The curtain of reform of employee medical insurance personal accounts will begin, and public opinions will be sought
Reduce the burden of outpatient expenses and personal accounts can pay for family medical expenses
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Improve the level of outpatient reimbursement protection, improve the medical insurance personal account accounting method, optimize the overall fund and personal account structure... Recently, the National Medical Insurance Bureau publicly solicited opinions on establishing and improving the outpatient mutual aid guarantee mechanism for basic medical insurance for employees. This means that in the future, employees can be reimbursed at a minimum of 50% for outpatient expenses, and the amount of money newly transferred to personal accounts will be reduced, which translates into strengthening outpatient protection.
Since 1998, after the establishment of a basic medical insurance system for employees with a "pooled account", hospitalization expenses were paid by the pooling fund, and outpatient services were mainly paid by personal accounts. In recent years, personal accounts have attracted attention from all walks of life due to insufficient outpatient protection.
On August 26, the National Medical Insurance Bureau solicited opinions on the reform of employee medical insurance personal accounts. This "Guiding Opinions on Establishing and Improving the Employee Basic Medical Insurance Outpatient Mutual Aid Guarantee Mechanism (Draft for Comment)" proposes to enhance the outpatient mutual aid guarantee function, improve the personal account accounting method, and standardize the use of personal accounts.
Outpatient reimbursement starts at 50% and is inclined to retirees
The "Draft for Solicitation of Comments" proposes to establish and improve the general outpatient medical expenses overall guarantee mechanism, starting from the outpatient chronic diseases with heavy burdens such as hypertension and diabetes, and gradually including the general outpatient medical expenses of frequently-occurring and common diseases into the scope of the overall fund payment. Ordinary outpatient clinics cover all employees who are covered by medical insurance, and the payment ratio starts from 50%, and the payment of benefits can be appropriately tilted to retirees.
According to Wang Zongfan, a researcher at the Chinese Academy of Labor and Social Security Sciences, my country’s medical insurance system mainly guarantees hospitalization and provides relatively high guarantees for hospitalization. In 2019, the medical expenses reimbursement rate within the hospitalization policy of employee medical insurance reached more than 80%. However, outpatient coverage is relatively weak.
In his view, most outpatient expenses are paid through personal accounts, but personal accounts do not have the function of mutual aid and cannot spread the cost risk among the population, resulting in an abnormally heavy burden of outpatient expenses. Most healthy people have a large balance in their personal accounts, while a few years The personal accounts of the elderly and the infirm are unable to make ends meet and bear heavy burdens.
In addition, the cost of outpatient diseases is not necessarily low. For example, tumor radiotherapy and chemotherapy, organ transplantation outpatient anti-rejection treatment, leukemia, etc., often cost more than hospitalization. Even for some outpatient chronic diseases, such as hypertension and diabetes, the cost of each treatment is not high, but long-term continuous medication is required and the burden is heavy.
Wang Zongfan believes that the basic medical insurance system for employees in my country should extend from covering major illnesses and hospitalizations to protecting minor illnesses and outpatient clinics, covering both large and small illnesses, making up for the shortcomings of outpatient protection, and balancing outpatient and hospitalization protection.
At present, some outpatient insurance systems established in various regions mainly focus on outpatient coordination for serious, serious, special, and chronic diseases. Some areas such as Beijing and Shanghai have established cost-based outpatient coordination, and outpatient fees exceed the set threshold. You can be reimbursed online.
According to Qiu Yulin, a professor at the School of Labor and Human Resources of Renmin University of China, the coverage of outpatient clinics by disease types is limited, and there is no guarantee for insured persons outside specific diseases, and the outpatient coordination for expenses lacks regional universality and fairness. With the changes in the disease spectrum and the increasing number of chronic patients in my country, she believes that it is necessary to pay attention to the management of chronic diseases and establish an outpatient protection system.
The newly credited personal account will be reduced and used to strengthen outpatient protection
Outpatient expenses can be reimbursed, where does the money come from?
The "Draft for Comments" proposes that the basic medical insurance premiums paid by individuals shall be included in the personal accounts of current employees. In principle, the accounting standard shall be controlled within 2% of the insurance payment base of the individual, and all basic medical insurance premiums paid by the unit shall be included in the overall plan. fund.
At present, the funds in the employee medical insurance personal account are composed of two parts: one part is the employee’s personal payment, which is included in the personal account according to the employee’s medical insurance payment rate, which is about 2% of the monthly salary; the other part is the 30% of the employer’s medical insurance premium. %, enter the employee's personal account. After the reform of the personal account, the part of individual payment is still included in the personal account, but the part of the unit payment is no longer included in the personal account, and all is included in the overall fund.
This means that the funds for outpatient mutual aid protection come from reducing the part of the unit's payment and transferring it to the personal account, and not adding new unit and individual payments. The reporter learned that the current average rate of payment by units in my country is 7.58% of the total wages of employees, 30% of which is about 2% of the total wages of employees, and will not be included in personal accounts. By optimizing the structure of personal accounts, strengthening and expanding the overall fund, simultaneously expanding the coverage of the fund, and including minor outpatient diseases into the coverage.
The main reason for the reform of the employee medical insurance personal account is that it is a product of a specific historical period. At this stage, the personal account protection function is difficult to adapt to the more adequate protection needs of the insured.
Regarding the funds accumulated in the medical insurance personal account before the reform, some experts explained that this part of the money remains unchanged and still belongs to the individual. In terms of use, what policies were originally implemented and what policies were implemented. "The reform is by no means a question of the abolition of personal accounts. Personal accounts will continue to be retained, but the accounting method has been adjusted."
After the reform, the amount of money newly transferred to the personal account will be reduced. Wang Zhen, a researcher at the Institute of Economics of the Chinese Academy of Social Sciences, believes that this is the replacement of part of the funds in the personal account with a mutual aid guarantee mechanism for outpatient expenses. The protection is not limited to the funds in the personal account, and the protection capacity and level will be significantly improved.
Families can share personal account funds to promote health management
It is worth noting that the use of personal accounts will be further expanded.
The "Draft for Comments" proposes that personal accounts can be used to pay for out-of-pocket expenses incurred by insured employees in designated medical institutions or designated retail pharmacies, or to pay for the employees themselves, their spouses, parents, and children at designated medical insurance sites. Medical expenses incurred by individuals incurred by medical institutions, and expenses incurred by individuals incurred in purchasing drugs and medical consumables in designated retail pharmacies.
The breakthrough is that individual payment for spouses, parents, and children participating in the basic medical insurance for urban and rural residents can also be paid through individual employee accounts in the future.
As of the end of 2019, the cumulative balance of employee medical insurance personal accounts reached 842.6 billion yuan. Some insured persons use personal account funds to purchase health care products and daily necessities, and even some areas have violated regulations such as cashing out of insured persons' personal accounts.
In this regard, the "Draft for Solicitation of Comments" clarified that personal accounts shall not be used for public health expenses, physical fitness or health care consumption and other expenditures that are not covered by basic medical insurance. In the eyes of the above-mentioned experts, this will help improve the efficiency of the use of personal account funds and increase the standardization of outpatient and pharmacy expenses.
In the past, due to the weak protection function of personal accounts, insured persons were more inclined to use pooled funds when seeking medical treatment, which resulted in an excessively high rate of hospitalization for employee medical insurance. Wang Zhen believes that after the implementation of outpatient mutual aid protection, excessive hospitalizations that originally occurred because of outpatient coordination will be reduced.
In addition, although the burden of most common and frequently-occurring outpatient clinics is not heavy, the non-reimbursement of outpatient expenses affects people's medical treatment behavior to a certain extent, especially for some low-income groups when the disease is milder because the expenses are not reimbursed. Seek medical attention and delay treatment.
"In the process of establishing and improving the overall planning of employee medical insurance outpatient clinics, insured persons will be gradually promoted to seek medical treatment at primary-level medical institutions and pay per capita. This will help motivate primary-level doctors to carry out health management and chronic disease management." Wang Zongfan said, its significance It is not only to provide better and fairer outpatient protection, but also to open a key door for medical insurance to promote health management.
Our reporter Li Danqing
"Worker Daily" (version 06, August 31, 2020)