新京报讯 (记者韩宇明)人社部、财政部以及卫生部近日联合下发《关于开展基本医疗保险付费总额控制的意见》，明确我国医保在两年时间内全面推行付费总额控制(以下简称“总额控制”)，通过合理预算，控制医保费用支出，使之合理增长。

The Beijing news - (Reporter HanYuMing)People club department/The ministry of finance and the ministry of health recently jointly issued[About the development of the basic medical insurance for the opinions of the total amount control],Clear medical insurance in our country in two years time for the full implementation of the total amount control(Hereinafter referred to as"Total amount control"),Through the reasonable budget,To control the medical insurance cost,Make the reasonable growth.

医保费用不合理增长成改革重点 The medical insurance cost is not reasonable growth into reform key

　　伴随着我国医保的全覆盖，医保费用增长过快的问题逐步凸显。一些地方甚至出现了医保基金亏损的现象。

Along with our country all the medical insurance coverage,The medical insurance cost growth too fast problem gradually highlight.Some places even appeared the phenomenon of the medical insurance fund losses.

　　复旦大学经济系副系主任、社保研究中心研究员封进介绍，以往医院和医保结算费用是后付制、医生主导费用有牟利冲动；而医保覆盖后，患者因为能报销，也就会更多地去看病。尤其是前者，是当下产生过度诊疗的主要原因。这些都会导致医保费用支出不合理增长，给医保基金带来风险。

Fudan university department of economics vice dean/Social security research center researchers seal into is introduced,In the past the hospital and medical insurance settlement fee is paid after the system/The doctor is leading cost profit impulse;And after the medical insurance coverage,Because patients can submit an expense account,Will have more to go to the doctor.Especially the former,Is instantly unduly the main reason for the diagnosis and treatment.These will lead to medical insurance cost is not reasonable growth,The medical insurance fund to risks.

控费需以近三年数据为准 To control cost nearly three years data shall prevail

　　近日，三部委联合下发《意见》，明确我国医保在两年时间内全面推行付费总额控制(以下简称“总额控制”)，通过合理预算，控制医保费用支出，使之合理增长。

recently,The three ministries jointly issued[opinion],Clear medical insurance in our country in two years time for the full implementation of the total amount control(Hereinafter referred to as"Total amount control"),Through the reasonable budget,To control the medical insurance cost,Make the reasonable growth.

　　《意见》明确了总额控制的费用测算方法。即以定点医疗机构历史费用数据和医保基金预算为基础测算，同时考虑医疗成本上涨、基金和医疗服务变动等情况合理确定。

[opinion]Has been clear about the total amount control of cost calculation method.That is to nod medical establishment historical cost data and based on the medical insurance fund budget estimates,At the same time considering the rising medical costs/Fund and medical service changes to reasonably determine the situation.

　　确定控费总量时，要扣除参保单位和个人一次性预缴保费、统筹区域外就医、离休人员就医和定点零售药店支出等费用。综合考虑各类支出风险，统筹考虑物价水平、参保人员医疗消费水平等因素，确定医保基金支付的年度总额控制目标。

Determine the total amount control fee when,To deduct ginseng protect unit and individual one-time pay insurance cost/The plan as a whole to regional medical treatment/Medical personnel retire and designated retail pharmacy spending and other fees.Considering the risk of all kinds of spending,Considering the overall price level/Ginseng protect personnel to factors such as medical consumption level,Determine the medical insurance fund pays annual total amount control target.

　　控费总量确定后，再细化分解到各类医疗机构。意见明确，细化控费目标，需要以近三年的数据为准，主要包括服务提供情况和实际医疗费用。然后按照不同级别、类别、定点服务范围、有效服务量以及承担的首诊、转诊任务等因素，并区分门诊、住院等费用，细化落实到各定点医疗机构。

The total amount control cost is determined,Then refining decomposition to all kinds of medical institutions.Opinion clear,Refining control cost target,Need to nearly three years of data shall prevail,Mainly includes the service conditions and actual medical expenses.Then according to the different levels/category/Point scope of services/Effective services and take the first diagnosis/Factors such as referral tasks,And distinguish outpatient service/Hospitalization expenses,Refining implement to the designated medical institutions.

【监管】 控费情况要公开通报 [supervision] Control fee situation to public bulletin

　　总额付费改革将逐步建立以保证质量、控制成本、规范诊疗为核心的医疗服务评价与监管体系。控制医疗费用过快增长，提升医保保障绩效。

Pay the total reform will gradually establish to ensure quality/Control cost/Standard diagnosis and treatment is the core of the medical service evaluation and supervision system.Control medical cost too fast growth,Improve health care security performance.

　　记者了解到，此前部分地方已试点医保付费总额控制，但是大多限于医保部门和医院内部。公众对于控费的程序和控费效果知之甚少。

The reporter understands,Previous parts already pilot medical insurance pay total amount control,But mostly confined to the health department and hospital internal.To control the cost of the program and control cost little effect.

　　对此，此次意见特别明确，医保总额控制情况要定期公开。其管理程序要公开透明，控制管理情况要定期向社会通报。

this,The opinions specifically,Total amount control of medical insurance to the public on a regular basis.Its management program to transparent,Control management to the society regularly to report.

　　同时，要建立医保经办机构和医院之间协商的机制。在分解地区总额控制目标时，广泛征求医院、相关行业协会和参保人员代表的意见。

At the same time,To establish medical insurance agency orgnaization and between hospital consultation mechanism.The total area in decomposition control goal,Asked for a wide range of hospital/Relevant industry associations and ginseng protect personnel representative opinions.

　　为避免协商中出现暗箱操作的情况，意见明确，医保经办机构与医院协商不搞“一院一谈”，协商确定的总额控制指标要及时向社会公开。

In order to avoid negotiations appear black case work situation,Opinion clear,Protects agency orgnaization and hospital consultation don't make"A court a talk about",Consult to determine the total amount of the control indicators to the public in time.

【处罚】 推诿病人将扣保证金 [punishment] Shuffle the patient will buckle margin

　　总额控制的目的是通过合理预算，控制医保费用支出，使之合理增长。不过，在前期各地试点中，也出现了一些负面效应。一些医院为了完成控费目标，推诿病人或者降低诊疗服务。

The purpose of total amount control is through the reasonable budget,To control the medical insurance cost,Make the reasonable growth.but,The pilot in all in,Also appeared some negative effect.Some hospitals in order to complete the control cost target,Shuffle the patient or lower medical services.

　　对此，意见提出各地在确定医院的控费总量后，可以先预留一定比例的质量保证金和年终清算资金。控费目标以月结算，年终再进行审核。在此基础上，医疗服务数量或质量不符合要求的，将扣除保证金。

this,All opinions put forward in the determination of the hospital after total cost control,We can reserve a certain proportion of quality security and year-end settlement fund.Control cost target on settlement,Year-end audit again.On the basis of,The medical service quantity or quality does not comply with the requirements,Deposit will be deducted.

　　此外，各地将完善医疗保险信息系统，畅通举报投诉渠道，明确监测指标，加强重点风险防范。同时建立部门联动工作机制，加强对违约、违规医疗行为的查处力度。

In addition,Cities will be perfect medical insurance information system,Clear reporting and complaint channels,Clear monitoring indicators,Strengthen the key risk prevention.At the same time, set up department linkage mechanism,Strengthen the breach of contract/Illegal medical behavior investigation dynamics.