Author: Guo Jinhui
Some seriously ill patients have a heavy medical burden, which is a shortcoming in my country's medical security system.
It is one of the important reforms in the field of medical security during the "14th Five-Year Plan" period to promote the construction of medical insurance and assistance systems for major and serious diseases, make up for the shortcomings of security, and solve the problem of insufficient security in a targeted manner.
Nankai University Health Economics and Medical Security Research Center recently released a report entitled "Research Report on Multi-level Medical Security Development Index for Serious and Extraordinary Diseases" (hereinafter referred to as the "Report"), which stated that the payment structure of medical income is used to measure multi-level medical security. The security level of the system, from a nationwide perspective, in the multi-level medical security system for major and major diseases in 2020, the level of personal out-of-pocket payment for medical expenses exceeded 30%.
In recent years, medical insurance has made breakthroughs in solving the problems of "difficulty seeing a doctor" and "expensive medical treatment", and has continued to reduce the burden of medical expenses for the masses.
Wang Zongfan, a researcher at the Chinese Academy of Labor and Social Security, said at a recent seminar on the construction of multi-level medical security that the problem of overburdened medical expenses for major diseases is still relatively prominent. Guide other security measures such as commercial insurance, charity, and mutual assistance to give full play to their own advantages to provide more complementary security supplies.
The individual medical burden of serious diseases is still too heavy
The report estimates that in 2020, the total coverage of the multi-level medical security system for major and serious diseases will be 68.06%, of which the coverage of basic medical insurance will be 57.39%, the coverage of critical illness insurance will be 1.50%, and the coverage of medical assistance will be 0.99%. , the protection level of commercial health insurance is 8.18%, and the level of personal out-of-pocket payment for medical expenses is 31.94%.
Zhu Minglai, director of the Center for Health Economics and Medical Security Research at Nankai University, said that the report revealed my country's multi-level medical security system for major diseases, the overall level of coverage for medical expenses and the level of out-of-pocket payments for medical expenses, reflecting the actual medical burden of Chinese residents. situation.
What is a serious disease?
my country's medical insurance system is based on medical expenses. When the medical expenses after the illness exceed the patient's financial ability, and then seriously affect the normal life of the patient and the family, it can be identified as a major disease.
An important policy goal of the medical insurance system is to reduce the burden of medical expenses for major diseases of the poor and to resolve the risk of becoming poor due to illness and returning to poverty due to illness.
According to the report, data from the "China Health Statistical Yearbook" shows that in recent years, the medical expenses for the treatment of serious diseases have been on the rise, and medical expenses have risen rapidly, such as lung cancer.
Wang Zongfan said that after the establishment of the National Medical Insurance Bureau, the scope of the medical insurance catalog has been continuously expanded, and expensive innovative drugs have continued to be included in the reimbursement scope.
Although the variety of drugs that can be reimbursed is increasing (2,860 kinds), there are still many innovative drugs that have not been included in the medical insurance catalogue in time, and new technologies and diagnosis and treatment projects are also facing the same problems.
Malignant tumors reflect the current situation of drug cost burden for major diseases.
In the multi-level payment system for special oncology drugs, the basic security layer includes basic medical insurance, critical illness insurance and medical assistance, and the current payment contribution rate is 35% to 45%; in the social supplementary security layer, commercial health insurance payment contribution is about 6% , supplementary medical insurance is less than 1%; at the level of personal burden, in order to reduce the burden of personal expenses, prevent poverty due to illness and return to poverty due to illness, and reduce the comprehensive burden of patients through innovative payment and service methods, the contribution rate of personal out-of-pocket payment is 45%~55% %, and innovation payment is about 6%.
The critical illness insurance system for urban and rural residents was issued and implemented in August 2012. As of the tenth anniversary of the implementation of the system, it has become an important part of the medical insurance system with Chinese characteristics.
Since the implementation of this system, it has played a very important role in reducing the large medical expenses of patients.
Wang Zongfan said that critical illness insurance has played a more "secondary reimbursement" role, but the protection for people with major and serious diseases is not significantly higher than that of other people who have entered the coverage of critical illness insurance, and the protection effect of high expenses has not been accurately and effectively played. .
Whether it is 50,000~60,000, 60,000~70,000 yuan, or 130,000~140,000, 140,000~150,000 yuan, the increased reimbursement ratio is not much different, and there is no obvious high cost tilt.
Introducing social forces to reduce the burden of medical treatment
Doing a good job in medical security for serious and serious diseases is an important measure to further reduce the burden of medical expenses for the poor and the patients with serious diseases, prevent them from returning to poverty due to illness, and build a bottom line for people's livelihood security.
At present, my country has established a multi-level medical security system for major and serious diseases, which consists of basic medical insurance, critical illness insurance, medical assistance and commercial health insurance.
According to the report, according to the national medical security treatment list (2020 version), the hospitalization threshold (the threshold for employee medical insurance is in principle not higher than 10% of the average annual salary of employees in the overall planning area), the hospital fund payment limit (employee medical insurance superimposed on employees) Subsidy for large medical expenses, the maximum payment limit of residents’ medical insurance plus serious illness insurance is in principle about 6 times the average annual salary of local employees and the per capita disposable income of residents), general outpatient clinics (for policies above the threshold and below the maximum payment limit) The payment policy for basic medical insurance benefits such as outpatient medical insurance for outpatient medical insurance and outpatient treatment for chronic and special diseases (including hypertension, diabetes and other outpatient drugs into medical insurance reimbursement), and the medical insurance for the majority of employees and urban and rural residents. The demand for health services has been guaranteed to a certain extent.
Zhu Minglai said that the maximum payment limit of basic medical insurance is limited. Considering the restrictions on the basic medical insurance catalogue and the increasing pressure on fund payment, it is difficult to further improve the level of basic medical insurance benefits. Therefore, vigorously develop large-scale employees, serious illnesses, medical assistance and commercial supplements. Insurance is imminent.
Many places have begun to explore the construction of medical security systems for major and serious diseases.
Tianjin has recently issued the "Notice on Several Measures to Improve the Medical Insurance and Assistance System for Major and Serious Diseases", focusing on reducing the burden of medical expenses for major and major diseases of the poor, and strengthening the comprehensive protection functions of basic medical insurance, serious illness insurance, and medical assistance (that is, the triple system). , to build a government-led, multi-participated multi-level medical security system.
Tianjin's policy stipulates that medical assistance will not only cover the needy people with a heavy burden of medical expenses, but also cover critically ill patients who have serious difficulties in the basic life of their families due to high medical expenses The conditions for the identification of poor and seriously ill patients shall be reasonably determined by the Civil Affairs Bureau in conjunction with the Municipal Medical Insurance Bureau and other departments.
This notice proposes to encourage the development of mutual medical assistance and commercial health insurance.
Support the development of commercial health insurance, encourage commercial insurance institutions to develop urban customized commercial medical insurance products, strengthen product innovation, do a good job of connecting and complementing basic medical insurance, and give appropriate preference to people in need in terms of product pricing, compensation conditions, and coverage.
Wang Zongfan suggested that we should take "benefiting the people's insurance" as a breakthrough point, speed up the development of commercial health insurance, strengthen the complementary connection between commercial insurance, charity and other security measures and the triple system, and amplify the joint force of protection for major and serious diseases.