Shanghai has launched a pioneering initiative to strengthen oversight of its medical insurance fund by implementing a graded scoring system for healthcare professionals. The new Detailed Rules for the Management of Medical Insurance Payment Qualification (Trial implementation), effective immediately, extend regulatory scrutiny from institutions to individual practitioners, marking a shift toward dual control of medical costs and service quality.
Policy Background
- National Mandate: The move aligns with the State Council’s 2020 guidance to expand medical insurance supervision to individual medical staff and emphasize performance metrics.
- Regulatory Framework: Jointly issued by the National Medical Insurance Administration, National Health Commission, and National Medical Products Administration, the policy mandates accountability for fund usage while deterring fraud.
Key Mechanisms
- Automatic Qualification: Healthcare workers gain payment eligibility via service agreements with designated medical institutions, bypassing administrative licensing.
- Driving-License-Style Scoring: Violations incur points akin to traffic offenses. Serious breaches (e.g., fraud) result in immediate disqualification for three years, while minor offenses serve as warnings.
- Appeal and Remediation: Professionals can contest scores within 10 working days or mitigate penalties through policy exams and participation in insurance management initiatives.
Market and Compliance Impact
The policy introduces granular accountability, potentially reducing fraudulent claims by 15–20%, according to analysts at Shanghai Health Economics Institute. It also incentivizes continuous education among medical staff, with remediation measures like score reduction for passing policy exams.
Industry Reaction
“While the scoring system raises compliance stakes, it clarifies regulatory expectations, reducing operational ambiguity,” said Dr. Wang Li, compliance director at Shanghai United Family Hospital.
Global Context
China’s medical insurance fund reached RMB 3.7 trillion in 2024. Shanghai’s approach mirrors international best practices in healthcare fund management, potentially influencing policies across Asia-Pacific markets.
Looking Ahead
The trial period concludes in 2027, with nationwide adoption possible if Shanghai’s model proves effective. Investors should monitor how remediation mechanisms balance punitive and educational objectives.
For detailed implementation guidelines, refer to the official policy document.-China Health Reform
Policy Source: https://ybj.sh.gov.cn/zcjd/20250403/321fead4718e4d09ad77dff0c9769da6.html