Up to now, 27 provinces and 130 cities across the country have launched major illness insurance pilots. How do urban and rural residents benefit from it? Can the full implementation of the pilot project draw a "full stop" for poverty caused by illness?
status
In the face of serious illness, the existing medical assistance system is "a drop in the bucket"
According to the data of the State Council Medical Reform Office, 27 provinces in China have launched a pilot project of serious illness insurance, covering 290 million urban and rural residents. By the end of August, 20 13, the accumulated compensation amount of serious illness insurance was 630 million yuan.
From August 2065438 to August 2002, the trial of serious illness insurance began. Six ministries and commissions, including the National Development and Reform Commission, issued the Guiding Opinions on Developing Serious Illness Insurance for Urban and Rural Residents, clearly cutting out a part from the New Rural Cooperative Medical Insurance Fund or the Medical Insurance Fund for Urban Residents to provide "second reimbursement" for seriously ill patients and prevent "poverty caused by illness".
Although China's new rural cooperative medical system and basic medical insurance have achieved universal coverage, many families are still in trouble due to catastrophic medical expenses because of the low level of financing and security, and there are phenomena of "sawing their legs to save themselves", "carving chapters to save their wives" and "grabbing money to save their children".
Yu Xinle, deputy director of the Medical Affairs Department of the Zhejiang Provincial Health Planning Commission, said that statistically, patients with chronic malignant diseases such as tumors and end-stage renal disease, which take a long time and cost a lot, are the main groups causing poverty and returning to poverty.
Faced with these serious illnesses, the existing urban and rural medical assistance system is only a drop in the bucket for patients. On the one hand, the funds are meager. According to the data, in 20 10, the national urban medical assistance expenditure exceeded 4.9 billion yuan, with a per capita expenditure of 258 yuan. Rural expenditure is 8.3 billion yuan, per capita 1.48 yuan; On the other hand, the scope of assistance is limited, and medical assistance is mainly aimed at people in urban and rural areas. It's not just this that is overwhelmed by serious illness. Ordinary farmers, urban residents and even employees may "return to poverty due to illness".
Sun Zhigang, director of the State Council Medical Reform Office, said that serious illness insurance is to further protect the high medical expenses of seriously ill patients on the basis of basic medical security, which is conducive to building a poverty alleviation network for the masses when they see a doctor.
difficulty
The system is "fragmented" and the pilots are stretched.
At present, the national major illness insurance pilot is progressing smoothly. However, due to the lack of understanding of local governments, inadequate adjustment of departmental functions, and separation of urban and rural medical insurance systems, the progress of pilot projects varies from place to place: individual provinces have not yet launched pilot projects; In the provinces that have been carried out, most of them are local pilots, and some of them are self-pilot at the county (district) level; Some urban residents' serious illness insurance has been pushed forward, while the new rural cooperative medical system has just started.
The design of local systems is also "diverse". Wang Wan, Ph.D., university of international business and economics Insurance College, said that when she recently participated in a survey on serious illness insurance organized by insurance institute of china, she found that there were more than 20 pilot projects in more than 20 provinces, and there were differences among provinces, cities within provinces, urban residents and farmers. "This will affect the comprehensive push of the major illness insurance policy."
The level of overall planning is uneven. Jilin, Qinghai, Gansu and Shandong provinces are provincial-level overall planning, most of the pilot areas are municipal-level overall planning, and some areas are county-level overall planning. Huang Hong, vice chairman of the China Insurance Regulatory Commission, said: "Taking the county as the overall planning unit does not conform to the regulations. Insurance is the law of large numbers. The lower the overall level, the weaker the ability to take risks. "
The source of funds is far-sighted. The six ministries and commissions clearly "draw a certain proportion or quota from the urban residents' medical insurance fund and the new rural cooperative medical fund." "It is understood that the current per capita funding standard for each pilot is between 10 yuan and 60 yuan. Some are the basic medical insurance and the balance of the new rural cooperative medical insurance fund, some are released from the personal account of medical insurance, and some also include urban workers in the "reservoir" of expanding funds for serious illness protection.
"At present, there are some balances in the medical insurance fund, but in the future, we should worry about the support ability of the medical insurance fund." Rao Keqin, secretary of the Party Committee of the Chinese Medical Association, said that due to the increasing burden of diseases in an aging society, the balance of medical insurance will be less and less, and a scientific long-term financing mechanism should be explored to avoid the bottom line being broken.
The organizers embodied vicious competition. Six ministries and commissions stipulate that medical insurance for serious illness shall be undertaken by commercial insurance institutions, and the government shall invite tenders to choose, but some pilot areas are still undertaken by medical insurance institutions. At the same time, vicious price competition among insurance companies has appeared in some places.
Wang Wan said that when bidding, insurance companies should make scientific calculations based on comprehensive factors such as incidence probability, medical expenses and population size, but due to the lack of basic data, some companies' quotations fell. "This is not conducive to the development of the industry and the stability of the serious illness insurance system."
Kenichi
Speed up comprehensively,
Beware of excessive medical treatment devouring funds.
Whether the funds are safe and sufficient determines the life of the serious illness insurance system. Respondents suggested that in the process of fully implementing the pilot project of serious illness insurance, we should explore the sustainability of the system from the aspects of financing mechanism and financial guarantee.
Establish a scientific long-term financing mechanism. "The balance of basic medical insurance is only a risk fund, and the proportion is very low. Critical illness insurance won't last long. " Huang Xiaogang, director of the Medical Insurance Department of Jiangxi Provincial Department of Human Resources and Social Security, said that it is urgent to explore the establishment of a multi-channel and sustainable financing mechanism for major illness insurance. Jiangxi uses the personal account funds of residents' basic medical insurance and also uses the balance of the overall fund; For areas with insufficient balance, the overall plan will be solved by raising the annual financing standard.
Strengthen the supervision of medical behavior and let the serious illness insurance fund be used in the cutting edge. "Without the participation of medical and health institutions, medical insurance funds can easily enter the' bottomless pit'." Yao, deputy director of the Department of Physical Reform of the National Health and Family Planning Commission, said that in promoting serious illness insurance, it is necessary to strengthen the supervision of excessive medical behavior and prevent various unreasonable interest groups from eroding the rights and interests of ordinary people.
How to transform medical insurance funds into reasonable medical services most effectively? Rao Keqin suggested that we can take the opportunity of serious illness insurance to explore the establishment of a negotiation mechanism between insurance payers and medical service providers to control the unreasonable rise of medical expenses.
Strengthen the supervision of commercial insurance institutions and establish a reasonable and fair risk-taking mechanism. Entrusting serious illness insurance to commercial insurance institutions will help reduce the phenomenon of "human compensation" and improper medical behavior and reduce medical expenses.
Liu Gang, deputy director of Zhejiang Insurance Regulatory Bureau, said that the government should not only look at the price given, but also look at the service level of its outlets and timeliness. At the same time, it is necessary to establish a market exit mechanism. For problems that arise, such as insurance companies failing to pay in time as promised, they must be severely punished; Those who fail to pass the examination shall be ordered to make rectification within a time limit or make compensation for returning the bid. Government departments should also reserve appropriate business space for commercial insurance institutions, and earnestly implement the principle of "guaranteeing capital and making small profits at your own risk".
In addition, some experts suggested that the scope of the catalogue of serious illness insurance should be appropriately expanded to maximize the fundamental goal of the design of serious illness insurance policy.
According to the existing policy, the scope of serious illness insurance is consistent with the basic medical insurance. He Wenjiong, vice president of insurance institute of china, said that this means that the major illness insurance mainly solves the problems of low reimbursement rate, high deductible line and low capping line of basic medical insurance, and many contents that could not be reimbursed by the new rural cooperative medical system or basic medical insurance in the past are still not reimbursed.
For example, patients with Gaucher's disease, a rare disease, need 2 million yuan in medical expenses every year, but the drugs they need are not listed in the medical insurance catalogue, and they can be reported if the basic medical insurance is less than 100 yuan, and many expenses can only be borne by their own families. Such patients are an important part of the poverty-stricken group due to illness.