Ngomhla we-5 Septemba, i-State Medical Security Bureau yakhupha iSaziso se-State Medical Security Bureau ngokwenza umsebenzi oMhle ekuLawulweni kweNtlawulo yezoNyango kwi-Inshurensi yoNyango oluSisiseko (emva koku lubizwa ngokuba "yiSaziso"), ebandakanya i-4 enkulu. iinxalenye kunye namanqaku ali-15.Izinto zonyango ezisetyenziswayo ekubhekiselwe kuzo kwiSaziso zezo zibhalisiweyo okanye zafayilishwa ngabasemagunyeni bezixhobo zonyango, zinikwe ubume boluhlu kwaye zinokuhlawuliswa ngokwahlukeneyo.
NgokweSaziso, ukususela kumhla wokukhutshwa kwesi Saziso, amaphondo kufuneka anike ingxelo kwi-State Medical Insurance Bureau ukuze afumane irekhodi phambi kokuba azise ikhathalogu yezinto ezisetyenziswa zonyango ukuze ziphunyezwe.Amasebe e-inshorensi yezonyango kwiphondo ayakhuthazwa ukuba athathe imo yomanyano lwengingqi okanye intsebenziswano ukuze ahlolisise ukusekwa kwekhathalogu edibeneyo esetyenziswayo kunye nemigangatho yokuhlawula ngaphakathi kwimbumba okanye ummandla.I-NHPA iya kuphehlelela uphuhliso lwekhathalogu yesizwe yezinto ezityiwayo zonyango kwi-inshurensi yezonyango ngexesha elifanelekileyo.
Amanqaku aphambili ashwankathelwa ngezantsi:
Inqaku 1: Ukukhuthaza umanyano lwesizwe lokuhlelwa kunye nekhowudi yezinto ezisetyenziswayo
ISaziso sichaza ukuba ukuhlelwa kunye nekhowudi yezinto ezityiwayo zonyango kufuneka zidityaniswe.Ukukhuthaza ngokuqinileyo ukusetyenziswa kwekhowudi yonyango ye-inshorensi yezempilo yesizwe, ngexesha elifanelekileyo ngokuhambelana ne-National Health Insurance Bureau ukuphuhlisa ulwahlulo lwezinto ezityiwayo zonyango kunye nekhowudi yogcino-lwazi ukwenza umsebenzi omhle wokuhlaziya ikhowudi ye-medical consumables codes ukusetyenziswa kokuchaneka kunye nomgangatho wekhowudi yezinto ezityiwayo zonyango ukufezekisa izinto ezityiwayo zonyango kunye nekhowudi yokuthengwa kwempahla, kunye nekhowudi yokusetyenziswa, kunye nokuhlawula ikhowudi, kunye nokulawulwa kwekhowudi, kunye nokuqinisekisa ukuba ukuhlelwa kwezinto ezidliwayo zonyango kunye nekhowudi umanyano lwesizwe.
Inqaku lesibini: ukwahlulwa kokusetyenziswa kwetekhnoloji, olu hlobo lwezinto ezisetyenziswayo kwintlawulo ye-inshorensi yezonyango
ISaziso sibonisa ukuba ububanzi bezinto ezisetyenziswayo ezinokuthi zibandakanywe kwintlawulo ye-inshurensi yezonyango.Ukuziqhelanisa nohlaziyo lwexabiso lenkonzo yonyango "iinkonzo zobugcisa kunye nokusetyenziswa kwezinto ezahlukeneyo" umgaqo, ukomeleza iprojekthi yexabiso leenkonzo zonyango kunye noqhagamshelwano lolawulo lwentlawulo yeendleko ezityiwayo, kwaye ngokuthe ngcembe aziyi kufakwa kwixabiso lenkonzo yonyango ekubunjweni kwexabiso lezinto ezityiwayo zonyango ngokutsho amalungiselelo olawulo lwentlawulo ye-inshorensi yonyango.
Inqaku lesithathu: ezi zinto zisetyenziswayo aziyi kufakwa kumgaqo-siseko kwintlawulo ye-inshurensi yonyango
Ngokumalunga nokufikelela kwi-inshurensi yezonyango, "iSaziso" sibonelela ngokuhambelana "nesiseko" sokubeka umsebenzi.Ukufikelela kunye nolawulo lwezinto ezisetyenziswa kwi-inshorensi yonyango esisiseko kufuneka zihlale zibambelele ngokuqinileyo kwindawo yokusebenza "esisiseko", benze konke okusemandleni abo, ngokweendlela zabo, kwaye bamisele ngokufanelekileyo umda wentlawulo kunye nemigangatho yokuhlawula, kugxininise kwindima yokuthenga ngobuchule bonyango. ingxowa-mali ye-inshorensi, iya kuba yimfuneko ngokwezonyango, ikhuselekile kwaye isebenzayo, izinto ezisetyenziswayo zonyango ezinexabiso elifanelekileyo kumda wentlawulo ye-inshurensi yezonyango ngokuhambelana neenkqubo.Izinto ezisetyenziswayo zonyango ziya kufakwa kwi-scope yentlawulo ye-inshurensi yonyango ngokuhambelana neprogram.
Ngokomgaqo, izinto ezisetyenziswa zonyango ezinexabiso eliphantsi lonyango, amaxabiso okanye iindleko ezidlula kude ukufikeleleka kwengxowa-mali kunye nezigulana, kunye nezixhobo ezingezizo ezonyango lokubuyisela kwisimo sangaphambili aziyi kubandakanywa kwintlawulo ye-inshorensi yezonyango.Ukuze urhulumente afune ngokucacileyo ukuba angabandakanyi kwi-scope ye-inshurensi ye-inshurensi yokuhlawula izinto ezisetyenziswayo, zihambelane nemimiselo yokuqala.
Inqaku lesine: ukuphunyezwa ngokuthe ngcembe kwe-inshorensi yonyango yolawulo lwegama eliqhelekileyo
ISaziso sibonisa ukuba i-State Medical Insurance Bureau iya kufunda ngokusekwa kwenkqubo yolawulo lwamagama aqhelekileyo kwizinto ezisetyenziswa zonyango phantsi kwe-inshorensi yezonyango, ngokusekelwe kuluhlu kunye nekhowudi yolwazi lwezinto ezityiwayo zonyango phantsi kwe-inshurensi yezonyango, imisela imimiselo yokubiza amagama afanelekileyo kulawulo lwe-inshorensi yezonyango. intlawulo ye-inshurensi yonyango, ngokuthe ngcembe iqulunqe imigaqo yokubiza amagama aqhelekileyo kwiindidi ezahlukeneyo zokusetyenziswa kwezonyango, kwaye uhlanganise igama eliqhelekileyo le-inshurensi yezonyango njengesiseko sesinyathelo esilandelayo ekulawuleni intlawulo ye-inshurensi yezonyango.
Kwizinto ezisetyenziswayo zonyango ezinamagama aqhelekileyo asele aqulunqwe, kufuneka sikhuthaze ngokunyanisekileyo ulawulo lwentlawulo ye-inshurensi yonyango kwizinto ezidliwayo zonyango ngokwamagama aqhelekileyo.Ukusetyenziswa kwezonyango ezingekaphuhli igama eliqhelekileyo, ulwahlulo lwangoku kunye nekhowudi iya kusetyenziswa ngexesha lolawulo lwentlawulo ye-inshurensi yonyango.
Inqaku lesi-5: Ixesha “le-14 leminyaka emihlanu”, ukusekwa kwekhathalogu yephondo yezinto ezisetyenziswayo kwi-inshorensi yezonyango
ISaziso sikwenza kucace ukuba ulawulo lofikelelo lwekhathalogu yezinto ezityiwayo zonyango luqhubela phambili ngokuthe chu.Ukukhuthaza ukusekwa kwenkqubo evakalayo yokufikelela kwizinto ezityiwayo zonyango, ixesha “le-14 leminyaka emihlanu”, kufuneka ligqitywe ngokomthetho wofikelelo ukuze kuphuhliswe iphondo (imimandla ezimeleyo, oomasipala ngokuthe ngqo phantsi koRhulumente oMkhulu) ulawulo oludityanisiweyo lwe-inshorensi yonyango olusisiseko lwe-inshorensi yonyango.
Kweli nqanaba sele kumiselwe i-inshorensi yonyango emanyeneyo ye-inshorensi yonyango kwi-consumables directory yommandla, ngokusekwe okwethutyana kwi-inshorensi yezonyango ye-inshorensi yonyango ye-medical classification kunye nekhowudi, kwaye ngokuthe ngcembe ukuya kwi-inshorensi yonyango yenguqu yolawulo lwegama eliqhelekileyo.Okwangoku akukasenzi uluhlu lwezixhobo zonyango ezimanyeneyo zephondo zokwandisa iinzame ukuya “kwiSicwangciso seMinyaka emiHlanu ye-14” ukuseka uluhlu lwezixhobo zonyango olumanyeneyo lwephondo.
Ukwenzela ulawulo lwamayeza afana nalawo asetyenziswe ngabenzi asele ekhulile, urhulumente uya kuthi ngokuthe ngcembe aphuhlise ikhathalogu ye-inshorensi yonyango emanyeneyo yesizwe, kwaye ngokuthe ngcembe andise umda wekhathalogu yesizwe egutyungelwe ludidi lwezinto ezisetyenziswayo.
Inqaku lesi-6: Ukuseka indlela yolungelelwaniso oluguquguqukayo kwaye uphonononge ufikelelo ekuvunyelwene ngalo kwizinto ezityiwayo kuphela.
NgokweSaziso, iphondo ngalinye kufuneka liququzelele izinto ezityiwayo zonyango, iklinikhi, ulawulo lwe-inshurensi yezempilo, uvavanyo lwetekhnoloji kunye nezinye iingcali kunye nemibutho enxulumene noshishino, ngenkqubo yovavanyo olusemgangathweni, izinto ezisetyenziswayo zonyango ezifanelekileyo kuluhlu ngokuhambelana neenkqubo, kunye iziphumo zovavanyo ziya kubhengezwa kuluntu kwangexesha.Khuthaza umba ophambili uqukwe kwikhathalogu yezinto ezityiwayo ezikhethiweyo ukusuka kwintengiso ephakathi nendawo ethobela umgaqo-nkqubo wentlawulo yangoku.Jonga ufikelelo kwiimveliso ezikhethekileyo okanye zexabiso eliphezulu ngothethathethwano kunye nezinye iindlela.
Ukongeza, kufuneka kusekwe indlela yohlengahlengiso oluvakalayo.Ukuqwalasela ngokubanzi inkqubela yobuchwepheshe yezinto ezityiwayo zonyango, ukusetyenziswa kwezonyango, amaxabiso kunye namanqanaba eendleko, kunye nokufikeleleka kwengxowa-mali ye-inshorensi yezonyango kunye nabantu abafakwe kwi-inshorensi, njl. njl., ukuqonda uhlengahlengiso oluguqukayo lokungena nokuphuma.Ukuzaliswa kwangexesha kweemveliso zeteknoloji entsha eziyimfuneko, ukurhoxiswa kweklinikhi kunokutshintshwa ngcono, ukuvavanywa koqoqosho olubi, ngamasebe afanelekileyo afakwe kuluhlu olubi kunye nezinye iimveliso azihlangabezani neemfuno ze-inshurensi yezonyango.
Kwangaxeshanye, ukusekwa kwenkqubo evakalayo yokuthintela ubungozi bokulungelelaniswa kobubanzi bokuhlawula i-inshurensi yonyango, ukhuseleko lwengxowa-mali, unyango lwezigulane ixesha elide lokubala ngokuchanekileyo, ngenxa yeengozi ezinokubakho ukuphuhliswa kwesicwangciso, ngokukodwa ukubandakanya ukudluliselwa kobubanzi bentlawulo yeentlobo zezinye iindlela ukwenza umsebenzi omhle wokuqinisekisa ukukhuselwa kwamalungelo kunye nomdla wezigulane.
Inqaku lesi-7: Kancinci-kancinci ukulungelelanisa umgaqo-nkqubo wentlawulo kwiphondo
ISaziso sichaza ukuba umgaqo-nkqubo wentlawulo kufuneka ulungelelaniswe kwaye uphuculwe.Ukukhuthaza umgaqo-nkqubo wentlawulo ukuba ube nobunzululwazi ngakumbi kwaye usulungekiswe, kwaye ngokuthe ngcembe ukhuphe umgaqo-nkqubo wentlawulo oqhabalakayo osekelwe kuphela kwintlawulo ecandiweyo yenqanaba leendleko, kunye nenani elinye-lilingana-konke i-quota okanye intlawulo eqingqiweyo.
Imimandla elungelelanisiweyo inokuthathela ingqalelo izinto ezifana nokufikeleleka kwengxowa-mali kunye nomthwalo kumntu ofakwe kwi-inshorensi, kwaye ngokwemeko yokwenyani yexabiso elithile eliphezulu okanye ixabiso lezinto ezityiwayo zonyango ukuseta umlinganiselo wentlawulo wokuqala ophuma epokothweni.Amasebe e-inshorensi yezempilo yephondo kufuneka aqinise ulungelelwaniso, alinganise ngokuthe ngcembe imigaqo-nkqubo yentlawulo kunye namanqanaba okhuseleko emimandla ehlangeneyo yephondo, kwaye akhuthaze amaphondo anemiqathango ukuba aqonde umanyano ngokwesiseko sephondo kwangethuba.
Inqaku lesi-8: Ukusekwa kwendlela yokukhuthaza i-DRG/DIP ye-synergistic
Ukukhuthaza imigangatho yentlawulo ngendlela ezinzileyo nelungeleleneyo.Ukukhuthaza amaphondo ukuba ahlolisise uphuhliso lwemigangatho yokuhlawula izinto ezisetyenziswa zonyango kwi-inshurensi yezonyango kunye nokwenza uhlengahlengiso oluguqukayo.Ukuphucula indlela yokusebenzisana phakathi kwemigangatho yentlawulo kunye namaxabiso okuthenga kwindawo enye, kwaye umisele imigangatho yentlawulo yeemveliso ezikhethwe kwindawo ekumbindi yokuthenga ngokuhambelana nemimiselo efanelekileyo.Phonononga uthethathethwano lofikelelo kunye nezinye iindlela zokumisela ngokwengqiqo imigangatho yentlawulo yexabiso eliphezulu lezinto ezityiwayo zonyango.Kwizinto ezisetyenziswayo zonyango ezinomsebenzi ofanayo kunye nokusetyenziswa, izinto ezifanayo kunye neempawu, ukutshintshwa kwekliniki, kunye nokudibana kolawulo lwe-inshurensi yezonyango, imigangatho yentlawulo edibeneyo inokuqulunqwa.
I-Synergize uhlaziyo lwendlela yokuhlawula.Ukuseka indlela yokukhuthazwa kwe-synergistic ne-DRG, uhlaziyo lwendlela yokuhlawula ye-DIP kunye neminye imigaqo-nkqubo ukwenza isiphumo esihle sokupakisha.Qwalasela umda wentlawulo, umgangatho wentlawulo kunye nomgaqo-nkqubo wentlawulo yezinto ezisetyenziswa zonyango ngendlela edibeneyo, kwaye uphucule uhlahlo lwabiwo-mali olupheleleyo kunye nomgangatho wentlawulo yeentlobo zezifo / amaqela ngexesha elifanelekileyo.
Inqaku lesithoba: ezi zinto zisetyenziswayo zijolise ekubekeni iliso
NgokweSaziso, kufuneka kusekwe indlela yokubeka iliso nokuvavanya intlawulo ye-inshorensi yezonyango.Amaphondo rhoqo malunga nokufikelela kwi-inshurensi yezempilo kwi-inshurensi yezempilo, intlawulo ye-inshurensi yezempilo, umthwalo wezigulane, njl. njl., kunye nokuthengwa kwe-intanethi, izinga lokuthengwa kwe-intanethi, njl. ukusetyenziswa kwengxowa-mali kunye nomthwalo wesigulane wezinto ezityiwayo zonyango ukujonga umthwalo onzima.
Ukhathalelo lwaseHongguan malunga nempilo yakho.
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Ukuba kukho naziphi na iimfuno zezinto ezinokusetyenziswa zonyango, nceda uzive ukhululekile ukuqhagamshelana nathi.
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Ixesha lokuposa: Sep-11-2023