At the beginning of this year, many places began to start the reform of mutual aid security for outpatient services for employees.
This system, which is related to the interests of 354 million medical insurance participants, requires that the payment of benefits should be tilted towards retirees. As of the end of 2021, there will be 93.24 million retired employees in the basic medical insurance system for employees.
At present, 31 provinces, autonomous regions, municipalities directly under the Central Government and the Xinjiang Production and Construction Corps have issued documents to improve the medical insurance outpatient mutual aid guarantee mechanism for local employees.
Among them, many provinces and cities stipulate that the outpatient payment limit and payment ratio of retirees are higher than those of in-service personnel.
Even so, among the public opinions received by local medical insurance departments, retirees believed that “after the reform, the reduction in the amount transferred to personal accounts led to a decline in the level of benefits”, accounting for the majority.
The medical insurance departments in many places have made it clear in their policy explanations that after the reform, most of the insured’s personal accounts will be reduced in the current period. For retirees, the benefits of outpatient mutual aid far exceed the deduction of personal accounts, often deduction of hundreds of yuan, reimbursement of more than a thousand yuan or even thousands of yuan.
The Hunan Provincial Medical Security Bureau stated in the "Policy Interpretation on Improving the Ways of Retiring Employees' Personal Accounts" that the outpatient mutual aid mechanism uses the law of large numbers to resolve the risks of social groups. There is a difference between more and less, but from an institutional point of view, mutual aid guarantees have more risk prevention functions.
Employee medical insurance not only includes personal accounts and general outpatient services, but also a series of policies such as outpatient treatment for chronic special diseases, hospitalization treatment, etc., and thus constitutes a complete security system.
A few days ago, China Business News interviewed a number of experts in the industry on hot issues concerning the reform of individual medical insurance accounts that are of public concern.
Experts generally believe that the medical insurance personal account has been in operation for more than 20 years, and has completed its historical mission and its limitations are gradually becoming apparent. According to the principle of "equity replacement", it is the general direction to gradually replace personal accounts with outpatient mutual aid.
This is a reform that affects the whole body. In the long run, all insured persons will benefit from the reform, but in the short term, the interests of some people will be damaged.
How to improve the supporting mechanism to make the insured have a greater sense of gain is a problem that must be focused on in the next step of reform.
China Business News also learned from relevant departments that some targeted measures are being rolled out one after another. For example, in order to facilitate patients to enjoy treatment nearby, patients are supported to settle and dispense medicines at designated retail pharmacies with external prescriptions, and enjoy the same reimbursement as in medical institutions. treatment, and explore the inclusion of qualified "Internet +" medical services in the scope of protection, and improve the convenience of enjoying treatment.
Question: At the beginning of this year, outpatient mutual aid reforms were launched in many places. Retirees in some areas reported that the funds in their medical insurance personal accounts have decreased, which has affected the daily cost of buying medicines.
The reform of mutual aid in outpatient clinics is intended to favor the elderly, but why do the elderly think that their interests have been damaged?
Zhu Minglai (Director of the Health Economics and Medical Security Research Center of Nankai University): The original intention of this reform is to hope that the sick and the elderly with poor health can have more benefits, rather than harming their interests.
It is only a part of the elderly who think that their interests have been damaged, and it does not represent all the elderly. Different groups of people have different demands.
The people who feel that their interests have been damaged are mainly the elderly who usually suffer from minor illnesses. The funds in their personal accounts can cover their daily medical expenses. If the personal account funds decline, it will affect their daily medical payment; but for patients For the elderly who have chronic diseases, need long-term medication and go to outpatient clinics, the funds in his personal account are not enough. According to the previous policy, after the funds in the personal account are spent, the outpatient expenses have to be paid by themselves.
Therefore, for the elderly with high outpatient expenses, not only will their interests not be damaged, but they will be able to obtain a higher level of reimbursement.
It is also mentioned in the policy interpretation of the "Wuhan City Employee Basic Medical Insurance Outpatient Mutual Aid Security Implementation Rules" that the insured person Zhou, a retiree, is 68 years old and has an annual pension income of 50,000 yuan. Before the reform, his personal account was transferred to 2,400 yuan per year. .
Suffering from cerebral infarction, I went to a tertiary hospital for outpatient treatment, and the reimbursement expenses incurred this year were 7,150 yuan. If I am reimbursed according to the outpatient overall policy, excluding the threshold fee of 500 yuan, I can be reimbursed according to the 60% reimbursement ratio of a tertiary hospital (7150- 500) yuan * 60% = 3990 yuan.
Although 1,404 yuan less was transferred to Zhou's personal account after the reform, his treatment was 2,586 yuan more.
Second question: After the State Council issued the guiding opinions on outpatient mutual aid reform in April 2021, the local government received a lot of public opinions when formulating implementation rules and popularizing policies.
For example, the Hunan Provincial Medical Insurance Bureau stated that the public opinions received recently focused on the reflection that "the level of treatment after the reform has declined", especially for retired employees whose annual personal account credit level was more than 2,900 yuan.
What do you think is wrong with retirees' focus on outpatient mutual aid reform?
Lou Yu (Professor of the School of Civil, Commercial and Economic Law of China University of Political Science and Law, director of the Institute of Social Law): Since the basic medical insurance system for employees was fully rolled out in my country in 1997, personal accounts have existed as an important medical insurance system so far. Not only many Structural systems have constituted path dependence. Reforming one of these systems will "affect the whole body". In the short term, the reform will damage the interests of some people. How to make reasonable compensation for those whose interests have been damaged? It is also a major event related to the success or failure of reform.
Outpatient Mutual Aid Reform Program is to reduce the funds remitted to personal accounts by retired insured persons every month, and the saved funds are used for outpatient and serious illness overall planning. This program is in line with the development direction of medical insurance. The original intention is very good. Thorough consideration of the details is very critical, it may affect the acceptance of the reform by the insured, and also affect the effect of the reform.
The most important thing is to publicize it well. After all, personal accounts have existed for more than 20 years. Although the nature of personal property has not been written into the law, a basic consensus has been formed in the whole society.
Second, supporting measures must be kept up to date, such as increasing the provision of common disease medicines in grassroots medical institutions, so that insured persons will have less time to travel, improve the convenience of the system, and reduce personal burdens.
Three questions: Some netizens said that "there are fewer transfers to personal accounts, and they are 'losing'". For individuals, will the medical cost increase due to this reform?
Liao Zangyi (Associate Professor, School of Politics and Public Administration, China University of Political Science and Law): Generally speaking, for individuals, their medical costs will not increase because of this reform.
Everyone has to calculate both small accounts and big accounts.
After the reform, the overall planning fund has been strengthened, and after illness can be reimbursed through the overall planning fund, everyone will help each other and the protection will be more adequate.
It is necessary to calculate both immediate accounts and long-term accounts.
Everyone has old age and sickness. Although young and healthy people don't see many doctors now, the economic risks brought by diseases will exist for a long time.
Everyone should also rationally look at the difference between the income mechanism and the insurance mechanism. Under the general framework of social medical insurance, the funds in personal accounts are "medical money", not salary income, nor benefits.
When old and sick, personal accounts and personal accumulation are always limited, and solid and sustainable medical insurance is needed to achieve social mutual assistance to resolve disease risks. In the long run, they will all benefit from this reform.
The Guangdong Provincial Medical Insurance Bureau mentioned a case in the Q&A on the reform of the outpatient mutual aid security mechanism, showing that retired employee Hua Jie had a total medical cost of more than 480 yuan for lung CT due to respiratory rales in November 2022, which was paid in full by herself.
After the implementation of outpatient mutual aid in Guangzhou, Sister Hua recently went to the hospital for CT and found that she only needed to pay more than 140 yuan for the same project, and the overall fund paid 70%.
According to the calculations of the Hunan Provincial Medical Insurance Bureau, after the reform, the maximum payment limit of the pooling fund for active employees is 1,500 yuan, and the maximum payment limit of the pooling fund for retirees is 2,000 yuan.
In 2021, the province's annual per capita personal account fund income will be 1,727 yuan/person, and personal account fund expenditure will be 1,438 yuan/person.
At present, the payment limit determined by the general outpatient policy, together with the amount transferred to the personal account, can basically meet the outpatient medical needs of the insured.
Question 4: Personal accounts have existed in my country for more than 20 years. Why should the outpatient security reform including personal accounts be launched recently?
Lou Yu: The original intention of the design of the medical insurance personal account system is to hope that the insured can share the risk of outpatient expenses through long-term accumulation. .
However, this original intention has not been well realized in practice: all insured people tend to be short-sighted, and a large amount of funds have accumulated in their personal accounts, which has caused a high moral hazard, which not only doubles the pressure on supervision, but also increases the pressure on each insured person. The funds in the personal account are limited, which can only be used to pay small outpatient expenses, and the high outpatient expenses cannot be paid. Fees are unfair to insured patients.
Therefore, in the practice of medical insurance, there are many criticisms of personal accounts, and all sectors of society are actively seeking reform plans for accounts.
Once any system is fixed, it will be very difficult to reform, because any reform is a redistribution of interests.
It is easy to reform a specific system, but it is a test of the reformer's wisdom to conduct a comprehensive and comprehensive assessment of the system and find a systematic solution to the problem.
No matter from the perspective of my country's medical insurance practice or from the implementation of systems in various countries in the world, it is difficult for purely accumulated personal accounts to play the function of the law of large numbers in insurance, and it is impossible to share disease risks and funds on a larger scale mutual aid.
There has been a social consensus on the use of personal account funds for coordinating high outpatient expenses, and it should become the general direction of reform.
However, this reform requires a systematic system design. While reducing the proportion of medical insurance account transfers, necessary supporting measures must be introduced in a timely manner.
Five questions: Outpatient overall planning reform is a systematic project, among which reducing the funds transferred from personal accounts should be the easiest to operate, but if the supporting policies cannot keep up, rights and interests may also be damaged.
In your opinion, what supporting reforms are indispensable for the outpatient mutual aid system to truly protect the interests of the insured?
Zhu Minglai: I think one of the important reasons why some retirees are concerned about the reduction of personal account funds is that some supporting policies have not kept up with it in time.
The biggest supporting policy for outpatient mutual aid reform is medical care and medicine. For example, the accessibility of medical services has been reported by elderly people. What used to be solved by swiping the card at the pharmacy, but now they have to go to the hospital. If they don’t trust a If you go to a secondary hospital, you may have to queue for a long time to go to a tertiary hospital; and sometimes when you arrive at the hospital, the hospital may be short of medicines, and you have to go to the pharmacy to get the medicines.
This will add a lot of errands to the elderly.
This is also the direction to further improve the supporting policies. Specifically, three efforts can be made: First, support patients to settle and dispense prescriptions at designated retail pharmacies with external prescriptions, enjoy the same reimbursement treatment as in medical institutions, and give full play to the convenience of designated retail pharmacies role.
The second is to explore the inclusion of eligible "Internet +" medical services in the scope of protection to improve the convenience of enjoying benefits.
The third is to explore and promote electronic prescription circulation to better meet the needs of drug purchase settlement.
Six questions: Different regions have different levels of economic development and welfare, as well as different guarantee levels for outpatient co-ordination.
If the level of outpatient pooling in a region is relatively low, can it make up for the loss of benefits caused by the reduction of personal account funds?
Liao Zangyi: The local government will encounter some difficulties when establishing outpatient coordination. First, the medical insurance information system must keep up with it, and all designated pharmacies in the coordination area must be opened up to ensure that patients can enjoy real-time settlement without having to go through manual reimbursement; secondly, medical insurance Supervision and smart audits must keep up. After the improvement of outpatient insurance benefits, many people will certainly be tempted to resell drugs to gain profits. This puts forward higher requirements for the refined management and intelligent monitoring of medical insurance.
Regarding the welfare loss that may be caused by a low level of overall planning, we can start from three aspects. First, after the implementation of the outpatient mutual aid system, the minimum payment line for outpatient reimbursement should be appropriately reduced, and the reimbursement ratio can be appropriately increased. This requires approval by the medical insurance department. Actuarial calculations are used to make dynamic adjustments to effectively enhance the sense of gain of the people; second, the coverage of outpatient mutual aid should be improved, from the existing two diseases, kidney dialysis, outpatient radiotherapy and chemotherapy, etc., to gradually expand to most diseases can enjoy reimbursement Third, you can refer to the guarantee policy for hospital treatment. If the annual outpatient expenses of the insured exceed a certain percentage, it can be classified as large medical expenses, and should be given secondary guarantees or a corresponding bottom-up mechanism.
Question 7: Many retirees are used to going to designated retail pharmacies to buy medicines. After the implementation of outpatient mutual aid, what support measures are there for designated retail pharmacies?
Zhu Minglai: The reform proposes to include eligible designated retail pharmacy drug guarantee services into the scope of outpatient coverage, and extend the pooling fund payment to eligible medical insurance designated pharmacies. The purpose is to facilitate reimbursement for patients nearby and reduce the burden of expenses.
Insured patients could only use their personal accounts to pay for medicines at designated retail pharmacies. After the reform, they can either use their personal accounts or enjoy reimbursement from the overall planning fund with external prescriptions.
According to relevant data, since the implementation of the reform, the use of personal accounts in designated retail pharmacies has increased, which also shows that reform measures such as personal account family assistance and expanding the use of personal accounts have benefited pharmacies.
However, violations of laws and regulations in the operation of designated retail pharmacies cannot be ignored. For example, it is very common for pharmacies in some cities to use medical insurance funds to pay for health products and daily necessities. Supervision must be strengthened for this kind of misappropriation of medical insurance funds.
Eight questions: After the implementation of outpatient mutual aid, will the outpatient volume and labor cost of the hospital be increased?
Liao Zangyi: In the short term, the number of outpatient visits in hospitals may increase. Before the reform, many patients would have to deal with minor illnesses such as colds and coughs and rely on autoimmunity to recover. After all, it can save money.
After the reform, considering that medical insurance can be reimbursed, some people will have the mentality of "don't spend it in vain". In the short term, there is indeed a risk of increasing the number of hospital outpatients and labor costs. However, as time goes by and the market gradually returns to rationality, this This phenomenon will gradually return to the state before the reform.
Question 9: What is the nature of the funds in the medical insurance personal account?
Lou Yu: According to the "Decision on Establishing the Basic Medical Insurance System for Urban Employees" promulgated by the State Council in 1998, the combination of social pooling and personal accounts is the basic principle of basic medical insurance for employees. Carry forward usage and inheritance.
This is the basis for the general public to consider the legal nature of personal accounts to be personal property.
However, the legal status of this decision is relatively low. It is not an administrative regulation with external legal effect, but a normative document for the construction of the medical insurance system within the human resources and social administrative organs. It only has guiding significance for the regulation of the nature of personal accounts.
The "Social Insurance Law" promulgated in 2010 did not stipulate the combination of pooling and accounting as the financing principle of basic medical insurance, nor did it stipulate the legal nature of personal accounts. There is room for reform.
Question 10: The Social Insurance Law promulgated in 2010 did not mention personal medical insurance accounts. Does this mean that the general direction of future reform is to replace personal accounts with outpatient mutual aid security mechanisms?
Liao Zangyi: The general direction of future reforms can consider gradually reducing personal accounts until they are cancelled.
On the one hand, gradually reduce or stop the proportion of unit payment transferred to individual accounts; on the other hand, gradually cancel the regulation of individual payment transferred to individual accounts, and include individual payment into the overall planning fund, such as the establishment of an outpatient mutual aid system.
Although there may be greater resistance in actual operation, in fact, some regions have already tried this approach and achieved good results.