Explain the medical insurance "14th Five-Year Plan" in detail! What changes will happen to reimbursement, drug prices, and commercial insurance?
The "14th Five-Year Plan" (hereinafter referred to as the "Plan") approved by the executive meeting of the State Council recently is my country's first special five-year plan for universal medical insurance and outlines the focus of my country's medical insurance reform in the next five years.
During the "14th Five-Year Plan" period, my country must further advance the reform of the medical insurance system, do its best, and do what it can. Medical insurance must adhere to the basic concept of insurance throughout, gradually improve the level, and achieve sustainability.
Zhu Minglai, director of the Health Economics and Medical Security Research Center of Nankai University, told China Business News that the core of the plan is to improve the multi-level medical security system and effectively and rationally divide the market and the government.
Liberalizing restrictions on insured household registration, improving outpatient treatment benefits, curbing falsely high pharmaceutical prices, and clarifying the development space for commercial insurance are all highlights of the plan.
Improve the multi-level medical insurance system
China Business News: my country’s medical insurance reform programmatic document "Opinions of the Central Committee of the Communist Party of China and the State Council on Deepening the Reform of the Medical Security System" proposes that by 2030, it will be fully completed with basic medical insurance as the main body, medical assistance as the foundation, and supplementary medical insurance and commercial health. A medical security system for joint development of insurance, charitable donations, and mutual medical assistance.
As the "14th Five-Year Plan" is a critical period for the construction of a multi-level medical insurance system, what aspects need to be improved?
Zhu Minglai: The executive meeting of the State Council on September 15 mentioned that "Improve the multi-level medical insurance system and optimize the medical insurance assistance policies by category."
Emphasizing that in the future it will not be possible to be responsible for all basic medical insurance. Commercial insurance, charity assistance, and mutual medical assistance will all usher in great development during the "14th Five-Year Plan" period. In particular, it must be combined with the current three-time distribution and common prosperity to build prevention of disease. System engineering that leads to poverty can no longer rely solely on basic medical insurance protection.
There have been many explorations in practice. For example, Huimin Insurance, which has a certain inclusive nature, has changed the direction of commercial health insurance to fully serve high-end customers in the past, but inclined to low- and middle-income groups to supplement their medical security.
In the future, charitable donations in the three distributions can also be used more to establish some medical security funds. For example, the "pillar" project of the China Foundation for Poverty Alleviation uses charitable donations for medical security for poor families.
The classification and optimization of medical insurance assistance policies is also very important. It is necessary to make the work detailed for different groups of people, not only at multiple levels but also to reflect differences, and at the same time reflect the preference for disadvantaged groups.
The list of national medical insurance benefits announced this year has abolished the threshold of assistance for subsistence allowance recipients and extremely poor people, which is a breakthrough.
It is also a very important task during the "14th Five-Year Plan" period to loosen restrictions on participation in household registration and promote participation in employment.
Now that the urban and rural economy is becoming more and more integrated, and the scale of the floating population is getting larger and larger, most of the traditional migrant workers will continue to retain the medical insurance in the place of household registration. Although the settlement policy for medical treatment in different places is now introduced, there will still be underreporting and out of insurance. In addition, there are differences in drug catalogues and payment ratios for settlement in different places. From the perspective of system fairness, the floating population has the right to enjoy the medical insurance benefits of the place of employment.
The liberalization of household registration restrictions is a general direction. In reality, it needs to be refined. For example, after the liberalization, whether to participate in the insurance in the form of employees or residents; the state provides subsidies for residents to participate in the insurance, and how the subsidy funds are used for employment Issues such as the transfer between the land and the household registration area should be clarified.
Improving the mutual aid system in outpatient clinics is also the main task during the "14th Five-Year Plan" period.
The above-mentioned National Standing Committee proposed to steadily increase the reimbursement of basic medical insurance outpatient services, and improve the outpatient medication protection of hypertension and diabetes for urban and rural residents.
The General Office of the State Council has issued the "Guiding Opinions on Establishing and Improving the Outpatient Mutual Assistance Mechanism for Basic Medical Insurance for Employees."
Various localities are also issuing supporting documents to implement the outpatient mutual aid policy, including general outpatient clinics, outpatient chronic diseases and special diseases, etc. The level of treatment needs to be further improved.
Aiming at "difficult medical treatment" and "expensive medical treatment"
China Business News: The plan proposes to promote hierarchical diagnosis and treatment, reduce "small diseases" and excessive medical treatment, and continue to expand the scope of mass purchases to curb the inflated prices of medicines and medical consumables, all of which are to alleviate the "difficult and expensive medical treatment" Measures.
How should these measures be implemented more effectively during the "14th Five-Year Plan" period?
Zhu Minglai: The plan proposes to establish a mechanism for the mutual adaptation of the basic medical system and the basic medical insurance system.
Whether medical security is done well is closely related to whether it can form a benign interaction with basic medical care.
In the future, medical insurance needs certain policy support and tilt for hierarchical diagnosis and treatment and the construction of medical community and medical consortium.
While providing financial leverage, medical insurance should also control the supervision and quality of primary hospitals, cooperate with or guide the medical system to improve the quality of primary medical care, so that people can be assured of the quality of services provided by primary medical institutions.
The effect of the volume purchase policy has been demonstrated, and the price level of pharmaceutical consumables has dropped significantly.
Through the centralized procurement of medical insurance organizations, there is no problem in reducing the burden of patients’ medical care. During the "14th Five-Year Plan" period, I believe that a regular evaluation and review system should be established for the implementation and effectiveness of these policies to ensure that mass purchases are reducing people’s health. At the same time as the medical expenses of the masses, is there any negative impact on the quality of medicines and equipment?
Delimit the boundary between the government and the market
China Business News: During the "14th Five-Year Plan" period, what development space and opportunities will commercial health insurance usher in?
Zhu Minglai: The plan consistently proposes to support the development of commercial health insurance, and the effective and reasonable division of labor between the market and the government is the focus of the reform of the medical insurance system during the "14th Five-Year Plan" period.
The "Opinions on Establishing a Medical Security Benefit List System" (hereinafter referred to as the "Opinions") announced in August has clarified that my country's medical insurance system consists of three parts: the basic medical insurance system, the supplementary medical insurance system, and the medical assistance system. The sustainable and standardized management of the company keeps the boundaries of government responsibility, and also leaves room for the development of commercial insurance.
The "Opinions" emphasized "holding the boundaries of government responsibility" and clarified the difference between the government's supplementary medical insurance system and commercial supplementary medical insurance.
For example, the popular Huimin Insurance, although it is universally beneficial, is a commercial insurance and has nothing to do with the government.
In addition to the catalog that the government must manage, there is the space for commercial insurance. The catalog of Huimin Insurance and the scope of responsibility are determined by commercial insurance itself.
Another example is the "Opinions" stipulating that the maximum payment limit of the fund shall not exceed about 6 times the annual average salary of local employees and the per capita disposable income of residents.
This is the level of medical protection provided by the government. If people feel that the money is not enough for the treatment of serious illnesses, they need to buy some supplementary commercial serious illness insurance. This is also the space for commercial insurance.
Another opportunity for commercial insurance companies is to participate in the supervision of medical insurance funds.
The plan also proposes to introduce third-party forces such as commercial insurance institutions to enhance the professionalism of supervision and give more effective play to the role of social supervision.
We found in local surveys that according to the current staffing of medical insurance personnel, the overall supervision of medical institutions and pharmacies is relatively weak. In this case, the government can introduce commercial insurance institutions to supervise.
In the future, commercial insurance will play a more important role in ancillary services and management services.
Two issues must be dealt with in the introduction of commercial insurance to enhance the professionalism of supervision. One is that it requires clear authorization from the government. Commercial insurance is not a government department. It has no right to supervise medical insurance funds. The government must define the boundaries of authority when authorizing it to supervise. There must be a unified standard for what can be done and what cannot be done.
In addition, the effect of commercial insurance supervision needs to be evaluated in economics. For example, how much illegal funds can be found under its supervision, how many unreasonable medical expenses can be recovered, and how much insurance fraud and compensation can be found. This actually requires Make a base for the assessment of supervisory functions.
Author: Guo Jinhui