Ten Questions and Ten Answers on the Reform of Medical Insurance Account: How to Protect the Benefits of Retirees by Outpatient Mutual Aid
At the beginning of this year, many places began to start the reform of employee outpatient mutual aid security. This system, which concerns the interests of 354 million medical insurance participants, requires that the payment of benefits be tilted towards retirees. By the end of 2021, there were 93.24 million retired employees in the basic medical insurance system for employees.
At present, 31 provinces, autonomous regions, municipalities directly under the Central Government and Xinjiang Production and Construction Corps have issued documents to improve the mutual aid guarantee mechanism for local employees’ medical insurance clinics. Among them, many provinces and cities stipulate that the outpatient payment limit and payment ratio of retirees are higher than those of on-the-job employees.
Even so, among the public opinions received by local medical insurance departments, retirees think that "after the reform, the level of treatment has decreased due to the reduction of the amount of personal accounts", accounting for the majority.
In the policy explanation, the medical insurance departments in many places clearly stated that after the reform, the personal accounts of most insured persons will be reduced in the current period. At the same time, they also used specific data and cases to explain to the public that for retirees who suffer from chronic diseases at their own expense, the benefits of outpatient mutual aid far exceed the reduction of personal accounts, often by reducing hundreds of yuan, reimbursing thousands or even thousands of yuan.
Medical insurance bureau, Hunan Province, said in "Interpretation of Policies on Improving Personal Accounts of Retired Workers" that the outpatient mutual aid mechanism is to use the law of large numbers to resolve the risks of social groups. The number of personal accounts for medical insurance is different from that of individuals at present, but in terms of system, mutual aid guarantee has a more risk prevention function. Workers’ medical insurance is not only a personal account and general outpatient co-ordination, but also a series of policies such as outpatient treatment of chronic and special diseases and hospitalization treatment, which constitute a complete security system.
A few days ago, CBN interviewed many experts in the industry on the hot issues of personal account reform of medical insurance that the public cares about. Experts generally believe that the medical insurance personal account has completed its historical mission for more than 20 years and its limitations are gradually becoming prominent. It is the general direction to gradually replace the personal account with outpatient mutual aid according to the principle of "rights replacement".
This is a reform that affects the whole body. In the long run, the insured will benefit from the reform, but in the short term, the interests of some people will be damaged. How to improve the supporting mechanism to make the insured more sense of acquisition is a key issue that must be paid attention to in the next step of reform.
CBN also learned from relevant departments that some targeted measures are being introduced one after another, for example, in order to facilitate patients to enjoy treatment nearby, support patients to settle accounts and dispense medicines in designated retail pharmacies with prescriptions, enjoy the same reimbursement treatment as those in medical institutions, and explore the inclusion of qualified "internet plus" medical services in the scope of protection to improve the convenience of enjoying treatment.
Q: At the beginning of this year, the reform of outpatient mutual aid was launched in many places. In some areas, retirees reported that the funds in personal accounts of medical insurance were reduced, which affected the daily cost of buying medicines. The reform of outpatient mutual aid is inclined to the elderly, but why do the elderly think that their interests are damaged?
Zhu Minglai (Director, Health Economy and Medical Security Research Center, Nankai University)The original intention of this reform is to hope that the sick and the elderly with poor health can have more benefits, rather than harming their interests.
It is believed that only a part of the elderly people have their interests damaged, which does not mean all the elderly people. Different groups of people have different demands. At present, people who feel that their interests are damaged are mainly elderly people who usually have minor illnesses. The funds in personal accounts can cover their daily expenses for buying medicines and seeing a doctor. If the funds in personal accounts decline, it will have an impact on their daily medical payment; However, for the elderly who suffer from chronic diseases, need to take medicine for a long time and go to the clinic for medical treatment, the funds in his personal account are not enough. According to the previous policy, after spending the funds in his personal account, the outpatient expenses have to be paid at his own expense. Therefore, for the elderly with higher outpatient expenses, the benefits will not be damaged, but a higher reimbursement level will be obtained.
It is also mentioned in the policy interpretation of "Detailed Rules for the Implementation of Wuhan Employees’ Basic Medical Insurance Outpatient Mutual Aid Security" that the insured Zhou, a retired person, is 68 years old, with an annual pension income of 50,000 yuan. Before the reform, his personal account was transferred to 2,400 yuan every year. Suffering from cerebral infarction, I went to the outpatient department of a tertiary hospital for medical treatment. This year, I incurred a reimbursable expense of 7,150 yuan. If I reimbursed according to the outpatient co-ordination policy, excluding the threshold fee of 500 yuan, I can reimburse (7,150-500) yuan * 60% = 3,990 yuan according to the reimbursement ratio of 60% in tertiary hospitals. Although Zhou’s personal account was less than 1404 yuan after the reform, he enjoyed more than 2586 yuan.
twoQ: In April 2021, the State Council issued the guiding opinions on the reform of outpatient mutual aid, and the local authorities received many public opinions when formulating implementation rules and popularizing policies. For example, the Hunan Provincial Medical Insurance Bureau said that the public opinions received recently focused on reflecting that "the level of treatment after the reform has declined", especially for retired employees whose original personal accounts were included in the annual level of more than 2,900 yuan. In your opinion, what problems do retirees’ concerns about the reform of outpatient mutual aid reflect?
Lou Yu (Professor, School of Civil and Commercial Economics, China University of Political Science and Law, Director of Institute of Social Law)Since the basic medical insurance system for employees was fully implemented in China in 1997, personal account has been an important medical insurance system. Not only have many structural systems become path-dependent, but the reform of one of them will "affect the whole body", and in the short term, the reform will harm the interests of some people. How to make reasonable compensation for those who have lost interests is also a major event related to the success or failure of the reform.
The reform plan of outpatient mutual aid is to reduce the funds remitted by retired insured persons into their personal accounts every month, and the saved funds are used for outpatient serious illness co-ordination. This plan is in line with the development direction of medical insurance, and its original intention is very good, but it is very important to consider the details comprehensively in implementation, which may affect the insured persons’ acceptance of the reform and the effect of the reform. The first thing is that publicity must be in place. After all, personal accounts have existed for more than 20 years. Although the nature of their personal property has not been written into the law, it has formed a basic consensus in the whole society. Secondly, supporting measures must be kept up in time, such as increasing the allocation of common diseases drugs in primary medical institutions, making insured people run less, improving the convenience of the system and reducing personal burden.
threeQ: Some netizens said that "the personal account has been transferred less, ‘ Lose money ’ ",for individuals, medical costs will increase because of this reform?
Liao Zangyi (Associate Professor, School of Politics and Public Administration, China University of Political Science and Law)Generally speaking, for individuals, their medical costs will not increase because of this reform. Everyone should calculate both small accounts and big accounts. After the reform, the overall planning fund has been strengthened, and after illness, it can be reimbursed through the overall planning fund. Everyone helps each other and the protection will be more adequate. It is necessary to calculate both immediate accounts and long-term accounts. Everyone is old and sick sometimes. Although young and healthy people don’t see many doctors now, the economic risks brought by diseases exist for a long time. Everyone should also look at the difference between income mechanism and insurance mechanism rationally. Under the big framework of social medical insurance, the funds in personal accounts are "medical expenses", not salary income or welfare. When people are old and sick, it is always limited to rely on personal accounts and personal accumulation. All of them need solid and sustainable medical insurance to realize social mutual help and help to resolve the disease risk, and they will benefit from this reform in the long run.
Guangdong Medical Insurance Bureau mentioned a case in the Q&A on the reform of outpatient mutual aid guarantee mechanism, which showed that Hua Jie, a retired employee, paid more than 480 yuan for lung CT in November 2022, and paid for it in full. After the implementation of outpatient mutual aid in Guangzhou, Sister Hua recently went to the hospital for CT and found that she only had to pay more than 140 yuan for the same project, and the overall fund paid 70%.
According to the calculation of Hunan Medical Insurance Bureau, after the reform, the maximum payment limit of the on-the-job employee pooling fund is 1,500 yuan, and the maximum payment limit of the retirees pooling fund is 2,000 yuan. In 2021, the province’s annual per capita personal account fund income was 1,727 yuan/person, and the personal account fund expenditure was 1,438 yuan/person. At present, the payment limit determined by the general outpatient co-ordination policy, plus the amount transferred from the personal account, can basically meet the outpatient medical needs of the insured.
Four questions: China’s personal accounts have existed for more than 20 years. Why should we start the reform of outpatient security including personal accounts recently?
Lou Yu:The original intention of the medical insurance personal account system design is to hope that the insured can share the risk of outpatient expenses through long-term accumulation, that is, pay more to the personal account when they are young, but not when they are old, and the medical insurance account is used to pay for outpatient expenses. However, this original intention has not been well realized in practice: the insured people tend to be short-sighted, and a large amount of funds have accumulated in their personal accounts, which has caused high moral hazard, which not only doubled the pressure of supervision, but also limited funds in each insured person’s account, which can only be used to pay small outpatient expenses, and the high outpatient expenses cannot be paid, which is also inconsistent with the principle of "ensuring the big but not the small" in medical insurance, and unfair to insured patients who really need to rely on the medical insurance system to solve high expenses. Therefore, there are many criticisms about personal accounts in medical insurance practice, and all sectors of society are actively seeking reform plans for accounts.
Once any system is fixed, it will be very difficult to reform, because any reform is a redistribution of interests. It is easy to reform a specific system, but a comprehensive and comprehensive evaluation of the system and a systematic solution to the problem test the wisdom of the reformers. No matter from the medical insurance practice in China or the system implementation in other countries, it is difficult for a purely accumulated personal account to play the role of the law of large insurance numbers, and it is impossible to share the disease risk and help the funds in a larger scope. It has reached a social consensus that personal account funds should be used for the overall planning of high outpatient expenses, which should be the general direction of reform. However, this reform needs a systematic system design, and necessary supporting measures must be introduced in time to reduce the proportion of medical insurance account allocation.
Five questions: The reform of outpatient co-ordination is a systematic project, in which reducing the funds allocated by personal accounts should be the simplest to operate, but if the supporting policies can’t keep up, there may also be cases of damage to rights and interests. In your opinion, the outpatient mutual aid system should really protect the interests of the insured, which supporting reforms are indispensable?
Zhu Minglai:I think one of the important reasons why some retirees are concerned about the reduction of personal account funds is that some supporting policies have not kept up in time. The biggest supporting policy of outpatient mutual aid reform is medical care and medicine, such as the accessibility of medical services. Some elderly people have reported that things that could be solved by taking medicine and swiping cards at pharmacies are now going to the hospital. If he does not trust the first-and second-level hospitals, he may have to queue up for a long time at the third-level hospitals. And sometimes when you get to the hospital, the hospital may be short of medicine, and you have to go to the pharmacy to get medicine. This will add a lot of burden to the elderly in running errands.
This is also the direction to further improve the supporting policies. Specifically, efforts can be made in three aspects: First, support patients to settle accounts and dispense medicines in designated retail pharmacies with external prescriptions, enjoy the same reimbursement treatment as in medical institutions, and give full play to the convenience of designated retail pharmacies. The second is to explore the inclusion of qualified "internet plus" medical services in the scope of protection, so as to improve the convenience of enjoying treatment. The third is to explore and promote the circulation of electronic prescriptions to better solve the needs of drug purchase settlement.
Six questions: The level of economic development and welfare varies from place to place, so does the level of outpatient co-ordination. If the overall level of outpatient service in a region is relatively low, can it make up for the welfare loss caused by reducing the funds in personal accounts?
Liao Zangyi:Local governments will encounter some difficulties in establishing outpatient co-ordination. First, the medical insurance information system should keep up, and all designated pharmacies in the co-ordination area should be opened to ensure that patients can enjoy real-time settlement without manual reimbursement. Secondly, medical insurance supervision and intelligent audit should keep up. After the outpatient service is improved, many people will definitely try their best to gain benefits by reselling drugs, which puts forward higher requirements for the refined management and intelligent monitoring of medical insurance.
For the welfare loss that may be caused by the low level of overall planning, we can start from three aspects. First, after the implementation of the outpatient mutual aid system, the deductible line for outpatient reimbursement should be appropriately reduced, and the proportion of reimbursement can be appropriately increased. This needs to be dynamically adjusted by the medical insurance department through actuarial science to effectively enhance the people’s sense of gain; Second, the coverage of outpatient mutual aid should be improved, from the existing two diseases, renal dialysis, outpatient radiotherapy and chemotherapy, etc., and gradually expanded to most diseases can enjoy reimbursement treatment to reflect fairness; Third, we can refer to the guarantee policy of hospitalization treatment. If the insured person’s annual outpatient expenses exceed a certain proportion, it can be classified as large medical expenses, and should be guaranteed twice or matched with the corresponding bottom-up mechanism.
Seven questions: Many retirees are used to going to designated retail pharmacies to buy medicines. After implementing outpatient mutual aid, what support measures are there for designated retail pharmacies?
Zhu Minglai:The reform puts forward that the drug guarantee service of qualified designated retail pharmacies should be included in the scope of outpatient service, and the payment of the overall fund should be extended to qualified designated medical insurance pharmacies, with the purpose of facilitating patients to submit reimbursement nearby and reducing the cost burden. Insured patients can only use personal accounts to pay for drugs purchased at designated retail pharmacies. After the reform, they can use personal accounts or enjoy reimbursement from the overall fund with external prescriptions. According to the relevant data, since the implementation of the reform, the scale of personal accounts used in designated retail pharmacies has increased, which also shows that pharmacies have benefited from the reform measures such as personal accounts helping families and expanding the scope of personal accounts.
However, we can’t ignore the violation of laws and regulations in the operation of designated retail pharmacies. For example, it is very common for some city pharmacies to use medical insurance funds to pay for health care products and daily necessities. We must strengthen supervision over this kind of misappropriation and application of medical insurance funds.
Eight questions: after the implementation of outpatient mutual aid, will it increase the number of hospital outpatients and labor costs?
Liao Zangyi:In the short term, it may increase the number of outpatients in hospitals, such as many minor illnesses such as colds and coughs. Before the reform, many patients will carry on and recover by their own immunity, which can save money after all. After the reform, considering that medical insurance can be reimbursed, some people will have the mentality of "not spending money and not spending money", and there is indeed a risk of increasing the number of hospital outpatients and labor costs in the short term, but with the passage of time, after the market gradually returns to rationality, this phenomenon will gradually fall back to the state before the reform.
Question 9: What is the nature of the funds in the medical insurance personal account?
Lou Yu:According to the Decision on Establishing the Basic Medical Insurance System for Urban Workers promulgated by the State Council in 1998, the combination of social pooling and individual accounts is the basic principle of basic medical insurance for employees. The principal and interest of individual accounts are owned by individuals and can be carried forward and inherited. This is the basis for the general public to believe that the legal nature of personal accounts is personal property. However, this decision has a low legal rank, and it is not an administrative regulation with external legal effect. It is only a normative document for building a medical insurance system within the administrative organs of people’s society, and it has only guiding significance for the provisions on the nature of individual accounts. The Social Insurance Law promulgated in 2010 didn’t stipulate the unified account as the financing principle of basic medical insurance, and didn’t stipulate the legal nature of individual account, which is considered that legislators don’t recognize the financing rules and payment methods of individual account, leaving enough room for future reform.
Question 10: The Social Insurance Law promulgated in 2010 did not mention the personal account of medical insurance. Does it mean that the general direction of future reform is to replace the personal account with the outpatient mutual aid guarantee mechanism?
Liao Zangyi:The general direction of future reform can consider gradually reducing personal accounts until they are cancelled. On the one hand, gradually reduce or stop the proportion of unit contributions to individual accounts; On the other hand, gradually abolish the regulation that individual contributions are transferred to individual accounts, and include individual contributions in the overall fund, such as establishing outpatient mutual aid system. Although there may be great resistance in actual operation, in fact, some areas have already tried this method and achieved good results.