understanding of the place, do not place them there will be a place, or even distorted, and this a process, coordination and balance in the interests of the middle of continuous exploration.











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