Recently, Guangdong, Hubei, Sichuan and other provinces have implemented the reform of mutual aid for employees’ medical insurance outpatient service, clearly carried out the overall planning of employees’ medical insurance outpatient service, reimbursed the insured’s general outpatient expenses according to regulations, and simultaneously adjusted the method of recording employees’ personal medical insurance accounts. Around the focus of public concern, "Xinhua Viewpoint" reporter interviewed authoritative experts and insiders.
The staff of the Medical Insurance Office of the First Hospital of Sanming City, Fujian Province (right) explained the relevant policies to the residents who came to consult about drug reimbursement (photo taken on November 18, 2020). Xinhua News Agency reporter Jiang Kehong photo
Focus 1: Will the lack of "money" in personal accounts affect medical insurance benefits?
With the implementation of multi-local policies, many insured people find that their medical insurance accounts have less "money" and are worried that it will affect their personal medical insurance benefits.
It is understood that the medical insurance reform plans recently introduced in many places have something in common: the amount included in the personal account of employee medical insurance has changed in the current period. For on-the-job employees, the part originally included by the unit payment is no longer included and is included in the overall fund; For retirees, the personal account is included in the pension from the past to the quota, and the quota standard is linked to the per capita pension in the year of overall regional reform.
From the book alone, the newly added "money" in personal accounts has indeed decreased, and some people have dropped a lot. This makes people wonder, where did the reduced "money" go? Will it affect personal medical insurance benefits?
"‘ on the personal account of medical insurance; Money ’ The reduction does not mean the reduction or loss of medical insurance benefits for insured employees. " Wang Zhen, director of the Public Economics Research Office of the China Academy of Social Sciences, said that the "money" reduced in personal accounts will be converted into the increment of the overall fund "big pool" to bear the general outpatient expenses paid by the "small pool" of personal accounts in the past, and the accumulated balance before personal accounts will still be used by individuals to realize the "increment" of protection.
In April, 2021, the General Office of the State Council issued the Guiding Opinions on Establishing and Perfecting the Outpatient Mutual Aid Guarantee Mechanism for Employees’ Basic Medical Insurance, which clearly adjusted the overall fund and individual account structure, and the increased overall fund was mainly used for outpatient mutual aid guarantee, so as to improve the outpatient treatment of the insured. That is to say, after the reform, ordinary outpatient expenses that could not be reimbursed before can be reimbursed.
Take Zhou, a retired employee in Wuhan as an example. Its annual pension income is 50,000 yuan, and before the reform, the personal account was transferred to 2,400 yuan every year. Zhou has a cerebral infarction, but because there is no outpatient co-ordination policy in the local area, he can’t enjoy reimbursement for seeing a doctor in an outpatient clinic. After the reform, the annual transfer of his personal account was adjusted to 996 yuan. After the outpatient expenses incurred in a tertiary hospital were 7,150 yuan, he was reimbursed according to the new outpatient co-ordination policy, except the threshold fee of 500 yuan, and the reimbursement rate was 60% in tertiary hospitals, so he could be reimbursed 3,990 yuan. That is to say, although Zhou’s personal account was less than 1,404 yuan in that year after the reform, his enjoyment increased by 2,586 yuan.
Focus 2: Is it because the overall fund is out of money to reform the employee medical insurance personal account?
There are doubts that the reform of employee medical insurance personal accounts is because the overall fund has no money, and it is necessary to use personal accounts to "fill the hole". In this regard, experts said that this is due to the misunderstanding of the income and expenditure of China’s medical insurance fund.
The data shows that in 2021, the income of the employee medical insurance pooling fund was 1,186.4 billion yuan, and the expenditure was 932.1 billion yuan. In other words, the overall fund not only breaks even, but also has a slight balance, so "the overall fund has no money" is not established.
In this case, some people wonder why the "money" in personal accounts is transferred to the overall fund for outpatient mutual assistance and let others spend their own "money".
"In the final analysis, medical insurance is a kind of social insurance, which means that it has the nature of mutual assistance, responsibility sharing and joint construction and sharing." Wang Zhen said that the insured people get sick less when they are young, and they are prone to get sick when they are old. It is limited to rely solely on personal account accumulation to see a doctor and take medicine. Putting everyone’s money together, the risk of social groups can be solved by the law of large numbers, and the public’s medical needs can be met in a wider range.
Wang Zhen said that the adjustment of personal accounts is to reduce the current period, without moving the personal historical balance. It should be recognized that both individual accounts and overall funds belong to the paid medical insurance fees and are "money" raised, distributed and used to solve the public’s disease prevention and treatment problems.
Before the reform, personal accounts could not be used by others, "those who are sick are not enough, and those who are not sick cannot be used", which gradually led to excessive precipitation, insufficient mutual assistance, fraudulent insurance fraud and other drawbacks.
"Under the framework of strategic purchase of medical insurance, optimizing outpatient security treatment is a structural adjustment." Gu Xuefei, director of the Medical Security Research Office of National Health Commission Health Development Research Center, said that this is to improve the level of outpatient security without raising additional funds and increasing the burden of payment by units and individuals.
Focus 3: What is the impact of personal account reform on the elderly?
Some elderly people see that personal accounts have less "money" after the reform, and they are worried that the use of medical treatment and medicine is limited.
The guidance is clear, and the level of general outpatient co-ordination security starts at 50%, and all localities are required to give inclined payment to retired elderly people on this basis.
Taking Hohhot as an example, after the opening of outpatient co-ordination guarantee, the proportion of outpatient payment for retirees has increased, and medical institutions at all levels have increased by 5% on the basis of the original method. At the same time, the annual maximum payment limit for outpatient co-ordination has been further increased, and the payment for retirees has increased from the original 4,000 yuan to 6,000 yuan, which is higher than that for on-the-job employees.
In addition, before the general outpatient service was improved, many areas first established the outpatient service security mechanism for chronic and special diseases, and used the overall fund to pay the expenses of chronic diseases and special diseases common to the elderly in outpatient service. Recently, some places have appropriately expanded outpatient special diseases. For example, Nanjing, Jiangsu Province has added 9 kinds of diseases on the basis of the original 4 kinds of special diseases; Wuhan has increased the number of special diseases such as hypertension and diabetes from 28 to 37, and the number of basic diseases from 32 to 70.
By comparing the reform schemes of individual accounts for employees’ medical insurance in many places, we can also find one thing in common — — The use scope of personal accounts has been broadened, with the users ranging from individuals to spouses, parents and children, and the objects ranging from drug payment to medical devices and medical consumables. This is even more good for the elderly.
Gu Xuefei said that after the reform, the insured can use the "money" from personal accounts to other family members such as the elderly, forming a "small mutual aid" within the family and improving the family’s ability to cope with medical risks.
Focus 4: How to improve the people’s sense of gain in reform?
With the implementation of reform plans in various places, some people also put forward opinions on the reform: in the past, they bought medicines at pharmacies at their doorsteps, but now they have to go to designated medical institutions for outpatient registration for reimbursement; Outpatient co-ordination reimbursement set deductible and maximum payment limit, and the guarantee is not as good as hospitalization reimbursement.
"Insured people feel the most intuitive about reform." Gu Xuefei said that in order for the reform dividend to truly benefit the overwhelming majority of the people, it is necessary to fully consider the impact on the people, medical institutions and other stakeholders, and make concerted efforts to facilitate the people to seek medical treatment and purchase medicines.
According to the relevant deployment, the reform of mutual aid for employees’ medical insurance outpatient service will be completed in three years. At present, most regions have announced the detailed rules for the reform of employees’ medical insurance personal accounts and the guarantee mechanism of outpatient mutual aid, but there are differences in the level of economic development and the overall strength of medical insurance in different regions, and the corresponding reform strategies and measures are not the same.
Interviewed experts and insiders suggested that we should effectively respond to the reasonable demands put forward by the masses, start with improving the convenience and accessibility of medical security services and strengthening policy interpretation, and effectively solve the problem of people seeking medical treatment and medicine.
"It is normal for different voices to exist in the reform process." Wang Zhen said that it will take time for the benefits of the reform policy to emerge, and it is necessary to promote coordinated supporting services at the same time, such as rationally adjusting the deductible line and the maximum payment limit for outpatient reimbursement, including qualified designated retail pharmacies as soon as possible, and exploring the inclusion of qualified "internet plus" medical services in the scope of protection.
Many regions have adopted step-by-step adjustments to promote a smooth transition of policies. There are also some areas that reduce the deductible line of outpatient reimbursement and increase the reimbursement limit. For example, Guangzhou has increased the reimbursement amount on the basis of adjusting the outpatient reimbursement from the monthly limit to the annual limit; Beijing no longer sets the maximum payment limit for medical insurance clinics.
The reporter learned that as of press time, some places have further optimized relevant supporting measures. Wuhan Medical Insurance Bureau issued an announcement to include the third batch of 4,065 designated retail pharmacies into the overall coverage of medical insurance outpatient service for employees on the basis of more than 1,000 retail pharmacies that have been announced in the early stage. (Reporter Peng Yunjia, Deng Nan, Deng Ruixuan, Dong Xiaohong, Huang Xiao)