The person in charge of the relevant department of the National Medical Insurance Administration answered questions from reporters on the reform of the mutual aid security mechanism for outpatient medical insurance for employees

　　Recently, some places have promoted the reform of the mutual aid security mechanism for outpatient medical insurance for employees, which has aroused the attention of some people.

Some people have doubts about the reduction in the transfer of employee medical insurance personal accounts after the reform, and have concerns about the convenience of seeing a doctor after the reform.

In response to the general concerns of the society in this reform, the person in charge of the relevant department of the National Medical Security Administration answered questions from reporters.

　Question 1: What is the background of this reform?

　　Answer: my country's employee medical insurance system was established in 1998, implementing a security model that combines social pooling and personal accounts.

Specifically, it is jointly paid by the unit and the individual employees.

A part of the payment by the unit and all the payment by the employee is transferred to the personal account, which is mainly used to protect the general outpatient service and drug purchase expenses.

The other part of the payment by the unit forms the overall planning fund, which is mainly used to guarantee the hospitalization expenses of the insured employees.

This system played an important role in the specific historical period at that time. However, with the huge changes in the economy and society for more than 20 years, it has become increasingly difficult to meet the needs of the public's health by taking the risk of personal accounts and self-guaranteed outpatient expenses. It is specifically manifested in "three incompatibility".

　　One is that it does not adapt to the increasingly chronic disease spectrum.

Over the past 20 years since the establishment of employee medical insurance, the disease spectrum in my country has undergone tremendous changes, and chronic diseases have become the main diseases affecting the health of Chinese residents.

The number of deaths caused by chronic diseases in the whole country accounts for more than 85% of the total death toll, and the resulting disease burden accounts for more than 70% of the total disease burden.

The most effective way to treat chronic diseases is to use outpatient clinics for early diagnosis and treatment and health management to prevent minor ailments from becoming serious and effectively reduce the pain and financial burden of the masses.

In the original institutional arrangement, it is difficult to meet the actual needs by using personal accounts to guarantee general outpatient expenses.

　　The second is that it does not adapt to the rapid progress of medical technology.

With the development of medical technology, the range of medical services that can be provided by outpatient clinics has increased significantly, and the service functions have been significantly strengthened.

Diagnosis and treatment services, which were previously required to be hospitalized by the masses, have increasingly been transformed into outpatient services.

In the past, inspections and some surgical items that had to be carried out through hospitalization can now be solved through outpatient clinics, and the volume of outpatient services has grown rapidly.

From 2001 to 2021, the number of outpatient and emergency visits in medical institutions across the country increased from 1.95 billion to 8.04 billion, an increase of 312%.

The limited accumulation of funds in personal accounts is difficult to adapt to the substantial increase in the demand for outpatient services of insured persons.

　　The third is that it does not adapt to the development trend of aging in my country.

my country entered into an aging society in 2001. Compared with other countries, my country has a faster aging rate and a larger proportion of the elderly population.

From 2001 to 2021, the national population aged 65 and over will grow rapidly from 90.62 million to 205 million, and its proportion in the total population will rise from 7.1% to 14.2%.

According to estimates, around 2035, my country's elderly population aged 60 and above will exceed 400 million, accounting for more than 30% of the total population, entering a stage of severe aging.

As the elderly grow older, the probability of illness is higher, and they are often prone to a variety of chronic diseases. The frequency of outpatient visits and medical expenses are significantly higher than those of young and middle-aged people.

In 2021, the number of outpatient visits per capita of retirees will be 2.17 times that of active employees, and the average outpatient fee will be 1.15 times that of active employees.

However, the original system does not provide enough protection for outpatient services. The elderly are not willing to spend money on treatment when they have minor illnesses, and it is not uncommon for minor illnesses to become serious and eventually have to be hospitalized.

This not only increases the physical and mental suffering of the elderly, but also increases the care burden of the family, and leads to more expenses.

　　Based on the above reasons, the public's demand for reimbursement of general outpatient expenses is getting louder and louder.

For this reason, the National Medical Insurance Administration began to plan reform work in 2018. After repeated demonstrations and in-depth research, a preliminary reform plan was formed, and it was widely disclosed to the public through platforms such as the China Government Network and the official website of the National Medical Insurance Administration in August 2020. Comments were sought.

In April 2021, the General Office of the State Council issued the "Guiding Opinions on Establishing and Improving the Outpatient Mutual Aid Mechanism of Basic Medical Insurance for Employees" (Guobanfa [2021] No. 14, hereinafter referred to as the "Guiding Opinions"), and the reform was officially launched.

　　Question 2: What benefits can this reform bring to the insured?

　　Answer: This reform will benefit the insured in the following three aspects.

　　The first is

In layman's terms, it means that areas where employee medical insurance participants were not reimbursed for ordinary outpatient clinics can be reimbursed after the reform; areas where ordinary outpatient clinics can be reimbursed before, the reimbursement amount has been further increased.

First, in addition to the reimbursement of drug expenses, expenses such as inspections, inspections, and treatments that meet the regulations can also be reimbursed.

Second, some outpatient expenses for diseases with long treatment cycles, great damage to health, and heavy burden of expenses will be included in the reimbursement of ordinary outpatient clinics, and enjoy a higher reimbursement ratio and amount.

Third, the drug guarantee services provided by qualified designated retail pharmacies are also included in the scope of outpatient reimbursement.

　　The second is

.

Before the reform, unreasonable medical behaviors such as "hospitalization without indications", "hospitalization in bed" and "hospitalization for minor illnesses" occurred frequently due to insufficient protection in general outpatient clinics.

After the reform, insured persons can enjoy reimbursement in ordinary outpatient clinics, which can reduce the previously high hospitalization rate to a certain extent, reduce the pressure on bed turnover in large hospitals, promote the rational allocation of medical resources, and leave high-quality medical resources to those who really need them patient.

　　The third is

Before the reform, personal accounts could only be used by insured employees themselves, and family members could not use relatives' personal accounts when they were sick.

This reform has expanded the use of personal accounts in three aspects: first, it can pay for the medical expenses borne by the spouse, parents, and children when they seek medical treatment in designated medical institutions; Retail pharmacies purchase drugs, medical equipment, and medical consumables that are borne by individuals; third, some areas can pay for spouses, parents, and children who participate in the basic medical insurance for urban and rural residents.

　Question 3: What is the specific path of this reform?

After the reform, will the balance in the personal account of the insured person be affected?

　　Answer: This reform is to establish an overall reimbursement mechanism for general outpatient medical insurance for employees without increasing the additional burden on society and individuals, and to provide funds for general outpatient reimbursement by reducing the unit payment and the proportion of overall planning funds transferred to personal accounts. support.

The reform clearly requires that all funds after the transfer be used for overall outpatient reimbursement to meet the needs of the general insured, especially retirees, for reimbursement of ordinary outpatient expenses.

　　Regarding the adjustment of the transfer method of personal accounts, the "Guiding Opinions" have a clear design.

Specifically, there are mainly 3 "unchanged" and 2 "adjusted".

　　3 "unchanged".

First,

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The principal and interest of personal accounts, whether they are historical balances before the reform or newly transferred balances after the reform, are still owned by the individual and can still be carried forward for use and inherited.

Second,

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The individual medical insurance premiums paid by employees are still fully transferred to their personal accounts.

Third,

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Retirees still do not need to pay fees, and the personal account funds are still transferred from the medical insurance pooling fund.

　　The two "adjustments" refer to adjusting the transfer methods of personal accounts of active employees and retired employees according to different methods.

First, for current employees, before the reform, the source of funds for personal accounts consisted of part of the unit’s payment and personal payment; after the reform, all personal payments are still transferred to the personal account, and the part of the original unit’s payment that was transferred to the personal account is transferred to the Co-ordinating funds.

Second, for retirees, before the reform, the funds transferred to personal accounts in most places every month were "the actual amount of personal pension payment × transfer standard"; The average level of the basic pension in the year of the reform × the inclusion standard”, in which, the inclusion standard after the reform is lower than that before the reform.

　　The core of this

.

The reform involves the adjustment of interests, and the funds transferred to the personal accounts of many insured persons will be reduced to varying degrees.

Especially considering the uneven development among different regions in our country and certain differences in medical insurance policies, we have been insisting on steady progress, trying to handle the policy convergence before and after the reform, and gradually realize the reform goals.

　Question 4: What are the considerations of this reform in terms of helping the sick and the needy?

　　Answer: In order to give full play to the role of general outpatient clinics in reimbursement for the sick and the poor, and to prevent the occurrence of poverty due to illness and return to poverty due to illness, we have also considered the actual difficulties of the masses and given preference in this reform.

　　One is

.

Before the reform, outpatient medical treatment for employees mainly relied on personal account protection, and they were responsible for their own risks and expenses.

For healthy people, personal accounts are often inexhaustible, forming a deposit of funds; for groups with a lot of illnesses, personal accounts are often not enough, which affects medical treatment.

The reform and establishment of a unified reimbursement system for outpatient clinics will promote the use of more medical insurance funds for people with a lot of illnesses.

　　The second is

.

The reform clearly requires that when designing reimbursement policies in various regions, arrangements should be made for retirees in terms of "one low and two high", that is, the reimbursement "threshold line" is lower than that of in-service employees, the reimbursement ratio is higher than that of in-service employees, and the reimbursement "capped" line" is higher than that of active workers.

At present, all the coordinated regions that have carried out reforms have basically clarified that retired employees enjoy higher reimbursement benefits to better protect the health rights of the elderly.

　　In addition, considering that it is more convenient for many insured persons, especially retirees, to seek medical treatment and obtain medicines in grassroots medical institutions, the reform requires that grassroots medical institutions should be favored in terms of outpatient reimbursement treatment, and the drug guarantee provided by eligible designated retail pharmacies should be included in the reimbursement The range is convenient for the masses to seek medical treatment and purchase medicines at their doorsteps.

　　Question 5: In order to solve the problem of high outpatient expenses, besides the reform carried out this time, what other work has the National Medical Insurance Bureau carried out?

　　Answer: In order to reduce the burden of general outpatient expenses that the masses have strongly reported, it is not only necessary to establish a general outpatient reimbursement mechanism, but also to support each other with a series of systemic reforms.

Since its establishment in 2018, the National Medical Insurance Bureau has launched a series of measures to benefit the people, providing effective support for this reform.

　　One is to reduce drug prices.

The state organized centralized procurement of 294 kinds of medicines, and the average price of a batch of outpatient common diseases and chronic diseases such as hypertension, coronary heart disease, and diabetes was reduced by more than 50%.

Thanks to the sharp price cuts, the proportion of patients using high-quality drugs has increased from 50% before centralized procurement to more than 90%.

At the same time, the medical insurance catalog is dynamically adjusted every year according to the principle of "same price, better effect, and better price". A total of 618 new drugs have been reimbursed, of which 341 drugs have been reduced by an average of more than 50% through "soul bargaining", ensuring more patients. I have received new and good medicines that I could not afford or buy in the past.

　　The second is to optimize medical insurance services.

On the basis of continuously optimizing the direct settlement of hospitalization expenses in different places, the scope of direct settlement of outpatient expenses in different places is continuously expanded. In 2022, the direct settlement of outpatient expenses across provinces across the country will benefit 32.4356 million person-times.

Optimize and standardize the management of long-term prescriptions to meet the long-term medication needs of patients with chronic diseases. The maximum amount of prescriptions that can be issued in one visit to the doctor is up to 12 weeks.

　　The third is to strengthen the supervision of medical prices and expenses.

Continue to rectify behaviors that endanger the interests of the masses, such as "minor illnesses and big cures", overcharging, arbitrary fees, and untrustworthy prices, which are strongly reported by the masses.

Since 2018, a total of 1.543 million medical institutions have been dealt with, and 245,000 typical cases have been exposed, actively promoting the standardization of medical service behaviors, and striving to allow the public to enjoy high-quality and affordable medical services.

　　After this reform, as the medical insurance management service is further extended to the outpatient field, the above-mentioned mechanisms for benefiting the people will further play a role in system integration on the new platform of general outpatient clinic coordination, providing strong support for the reform, so as to enhance the benefits of insured employees. health and wellbeing.

　　Question 6: At present, what is the situation of promoting reform and implementation in various places?

　　Answer: At present,

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Since 2023, designated medical institutions across the country have achieved overall settlement of 441 million outpatient visits, with an average daily settlement of more than 7.8 million visits and a settlement amount of 46.24 billion yuan.

Through "treatment replacement and capital transfer", the effect of the reform has gradually emerged.

　　Of course, due to the unbalanced economic and social development of the various planning regions, there is also an imbalance in promoting reforms, and some local reform dividends have not been fully released.

In this regard, we will guide all localities to continue to optimize and improve supporting measures to ensure that the expected goals are achieved.

　　One is

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Some people have reported that although general outpatient expenses can be reimbursed after the reform, it is inconvenient for patients who are accustomed to purchasing medicines in pharmacies.

In this regard, the National Medical Insurance Bureau recently issued the "Notice on Further Improving the Incorporation of Designated Retail Pharmacies into the Overall Management of Outpatient Clinics" (Milbaobanfa [2023] No. 4, hereinafter referred to as the "Notice"), which clearly states that the insured person will be in the The designated retail pharmacies can purchase drugs included in the medical insurance catalog, which can be reimbursed by the overall planning fund in accordance with regulations.

The "Notice" also requires all localities to step up efforts to realize the smooth flow of electronic prescriptions from designated medical institutions to designated retail pharmacies, so that insured people can prescribe medicines with prescriptions.

Since 2023, 29.62 million person-times across the country have achieved settlements at designated retail pharmacies, with a settlement amount of 1.434 billion yuan, and employee insureds have been reimbursed an average of 48.41 yuan per time in pharmacies.

　　The second is

Some people worry that primary medical institutions are not equipped with enough medicines, and they cannot buy the medicines they need in primary and secondary medical institutions.

In this regard, the National Medical Insurance Administration will strengthen departmental coordination, cooperate with relevant departments to continuously improve policies, support the construction of the grassroots medical service system, optimize the allocation of medical resources, improve family doctor contracting services, and urge grassroots medical institutions to strengthen drug allocation, etc., and strive to make the people nearby Access to medical services.

　　The third is

Some people have appealed to further improve the convenience of medical insurance services, so that the people can "run less errands" when doing things.

In this regard, the National Medical Insurance Bureau actively promotes the "Internet + medical insurance" service, promotes the application of the entire process of medical insurance electronic vouchers for medical purchases, expands the scope of medical insurance mobile payment access, and allows insured persons to complete registration for medical treatment, medical insurance settlement, and participation through mobile phones. Insurance information inquiry, medical record filing in other places and other related services.

　　The masses have called, and medical insurance has responded.

The National Medical Insurance Bureau will continue to guide local medical insurance departments to continue to implement the reform deployment, listen carefully to the voices of the masses, regularly evaluate the implementation of the reform, and study and optimize the outpatient reimbursement ratio, "deductible line" and "capping" according to the local economic and social development level and the medical needs of the masses. We will continue to refine supporting measures, optimize management services, improve security levels, and strive to enhance the people's sense of gain, happiness, and security.