Outpatient overall planning is a form of medical insurance benefits. Simply put, the outpatient expenses of the insured are included in the scope of reimbursement of the overall fund.
The personal insurance reform of urban employee medical insurance, which involves 300 million people and involves over 700 billion in existing funds, has now determined the general direction: improving the outpatient protection mechanism to reduce the accumulation of personal account funds and improve the efficiency of medical insurance funds.
The "Opinions of the CPC Central Committee and the State Council on Deepening the Reform of the Medical Security System" (hereinafter referred to as "Opinions") issued on the evening of March 5 is the highest-level document issued in the 22 years since the establishment of China's medical security system, planning the development of medical insurance reform in the next ten years. aims. The document proposes that the outpatient medical expenses be gradually included in the scope of payment of the basic medical insurance unified fund, the personal account of employees' basic medical insurance is reformed, and the outpatient mutual aid guarantee mechanism is established.
Zhu Minglai, director of the Research Center for Health Economics and Medical Security of Nankai University, told First Business Finance that the "Opinions" set out the general direction of the next reform of personal accounts for medical insurance, that is, the gradual transition to overall outpatient planning.
Outpatient overall planning is a form of medical insurance benefits. Simply put, the outpatient expenses of the insured are included in the scope of reimbursement of the overall fund.
On the reform path, Qiu Yulin, a professor at the School of Labor and Human Resources of Renmin University of China, said to CBN that it is imperative to adjust personal accounts. Personal accounts. Existing personal accounts will be retained and expanded. "But the reform does not start immediately, and the specific starting point needs further research."
700 billion precipitation funds activated
China's urban employee medical insurance funds are composed of pooled funds and personal accounts. The employer's contribution rate is generally about 6% of the employee's total wages, and the employee's contribution rate is generally 2% of his salary. All basic medical insurance premiums paid by individual employees are included in personal accounts. The basic medical insurance premiums paid by the employer are divided into two parts: one is used to establish a unified fund, and the other is transferred to a personal account.
According to the Statistical Bulletin on the Development of the National Basic Medical Insurance Industry in 2018, 314.681 million employees participated in medical insurance in 2018, and the overall fund income was 824.1 billion yuan, an increase of 7.8% over the previous year. The overall fund expenditure was 649.4 billion yuan, an increase of 12.7% over the previous year. The current balance of the unified fund was 174.7 billion yuan, with a cumulative balance of 114.6 billion yuan. In 2018, the personal account income of employees' medical insurance was 529.7 billion yuan, an increase of 14.3% over the previous year. The personal account expenditure was 421.2 billion yuan, an increase of 13.7% over the previous year. The personal account accumulated 108.4 billion yuan in the current period, accumulatively accumulating 728.4 billion yuan.
China's employee medical insurance pooling funds and personal accounts define their respective payment scopes, which are accounted for separately and are not crowded out. The unified fund is mainly used to pay medical expenses within the policy range above the minimum payment standard and below the maximum payment limit. The personal account is mainly used to protect minor illnesses in the outpatient clinic and to pay medical expenses borne by individuals after enjoying the reimbursement benefit of the pooled fund.
In recent years, due to rising medical expenses, increasing ageing and reimbursement treatment, medical insurance funds in many places have become tight, while a large amount of funds have been deposited in personal accounts. The low efficiency of funds is an important cause of controversy in personal accounts for medical insurance.
Qiu Yulin said that the function of deepening medical insurance depends on a strong amount of funds, especially the size of the pooled funds, but the personal account has dispersed the total pooled funds and reduced its protection capacity.
Zhu Hengpeng, director of the Public Policy Research Center of the Chinese Academy of Social Sciences, wrote in February that due to the limited funding of the pooled funds, it is often preferred to be used for reimbursement of hospitalization costs. There is no better outpatient pooling in most areas, which burdens the elderly with higher outpatient costs. Heavier. In addition, this will encourage patients to reimburse for medical insurance, treat minor illnesses and over-hospitalization. The data also shows that there is obvious over-hospitalization in areas with poor overall outpatient pay, which has also caused a huge waste of pooled funds.
Personal account funds are part of the basic health insurance fund. In order to ensure the safety of the fund, according to the "Social Insurance Law" and relevant provisions of basic medical insurance, personal accounts are prohibited from being used for other consumer expenditures other than medical insurance. Although the reform plan for individual accounts of medical insurance has not yet been issued at the central level, in order to improve the efficiency of the use of personal insurance funds in medical insurance, some places have begun to explore the expansion of the use of personal account funds.
For example, from January 1, 2017, participants in the Shanghai Employees Basic Medical Insurance can use the balance of personal account calendar years to purchase commercial health insurance; starting in 2019, Sichuan Province employees' basic medical insurance personal account funds can be given to spouses , Parents and children of both husband and wife are shared; in Shenyang, the medical insurance personal account insurance policy allows 50% of funds to be used to purchase commercial health insurance.
How to protect personal rights
“Improving personal accounts and coordinating outpatient expenses” has also been written into the “Thirteenth Five-Year Plan”, and local exploration has been affirmed and recognized by the National Medical Insurance Bureau.
Last year, the National Health Insurance Bureau's response to the proposal of the National People's Congress was that the country is actively summarizing local experience, studying and formulating reform plans to improve employee medical insurance personal accounts, improving employee medical insurance outpatient protection mechanisms, reducing personal account fund precipitation, and improving fund utilization efficiency. Promote the stable and sustainable development of the employee medical insurance system.
First Finance has learned from industry insiders that there are two ways to reform personal accounts: one is to directly cancel the personal account, and all the personal payment and unit payment are integrated into the fund; the second is to gradually reform the personal account, first reduce the size of the personal account. Scale, if the unit payment is no longer transferred to the personal account but an outpatient pool fund is established, and the scope of use of the personal account is expanded.
Although there are no legal obstacles to the cancellation of personal accounts, when the Social Insurance Law was enacted 10 years ago, personal accounts for medical insurance did not receive legal recognition. However, based on the principle of welfare rigidity, it is not realistic to cancel one-step personal insurance accounts.
Last year, after the National Medical Insurance Bureau proposed that “the personal (family) accounts in urban and rural residents’ health insurance will be canceled by the end of 2020, and the transition to the outpatient overall planning will be smooth. ” "Zero" and medical insurance benefits will be reduced.
It turned out to be a false alarm-after the urban and rural residents' medical insurance canceled their personal account, the funds in the account still belonged to the individual. According to the National Medical Insurance Bureau, after promoting outpatient pooling in various places, urban and rural residents can include outpatient medical expenses into the scope of the unified fund, and the common and frequently occurring outpatient medical expenses of the masses at the grass-roots medical institutions can be reimbursed, the proportion is 50%. about.
From the perspective of the number of personal accounts and the scale of fund accumulation, the impact of reforming the personal accounts of employees 'medical insurance is far greater than the cancellation of individual accounts of urban and rural residents' medical insurance, and policymakers have been cautious about this reform. This is also the reason why the Social Insurance Law has been passed for ten years, and the reform of personal accounts for employee medical insurance has not yet broken the ice.
Participants are most worried that cancelling their personal insurance account will increase the financial burden of seeking medical advice. For example, some diseases usually cost a lot and are not listed as chronic diseases. Outpatient clinics cannot be reimbursed. Cancellation of personal accounts can only be borne by individuals. Even patients with chronic diseases are also worried that after canceling their personal accounts, if the outpatient overall planning cannot be reimbursed in full, they will have to pay for the medicines themselves.
Therefore, the reform of the personal account cannot be made by itself, but must be coordinated with other reforms guaranteed by the outpatient clinic, and the rights and interests of the insured must not be damaged.
Qiu Yulin said that on the one hand, it is imperative to adjust personal accounts, but the reform and adjustment need to adhere to the principles of equity replacement, smooth transition, reasonable conversion, and policy coordination. That is, old methods for old people, new methods for new people. Specifically, the existing accumulated part of the personal account (the stock fund) is owned by the individual, and the existing personal account can be retained and its functions expanded, and new personnel participating in medical insurance no longer establish personal accounts.
"On the other hand, individual payments still enter personal accounts, but unit payments are gradually transferred to the pooling fund, and an outpatient pooling system is established to provide policy protection for insured patients' outpatient expenses." Qiu Yulin said.
Zhu Minglai told First Business Finance that reforming personal accounts for medical insurance involves issues of flow and stock. Flow, that is, funds paid in the future, is relatively easy to handle. You can improve the level of protection by establishing outpatient overall planning, but the stock is the current personal account. How to make effective use of funds is an area that should be considered.
Author: Guo Jinhui