In the interpretation of relevant policies, Shenzhen said that the core of this reform is to change the medical expenses of the "overall account" employee medical insurance outpatient service from the individual accumulation security model to the social mutual economic security model.
Liao Zangyi, an associate professor at the School of Politics and Public Administration of China University of Political Science and Law, told CBN that for Shenzhen, the outpatient economic reform is a system adjustment made in response to the national and provincial reform trends, and there is no risk of medical insurance fund. The reform of outpatient economic security in Shenzhen, like the national reform, is essentially a kind of right replacement. The funds in personal accounts are replaced by pooling funds, and the outpatient pooling system is established to solve the problem of outpatient expenses burden of insured persons by the law of large numbers.
Establishing and perfecting the outpatient economic security mechanism of basic medical insurance for employees is the established goal of deepening the reform of medical insurance in China. After the State Council issued relevant guidance in April last year, various provinces successively issued provincial-level guidance documents, which made arrangements for the progress of the reform of the medical insurance outpatient guarantee mechanism in this province. At present, the outpatient service reform is being accelerated nationwide.
Shenzhen promotes outpatient treatment of first-class insured persons
On June 5438+05, the General Office of Shenzhen Municipal Government issued the Notice on Matters Related to the Overall Implementation Measures of Basic Medical Insurance Outpatients in Guangdong Province (hereinafter referred to as the Notice), which was officially implemented on June 5438+February 1 day, 2022.
The specific contents include: increasing the overall planning of general outpatient service, reducing the funds transferred to personal accounts, standardizing and expanding the use scope of personal accounts, etc.
One of the key points of this reform is to adjust the funds transferred to personal accounts. According to the notice, employees who pay the basic medical insurance premium at 8% of the payment base will be included in the monthly personal account at 2% of the payment base, and the rest will enter the basic medical insurance serious illness pooling fund (hereinafter referred to as the "pooling fund"). For retirees who stop paying and continue to enjoy the first-class treatment of basic medical insurance, their personal accounts are allocated by the overall fund according to the quota, and the monthly allocation standard is 2.8%+0 of the average monthly basic pension in this city in 20265438.
Due to the current policy, the first-class insured person pays the basic medical insurance premium at 8% of the payment base, of which 5 percentage points are included in the personal account and 3 percentage points are included in the overall fund. Compared with the old and new policies, the funds transferred to personal accounts have decreased by 3 percentage points, which is the part that the insured thinks the rights and interests have been damaged.
On the 23rd, the reporter inquired about the advantages and disadvantages of this reform for the insured by the hotline of Shenzhen 12345. The hotline staff said that for the first-class insured, the disadvantage is that there is less money in the personal account, and the advantage is that the outpatient service can also be reimbursed. Generally speaking, for people who see more clinics, the treatment has become better; If you don't go to the clinic, you will feel a little disadvantaged if you have less funds in your personal account.
Liao Zangyi believes that the outpatient economic reform has not reduced the medical treatment of the insured, but has reformed the institutional structure through a way of equity swap, further strengthening and expanding the efficiency of the use of personal accounts. "The insured believes that the interest is damaged after the amount of personal account is reduced. One reason is that it involves welfare perception, and the other reason is that it has a certain understanding of this reform. " Liao Zangyi said.
Judging from the effect of the policy, for on-the-job employees, the insured who are not used or used less at ordinary times have no 3% allocation from the social pooling fund, and it seems that less money has entered the personal account, but in fact the reimbursement has not changed. In the past, the personal account was brushed as "personal account+overall fund" * * * to benefit the whole family.
For the on-the-job insured who usually rely on personal accounts to buy medicine in spite of illness, the money in personal accounts was not enough in the past. Now, due to the reform of this system, with the payment of the overall fund, the treatment level of these insured people has been improved, and the personal burden has been effectively reduced.
The notice proposes that on the basis of outpatient treatment and medical treatment such as personal accounts and outpatient specific diseases, the general outpatient treatment of insured persons such as basic medical insurance for employees should be increased. A class of employees' basic medical insurance participants can choose 1 social health institutions or other primary medical institutions, 1 secondary hospitals and specialized hospitals as designated medical institutions for general outpatient clinics within the scope of designated medical institutions in the city.
The staff of Shenzhen hotline 12345 specially reminded that in February 1 65438, what the first-level insured should do is to choose designated medical institutions as far as possible, so as to enjoy the outpatient reimbursement treatment of first-and second-level hospitals. If you are not selected, you will still be reimbursed according to the original policy, that is, 70% will be paid by the individual in the first-level hospital and 30% will be paid as a whole. After selection, first-class hospitals will make overall planning.
Shenzhen reform has nothing to do with the risk of medical insurance fund.
Because the outpatient economic reform involves the adjustment of personal account funds, some insured people will think that it is because the medical insurance fund has no money, or the expenditure of the medical insurance fund on epidemic prevention has increased the pressure on the fund. In this regard, Liao Zangyi made it clear that the reform of personal account system and outpatient system of Shenzhen medical insurance fund has nothing to do with the risk of medical insurance fund, but is an institutional adjustment in response to the policy reform of the state and Guangdong Province.
According to the budget implementation table of Shenzhen Medical Insurance Fund from June 5438+0 to June 5438+00 in 2022 published by Shenzhen Medical Insurance Bureau, as of June 5438+00 this year, the current balance of basic medical insurance for urban employees in Shenzhen was 20.749 billion yuan, with a cumulative balance of 177075 billion yuan.
The Guiding Opinions of the General Office of the State Council on Establishing and Perfecting the Outpatient Security Mechanism for Employees' Basic Medical Insurance (Guo Ban Fa [202 1]14) issued on April 4, 20021requires that the people's governments at the provincial level,
The Notice of the General Office of the People's Government of Guangdong Province on Printing and Distributing the Implementation Measures of the Basic Medical Insurance for Outpatients in Guangdong Province (No.56 of Guangdong Government Office [202 1]) issued on February 3, 2022 requires all localities and cities to issue detailed implementation rules, which will be implemented before July/kloc-0.
According to the Analysis of the Current Situation of the Economic Security Mechanism Reform of Workers' Medical Insurance Outpatients published by Li Juan and Wang Zongfan of the Chinese Academy of Labor and Social Security in Lanzhou Academic Journal on June 5, 438+05, this paper sorts out 3/kloc-0 provinces and cities in China, and the issuing time of each province is concentrated in the end of 2002/kloc-0 and the beginning of 2022, and the issuing unit is basically the general office of the provincial people's government. Most provinces have issued guidance documents from local governments, and arranged the progress of promoting the reform of the economic security mechanism of medical insurance clinics for employees in the whole province. However, as of the end of July, most of the overall planning areas have not yet issued the landing documents for the reform of the economic security mechanism for employees' medical insurance clinics, and some cities have issued implementation rules under the guidance of national and provincial documents.
At present, many parts of the country have accelerated the reform of outpatient service. The Liaoning Provincial Medical Insurance Bureau said that it is making efforts to establish and improve the economic security mechanism for employees' basic medical insurance clinics. Before the end of this year, all the overall planning areas in the province will begin to implement reforms.
From June 5438+February 1 in 2022, Beijing began to provide personal medical insurance account funds for family members, which can be used by family members.
The Hunan Provincial Medical Insurance Bureau recently announced that the province will comprehensively establish a general outpatient co-ordination system for employee medical insurance before the end of the year. From June 65438+1 October1day, 2023, personal accounts will be recorded in a new way. After the reform, family members will be allowed to use personal accounts with each other.