On November 11, the "Notice of the Office of the National Medical Insurance Administration and the General Office of the Ministry of Finance on Doing a Good Job in Prepayment of Medical Insurance Funds" (full text attached at the end of the article) was officially released. According to the notice, in principle, the prepayment is based on the average monthly expenditure of the relevant medical insurance funds in the previous one to three years, and the basic scale is determined, and adjusted in combination with the annual comprehensive evaluation and credit evaluation of designated medical institutions. The prepayment scale is about 1 month.

The document clearly stipulates that medical insurance prepayments shall not be used for non-medical expenses such as medical institution infrastructure investment, daily operation, and debt repayment. The special prepayment of medical insurance funds for centralized volume procurement of drugs and medical consumables shall be implemented in accordance with the original regulations-local medical insurance departments shall prepay medical insurance funds to medical institutions at a special rate of not less than 30% of the annual agreed procurement amount, and support medical institutions to pay the centralized procurement drug money in a timely manner.

At the same time, designated medical institutions need to set up separate ledger management, strictly follow the approval and expenditure procedures for the use of funds, and strictly prohibit borrowing or diverting them for other purposes. Designated medical institutions are also required to set up a detailed account of "medical insurance prepayment" under relevant subjects and calculate it separately. Designated medical institutions applying for prepayment should meet certain basic conditions.

Overall, medical insurance prepayment will be moderately inclined towards medical institutions that cooperate with key medical insurance tasks such as payment method reform, centralized volume procurement, and the implementation of national negotiated drugs; the traceability code information of drugs and consumables should be "scanned and transmitted"; and cooperate with medical insurance departments to carry out routine inspections, special inspections, and flight inspections of fund supervision. However, the coordinated areas that have had a current deficit in the previous year or are expected to have a deficit this year according to the 12-month rolling calculation method cannot make prepayments.

The document further emphasizes that relying on the national unified medical insurance information platform, the prepayment application module should be optimized and improved to realize the integrated operation and management of business flow, capital flow and information flow. The full process of prepayment calculation, payment, recovery, supervision, etc. is implemented in the prepayment application module.

Overall, the document stipulates clear purposes, clear conditions for obtaining, and clear expenditure standards for the medical insurance prepayment system, and also proposes standardized process management, accounting, and fund supervision.

On November 7, the Ministry of Commerce issued the "2023 Statistical Analysis Report on the Operation of the Pharmaceutical Distribution Industry". The report proposes that in 2023, the China Pharmaceutical Commerce Association will conduct a typical survey on the accounts receivable of 545 pharmaceutical wholesalers in 31 provinces (autonomous regions and municipalities).

Data show that the average number of days to collect accounts receivable from medical institutions is 152 days, an increase of 2 days from 2022. The problem of medical institutions defaulting on payments to pharmaceutical wholesalers has not improved, and the financial pressure and financial cost burden of pharmaceutical wholesalers are increasing.

The number of days for pharmaceutical wholesalers to collect accounts receivable from medical institutions from 2019 to 2023

The National Medical Insurance Administration also issued a document pointing out that before drugs are included in centralized procurement, medical institutions and pharmaceutical companies establish a drug buying and selling relationship through contracts, and the contract clearly states the payment time for drugs. The payment time agreed in the contract is often long, and even medical institutions seriously default on payments. It generally takes more than 6 months for pharmaceutical companies to collect payments.

By the end of 2023, there were 14,800 wholesale companies in China. In recent years, the average profit margin of the pharmaceutical distribution industry has been under great pressure, and the payment difficulties of pharmaceutical commercial companies remain to be solved.

Promote prepayment of medical insurance funds: First of all, the "Opinions on Deepening the Reform of the Medical Insurance System", "The 14th Five-Year Plan for Universal Medical Insurance", "Interim Measures for the Management of Medical Insurance Designated Points for Medical Institutions" and other documents require that the medical insurance department may prepay part of the medical insurance funds to medical institutions in accordance with the agreement to alleviate their financial operation pressure.

On July 23, the Office of the National Medical Insurance Administration issued the "Notice of the Office of the National Medical Insurance Administration on Issuing the 2.0 Grouping Scheme for Payment by Disease Group and Disease Score and Deepening the Related Work", which proposed to encourage the use of fund prepayment to alleviate the financial pressure of medical institutions.

"Medical insurance departments in various places can consult with the financial departments at the same level to reasonably determine the basic scale of prepayments based on the fund balance, and prepay about one month's prepayments to designated medical institutions." Wang Guodong, deputy director of the Medical Insurance Center of the National Medical Insurance Administration, pointed out that according to statistics, more than 60% of the coordinated regions in the country are currently exploring prepayments for medical institutions, such as Sichuan and Shaanxi. For example, Sichuan Province prepaid 5.1 billion yuan in settlement fees for 2,345 designated medical institutions in 20 coordinated regions in the province in 2023, accounting for 62.9% of the number of medical institutions above the first level in the previous year, and 6.7% of the basic medical insurance fund hospitalization expenses in the previous year. Fujian Province has established a reserve fund system specifically for ensuring monthly settlement of drug and equipment payments. Fujian's medical insurance and financial departments jointly formulate a unified settlement policy, and the health and health departments are responsible for urging public hospitals to resolve historical debts, and the settlement rate is included in the performance assessment of local governments. Direct medical insurance settlement continues to expand. Recently, the National Medical Insurance Administration has issued several documents introducing measures to explore solutions to the difficulty of collecting payments in many provinces across the country. The collection cycle in some areas has been shortened from 6 months to 30 days. In January 2021, the General Office of the State Council issued the "Opinions on Promoting the Regularization and Institutionalization of Centralized Volume Procurement of Drugs", proposing to explore ways to promote direct settlement between medical insurance funds and pharmaceutical companies by setting up electronic settlement centers for drugs in provincial centralized drug procurement institutions.

So far, Tianjin, Shandong, Fujian, Jiangxi, Inner Mongolia, Hunan, Liaoning, Anhui, Henan, Hebei, Jiangsu and other places have begun to explore and promote the model of direct settlement between medical insurance funds and enterprises for centralized procurement of drugs/consumables.

Among them, the Fujian Provincial Medical Insurance Bureau established a provincial medical insurance monitoring and electronic settlement center to realize the online processing of the entire process of enterprise settlement application, hospital review, medical insurance review, hospital-enterprise reconciliation, and settlement statistical report summary.

The scope of implementation of unified settlement of payment in Fujian has been expanded from drugs in the province to centralized procurement varieties of medical consumables, and the settlement cycle is controlled within 23 working days. From 2017 to 2023, Fujian Province has accumulated direct settlement of 153.3 billion yuan of enterprise drug payments, with a settlement rate of more than 99%, and settled 10.2 billion yuan of centralized procurement medical consumables payments, with a settlement rate of more than 95%.

So far, in addition to Fujian Province, documents from Hainan, Shandong, and Hunan have also revealed signals that direct medical insurance settlement will be expanded to non-centrally purchased drugs/consumables.

On August 21, the Hainan Provincial Medical Insurance Bureau and the Hainan Provincial Medical Insurance Service Center issued the "Implementation Plan for Direct Settlement of Medical Payments between Hainan Medical Insurance Funds and Pharmaceutical Companies".

The plan clearly states that starting from the centralized procurement of drugs, medical consumables and innovative drugs and equipment, direct settlement work will be carried out in designated medical institutions across Hainan Province; at the same time, Wenchang City will be selected as a pilot, and non-centrally purchased drugs and medical consumables of designated public medical institutions within its jurisdiction will be included in the direct settlement scope, and experience will be summarized and implemented throughout the province in due course.

Timely settlement of medical insurance funds, the "Notice of the Office of the National Medical Insurance Administration on Issuing the 2.0 Version of the Grouping Scheme for Payment by Disease Group and Disease Type and Deepening the Promotion of Related Work" proposes to comprehensively clean up the unpaid medical insurance expenses. Before the end of September this year, all localities must carry out a comprehensive cleanup of the medical insurance funds (including residents' medical insurance major disease insurance, etc.) that were unpaid according to the agreement before 2023, and the National Medical Insurance Administration will conduct supervision in due time.

Wang Guodong, deputy director of the National Medical Insurance Administration's Medical Insurance Center, pointed out that in terms of year-end settlement, in the past two years, the National Medical Insurance Administration has issued annual settlement work notices at the beginning of the year to strengthen work deployment, clarify work tasks, and continuously supervise and dispatch. Since the implementation of the DRG/DIP payment method reform in 2019, this year has basically completed the previous year's settlement by the end of June for the first time.

In February this year, the National Medical Insurance Administration issued the "Notice on Promoting "Efficient One-Stop Service" in the Field of Medical Insurance Services", which listed "timely settlement of compliant medical expenses with designated medical institutions" as one of the 12 key items. The "2024 Annual "Efficient One-Stop Service" Handling Work Guide" breaks it down into four links: settlement declaration, intelligent review, timely payment, and encouragement of prepayment. By retrieving data from the national medical insurance information platform, conducting research, supervision and dispatch, etc., follow up on the local settlement situation every month and speed up the timely payment of medical insurance funds.

The continuous solution to the difficulty of collecting payments is conducive to alleviating the financial pressure of enterprises and building a good medical and pharmaceutical relationship.

https://mp.weixin.qq.com/