Are Health Insurance Personal Account Reform Good or Bad for Pharmacies?

On August 26th, the guidance on establishing and improving the basic medical insurance outpatient co-payment guarantee mechanism for employees (draft for comments) (hereinafter referred to as the "Opinion Draft") caused a strong reaction in the industry, and the core of the debate was "to transfer the unit contributions originally as individual accounts into the co-ordination account", in short, if the "Opinion Draft" is implemented, the funds allocated to the individual accounts of health insurance will shrink every month.
so, does personal account reform have only drawbacks for pharmacies? How on earth do we interpret the impact of personal account reform on pharmacies? September 6th is the last day for public consultation on the guidance on establishing and improving the mechanism for the protection of basic medical insurance outpatient co-care for workers (draft for comments).
During the consultation period, the opposition was much less than expected, but still heard some views for the benefit of pharmacies, mainly the following voices: 1, personal health insurance account funds into co-ordination of health insurance, unfair and unreasonable; 2, this policy not only can not solve the problem of medical insurance outpatient co-assistance, but also increase the tension of medical resources; 3, the adjustment of this health insurance policy will reduce the overall national health level; 4, individual health insurance fraud is not the reason to adjust the health insurance policy; 5, should tap the potential from the overall medical insurance account to solve the problem of outpatient co-payment; 6, the family shared personal health insurance account, no real new ideas.
we expect that there will be more objections or adjustments by asking for advice.
Although from 2009, when the second round of medical reform was launched, the Guidance on Further Strengthening the Management of the Basic Medical Insurance Fund (No. 67 of the Ministry of Human and Social Affairs) pointed out that conditional co-ordination areas can explore ways to adjust the use of basic medical insurance personal accounts for urban workers, pilot the co-ordination of out-patient medical expenses for urban workers, gradually expand and increase the scope and proportion of reimbursement for outpatient expenses, and improve the efficiency of the use of individual account funds.
To February 2020, the Opinions on Deepening the Reform of the Health Care System (Zhongfa (2020) No. 5) made it clear: reform the basic medical insurance personal accounts of workers, establish and improve the mechanism of outpatient mutual assistance guarantee, individual account reform and outpatient co-ordination of this important event for more than a decade, once the mountain and rain come, it is inevitable that the interests of pharmacies should be touched, we believe that: reform should take into account the legitimate interests of opponents.
this article, we focus on the above six questioning opposition voices, article by article corresponding analysis, not purely rebuttal, only to cite dialectics.
. First, the fairness of the use of personal account balances We must first reiterate and clarify a few points: First, all the money in the balance of individual accounts is an integral part of the employee health insurance fund, as detailed in the provisions of the Social Security Law; Second, the draft for comments on individual account reform, clearly adopt gradual reform, do not move the historical balance, do not interfere with the accumulation and inheritance of this part of the balance;
This "one size fits all" can also be seen as the action of the internal management of the health insurance fund, and temporarily with which, which type of insured person directly relief another, another type of insured person's medical expenses are not related, that is, insurance.
. The balance between active and retired persons In accordance with the international practice of social medical insurance, it is indeed intergenerational help for the insured groups of active personnel to share the medical risks and cost burdens of the insured groups of retirees.
intergenerational help in China's basic medical insurance system, nor does it appear today.
the existence of intergenerational help, for the basic medical insurance system to stabilize far and far put forward realistic requirements.
In accordance with the assumption that the level of reform dividends has been solidly increasing over time, the investment of active personnel today to support the reform of personal accounts and outpatient co-ordination will be better than not doing this investment to reap a better risk premium, not to mention that basic medical insurance for workers is a compulsory social insurance coverage.
In the draft for comments, "retirement" appeared twice in total: First, "as the fund's affordability gradually improves the level of protection, the payment of treatment can be appropriately tilted towards retirees", which means that not now tilt, depending on future development, and now put forward to adapt to the demands of the elderly society, but also to minimize the possibility of blind opposition of the group of retirees; The second is that "the individual accounts of retirees shall, in principle, be allocated by the co-ordination fund on a fixed basis, and the amount allocated shall be calculated according to the basic pension of the region at that time, and will not be adjusted in the coming years", indicating that the co-ordination fund will be occupied and is only a transitional measure.
Iii, the medical system needs to undertake a greater burden of personal account reform and outpatient co-ordination, not a matter of health insurance, will greatly interfere with the medical industry's internal interest pattern, especially between different levels of hospitals in the competition for inpatient, outpatient cases and their medical expenses situation.
view, the situation is currently unbalanced and inadequate.
of patients in higher-grade hospitals have poor medical experience, health insurance fund to pay for the cost-effective is not high, especially in outpatient care, patients pay for and health insurance funds have this feeling.
lower-grade hospitals in the graded treatment of higher-grade hospitals and a considerable number of patients discrimination, prejudice, mistrust, but lower-grade hospitals are required to reform the energy.
This is not to save the secondary public hospitals, village health rooms or encourage private clinics, family doctors so narrow, but related to the people's efficient medical care, industry service facilities, and gradually solve the medical reform ship difficult to turn the difficult focus.
to high blood pressure, diabetes outpatient drug protection as a breakthrough, we are happy to see secondary and lower medical and health institutions with the help of personal account reform to obtain more and more direct empowerment.
it is worth mentioning that lower-grade hospitals need retail pharmacies to work together.
4. The meaning of family sharing of personal health insurance accounts Questioning the opposition is that: before the launch of this specific reform, many insured people actually use health insurance cards in pharmacies for health-related services, commodity consumption, in fact, not only for their own use, but also long ago to achieve the personal will to control the sharing of the family.
on this basis to determine that the draft "family sharing personal health insurance accounts, no substantive new ideas" is not accurate.
Because the draft emphasizes "regulating the scope of use of individual accounts": First, the employee himself and his spouse, parents and children can be paid for the purchase of medicines and medical supplies at designated retail pharmacies.
, explore individual contributions for spouses, parents and children to participate in basic medical insurance for urban and rural residents.
, it shall not be used for other expenses such as public health expenses, sports fitness or health care consumption that are not covered by basic medical insurance.
, according to a statistical bulletin issued by the National Health Insurance Administration, the cost of spending on pharmacies on individual accounts increased from 164.5 billion yuan in 2018 to 202.9 billion yuan in 2019.
combined with milnet's estimate that sales of brick-and-mortar retail pharmacies will reach 405.7 billion yuan in 2019, retail channels still account for nearly 50% of sales from health insurance.
" in the "normative scope", the above three are three levels, respectively, corresponding to: can pay, explore payment, not pay.
Xinlies are: in the scope of payment, in the top-level design to guide all places to medical supplies out-of-the-box, self-purchase into the scope of cooperation between pharmacies and health insurance funds, which for pharmacies to join the purchase of consumables belt volume brings a lot of imagination space.
the scope of payments, there is no mention of commercial health insurance and medical reimbursement, participation in urban and rural residents' health insurance is still closely around the basic health insurance system arrangements.
In the non-payment range, I am afraid that there are many gray services, goods are in fact significantly beyond the latest version of the scope of health insurance payments, for retail pharmacies, these small profits of the business is always sneaky to do, difficult to develop on a scale, compared with to undertake prescription outflow, it is simply not worth mentioning.
this is a convenience store advantage, not a pharmacy advantage.
, to improve the overall health level of the people Social health insurance, especially the basic medical insurance system, has developed into a roof-high social safety net.
, however, the co-ordination fund suffered from high hospitalization rate, excessive medical treatment, fraud insurance and so on run, objectively speaking, there is a fund security risk.
if the social safety net and the basic medical rights and interests of its insured cannot be balanced and fully protected, what about the overall health level of the nation? Some of the drugs that have been cleared from the health insurance list, especially Class B OTC drugs, will be more dependent on the pharmacy sales side, a considerable proportion of these drugs will not be de-listed, drug buyers will favor pharmacy pharmacy pharmacy services, pharmacies and hospitals will compete on pharmaceutical services.
some customers who don't come to the pharmacy to swipe their cards to buy eggs, when they visit the pharmacy again, will really think of the pharmacy as a place to "sell medicine" first and "provide pharmaceutical consulting services".
sense, it's a modern pharmacy.
6. Should tap the potential from the co-ordination of medical insurance accounts" there are drugstore chains related to the person in charge pointed out: at present, including zero margin, two-vote system, health insurance payment method reform, volume procurement, strengthen the supervision of medical insurance funds, basic medical insurance drug management interim measures and medical insurance co-ordination of retail pharmacies and a series of policies, has become the main thrust of prescription drug outflow.
the success of medical reform can not be separated from the modern hospital management, modern pharmacy management of the successful construction.
In good faith, as the above chain of drugstores related to the person in charge of the open position and comprehensive medical reform in the same way, pharmacy stakeholders must turn disadvantage into advantage, narrow into broad, into self-confidence, in order to escape the blow, embrace traffic."
summary, the huge future development space of retail pharmacies includes, but is not limited to: actively compete with medical and health institutions, cooperate, to undertake routine, characteristic prescription outflow; Enthusiasm into the joint fight against any form of fraud and insurance action, to do health insurance funds, patients and pharmacies of their own interests, goodwill maintainers;
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