National Healthcare Security Administration Issues 'Guiding Opinions on Healthcare Security Standardization' to Establish a Unified 'Common Language' for the System

VCBeat (WeChat ID: vcbeat) has learned that, to accelerate the establishment of a unified national standardization system for medical security, the National Healthcare Security Administration issued the “Guiding Opinions on Standardization Work in Medical Security” on June 27.

The Opinions point out that medical security is a major livelihood project concerning the health and well-being of the people, and its standardization work will affect the improvement of the medical security system. China's medical security system has been established and operated for more than 20 years, but a unified standardization system has not yet been formed, making it difficult to meet the requirements of modernizing medical security governance. Against this background, the National Healthcare Security Administration formulated these Opinions in accordance with the requirements of documents such as the Notice of the State Council on Issuing the Plan for Deepening the Reform of Standardization Work (Guo Fa [2015] No. 13) and the Development Plan for the Construction of the National Standardization System (2016-2020), taking into account the needs of medical security reform and development.

The main contents of the "Opinions" are as follows:

The “Opinions” clarify that the primary objectives of standardization in medical security are: to establish a standardized working mechanism led by the National Healthcare Security Administration, endorsed by relevant departments, and collaboratively advanced by local authorities, thereby forming a standardization system aligned with the reform and development of medical security. By 2020, on the basis of constructing a nationally unified medical security information system, the implementation and application of 15 information business coding standards, including those for disease diagnosis and surgical procedures, were to be gradually achieved. During the 14th Five-Year Plan period, a national list of medical security standards was to be established, initiating the research, formulation, pilot testing, and refinement of selected medical security standards.

Basic principles include:

1. Adhere to top-level design and overall planning. Centering on the goal of modernizing medical security governance, give full play to the leading role of the National Healthcare Security Administration in policy guidance, system construction, and organizational coordination, so as to comprehensively advance the standardization of medical security across China.

2. Uphold scientific authority and a people-centered approach. Drawing on existing international, national, and industry standards, we will extensively solicit input, build consensus across all sectors, and develop standards through a rigorous scientific process. With the aim of standardizing management and enhancing service quality, we will improve the applicability and accessibility of these standards.

3. Adhere to demand orientation and prioritize the establishment of urgently needed standards. In accordance with the needs of healthcare security reform and development, highlight key areas, prioritize urgently needed standards, and formulate and implement various healthcare security standards in batches. Supported by the construction of national healthcare security information systems, gradually form unified standards and specifications across China.

4. Adhere to the principle of piloting first and ensuring steady progress. In accordance with the requirements for standardization, medical security standards shall be implemented first in pilot regions for informatization, strengthened through dynamic maintenance, continuously improved and revised, to facilitate the smooth adoption of standards and ensure that public access to medical services and settlement remains unaffected.

First, strengthen the foundation for standardization work.

1. Conduct basic research. Adhering to goal-oriented and problem-oriented approaches, strengthen basic research on medical security standardization within the framework of the national standardization strategy, providing theoretical basis and practical support for the construction of the medical security standardization system. Carry out comparative studies on foreign medical security standardization and related industry standardization to improve the quality of standardization work and promote the alignment of medical security standards with other industry standards.

2. Establish a working mechanism. Establish a standardized working mechanism for medical security that features vertical coordination, systemic synergy, and clearly defined responsibilities. The National Healthcare Security Administration shall assume centralized management, mobilize system-wide resources to organize the research and development of various standards, and carry out dynamic maintenance, improvement, and revision. Local medical security departments shall actively participate in standard formulation and implement all standards in accordance with national arrangements, and formulate local standards based on actual needs and regional characteristics.

Second, strengthen standardization efforts in key areas.

1. Basic Common Standards. Establish nationally unified basic common standards for healthcare security, forming a “common language” for the joint construction and sharing of the national healthcare security system and for the interoperability and data exchange among relevant departments and entities. These standards include healthcare security information business coding standards, unified identifiers, and archival management specifications, as well as technical standards related to cybersecurity, data exchange, and operation and maintenance involved in the informatization development of healthcare security.

2. Operational Management Standards. Improve work standards covering the management of medical security funds, operational handling, and the administration of medical service prices and centralized procurement. This includes standards for fund management and operational services such as audit, settlement, payment, transfer and continuation of insurance relations, cross-regional settlement, and payment method management; standards for the construction of the operational system, including the development of handling agencies and the conduct of operational personnel; and management standards for medical service items and pricing, as well as the centralized procurement of pharmaceuticals and medical consumables.

3. Public Service Standards. Optimize public service standards for medical security to ensure they are efficient, convenient, and practical. These standards include specifications for basic medical insurance enrollment registration, information disclosure, and personal information inquiries; management norms for agreements between medical security handling agencies and third-party institutions such as designated medical and pharmaceutical institutions; and standards for disability assessment and service items under long-term care insurance.

4. Evaluation and Supervision Standards. Establish performance assessment and service evaluation standards for medical security. This includes credit evaluation standards for insured individuals, participating entities, designated medical and pharmaceutical institutions, and their staff, as well as management specifications for the monitoring of medical security fund operations and guidelines for monitoring prices of medical and pharmaceutical services.

Third, ensure the effective implementation and enforcement of standards.

1. Organize pilot implementation. Adhering to the principle of “pilot first for refinement, then widespread promotion,” steadily advance the implementation of various medical security standards. In the initial phase, focus on testing and applying the four information business coding standards for medical insurance disease diagnoses and surgical procedures, medical service items, pharmaceuticals, and medical consumables. Timely summarize experiences and best practices to provide feasible experience and demonstrative guidance for the comprehensive implementation of the remaining 11 information business coding standards.

2. Strengthen dynamic maintenance. Establish a dynamic maintenance team, build a dynamic maintenance platform, and carry out dynamic maintenance of medical security standards. Ensure coordination and linkage with national and provincial dynamic maintenance efforts, strengthen communication and collaboration between the maintenance team and relevant business departments, and improve the efficiency of standard maintenance. Form various expert advisory teams to assist in resolving key and difficult issues.

3. Promote the integration of standardization and informatization. Leverage standardization to strengthen the foundational support for informatization development, and harness informatization to enhance and guide standardization efforts. Integrate informatization throughout the entire standardization process to improve the efficiency of data collection, analysis, and organization. Utilize information technology platforms for event management, ensuring full-process traceability.

4. Strengthen the supervision and evaluation of standard implementation. Establish a supervision mechanism for the implementation of medical security standards, and develop scientific and reasonable performance indicators and assessment methods. Establish mechanisms for incentives, constraints, optimization, and improvement; conduct follow-up surveys and inspection evaluations; and foster a virtuous cycle encompassing standard formulation, implementation, supervision and evaluation, and refinement and revision, thereby enhancing the practical effectiveness of medical security standardization work.

First, strengthen organizational leadership. Healthcare security departments at all levels shall enhance organizational leadership and overall coordination for healthcare security standardization, establish corresponding working mechanisms, consolidate workforce capacity, prioritize standardization on the important agenda, formulate work plans in a scientific and reasonable manner, and meticulously organize and implement standardization initiatives.

Second, pool resources from all sectors. Establish a high-level think tank for medical security standardization, engage experts from relevant fields, strengthen theoretical research on standardization, and enhance the overall quality of standardization work. Develop collaborative mechanisms with relevant departments, higher education institutions, social organizations, and other entities to fully leverage expert contributions and provide support for the formulation and implementation of standards.

Third, strengthen professional training. Intensify training efforts on medical security standards, develop training materials, innovate training methods, and improve the efficiency of standardization training. Focus on enhancing the competencies of standardization practitioners, optimizing their knowledge structures, and cultivating a team of standardized professionals with solid expertise and extensive experience.

Fourth, strengthen publicity and guidance. Utilize various media channels to comprehensively and multi-dimensionally publicize and interpret medical security standards and their implementation outcomes, thereby enhancing the influence and credibility of these standards. Guide relevant institutions to accurately grasp the content and understand the requirements of the standards, so as to improve the level of standardized implementation. Promote the widespread adoption of standards within the medical security system, fostering a strong atmosphere where stakeholders learn, understand, and apply the standards.

Image source: National Healthcare Security Administration official WeChat account

Content Source:National Healthcare Security Administration