Chinanews client, Beijing, April 23 (Reporter Zhang Ni) Including more general outpatient expenses into the payment scope of the overall planning fund, implementing family mutual aid in personal accounts, and not having to run errands to major hospitals for minor illnesses... A few days ago, the General Office of the State Council The "Guiding Opinions on Establishing and Improving the Mechanism for Establishing and Improving the Employee Basic Medical Insurance Outpatient Mutual Aid Guarantee Mechanism" is issued, and major changes related to the family's medical treatment will occur!
Data map: A patient uses the face recognition system to make an appointment with an expert number under the guidance.
Photo by Wang Guangzhao
——Incorporate more general outpatient fees into the payment scope of the overall planning fund
Employee medical insurance was established in 1998. It implements a security model that combines social pooling and personal accounts. The pooled fund guarantees hospitalization and outpatient major illnesses, and the personal account guarantees outpatient expenses for minor illnesses and medicines.
The opinions announced this time put forward the establishment and improvement of an overall insurance mechanism for general outpatient expenses of medical insurance for employees, based on the medical insurance for outpatient chronic diseases and special diseases (hereinafter collectively referred to as outpatient chronic diseases) that are burdened by the masses such as hypertension and diabetes. , Gradually include common outpatient expenses for frequently-occurring and common diseases into the scope of payment by the overall planning fund.
In addition, general outpatient clinics cover all insured employees of employee medical insurance, and the payment ratio within the policy range starts from 50%. With the increase in the affordability of the medical insurance fund, the level of protection is gradually increased, and the payment of benefits can be appropriately tilted to retirees.
According to Chen Jinfu, deputy director of the National Medical Insurance Administration, on the 22nd, the opinions issued this time mainly include three measures in establishing an outpatient mutual aid guarantee mechanism.
One is to establish an overall plan for general outpatient clinics, and gradually include frequently-occurring and common diseases in outpatient clinics into the medical insurance overall plan for reimbursement.
These expenses were basically solved by personal accounts.
The second is to strengthen the outpatient protection for chronic diseases and special diseases, and gradually include the outpatient expenses for diseases with high costs and long treatment cycles into the scope of outpatient protection.
For some outpatients, chronic diseases, and serious illness related treatments, they are seen in the outpatient clinic, but they are managed according to the hospitalization policy.
Third, in addition to attending designated medical institutions, insured persons can settle and purchase medicines at designated retail pharmacies with prescriptions outside the hospital. Those who meet the regulations will be included in the payment scope of the overall planning fund, and the corresponding designated retail pharmacies will also be included in such a designated scope of protection.
This also means that in the future, more outpatient expenses will be included in medical insurance reimbursement, which will help reduce the medical burden of insured persons.
Data map: People swipe their cards to pay at the window of a hospital in Qinghai.
Photo by Zhang Tianfu
——The unit payment is no longer included in the personal account
According to opinions, in the future, the personal account credit method will also be improved.
The document proposes that it is necessary to scientifically and reasonably determine the crediting method and crediting level of personal accounts. The personal accounts of employees should be credited by the basic medical insurance premiums paid by individuals. The crediting standard is controlled at 2% of the insurance payment base in principle and paid by the unit. All basic medical insurance premiums are included in the overall planning fund; in principle, the individual accounts of retirees are allocated from the overall planning fund at a fixed amount, and the amount allocated is gradually adjusted to about 2% of the average level of the basic pension in the year that the overall planning area implemented the reform according to this opinion.
Regarding this adjustment, Chen Jinfu explained that after the reform of the personal account, personal accumulation is still owned by the individual, and the rights and interests have not changed.
After more than 20 years of reforms, the personal account has a cumulative balance of 1 trillion yuan. The money has not moved, and it is still personal rights.
He emphasized that reforming personal accounts is not about canceling personal accounts, but adjusting the credit ratio of personal accounts. This is a rotation of two aspects to achieve a system transformation.
The reduction of new credits in general personal accounts means the establishment, expansion, improvement, and enhancement of the outpatient mutual aid guarantee system.
Reducing the part does not mean that the guarantee will be lost, but put it in the big pool of mutual aid guarantee, forming a new guarantee mechanism.
Data map: outpatient building of a hospital.
Photo by China News Agency reporter Yin Liqin
——Personal accounts implement family mutual aid
Among the documents issued this time, there is also the implementation of family mutual aid in personal accounts that attracts attention.
According to the documents, personal accounts are mainly used to pay for out-of-pocket expenses incurred by insured persons in designated medical institutions or designated retail pharmacies.
It can be used to pay for the medical expenses incurred by the insured person, his spouse, parents, and children in the designated medical institution for medical treatment, and the expenses incurred by the individual incurred in the purchase of drugs, medical equipment, and medical consumables in the designated retail pharmacy.
Explore personal accounts for personal payment for spouses, parents, and children participating in basic medical insurance for urban and rural residents.
According to the policy, the personal out-of-pocket expenses after the reimbursement of the overall planning fund can be paid in cash or through a personal account.
After the reform, the scope of use of personal accounts has been expanded.
For children participating in employee medical insurance, personal accounts can be used by their parents to implement mutual aid within the family.
Data map
——No need to run errands to see a big hospital for minor illnesses
According to reports, the establishment and improvement of a mutual assistance mechanism for employee medical insurance outpatient clinics will also have a positive impact on the improvement of primary medical and health services.
Chen Jinfu said that the outpatient guarantee mechanism has a collective effect on the allocation of primary medical resources, the improvement of primary service capabilities, and the general outpatient guarantee for the masses.
Through this reform, the employee medical insurance has roughly replaced 200 billion funds. According to estimates and the current per capita outpatient medical level, it should be said that 80 billion funds should be invested in primary medical institutions. With personal payment, at least 100 billion additional fund resources can be added to support primary medical institutions.
For ordinary people, there are also system dividends. Minor illnesses can be seen in primary medical institutions. There is no need to run errands to see a major hospital, and the cost of medical care will be greatly reduced.
At the same time, for the entire country's resource allocation, it has formed a better allocation under the condition that the total amount of medical resource allocation remains unchanged.
Data map: Old people in a medical institution in Haidong City, Qinghai Province swipe their medical insurance cards.
(Data Map) Photo by Zhang Tianfu
——Retirees reduce the burden of outpatient expenses
The establishment of an outpatient mutual aid mechanism this time has improved the protection of the elderly.
According to Fan Weidong, head of the Treatment Protection Department of the National Medical Insurance Administration, the opinion proposes that the general outpatient overall protection level should start at 50%, and it is clearly required that all localities provide additional preferential payments to retired elderly people on this basis.
When the reform is implemented and the outpatient protection mechanism is fully implemented, it is preliminary estimated that this system can reduce the burden of outpatient expenses for retirees by nearly 100 billion yuan.
In addition, this time the improvement of the outpatient protection mechanism specifically proposed to further increase the types of outpatient chronic diseases and special outpatient diseases. The outpatient chronic disease protection paid by the overall fund has been strengthened. This is a very big problem for the elderly. Good.
In other words, during the reform process, this part of the population will benefit even more and the benefits will be wider.
Data map: The newly opened "smart pharmacy" on the streets of Kunming attracts citizens to experience.
Photo by Ren Dong, a reporter from China News Agency
——Eligible retail pharmacies are included in the scope of the overall fund settlement
Data shows that by the end of 2020, there are about 390,000 designated medical pharmacies nationwide, and the annual expenditure of personal accounts for designated pharmacies is about 200 billion yuan or more.
So, what impact will the establishment of an outpatient mutual aid mechanism have on retail pharmacies?
Fan Weidong said that this reform also paid great attention to continue to play the positive role of designated retail pharmacies in medical security services, and introduced some measures to continue to support the development of pharmacies.
In addition to the original personal account that can continue to be used for drug purchases in pharmacies, three main support measures have been clarified: first, include eligible retail pharmacies into the settlement scope of the overall fund; second, expand the scope of use of personal accounts and implement Family mutual aid; third, qualified "Internet +" medical services can also be included in the scope of basic medical insurance.
For eligible online medical services, funds can also be paid in accordance with regulations.
He emphasized that through the above measures, the preliminary judgment is that designated retail pharmacies can play a more important and active role in the process of basic medical insurance services. For the pharmacy retail industry, it will usher in a broader space for development. (Finish)