The first major reform of employee medical insurance personal account in 22 years
In 2007, China made clear the main structure of three vertical and three horizontal of the basic medical security system. The three vertical refers to the basic medical insurance system for urban employees, the new rural cooperative medical system and the basic medical insurance system for urban residents. Among them, the medical insurance for employees involved in the draft was established as early as 1988.
According to relevant regulations, employers should pay social security for employees. The medical insurance expenses are jointly paid by employers and employees in accordance with national regulations. These expenses are divided into two parts: overall account and individual account. The overall account mainly pays for hospitalization medical expenses, and the individual account consists of 2% of individual payment and 30% of unit payment, which is mainly used to pay for insurance participation The staff and workers shall pay the expenses within the policy scope of designated medical institutions or designated retail pharmacies.
According to the statistical bulletin on the development of medical security industry in 2019 (hereinafter referred to as statistical express), by the end of 2019, 329.26 million people had participated in the basic medical insurance for employees, an increase of 12.45 million over the previous year, an increase of 3.9%. There were 242.31 million employees and 86.95 million retirees in the basic medical insurance for employees, an increase of 9.23 million and 3.22 million respectively over the end of the previous year.
An industry person pointed out to the surging news analysis that for young people, because they are more healthy and spend less on medical treatment, the money in the personal account of medical insurance is often idle or precipitated, while for the elderly who often have to see a doctor, the money in the personal account is not enough. In this way, the original intention of the whole society to share the risk of medical insurance fund can not be realized smoothly.
According to the surging news, there are different exploration policies for the use of personal account funds in different places. For example, Beijing employee medical insurance personal account funds can also be withdrawn through the medical insurance passbook; since 2017, Shanghai has introduced the policy of purchasing commercial health insurance with personal account.
Do not cancel personal account, just adjust structure
Previously, there has been news that the state will cancel the individual account of medical insurance. This draft for comments dispels this concern. In terms of employee medical insurance, personal accounts still exist, but the internal capital structure has changed.
According to the draft, the reform of the employees medical insurance personal account is not to increase the payment amount of individual or enterprise, but to adjust the internal capital structure of the individual account, that is, the basic medical insurance premium paid by the individual is included in the personal account of on-the-job employees. In principle, the basic medical insurance premium paid by the unit is included in the basic medical insurance premium paid by the unit As a whole, the fund will no longer be transferred into individual accounts.
This means that in the future, the fund of individual account of employee medical insurance will decrease, while the fund of overall account will increase. Although it seems that the amount of money in individual accounts has decreased, with the increase of funds in the overall account and the optimization of use, we can improve the use efficiency of medical insurance fund and realize the more equitable and sustainable development of medical insurance system without increasing the payment amount.
First of all, the number of users of personal accounts has been expanded, emphasizing the shared responsibility of families.
It is worth noting that the draft clearly states that personal accounts should not be used for public health expenses, sports fitness or health care consumption and other expenditures that are not covered by the basic medical insurance.
Medical insurance funds used for purchasing health care products were once included. Under the influence of the concept of disease prevention rather than just treatment, medical insurance was used in sports and fitness to prevent diseases. For example, in 2016, the implementation opinions of Hangzhou Municipal Peoples Government on accelerating the development of sports industry and promoting sports consumption (Draft for comments) proposed that in accordance with the National Peoples governments implementation opinions on accelerating the development of sports industry and promoting sports consumption (Draft for comments), the government of Hangzhou City proposed that in accordance with the National Peoples government, the According to the relevant regulations of home and province, combined with the actual operation of municipal medical insurance fund, we should timely study the balance of individual medical insurance account to promote sports health consumption
In addition to the direct impact on peoples control of medical insurance funds and the prohibition of using personal account funds for health care consumption and other expenditures, the states attitude towards the special use of medical insurance funds is emphasized again, which may affect the behavior of purchasing health care products in pharmacies, thus affecting the revenue of pharmacies.
Strengthen the level of outpatient security
Strengthening the security level of outpatient service is undoubtedly one of the highlights of the draft. According to the draft, we should start with chronic diseases such as hypertension and diabetes, and gradually bring the common outpatient medical expenses of common diseases into the scope of fund payment. The general outpatient service covers all employees, and the payment proportion starts from 50%.
The draft also proposes to improve the payment mechanism suitable for the characteristics of outpatient treatment, and actively explore the combination of capitation and chronic disease management for primary medical services; implement payment by disease and disease diagnosis related groups for day surgery and qualified outpatient special diseases; and pay by project for outpatient expenses that are not suitable for package payment. We should speed up the formulation of medical insurance drug payment standards, and guide medical institutions and patients to take the initiative to use drugs with definite curative effect and reasonable price.
Industry insiders said that the policy will help to enhance the level of outpatient security, reduce unnecessary hospitalization, and will guide patients to primary medical institutions through payment, which will affect peoples medical behavior in many ways.
Some people in the industry believe that the policy will also make the outpatient service of the hospital a market that pharmaceutical enterprises are competing for, and the pharmaceutical industry may usher in a new round of reshuffle.
It should be noted that this is only a draft for comments on the reform of individual accounts of employees medical insurance, and the public can put forward their opinions before September 6. How the reform will affect the development of daily medical treatment and related industries still needs to be seen after implementation.
The full text of the guidance on the establishment and improvement of the outpatient mutual aid security mechanism for employees basic medical insurance is as follows:
In order to further improve the universal medical insurance system of mutual aid and responsibility sharing, better solve the outpatient security problem of employee basic medical insurance (hereinafter referred to as employee medical insurance) and effectively reduce the burden of medical expenses of employees, in accordance with the central task of deepening the reform of medical security system, the following opinions are put forward on the establishment and improvement of the medical insurance outpatient medical insurance guarantee mechanism.
1u3001 Guiding ideology and basic principles
uff081uff09 Guiding ideology. Guided by Xi Jinpings socialist ideology with Chinese characteristics in the new era, we should take care of the spirit of the nineteen and nineteen sessions of the second, third and fourth plenary sessions of Chinas Communist Party, and do our best to do everything in our power and do our best. We should adhere to the responsibilities of everyone, everyone, improve the system, guide the anticipation, accelerate the reform of key areas and key links of basic medical insurance, and bring the outpatient medical expenses into the basic medical insurance. We should plan the payment scope of the fund, reform the personal account of basic medical insurance for employees, establish and improve the outpatient mutual aid security mechanism, improve the utilization efficiency of the medical insurance fund, gradually reduce the medical expenses burden of the insured, and realize a more equitable and sustainable system.
uff082uff09 Basic principles. We should adhere to the basic guarantee, implement overall planning and help each other, and earnestly safeguard the rights and interests of the insured. We should adhere to a smooth transition, maintain policy continuity, and achieve a smooth convergence of treatment before and after the reform. Adhere to the overall planning and linkage, and realize the synchronous promotion and gradual transformation of the improvement of the individual account system and the improvement of the outpatient security mechanism. We should adhere to the principle of adjusting measures to local conditions, based on the overall design, proceed from the actual situation, and encourage local governments to actively explore effective ways to enhance the medical insurance outpatient service security of employees.
2u3001 Main measures and contents
uff081uff09 To strengthen the function of outpatient mutual aid. We should establish and improve the overall medical expenses guarantee mechanism of general outpatient department. We should start with chronic diseases such as hypertension and diabetes, and gradually bring the medical expenses of common diseases and common diseases into the scope of overall planning fund payment. The proportion of payment starts from 50%. With the increase of fund bearing capacity, the level of security is gradually improved, and the payment can be appropriately inclined to retirees. According to the characteristics of outpatient medical service, the starting payment standard and the maximum payment limit should be calculated scientifically, and the connection with inpatient payment policy should be done well.
According to the bearing capacity of the fund, all localities can explore gradually expanding the scope of outpatient chronic diseases and special diseases paid by the overall planning fund, and include the medical expenses for some chronic diseases and special diseases which have long treatment cycle, great damage to health and heavy economic burden. For some special treatment which needs to be carried out in outpatient department and more economical and convenient than hospitalization, it can be managed according to hospitalization treatment. With the gradual improvement of the outpatient mutual aid security mechanism, we should explore the transition from disease type guarantee to cost guarantee.
uff082uff09 Improve the method of personal account entry. Scientific and reasonable determination of personal account included method and level, in-service staff personal account by the individual payment of basic medical insurance premium included, included in the standard in principle within 2% of the insured contribution base, the basic medical insurance premium paid by the unit is included in the overall planning fund; in principle, the individual account of retirees is transferred by the overall planning fund according to the quota, and the amount transferred is determined by the Institute At the time of regional reform, the basic pension was estimated at about 2% and will not be adjusted in future years. According to the above principles, the provincial medical insurance department shall guide the overall planning area to determine the specific proportion or standard of individual account according to the above principles and in combination with local reality. After the adjustment of the unified account structure, the reduction of funds transferred into individual accounts is mainly used to support and improve outpatient mutual aid security and improve outpatient treatment.
uff083uff09 Standardize the use scope of personal account. The personal account is mainly used to pay the out of pocket expenses incurred by insured employees in designated medical institutions or designated retail pharmacies. It can be used to pay the medical expenses borne by the employees themselves and their spouses, parents and children in the medical institutions designated by medical insurance, and the expenses borne by individuals when purchasing drugs and medical consumables in designated retail pharmacies. The purpose of this study is to explore the individual payment of spouse, parents and children participating in basic medical insurance for urban and rural residents. Personal account shall not be used for public health expenses, sports fitness or health care consumption and other expenditures that are not covered by the basic medical insurance. We will improve and improve the management methods for the use of personal accounts and do a good job in the statistics of income and expenditure information.
uff084uff09 Strengthen supervision and management. We should improve the management and service measures, innovate the operation mechanism of the system, guide the rational use of medical resources, and ensure the stable operation of the medical insurance fund and the system guarantee effect. Strictly implement the fund budget management system, strengthen the fund audit system and internal control system construction. Establish a dynamic management mechanism for the whole process of individual accounts, and strengthen the audit of the use and settlement of individual accounts. We should strengthen the supervision of outpatient medical behavior and medical expenses, establish a fund security prevention and control mechanism, crack down on fraud and insurance fraud, and ensure the safe, efficient and rational use of the fund. We should innovate the management methods of outpatient medical services, improve the monitoring, analysis and assessment system of medical services, and guide medical institutions to control the cost of medical services. According to the requirements of the national unified medical insurance information platform construction, accelerate the informatization construction and explore the realization path of outpatient medical settlement in different places. Through promoting the construction of primary medical service system, improving the family doctor contract service and long-term prescription system, we can guide the insured to seek medical treatment at the primary level. Combined with the improvement of outpatient chronic disease and special disease management measures, standardize the diagnosis and treatment and referral behavior of primary medical institutions.
uff085uff09 Perfect the payment mechanism suitable for the characteristics of outpatient treatment. For primary medical services, capitation payment can be actively explored, and the combination of capitation and chronic disease management should be actively explored; for day surgery and special outpatient diseases that meet the conditions, payment by disease type and disease diagnosis related groups should be implemented; for outpatient expenses that are not suitable for package payment, they can be paid by project. We should speed up the formulation of medical insurance drug payment standards, and guide medical institutions and patients to take the initiative to use drugs with definite curative effect and reasonable price.
3u3001 Organizational leadership
uff081uff09 Seriously organize the implementation. Improving the medical insurance outpatient security mechanism involves the vital interests of the vast number of insured people. The medical security and financial departments in various regions should attach great importance to it, and study and formulate the implementation rules in combination with the local reality. In areas where relevant explorations have been carried out, policies should be further refined and improved and system standards should be standardized according to the opinions. In the areas where relevant work has not yet been carried out, it is necessary to actively and steadily study the scheme and speed up its implementation.
uff083uff09 Actively and steadily push forward. This opinion shall be implemented from December. All localities should issue provincial documents before the end of this year to guide the overall planning areas to implement them. In accordance with the spirit of this opinion and in combination with local conditions, we should further clarify the range of policy adjustment, make unified and detailed provisions, and clean up and revise policies and regulations that are inconsistent with this opinion. In the process of promoting the work, in case of new situations and problems, timely report to the State Medical Security Bureau.