4 keywords and 7 key issues, interpretation of health care "14th Five-Year Plan" period tasks

The preparation and implementation of five-year and medium- and long-term planning is an important way to govern the country, economic and social development, and is a major institutional arrangement of our Party and country.
The Recommendations of the CPC Central Committee on the Formulation of the 14th Five-Year Plan for National Economic and Social Development and the 2O35 Vision Adopted by the Fifth Plenary Session of the 19th CPC Central Committee clearly define the guiding ideology, basic principles, target requirements, main tasks and major initiatives of China's economic and social development during the 14th Five-Year Plan period.
The "14th Five-Year Plan" period is the first five years of China's overall construction of a well-off society and the realization of the first century's goal, taking advantage of the momentum to embark on a new journey towards building a socialist modern country in an all-round way and moving towards the goal of the second century.
In order to carry out in-depth the decision-making and deployment of the 19th National Congress of the Communist Party of China on the comprehensive establishment of a medical security system with Chinese characteristics and effectively solve the short-term problems of people's livelihood security, we first need to clarify the social basis and development goals of the reform and development of China's medical security industry, and on this basis, we should sort out the key work of the 14th Five-Year Plan period in a targeted manner, so as to realize the reform and development goals of the medical security system put forward by the CPC Central Committee and the State Council in the Opinions on Deepening the Reform of the Medical Security System (hereinafter referred to as the Opinions).
Three social foundations of the development of medical insurance during the 14th Five-Year Plan" period. Over the past 20 years since the establishment of the basic medical insurance system for the joint reform of medical insurance, medical care and medicine, breakthrough progress has been made in cracking the problem of difficult and expensive medical care, but the reform of the medical and health system has been lagging behind.
can say that the lack of systematic thinking is one of the important reasons why the new medical reform has not been successful.
In order to deeply implement the decision-making and deployment of the 19th National Congress of the Communist Party of China on the comprehensive establishment of a medical security system with Chinese characteristics, and to focus on solving the problem of unbalanced development of medical security, the Opinions clearly set out the basic principles to be followed in the reform, and put forward the principle of "adhering to system integration, synergy and efficiency, enhancing the integrity, system and synergy of medical insurance, medical and pharmaceutical reform, and ensuring the high quality and efficiency of the masses."
2. Insisting that basic health care be completed in primary communities in 1978, the World Health Organization, in the Almaty Declaration, stated that primary health care was the first phase of the national health system's links with individuals, families and population groups, and that it maximized access to where people worked and lived and was therefore the primary factor in the complete health care process.
the American Medical Association's committee defines primary care as a comprehensive and accessed health care service for patients in family and community settings through which physicians can build ongoing partnerships with a large number of patients.
Data analysis shows that 75-85 per cent of the population needs only primary health care and basic care within a year, 10 to 12 per cent of the population requires short-term secondary specialist care and only 5 to 10 per cent need health interventions from level III specialists.
can say that paying attention to and developing community medical care is the top priority in the field of medical and health care in the future.
3. Insist that the level of security is appropriate to the level of economic development, and that the level of medical security in a country should be in keeping with the level of economic and social development of that country.
China entered an ageing society by 2000, with GDP per capita reaching $10,000 in 2019.
The author has previously estimated that china will enter the intermediate stage from the initial stage of population aging in 2021-2025, when per capita GDP is expected to reach US$15,000, and by 2035, China will enter the super-ageing society, when GDP per capita will reach US$20,000 (see table 1).
with the gradual improvement of China's pre-rich old situation and the growing demand for healthy and long-lived consumption, China's total health expenditure and GDP ratio will also increase.
In formulating the 14th Five-Year Plan for Medical Insurance, we should attach importance to emphasizing the fairness and coordination of medical security, give full play to the strategic purchasing role of medical insurance funds, promote the coordinated development of high quality and coordination of medical security and medical services, and promote the implementation of the healthy China strategy so that the people can have more sense of access, happiness and security.
The "14th Five-Year Plan" period of health insurance development four key words 1. High-quality - high-quality health care services to implement classification to pay for high-quality health care services is not the pursuit of large hospitals, not only exist in the hospital or general hospital.
quality care should be based on professional division of labor and continuously improve the quality of work.
care services can be divided into emergency first aid, outpatient hospitalization, chronic disease management, medical rehabilitation, long-term care and end-of-life care.
In the specific division of roles, we should insist that "basic medical care is done in the grass-roots community", that is, based on the team of general practitioners, to provide guidance on the care and medication of common diseases in the community, leaving difficult problems to experts and general hospitals.
Health insurance should adhere to scientific classification when paying for high-quality medical care services, implement "head budget, money to go with people, balance retention, health assessment" for community medical care responsible for chronic disease management, and settle for emergency first aid and outpatient hospitalization according to the classification of diseases, and medical rehabilitation institutions, long-term care institutions and hospice hospitals should be settled by bed date or project.
It should be emphasized that in the design of medical insurance payment methods, we should not only adhere to patient-centered to improve the quality of health care, but also to avoid excessive medical treatment, rehabilitation "press" "transfer", end-of-life "stay" in the intensive care unit, brain death long-term dependence on ventilators and other waste of resources.
2. Efficiency - A truly efficient health care system that leads resource sharing through Medicare payments is an integrated, patient-centered care system.
We want to change the current situation where patients need multiple registrations, repeated examinations and inter-hospital information can not be shared, learn from the experience of developed countries and regions, activate patient health files and medical records, realize inter-hospital information sharing, and open a true green referral channel between community hospitals and general hospitals."
Health insurance composite payment policy should strengthen two ends, one is through the package pricing and average payment of the disease group, guide the general hospital reasonable treatment and control costs, the other is through the head budget and health assessment, guide the community hospital and family doctors to improve the contracting services, and then stimulate the establishment of a green channel between the two, activate the health file and case information sharing, change the residents graded medical treatment, file, examination and treatment of fragmented medical phenomenon.
the 14th Five-Year Plan period, a reasonable distribution index for the distribution of medical insurance funds to pay for outpatient and inpatient care in community hospitals and general hospitals should be established.
The author has calculated that the total health expenditure of OECD member countries accounts for more than 60% of the total health expenditure, medical care accounts for about 30%, and long-term care accounts for about 0.5%, which basically reflects the health care needs of middle-income countries.
based on the current situation of our country, the author suggests that by 2025, the proportion of community hospitals in the total expenditure of the health insurance co-ordination fund should reach 40%, 50% by 2030 and 60% by 2035.
- General Secretary Xi Jinping has always stressed the importance of putting the safety and health of the people first.
"The fundamental purpose of our universal health care system is to relieve the medical worries of all people," he said.
with the successful end of the fight against poverty, china's poor people's poverty patterns will also be fundamentally changed.
the post-poverty era, the functional orientation and mission objectives of rescue and the definition of the scope of the object of rescue also need to be recalcuited.
opinion calls for "the establishment of timely and accurate identification mechanism for the object of assistance, scientific determination of the scope of relief" and "the establishment of a long-term mechanism to prevent and resolve poverty due to disease."
In view of the problems such as the simplification of the definition criteria and fragmentation of aid methods in the previous poverty alleviation work, the 14th Five-Year Plan period should actively explore specific measures such as the "difficult group classification", "step-by-step relief policy" and "strategic purchase of affordable medical services by the Medical Assistance Fund", so as to solve the problem of catastrophic expenditure-type medical poverty by 2025, solve the problem of rare disease medical poverty by 2030, and basically eliminate poverty and return to poverty by 2035.
4. Pluralism - It is an important supplement to social medical insurance to carry out social and business cooperation and meet the needs of multi-level security.
with the improvement of China's per capita GDP level, people's demand for health care is also increasingly released, commercial health insurance has a very large market potential.
in order to promote the complementary convergence of various types of medical security and meet the diverse security needs of the masses, the Opinion clearly states that "accelerate the development of commercial health insurance and enrich the supply of health insurance products".
it should be noted that social medical insurance and commercial health insurance have obvious differences in coverage, financing methods, claims scope and principles, business models and so on, and need to establish cooperation mechanisms on the basis of clear boundaries.
health care is an important part of people's livelihood protection in the seven key issues of medical insurance development during the 14th Five-Year Plan period.
opinion, "by 2025, the health care system will be more mature and stereotyped."
In order to achieve this reform goal smoothly, the 14th Five-Year Plan period must continue to improve the medical security system in seven areas, such as perfecting the payment benchmark, establishing the list of medical insurance treatment, perfecting the prepaid system of medical insurance, realizing the intelligent supervision of the medical insurance fund, establishing the pricing mechanism to promote the reform of the medical supply side, promoting the corporate governance of the medical insurance operators, and promoting the in-depth cooperation of social security providers.
1. Improve the benchmark of medical insurance contributions for employees, reform the fund management model between 1998 and 2020, China's workers' medical insurance rates stable at about 8% of individual wages, of which Dongguan City minimum of 2.1%, Beijing's highest of 12% and 3 yuan.
The author through the analysis of other international social security system countries after the relevant information found that the current rate of medical insurance contributions of China's workers slightly higher than the average of similar countries, coupled with the state to promote enterprise development launched a number of tax cuts and fee reduction policies, workers' medical insurance contribution rates have basically no policy growth space (do not exclude wage base growth), only to seek stock reform, improve the efficiency of the use of health insurance funds.
in this context, the formulation of the "14th Five-Year Plan" for medical insurance should take into account the revision of the Labor Law of the People's Republic of China, requiring employers to report to the competent government departments the total wage and salary structure in order to standardize and consolidate the contribution base;
In the management and use of the employee medical insurance fund, China's employee medical insurance has been the implementation of outpatient and inpatient separation of the plate model, 30% of the enterprise contributions and all the fees paid by employees are included in the employee health insurance personal account, used to pay for in-patient out-of-the-way expenses, outpatient expenses and external drug distribution fees.
The "14th Five-Year Plan" period should, in accordance with the relevant provisions of the Social Insurance Law of the People's Republic of China, reform the accounting and payment methods of individual accounts of medical insurance for employees, improve the social mutual assistance of medical insurance funds, establish a channel-type co-ordination fund including emergency, inpatient, outpatient and community medical treatment; The three systems of policy, revenue and expenditure and operation are truly unified, exploring provincial adjustment and co-ordination, scientifically preparing the budget of medical insurance fund revenue and expenditure, fully implementing performance management, reasonably controlling the fund growth rate and balance rate, doing a good job in medium- and long-term actuarial, risk assessment and early warning emergency work, and constructing a long-term balance of income and expenditure mechanism.
2. To establish a list system of treatment, the basic medical insurance treatment of reasonable distribution of fund expenditure should be adapted to the level of economic development, and adhere to the basic principle of "receiving expenditure, reasonable distribution, balance of income and expenditure, and slight balance".
The OECD's main member countries currently control the proportion of individual out-of-payments below 15% (Japan has increased the out-of-pay ratio after entering a deeply ageing society), but our personal out-of-payment ratio is around 28%.
in view of the rapidly ageing population, it is recommended that the personal out-of-account ratio be set at 25 per cent in the future, thereby improving the treatment list system on the basis of this standard.
It should be emphasized that two priorities should be paid to the formulation of the treatment list: first, to improve the regulation of the "three major directories" of big data management, health economic assessment and dynamic adjustment mechanisms;
is tilting toward community health care in terms of reimbursement ratios because the slow-disease management system, which is actively responding to an aging population, should be arranged in community care rather than outpatient clinics in level three hospitals.
Outpatient and inpatients have complementary contributions, in order to prevent the emergence of three-level hospital outpatient siphon slow disease patients, in the process of replacement of the rights and interests of individual accounts of workers' medical insurance, it is recommended that the enterprise contribution part be transferred out for the establishment of community medical co-ordination, the individual account funds of employees can be used for family mutual assistance to pay the expenses of community medical treatment, so as to achieve a reasonable distribution of medical insurance fund expenditure between three-level hospitals and community hospitals.
, the government's decision-making authority should be regulated in accordance with the law, and no policy beyond the scope of the list authorization should be issued without approval, especially not to set the reimbursement ratio according to age.
, for example, Japan has even specifically increased the proportion of patients who pay out-of-the-way in order to prevent the problem of elderly patients relying on ventilator "presses" after brain death.
, in the formulation of treatment list must go through scientific demonstration, strict set the scope and standards of payment, to correct the problem of inadequate and excessive protection.
3. In implementing the annual total annual budget of the health insurance fund, the health insurance budget system and the fund's long-term balance mechanism should, first, scientifically formulate and pre-publish the total budget, payment standards, evaluation indicators and the proportion of advance funds, and create conditions for hospitals to carry out budget and cost accounting work, and second, to formulate and improve multi-composite medical insurance according to the behavior of general practitioners, specialists and medical experts. Payment methods (see Table 2), effectively play the role of compensation and incentives for medical insurance payments, third, to explore the establishment of medical association payment methods, the grass-roots close-knit corporate medical associations should do a good job of head budget and health assessment work (Jinhua, Shenzhen and other places have done micro-budget to individuals), loose-type professionals alliance should actively explore the payment methods of intensive inter-hospital DRG.
In summary, the 14th Five-Year Plan period should establish a comprehensive governance mechanism combining regional macro-control, mid-view incentive of medical insurance payments and micro-evaluation of pharmaceutical institutions, realize the reasonable distribution of all kinds of payments through incentive compatible, and establish a long-term balance of payments mechanism on the basis of improving the efficiency of the use of medical insurance funds.
4. Multi-dimensional intelligence of health insurance funds