On the "health insurance sector to strengthen multi-level medical security co-ordination" thinking

the | Hexian in the Opinion on Deepening the Reform of the Medical Security System, "multi-level" appeared twice: first, in the guiding ideology, adhere to the people's health as the center, accelerate the construction of a multi-level medical security system covering the whole people, urban and rural co-ordination, clear rights and responsibilities, moderate and sustainable protection;
Accelerate the development of commercial health insurance, make full use of the personal income tax policy of commercial health insurance, highlight the supervision of key links such as product design, sales and compensation of health insurance products, encourage social charitable donations to support the orderly development of mutual medical assistance, and explore the mechanism of drug protection for rare diseases.
Under the current situation, on the one hand, mutual insurance, universal insurance, special drug insurance and other domestic newer insurance products show a concentrated, rapid development trend, compliance rationality, sustainability has been tested;
In accordance with the requirements of the 19th National Congress report on "going through the bottom line, weaving the net and building the mechanism", standing at a new starting point for the construction of a medical security system with Chinese characteristics, we put forward the following views and opinions on the active role of the medical insurance department in the construction and operation of the multi-level medical security system.
The social health insurance system is under social pressure and transformed into a reform impetus (i) from the stability of universal coverage to the improvement of the level of protection on the one hand, in 2020 the number of people covered by basic medical insurance in the country reached 134.345 million, the participation rate of basic medical insurance is stable at more than 95%, the participation rate of the rural poor is stable at more than 99.9%, China has basically achieved universal coverage.
other hand, the operation of the basic medical insurance co-ordination fund has balanced requirements, and the contradiction between the increase in the treatment of insured persons and the expectation of social welfare growth is becoming more and more apparent.
international experience: in the United States, for example, 8% of the U.S. population has no health insurance, a clear lack of fairness and efficiency.
In terms of the interface between public security and private insurance, countries in the German model tend to be enhanced, countries in the national health service model tend to be replicable, and countries such as the Netherlands and Israel tend to be complementary insurance, using multi-layered networks of protection.
)From the effectiveness of the social health insurance system to the efficiency of commercial insurance on the one hand, through basic medical insurance, major disease insurance, medical assistance, in 2019 the poverty-poor outpatient chronic diseases and hospitalization triple system after the comprehensive protection of the actual reimbursement rate of about 80%.
the other hand, there are short boards in the development process for flexible employees to participate in insurance and enjoy treatment, and there are still many problems in the protection ability and consciousness of the people with commercial health insurance users.
from the domestic development point of view: improve the mechanism of sharing and adjustment of medical insurance financing, and gradually establish the benchmark rate system, is not only a reality, but also a trend.
with the comprehensive medical reform and medical insurance reform into the deep water period, the medical insurance strategy purchase, payment reform multi-pronged, in order to manage efficiently.
this principle is more important for commercial health insurance than for basic health insurance system arrangements that are "treatment-to-contribution".
(iii) from the imbalance of medical security is not sufficient, to help to solve the problem of china's unbalanced development of medical security, but also through a longer period of development.
in this period of urgency, major areas, relying only on the social health care system to the best of their ability, I am afraid that it is difficult to support alone.
some innovative practices, such as exploring management-based medical care covering non-standards, building a close-knit medical community that stimulates primary health care services, and improving the overall efficiency of health services.
in addition, if the total cost of health financing and multi-level health care system can be closely integrated, so that the burden of patient medical expenses forward premium translation, but also improve the efficiency of the purchase of total health costs.
for the classification of major diseases, we discuss how other protection schemes can be connected with the social health insurance system, which can not only solve the urgent need of fund medical insurance financing, but also promote the health insurance bureau to actively co-ordinate.
is a rare disease.
From the "700,000-day price drug", the genetic pathogenesis of rare diseases, we can see: First, we should recognize and give full play to charitable donations, drug-enterprise drug-giving activities, medical assistance, and second, we should recognize the basic medical insurance; The insurance nature of major disease insurance and commercial health insurance can not cover genetic diseases on a large scale for the time being, and thirdly, it is the responsibility of the whole society to make use of new medical technology and new health concepts to prevent them while increasing the access to medical treatment.
is chronic disease.
From the "urban and rural residents medical insurance can be reimbursed 'two diseases' outpatient expenses", "the implementation of outpatient outpatient drug protection mechanism", "employee medical insurance personal account reform", "local exploration of hypertension, diabetes drug belt procurement" and other initiatives, we can see: First, the national and local drug collection in a short period of time to achieve high blood pressure, diabetes treatment of the first line of drug prices significantly reduced, so that "two diseases" related to the payment or other medical insurance payment levels are more controllable.
Second, high blood pressure, diabetes as a breakthrough, vertically, can further standardize the diagnostic procedures and treatment paths, but also according to clinical fingering to choose drug use programs and program adjustments, but also a wider track, level of treatment drugs in a centralized negotiation or centralized recruitment into the health insurance catalog, public hospital drug use directory.
Sophase, it can also increase drug price reform for diseases such as slow-blocking lung, hyperlipidemia, cirrhosis, rheumatoid arthritis combined joint changes, chronic kidney failure, heart failure, anemia, etc., emphasizing the improvement of medical security according to outpatient chronic diseases, and further control the level of personal out-of-the-money or out-of-payment amount.
Third, combined with the common role of health prevention and health awareness, Internet plus medical care, family doctor contracting, commercial health insurance "management medical" and so on to do a good job in chronic disease management, improve the rate of diagnosis of diseases, control rate and rehabilitation period management.
third is mental illness.
The World Health Organization believes that mental health is a state of health in which everyone recognizes their potential, adapts to normal life pressures, works productively and contributes to the communities in which they live.
currently for the issue of psychological counseling fees, each province has different provisions, some provinces can be reimbursed a part of the cost of psychological treatment, psychological counseling costs are often less included in the scope of medical insurance payments.
October 1, 2020, Beijing will include severe psychiatric outpatient treatment in the basic medical insurance outpatient special disease reimbursement.
can be seen: mental illness medical insurance co-payment or personal self-funding, first of all, to do a good job of standardized treatment and drug research, followed by medical insurance collection to guide the price competition of related drugs.
is a serious disease.
From the Opinions on Deepening the Reform of the Medical Security System, it is proposed that "to improve the medical insurance and assistance system for serious and serious diseases", "to raise the level of medical needs for serious and major diseases", "to explore the establishment of a special group, a special disease medical expense exemption system" and so on: First, "medical insurance and assistance system for serious and serious diseases" is a force of basic medical insurance, supplementary medical insurance, medical assistance, commercial health insurance, charitable donations, medical mutual assistance as a joint force, and a large system of convergence.
Examples show that in the health poverty alleviation and medical insurance poverty alleviation actions, some places for the needy poor people to buy anti-poverty insurance, equivalent to economic poverty, disease-related poverty-related special groups as commercial insurance users, to insurable commercial insurance companies to buy specific diseases, special family economic conditions of comprehensive insurance products, indirectly explore "special groups, specific diseases medical expenses exemption."
Second, commercial health insurance, mutual medical assistance and charitable donations will serve as an important funding channel for the treatment of serious and serious diseases (especially those covered by medical insurance and inadequate protection) for a long time, and the mechanism of drug consumption collection under comprehensive medical reform, especially under the reform of medical insurance, will help the multi-level safeguard tools outside these medical insurance systems to find prices, innovate products and cooperate.
is an infectious disease.
"On deepening the reform of the medical security system" stressed "to improve the major epidemic medical treatment cost guarantee mechanism."
in the event of an emergency such as an outbreak, to ensure that medical institutions first treatment, after charges.
Sound the payment policy for medical treatment and medical care in major outbreaks, improve the system of direct settlement of medical treatment in different places, ensure that patients do not affect medical treatment due to cost problems", "co-ordinate the use of medical security funds and public health services funds, increase the proportion of payment to primary medical institutions, and achieve effective convergence of public health services and medical services", we can see: First, significant The epidemic is related to national public security, it is necessary to advance the total amount of medical insurance and "first see a doctor and then pay" two levels of special affairs, reflecting the "epidemic is the order", it is necessary to establish a hierarchical medical services and public health service network in the "combination of peace and war" efficient, professional convergence, reflecting the grass-roots and specialized role.
Second, to learn the lessons of the prevention and control of the outbreak of neo-crown pneumonia, from the newly revised "Infectious Disease Prevention and Control Law" in the draft for comments on the suspected, isolated, confirmed, full treatment and other links, we must ensure that the division of labor between the departments smooth, accurate information transmission, responsible and efficient.
The market innovation of multi-level medical security system needs to guide the regulation (i) a strong commercial insurance market, it is necessary to need strong supervision from the U.S. experience, financial insurance, life insurance companies involved in commercial health insurance business is very low degree, the main providers are professional commercial health insurance companies.
this may be related to regulatory restrictions on the administration of premiums and claims for commercial health insurance.
In contrast to many millions of domestic medical insurance products, with the overall high deductible amount, the overall low rate of compensation, to many insured factors to take no commitment to renew the insurance as a typical impression, one-sided use of the masses on social security, health insurance is not clear, insufficient.
commercial health insurance is naturally profit-profitable, some lack of "thick reason" of serious illness insurance is the same as gambling.
in a healthy China, multi-level medical security system, this "insurance personality" related to people's health is not guided and standardized, adding color will evolve into a scourge.
regulatory and regulatory measures are generally understood to inhibit the role of the market.
but from the experience of the U.S. insurance market, it is because of strong regulation that the market is stable and sustainable.
health insurance market needs to improve legislation, need to have an integrated mechanism, need new ideas to practice.
(ii) There are similarities between mutual insurance and the social medical insurance system, for example, from the mutual assistance activities of workers' unions to the mutual medical assistance on the Internet, the meaning and practice are becoming more and more open.
this brings unprecedented challenges to traditional commercial health insurance models, while at the same time providing a lesson in the total cost of health and the financing of social health insurance.
Mutual insurance in the new normal, the new environment of development, is completely from the bottom up by the individual to participate, can also be seen as mutual treasure first to make products, and then cheer up, with an opportunity, contract to start, from top to bottom rapid chain reaction, extraordinary.
successful mutual insurance, charitable giving, and social health insurance system always have some similar, such as social credibility, effectiveness, efficiency and so on.
would stand out if it were directly supported or indirectly recognized by the social health care system in these areas.
(iii) The Health Insurance Bureau has the opportunity to demonstrate mutual insurance products for other protection programs, a considerable proportion of users from third- and fourth-tier cities, in enhancing insurance access, the level of protection to make a performance demonstration.
there are still management blind spots inside and outside the product in the operation and supervision of their own funds, which need to be constrained equally.
Health Insurance Administration, which came into effect last year, emphasizes "health management."
but this is only the equivalent of drawing a circle of a box, how to implement, evaluate, adjust? The health insurance market is groping, and the social health insurance system should be paid attention to.
make up good things first, and then look for good results.
commercial health insurance, charitable donations, mutual insurance are facing the burden of marketing costs, as long as they are willing to insist on the minimum cost to provide maximum protection, are the social health insurance system would like to see, the support.
(4) big data, efficiency is all the protection plan claims to commercial health insurance as an example, its development prospects are in fact in crisis.
is the competition for medical assistance.
french mutual insurance coverage is greater than commercial insurance, is a ready-made example.
domestic Internet medical mutual assistance has been at the operating level to compete in the small test of the bull knife.
is the financial and technological competition between the giants.
Ping An Group has a strategic three-tier jump: integrated finance, finance and technology, finance and ecology.
in the era of financial and technological, financial and ecological competition, competitors with weak traffic imports are likely to be subverted and quickly replaced.
is hard to be trusted efficiency and image.
the development of commercial health insurance all the way to take advantage of the day, that is, there is better than no, efficiency is not important.
commercial insurance has a trend into the era of classification evaluation, big data competition will not be let go of by strong competitors.
At home, the social health insurance system has not been fully used, the use of local medical care, health insurance big data, social supervision is also difficult to obtain commercial health insurance must be open data, all security programs purchase efficiency, efficiency of use and compensation expenditure, should be fully transparent.
you go out? Whether in Indonesia, where the total cost of health per capita is low, or in Poland, where the cost is high, health insurance cannot be dumped at price, political and social trust is difficult to obtain, and sustainable efficiency is required.
Social health insurance system and other security programs have an interactive interface (a) universal insurance, should be successful, put an end to the pull of the hind legs to universal insurance as an example, so far has landed in forty or fifty cities, some by the local health insurance department "platform", some by the local civil affairs department "platform".
, some local health-care departments have come out to dispel rumors that they have not been involved in the design of universal insurance.
Surf is something that the health insurance market or some commercial insurance companies are pushing, and even if the health-care sector is in a passive position, it can see opportunities: something that the social-health-care system can't and can't explore, and that universal insurance is testing in danger or stupidity.
first, the universal insurance claims to be "profit-saving", but often there is no ready-made medical, medical big data conditions to do actuarial insurance, then, how to maintain the cost, how to micro-profit? I'm afraid it came out with a pat on the head.
is not good, but someone has to take care of it.
second, the company actually uses "government endorsements".
, it would be impossible to cover hundreds of thousands of people in the area in a short time,