More outpatient expenses are expected to be included in medical insurance reimbursement



China’s new round of health care reform has established the world’s largest basic medical insurance network, which benefits more than one billion people. On April 7, Premier Li Keqiang presided over an executive meeting of the State Council, which determined the measures to establish and improve the outpatient mutual assistance mechanism of basic medical insurance for employees, broaden the scope of personal account funds, reduce the medical burden of the masses, and include more outpatient expenses in medical insurance reimbursement, so as to further reduce the burden of patients.

The meeting called for the inclusion of some outpatient expenses for extra chronic diseases, frequently occurring diseases and common diseases that have great harm to health and heavy cost burden into the overall planning fund. It is stipulated that the payment proportion within the scope of the policy should start from 50% and be appropriately inclined to retirees. In the future, the security level will be gradually improved with the increase of the fund’s affordability.

“Since the establishment of the medical insurance system in China in the 1990s, there have been two plates, the overall fund and the individual account. At that time, personal accounts ensured a smooth transition from the labor insurance and public medical system to the social medical insurance system. ” Zhu hengpeng, deputy director of the Economic Research Institute of the Chinese Academy of Social Sciences, pointed out that since the establishment of the medical insurance system, some provisions have been unable to adapt to the current social changes, including unclear income accumulated by the fund, no mutual aid function, serious waste of individual account funds, LIMITED Fund-raising of overall planning funds, insufficient outpatient mutual aid, etc.

In his view, due to the lack of outpatient co-ordination capacity and limited financing of the co-ordination fund, priority is often given to the reimbursement of hospitalization expenses, and there is no better co-ordination of outpatient services in most areas, which also makes the burden of the elderly with higher outpatient expenses heavier. Part of the patients for medical insurance reimbursement, minor illness, excessive hospitalization.

In order to further supplement the overall planning fund, the meeting made it clear to improve the method of recording individual accounts. The payment of in-service employees is still included in their own personal accounts, and the unit payment is all included in the overall planning fund. The individual accounts of retirees are allocated from the overall planning fund according to the quota, and the amount of allocation is gradually adjusted to about 2% of the average level of basic pension in the year when the reform is implemented in the overall planning areas.

Not only that, the subject and matters of personal account will be further expanded. According to the regulations of the meeting, family members are allowed to help each other, which can be used to pay for the personal expenses incurred in the medical treatment in designated medical institutions and the purchase of drugs, medical devices and medical consumables in designated retail pharmacies. It is explored to use the personal expenses for family members to participate in the basic medical insurance for urban and rural residents.

Yu Qingsong, director of Huihong medical management research center, believes that by bringing the outpatient medical expenses into the payment scope of the basic medical insurance co-ordination fund, reforming the personal accounts of employees’ basic medical insurance, and establishing and improving the outpatient mutual aid security mechanism, the utilization efficiency of the medical insurance fund has been improved, and the medical expenses burden of the insured has been reduced.

It is understood that up to now, Beijing, Shanghai, Zhejiang, Guangdong, Shandong and Fujian are promoting the exploration of mutual assistance in basic medical insurance for employees. For example, in April last year, Fujian issued the administrative measures for the use of family mutual aid accounts of basic medical insurance in Fujian Province (for Trial Implementation), which made it clear that part of the funds (more than 2000 yuan) can be set up from the individual accounts of the insured employees to establish a family mutual aid account for comprehensive health protection among themselves, their minor children, spouses and other immediate family members. The mutual aid account can be used to pay out-patient and inpatient expenses, vaccinate class II vaccine, purchase drugs at designated retail drugstores, have physical examination, pay premiums for basic medical insurance for urban and rural residents and other expenses that meet the payment scope of individual account.

In order to prevent fraud, insurance fraud and other illegal operations, the meeting also stressed that the supervision and management of medical insurance fund will be strengthened. It includes improving the system of audit and internal control, seriously investigating and dealing with illegal behaviors such as false hospitalization, fraud and insurance fraud, and improving the payment mechanism suitable for outpatient mutual aid. Provincial governments can set a transition period of about three years to gradually and orderly achieve the reform goals. At the same time, we should simultaneously improve the outpatient coordination of basic medical insurance for urban and rural residents, and gradually improve the level of security.

Beijing Business News (reporter Tao Feng, Liu Hanlin)

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