"Guiding Opinions on Establishing and Improving the Employee Basic Medical Insurance Outpatient Mutual Aid Guarantee Mechanism (Draft for Solicitation of Comments)" announced
The planned reimbursement rate of outpatient medical insurance expenses for employees starts from 50%
Yesterday, the National Medical Insurance Bureau formally announced to the public the "Guiding Opinions on Establishing and Improving the Mechanism of Employee Basic Medical Insurance Outpatient Mutual Assistance (Draft for Comment)." The opinion proposes to stipulate that ordinary outpatient expenses can be reimbursed by medical insurance, and the reimbursement ratio starts from 50%. The method for calculating employee medical insurance personal accounts will also be changed. The part of the medical insurance unit's payment will no longer be included in the personal account, and all will be included in the overall fund. The scope of the use of personal accounts will be expanded. For example, it used to only pay for the medical expenses of the employees themselves. After the reform, it will be expanded to cover the expenses of the employees’ spouses, parents, and children.
Why do we need to reform the insurance policy for outpatient medical insurance for employees? After the reform, what changes will the medical protection enjoyed by the insured person? Can you get more benefits? What impact will this reform bring? On these issues, reporters from the Beijing News interviewed relevant experts on medical insurance benefits.
Interpretation 1
Why should the insurance policy for outpatient medical insurance for employees be reformed?
Solve the problem that the level of outpatient insurance does not meet the needs
Authoritative experts on medical insurance treatment said that the background of this reform is the combination of overall fund and personal accounts established at the beginning of the establishment of employee medical insurance. The overall fund is to manage the serious illnesses in the hospital, and the personal account is to manage the minor illnesses in the outpatient department.
With the establishment and improvement of the medical security system, while the level of hospitalization security has increased, the requirements for outpatient coverage have become stronger. Especially with the improvement of new medical technology, the protection of personal accounts is difficult to play a role.
The personal account is transferred to your own account and belongs to you. There will be a problem. The old people don’t have enough money for medical treatment, and the young people can’t spend it or spend it all. Now this little money is placed in the personal account, and the money accumulated in the personal account will not be enough to spend in the outpatient clinic in the future.
According to Qiu Yulin, a professor at the School of Labor and Human Resources at Renmin University of China, the personal account of employee medical insurance has the function of reimbursing outpatient expenses, but the design of the personal account is a product of a specific historical period. At the beginning of the implementation of the employee medical insurance system, the state considered that employees did not need to pay insurance premiums at all during the planned economy period and lacked the awareness of participating in insurance. It was necessary to establish a mechanism that allows the people to accept the payment smoothly, and at the same time cultivate personal awareness of saving and control medical expenses. Therefore, a model of "combined accounting" was established, and personal accounts were created.
"Different from the previous public medical and labor insurance medical care, the new employee basic medical insurance requires companies and individuals to pay jointly. From no payment to payment, there is a problem of employee payment compliance. The funds in personal accounts do not participate in overall planning and can be carried forward. Using it will help improve the enthusiasm of employees to participate in insurance and payment compliance. This is the first main reason for establishing a personal account." said Wang Zhen, a researcher at the Institute of Economics of the Chinese Academy of Social Sciences.
Interpretation 2
Why adjust the crediting method of personal account?
Personal accounts diversify the total amount of the overall fund
"Currently, personal accounts have basically achieved the two goals of'guaranteeing the smooth progress of reforms' and'incentivizing individual payment enthusiasm'." Qiu Yulin said, but the current increase in medical expenses is no longer purely caused by individuals without a sense of saving, social and economic development , Expansion of medical demand, advances in medical technology, changes in the spectrum of diseases, medical service misconduct and other factors have intensified the continued growth of medical expenses.
Qiu Yulin believes that with the introduction of policy goals such as fair participation by everyone, deepening the function of medical insurance, and reducing the burden of units and individuals, personal accounts cannot fully meet current needs. The function of deepening medical insurance relies on a strong fund volume, especially the size of the pooled fund, but personal accounts have dispersed the total amount of pooled funds and reduced their protection capabilities; in addition, individual payments are completely in personal accounts and a higher proportion of unit payments Transferring to personal accounts greatly reduces the medical insurance fund's function of mutual assistance.
The accumulation of personal accounts is also limited, Wang Zhen explained, although in a statistical sense, compared with young people, the elderly have higher medical expenses, so they can be accumulated when they are young and used when they are old. But for individuals, they face the risk of disease throughout their life cycle, and the accumulation function of personal accounts is limited. In 2018, the per capita accumulation of employee medical insurance personal accounts was only about 2,300 yuan; the per capita hospitalization expenses for employee medical insurance that year had exceeded 11,000 yuan. If there is no mutual assistance, this figure is limited to alleviating the high medical expenses after old age.
Interpretation 3
What is the effect of the first reform exploration?
Increased efficiency in the use of medical insurance funds
At present, most regions have included outpatient treatment of some serious diseases and chronic diseases, and day surgery, etc., into the scope of unified payment. Beijing, Shanghai, Zhejiang, Guangzhou, Qingdao, Xiamen and other places have gradually carried out personal account system reforms and outpatient expenses. Coordinated exploration. Wang Zhen believes that, in terms of effects, the outpatient treatment level of insured persons and the use efficiency of medical insurance funds have been improved.
The core measure of this national-level reform is to establish and improve the overall planning and guarantee mechanism for general outpatient medical expenses. The reform opinions are clear. The general outpatient clinics will cover all employees' medical insurance participants, and the payment ratio will start from 50%.
To enhance the mutual aid ability of the medical insurance pool fund, it is necessary to adjust the structure of personal accounts. This is one of the considerations for improving the personal account credit method policy.
Interpretation 4
How to better function after personal account reform?
Can be explored for more medical insurance fields
Regarding the reformed personal account of medical insurance, Qiu Yulin said that it is necessary to return to the essence of medical insurance and make adjustments to personal accounts that are compatible with the new environment, new situation, and new policy objectives, so as to realize the continuation of the old and new missions.
She believes that, on the one hand, it is imperative to adjust personal accounts, but reform and adjustment need to uphold the principles of equity replacement, smooth transition, reasonable conversion, and policy coordination. The existing accumulated part of the personal account (stock fund) is owned by the individual, and the existing personal account can be retained and expanded, and it can also be explored for more medical insurance-related fields.
On the other hand, unit payments are gradually transferred to the overall planning fund, and outpatient overall planning is established to provide policy guarantees for outpatient expenses of insured persons. In terms of outpatient co-ordination, combined with the existing co-ordination system for chronic, special and serious outpatients, comprehensive adjustments will be made from disease type outpatient coordinating to cost outpatient coordinating, that is, outpatient service items and drugs that meet the three catalogs will be reimbursed in accordance with medical insurance policies.
In the short term, personal accounts can be used to pay for outpatient expenses, and the social pooling fund will be supplemented simultaneously; in the long run, as the outpatient pool benefits are improved in terms of the types of diseases and services, the level of protection, and the people covered, the employee medical insurance Participants' outpatient visits can be more fully guaranteed.
Interpretation 5
Have you considered saving medical insurance fund expenditures?
The purpose is to improve the efficiency of fund use
Experts say that after calculations, the average number of outpatient visits a year for a person in my country is about 6 times. After the reform, the medical insurance benefits of outpatient clinics have been improved. Will the expenditure of the fund decrease or increase? The medical insurance fund may pay more for outpatient protection. The policy is mainly to increase the level of protection so that the insured can get more benefits.
But fund expenditure is not a consideration of policy design. In other words, the introduction of this policy is not to save money for the medical insurance fund, reform the personal accounts of basic medical insurance for employees, and establish a sound outpatient mutual aid guarantee mechanism. The purpose is to improve the efficiency of the use of medical insurance funds and gradually reduce the burden of medical expenses for the insured. Make the system more fair and sustainable.
Interpretation 6
What impact will the personal account reform have?
Can actually improve the level of protection
This reform not only improved the accounting method of personal accounts, but also expanded the scope of use of personal accounts.
Wang Zhen believes that the impact of this reform should be judged from three perspectives: one is to see whether the reform has improved the overall security level and capacity, which is the "total effect" of the reform; the second is to see whether the reform is balanced The relationship between stakeholders and full consideration of the vested interests of the insured is the "structural effect" of the reform; the third is whether the reform rationalizes the incentive mechanism and improves the efficiency of the use of funds. This is the "incentive effect" of the reform. .
In terms of "total effect", Wang Zhen said that it should be clearly understood that people participating in medical insurance are not for the accumulation of funds in their personal accounts, but to better deal with the economic risks brought about by diseases. Therefore, only through collective strength and mutual assistance can individual risks be resolved, and part of the funds in the personal account is replaced by the outpatient fee mutual aid guarantee mechanism. The outpatient fee protection is not limited to the funds in the personal account, and the guarantee capacity and level can be significantly improved. .
With the overall increase in support capabilities and support levels, the issue of interest adjustment is also involved. This is also the most concerned issue from all walks of life. In the case that the outpatient expenses are paid by the overall fund, weakening the personal account will not have a negative impact on the insured's outpatient protection rights, and the actual protection level is still improved.
Beijing News reporter Wu Wei