Summary of Key Points
The National Healthcare Security Administration is advancing the national unification of the medical service item catalog for healthcare insurance (this represents the final piece of the puzzle among the three major healthcare insurance catalogs: medications, consumables, and services). The first batch of 11 categories of items will be established, with priority given to scenarios involving cross-provincial medical treatment, in order to address issues such as inconsistent item names and reimbursement standards across different regions, which have previously caused difficulties in reimbursement and irregular hospital charges. The timing is now ripe for this initiative (as most of the preliminary guidelines for setting medical service prices have been implemented), and the process will be carried out in phases, impacting patients, hospitals, and medical enterprises.
Why Unify the National Medical Service Item Catalog Now?
The time has come to address long-standing issues. While the national medication catalog and the consumable catalogs have been unified in most provinces, the medical service items (such as consultation fees, surgery fees, and examination fees) have been managed independently by different regions. This has led to several problems:
1. Confusion in cross-provincial reimbursement: For example, while a certain surgical robot procedure is reimbursable in Shanghai, it may not be in other provinces, forcing patients to travel specifically to Shanghai for the procedure, leading to inefficient use of healthcare resources.
2. Irregular hospital charges: The lack of uniformity allows hospitals to charge arbitrarily or ambiguously.
3. Difficulties in regulation: Without national standards, it is challenging to conduct surprise inspections of healthcare facilities.
The timing is now favorable: the state has issued 39 batches of guidelines for setting medical service prices (which serve as a “menu” for hospital charges; without this menu, hospitals cannot charge arbitrarily). Twenty-nine provinces have already unified the scope of payments within their regions, and the names and definitions of eligible items are largely consistent nationwide, making it possible to advance the national catalog unification.
The First Batch of 11 Unified Items
The first batch of 11 categories to be unified includes clinical assessment scales, traditional Chinese medicine treatments (such as moxibustion, cupping, massage, external therapies, acupuncture, orthopedics, and special treatments), dental implants, assisted reproduction, obstetrics, radiological examinations, and rehabilitation.
What items can make it into the catalog? They must meet three criteria:
1. Be listed in the national guidelines for pricing.
2. Be clinically necessary, safe, and effective.
3. Have reasonable prices (not be overly expensive).
Which items will not be included? Items such as cosmetic procedures or weight loss treatments, those with uncertain or risky outcomes, and those whose prices are determined by the market (such as certain high-end services) will not be part of the catalog.
Additionally, the first batch of unified items will not be mandatory for use nationwide but will primarily be applied to cross-provincial medical treatment scenarios.
For Ordinary Patients
The most immediate benefits include:
1. Clearer reimbursement: When seeking medical treatment in different regions, patients no longer need to worry about whether a particular procedure is reimbursable, as the national catalog ensures consistent settlement processes.
2. More transparent charges: Hospitals will be required to charge according to the national standards, reducing the likelihood of arbitrary or confusing fees. Patients will have a clear understanding of the cost associated with each service and the reimbursement percentage.
For Hospitals
The changes will result in:
1. Higher compliance requirements: Hospitals must align their local services with the national catalog, significantly reducing the potential for non-compliant practices.
2. Potential changes in revenue structures: Fees for technical services (such as surgeries and nursing care) may increase, while those for examinations and tests (such as CT scans and blood tests) may decrease, putting more pressure on hospitals that rely heavily on these fees.
3. Fairer competition: With easier cross-provincial travel for patients, hospitals will need to compete based on the quality of their services and the reasonableness of their prices.
For Medical Enterprises
Opportunities and Challenges:
- Opportunities: Innovative technologies have a better chance of being approved for reimbursement. For example, surgical robots and brain-computer interfaces have already been included in the pricing guidelines, which can boost research and development efforts.
- Challenges: If innovative medical devices are not listed in the catalog, they will not be eligible for reimbursement, potentially hindering their market adoption. The slow pace of approval processes can also impact R&D progress. Therefore, companies need to quickly advance their valuable innovations to stay competitive.
Overall, this policy aims to standardize medical services nationwide and regulate fees, addressing patients' practical needs while encouraging hospitals and enterprises to focus on providing high-quality services and driving innovation.