关于进一步推进医疗保险付费方式改革的意见
人力资源和社会保障部
关于进一步推进医疗保险付费方式改革的意见
人社部发〔2011〕63号
各省、自治区、直辖市、人力资源社会保障厅(局),新疆生产建设兵团劳动保障局:
基本医疗保险制度建立以来,各地积极探索有效的医疗保险付费方式,在保障参保人员权益、规范医疗服务行为、控制医疗费用增长和促进医疗机构发展等方面发挥了重要作用。随着医药卫生体制改革的深化,对完善医疗保险付费体系提出了更新更高的要求。按照党中央、国务院关于深化医药卫生体制改革的总体部署,为进一步推进医疗保险付费方式改革,现提出如下意见:
一、推进付费方式改革的任务目标与基本原则
当前推进付费方式改革的任务目标是:结合基金收支预算管理加强总额控制,探索总额预付。在此基础上,结合门诊统筹的开展探索按人头付费,结合住院门诊大病的保障探索按病种付费。建立和完善医疗保险经办机构与医疗机构的谈判协商机制与风险分担机制,逐步形成与基本医疗保险制度发展相适应,激励与约束并重的支付制度。
推进付费方式改革必须把握以下基本原则:一是保障基本。要根据医疗保险基金规模,以收定支,科学合理确定支付标准,保障参保人员的基本医疗待遇。二是建立机制。要建立医疗保险经办机构和医疗机构之间的谈判协商机制和风险分担机制。三是加强管理。要针对不同付费方式特点,完善监督考核办法,在费用控制的基础上加强对医疗服务的质量控制。四是因地制宜。要从实际出发,积极探索,勇于创新,不断总结经验,完善医疗保险基金支付办法。
二、结合基金预算管理加强付费总额控制
付费方式改革要以建立和完善基金预算管理为基础。各统筹地区要按照《国务院关于试行社会保险基金预算的意见》(国发〔2010〕2号)文件要求,认真编制基本医疗保险基金收支预算。对基金支出预算要进行细化,将支出预算与支付方式相结合,进行支出预算分解。
要根据基金收支预算实行总额控制,探索总额预付办法。各地要按照基金支出总额,确定对每一种付费方式的总额控制指标,根据不同定点医疗机构级别、类别、特点以及承担的服务量等因素,落实到每一个定点医疗机构,以及每一结算周期,并体现在医保经办机构和定点医疗机构的协议中。医保经办机构要根据协议的规定,按时足额向定点医疗机构支付费用。同时,根据基金能力和结算周期,明确预拨定点医疗机构周转金的条件和金额。
要将定点医疗机构总额控制指标与其定点服务考评结果挂钩,在按周期进行医疗费用结算的基础上,按照“结余奖励、超支分担”的原则实行弹性结算,作为季度或年度最终结算的依据。
三、结合医保制度改革探索相应的付费办法
门诊医疗费用的支付,要结合居民医保门诊统筹的普遍开展,适应基层医疗机构或全科医生首诊制的建立,探索实行以按人头付费为主的付费方式。实行按人头付费必须明确门诊统筹基本医疗服务包,首先保障参保人员基本医疗保险甲类药品、一般诊疗费和其他必需的基层医疗服务费用的支付。要通过签订定点服务协议,将门诊统筹基本医疗服务包列入定点服务协议内容,落实签约定点基层医疗机构或全科医生的保障责任。
住院及门诊大病医疗费用的支付,要结合医疗保险统筹基金支付水平的提高,探索实行以按病种付费为主的付费方式。按病种付费可从单一病种起步,优先选择临床路径明确、并发症与合并症少、诊疗技术成熟、质量可控且费用稳定的常见病、多发病。同时,兼顾儿童白血病、先天性心脏病等当前有重大社会影响的疾病。具体病种由各地根据实际组织专家论证后确定。有条件的地区可逐步探索按病种分组(DRGs)付费的办法。生育保险住院分娩(包括顺产、器械产、剖宫产)医疗费用,原则上要按病种付费的方式,由经办机构与医疗机构直接结算。暂不具备实行按人头或按病种付费的地方,作为过渡方式,可以结合基金预算管理,将现行的按项目付费方式改为总额控制下的按平均定额付费方式。
各地在改革中要按照不增加参保人员个人负担的原则,根据不同的医疗保险付费方式,适当调整政策,合理确定个人费用分担比例。
四、结合谈判机制科学合理确定付费标准
付费标准应在调查测算的基础上确定。可以对改革前3年定点医疗机构的费用数据进行测算,了解掌握不同医疗机构参保人员就医分布以及费用支出水平。在此基础上,根据医保基金总体支付能力和现行医保支付政策,确定医保基础付费标准。要以基础付费标准为参照,通过经办机构与定点医疗机构的谈判协商,根据定点医疗机构服务内容、服务能力以及所承担医疗保险服务量,确定不同类型、不同级别医疗机构的具体的付费标准。同时,综合考虑经济社会发展、医疗服务提供能力、适宜技术服务利用、消费价格指数和医药价格变动等因素,建立付费标准动态调整机制。
统筹地区要遵循公开透明的原则,制定医保经办机构与定点医疗机构进行谈判的程序和办法,在实践中对谈判的组织、管理、方式、纠纷处理办法等方面进行积极探索。
五、建立完善医疗保险费用质量监控标准体系
要建立健全医疗保险服务监控标准体系。要在基本医疗保险药品目录、诊疗项目范围、医疗服务设施标准基础上,针对不同付费方式特点分类确定监控指标。应明确要求定点医疗机构执行相应的出入院标准,确定住院率、转诊转院率、次均费用、参保人自费项目费用比例以及医疗服务质量、临床路径管理、合理用药情况等方面的技术控制标准,并将此纳入协议,加强对医疗机构费用的控制和质量的监管,切实保障参保人权益。
要针对不同付费方式明确监管重点环节。采取按人头付费的,重点防范减少服务内容、降低服务标准等行为;采取按病种付费的,重点防范诊断升级、分解住院等行为;采取总额预付的,重点防范服务提供不足、推诿重症患者等行为。
要加强对定点医疗机构的监督检查。通过引入参保人满意度调查、同行评议等评价方式,完善考核评价办法。要充分利用信息管理系统,通过完善数据采集和加强数据分析,查找不同付费方式的风险点并设置阈值,强化对医疗行为和医疗费用的监控,并总结风险规律,建立诚信档案。要将监测、考评和监督检查的结果与医保实际付费挂钩。
六、统筹规划,精心组织,以点带面推动实施
推动医疗保险付费方式改革是一个长期的、不断完善的过程,各地要统一思想,提高认识,加强领导,落实责任,抓好组织工作。在推进医疗保险付费方式改革中,要按照有利于提高医疗保险基金使用效率,有利于调动医疗机构及其医务人员的积极性,有利于提高医保管理服务水平,有利于维护参保人员的基本医疗保障权益的指导思想,主动改革,敢于创新,针对改革中遇到的新情况、新问题,不断调整完善付费政策和办法。
各省级人力资源社会保障部门要按照本意见要求,在认真调研的基础上制定本省(区、市)推进付费方式改革总体规划。要通过建立重点联系城市制度,发现、培育、树立典型,通过搭建交流工作平台,充分发挥典型城市的示范带头作用,以点带面加强对所辖统筹地区的指导。
各统筹地区人力资源社会保障部门要按照省(区、市)的统一部署,制定本地区推动付费方式改革的工作方案,明确改革目标、改革思路以及推进步骤。统筹地区工作方案应报送省级人力资源社会保障部门备案。
付费方式改革涉及各方利益的调整,在改革中要注意维护政策的连续性和稳定性,妥善处理改革与稳定的关系。要加强与其他部门的沟通协调,充分听取社会各方意见建议,形成改革的合力。遇有重大事项要及时报告。
二○一一年五月三十一日
SECURITIES AND FUTURES COMMISSION ORDINANCE ——附加英文版
Hong Kong
SECURITIES AND FUTURES COMMISSION ORDINANCE
(CHAPTER 24)
ARRANGEMENT OF SECTIONS
ion
I PRELIMINARY
hort title
nterpretation
II SECURITIES AND FUTURES COMMISSION
ecurities and Futures Commission
unctions of Commission
onstitution of Commission
ommission may establish committees
taff of Commission
eneral powers of Commission
elegation and sub-delegation of Commission's functions
Advisory Committee
Directions to Commission
Annual report of Commission
Commission to furnish information
Financial year and estimates of income and expenditure
Accounts
Auditors and audit
Investment of funds
III SECURITIES AND FUTURES APPEALS PANEL
Constitution of Appeals Panel
Appeals (registration, forfeiture and notices)
Hearing of appeals by tribunal
Procedure for appeals
Case stated
IV ADDITIONAL REGISTRATION REQUIREMENTS
Applications under section 51 of Securities Ordinance or section
30 of
odities Trading Ordinance; supplementary provisions
Applicant under Securities Ordinance or Commodities Trading
Ordinance
urnish information to Commission
Certificates of registration to continue in force
Section 23 (2) and (3) to apply to inquiries under section 56 of
rities Ordinance or section 36 of Commodities Trading Ordinance
Registered persons to notify Commission where records etc. kept
Financial resources rules
Modification of financial resources rules in particular cases
V REGULATION OF REGISTERED PERSONS' BUSINESS, ETC.
Supervision
Information relating to transactions
Certification to High Court relating to non-compliance under
section
r 31 33. Investigations
Returns
Production of computerized information
Magistrate's warrant
Destruction etc. of documents
Powers of intervention
Restriction of business
Restriction on dealing with assets
Maintenance of assets
Provisions relating to notices under section 39, 40, 41 or 43
Withdrawal, substitution or variation of notices under section
39, 40
1 44. Appeals against notices under this Part
Winding-up orders
Receiving orders
VI SPECIAL PROVISIONS RELATING TO EXCHANGE COMPANIES AND
RING HOUSES 47. Transfer and resumption of functions
Information: Exchange Companies and clearing houses
Notice of closure or re-opening
Additional powers--restriction notices relating to Exchange
Companies
clearing houses
Additional powers--suspension orders relating to Exchange
Companies
clearing houses
VII FUNDING
Levies
Appropriation
Fees and other charges
VIII MISCELLANEOUS
Injunctions to restrain contraventions
Waiver or modification of requirements
Immunity, etc.
Liability of directors, etc.
Evidence
Preservation of secrecy, etc.
Service of notices
Penalties for offences
Prosecution of certain offences by Commission
Dissolution of Provisional Securities and Futures Commission
Limited
transfer of property
Transitional
DULE Functions of Commission to which section 9 does not apply
establish the Securities and Futures Commission and to amend the
law
ting to dealing in securities and trading in futures contracts;
and to
ide for connected or incidental matters.
he Ordinance other than sections 27 (1) to (8), 30, 31, 32 and
65 as
with item 1 (b) of paragraph 4 of Schedule 2 insofar as they
relate
he repeal of sections 122 and 123 of the Securities Ordinance
y 1989 L. N. 126 of 1989
remaining provisions: 1 August 1989] L. N. 230 of 1989
PART I PRELIMINARY
hort title
Ordinance may be cited as the Securities and Futures
Commission
nance.
nterpretation
his Ordinance, unless the context otherwise requires-
aring house" means a clearing house within the meaning of section
2
of the Commodities Trading Ordinance (Cap. 250) or a
recognized
ring house within the meaning of section 2 of the Securities
(Clearing
es) Ordinance (Cap. 420); (Amended 66 of 1990 s. 2; 68 of 1992
s. 20)
Commission" means the Securities and Futures Commission
established
ection 3; "Commodity Exchange" has the meaning assigned to
it by
ion 2 (1) of the Commodities Trading Ordinance (Cap. 250);
pany" means any company within the meaning of the Companies
Ordinance
. 32) and includes an overseas company within the meaning of
that
nance or any other body corporate incorporated in Hong Kong
having a
e capital;
a equipment" has the meaning assigned to it by section 27;
a material" means any document or other material used in
connection
or produced by data equipment;
ablishment day" means the day on which section 3 comes into
operation;
hange Company" means-
the Stock Exchange Company; or
the Futures Exchange Company,
"Exchange Companies" means both of those companies;
cutive director" and "non-executive director" mean a director
of the
ission who is appointed under section 5 as an executive director
and a
executive director thereof, respectively; "exempt dealer"
has the
ing assigned to it by section 2 (1) of the Securities Ordinance
(Cap.
;
ancial resources rules" means rules made under section 28;
"financial
" means the period specified in section 14 (1);
m" has the meaning assigned to it by section 2 (1) of the
Commodities
ing Ordinance (Cap. 250);
ction" includes power and duty;
ures contract" has the meaning assigned to it by section 2 (1)
of the
odities Trading Ordinance (Cap. 250);
ures Exchange Company" means the Exchange Company within the
meaning
ection 2 (1) of the Commodities Trading Ordinance (Cap. 250);
up of companies" has the meaning assigned to it by section 2 (1)
of
Companies Ordinance (Cap. 32);
etary Authority" means the Monetary Authority appointed under
section
f the Exchange Fund Ordinance (Cap. 66); (Added 82 of 1992 s. 6)
icer", in relation to a company, has the meaning assigned to
it by
ion 2 (1) of the Companies Ordinance (Cap. 32);
el" means the Securities and Futures Appeals Panel
established by
ion 18; "property investment arrangements" means
investment
ngements as defined in relation to property other than
securities by
ion 2 of the Protection of Investors Ordinance (Cap. 335);
ord or other document" includes--
a book, voucher, receipt or data material, or information
which is
rded in a non-legible form but is capable of being reproduced
in a
ble form; and (b) any document, disc, tape, sound track or
other
ce in which sounds or other data (not being visual
images) are
died so as to be capable (with or without the aid of other
equipment)
eing reproduced and any film (including a microfilm), tape or
other
ce in which visual images are embodied so as to be
capable (as
esaid) of being reproduced;
istered person" means a person who is registered under the
Securities
nance (Cap. 333), the Commodities Trading Ordinance (Cap.
250) (or
those Ordinances) as a dealer, dealing partnership,
dealer's
esentative, investment adviser, commodity trading adviser,
investment
sers' partnership, investment representative or a commodity
trading
ser's representative;
relevant Ordinances" means this Ordinance, Part II of the
Companies
nance (Cap. 32) (insofar as that Part relates, whether
directly or
rectly, to the performance of functions by the Commission in
relation
rospectuses and purchase by a company of its own shares) and Part
XII
hat Ordinance (insofar as that part relates, whether
directly or
rectly, to the performance of functions by the Commission in
relation
rospectuses), the Securities Ordinance (Cap. 333), the
Commodity
anges (Prohibition) Ordinance (Cap. 82), the Commodities
Trading
nance (Cap. 250), the Protection of Investors Ordinance (Cap.
335),
Stock Exchanges Unification Ordinance (Cap. 361), the Securities
aring Houses) Ordinance (Cap. 420), the Securities
(Disclosure of
rests) Ordinance (Cap. 396) and the Securities (Insider
Dealing)
nance (Cap. 395); (Amended 62 of 1990 s. 41; 68 of 1992 s. 20;
87 of
s. 2) "securities" has the meaning assigned to it by section 2
(1) of
Securities Ordinance (Cap. 333);
ck Exchange Company" means the Exchange Company within the
meaning of
ion 2 (1) of the Stock Exchanges Unification Ordinance (Cap. 361);
ding in commodity futures contracts" has the meaning assigned to
it by
ion 2 (1) of the Commodities Trading Ordinance (Cap. 250);
bunal" means a tribunal appointed under section 20;
fied Exchange" has the meaning assigned to it by section 2 (1)
of the
k Exchanges Unification Ordinance (Cap. 361).
PART II SECURITIES AND FUTURES COMMISSION
ecurities and Futures Commission
There is hereby established a body to be known as the Securities
and
res Commission.
The Commission shall be a body corporate with power to sue
and be
. (3) The receipts of the Commission shall not be subject to
taxation
r the Inland Revenue Ordinance (Cap. 112).
(a) The Commission shall provide itself with a seal.
The seal of the Commission shall be authenticated by the signature
of
chairman or deputy chairman of the Commission or, if both the
chairman
deputy chairman of the Commission are absent from Hong Kong or
unable
ct, the signature of some other director of the Commission
authorized
t to act in that behalf.
unctions of Commission
The Commission shall have the following functions--
to advise the Financial Secretary on all matters
relating to
rities, futures contracts and property investment arrangements;
without prejudice to any duties imposed or powers conferred
on any
r person in regard to the enforcement of the law
relating to
rities, futures contracts and property investment arrangements,
to be
onsible for ensuring that the provisions of the relevant
Ordinances,
the provisions of any other Ordinance so far as they
relate to
rities, futures contracts and property investment
arrangements, are
lied with;
to report to the Financial Secretary the occurrence of any dealing
in
tion to securities which it reasonably believes or suspects to
be an
der dealing within the meaning of section 9 of the Securities
(Insider
ing) Ordinance (Cap. 395); (Amended 62 of 1990 s. 42)
to be responsible for supervising and monitoring the activities
of the
ange Companies and clearing houses;
to take all reasonable steps to safeguard the interests of
persons
ing in securities or trading in futures contracts or entering
into
erty investment arrangements;
to promote and encourage proper conduct amongst members
of the
ange Companies and clearing houses, and other registered persons;
to suppress illegal, dishonourable and improper practices in
dealing
ecurities, trading in futures contracts, entering into
property
stment arrangements, and the provision of investment advice or
other
ices relating to securities, futures contracts and property
investment
ngements;
to promote and maintain the integrity of registered
persons and
urage the promulgation by registered persons of balanced and
informed
ce to their clients and to the public generally;
to consider and suggest reforms of the law relating to
securities,
res contracts and property investment arrangements;
to encourage the development of securities and futures markets
in Hong
and the increased use of such markets by investors in Hong Kong
and
where; (k) to promote and develop self-regulation by market
bodies in
securities and futures industries;
subject to the provisions of this Ordinance, to co-operate with
and
st authorities or regulatory organizations, in Hong Kong or
elsewhere,
are concerned with securities and futures, or with banking,
insurance
ther financial services or with the affairs of corporations;
(Added 67
991 s. 2)
to perform any other functions conferred by or under
any other
nance.
As regards any function, the Commission may, for the
guidance of
stered persons and others, prepare and cause to be published in
the
tte guidelines indicating the manner in which, in the absence of
any
icular consideration or circumstance, it proposes to
perform the
tion.
The Commission may from time to time engage such
consultants or
sers as it may consider necessary to assist the Commission
in the
ormance of its functions. (4) Nothing in subsection (1) (k)
shall be
rded as limiting or otherwise affecting any other function
of the
ission.
onstitution of Commission
Subject to subsection (2), the Commission shall consist of a
chairman
inted by the Governor and such uneven number, not being less than
7,
ther directors so appointed as the Governor may determine; and
when
number of such other directors ceases to be an uneven
number the
rnor shall make such appointment or appointments as may be
necessary
omply with this subsection.
Half of the directors of the Commission, including the chairman,
shall
ppointed to be executive directors and the remainder
shall be
inted to be non-executive directors.
The Governor may appoint an executive director to be deputy
chairman
he Commission.
(a) If no appointment has been made under subsection (3) or if
the
ce of deputy chairman of the Commission is vacant, the
Financial
etary may designate an executive director to act as chairman of
the
ission during any period during which the chairman of the
Commission
nable to act as chairman due to illness or other incapacity
or is
nt from Hong Kong.
A designation under this subsection shall cease when revoked
by the
ncial Secretary or an appointment is made under
subsection (3),
hever first occurs. (5) The terms and conditions of office
of a
ctor of the Commission shall be such as the Governor may
determine.
A director of the Commission may at any time resign his
office by
er sent to the Governor.
A director of the Commission shall be paid by the Commission
such
neration, allowances or expenses as the Governor may determine.
The Governor may by notice in writing remove from office any
director
he Commission whose removal appears to him to be desirable
for the
ctive performance by the Commission of its functions.
Meetings of the Commission shall be held as often as may be
necessary
the performance of its functions, and may be convened by the
chairman
he deputy chairman or any 2 other directors.
If the office of chairman of the Commission is vacant or the
chairman
he Commission is unable to act as chairman due to illness or
other
pacity or is absent from Hong Kong the deputy chairman or an
executive
ctor designated under subsection (4) shall act as chairman
in his
e.
At a meeting of the Commission--
the chairman shall be chairman of the meeting; or
if the chairman is not present, the deputy chairman shall be
chairman
he meeting; or
if neither the chairman nor the deputy chairman is
present, the
ctors present shall choose one of their number to be chairman of
the
ing.
The quorum for a meeting of the Commission shall be 4 directors
of
2 shall be executive directors and 2 shall be non-
executive
ctors.
Each director of the Commission present at a meeting thereof
shall
a vote. (14) (a) Every question for decision at a meeting of
the
ission shall be determined by a majority of votes of the
directors
ent and, in the event that voting is equally divided,
subject to
graph (b) the chairman of the meeting shall have a casting vote.
(b)
chairman of a meeting shall not exercise a casting vote until
after he
consulted the Financial Secretary as regards that exercise.
The Commission may act notwithstanding a vacancy among its
directors.
The Commission shall organize and regulate its
administration,
edure and business.
ommission may establish committees
The Commission may establish standing or special committees
and may
r or assign to any such committee any matter for
consideration,
iry or management by the committee.
The Commission may appoint any person to be a member of any
committee
blished under this section, whether that person is a director of
the
ission or not. (3) Any reference or assignment under
subsection (1)
every appointment under subsection (2) may be withdrawn or
revoked by
Commission at any time, and no such reference or assignment
shall
ent the performance by the Commission of any of its functions.
A committee established under this section may elect any
of its
ers to be chairman and may regulate its own procedure and
business;
in the exercise of its powers under this subsection such
committee
l be subject to and act in accordance with any direction given
to the
ittee by the Commission for the purposes of this subsection.
Meetings of a committee established under this section shall be
held
uch times and places as the chairman of that committee may,
subject to
ection (4), determine.
taff of Commission
The Commission may from time to time employ persons who shall be
paid
remuneration and allowances and shall hold their employment on
such
r terms and conditions as the Commission shall determine.
The Commission may make arrangements for or in respect
of the
ision and maintenance of such schemes (whether contributory or
not)
the payment to its employees and their dependants of such
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