First, the guiding ideology, main characteristics and effects of labor insurance medical reform, which focuses on ensuring basic medical care and strengthening medical management, and the expenses are appropriately linked to individuals.
The guiding ideology of this reform is: the medical expenses of employees are properly linked and shared by state enterprises and individuals; Strict labor insurance medical management system to reduce the waste of drugs and funds; Ensure the basic medical needs of employees and promote the development of production. The main features of the reform measures are: firstly, all state-owned enterprises in a county or even a city (prefecture) are carried out at the same time, forming a microclimate of reform, eliminating loopholes and preventing the transfer of medical expenses to enterprises that have not implemented reform. The second is to change the state and units' medical subsidies for employees from implicit subsidies to partial subsidies, and at the same time reform the fixed contract method for employees' outpatient service. That is, the welfare fund extracted by an enterprise according to the total wages of its employees is 1 1%, of which 8% is designated as the medical expenses of employees, and then 50% of the medical expenses are uniformly adjusted by the unit, and the remaining 50% is calculated according to a certain proportion of the length of service of employees (the grade is 10, and the length of service is 65438). 85% over 20 years and less than 25 years, 95% over 25 years and less than 30 years, and 100% over 30 years) and record them in their medical cards and medical certificates as subsidies for employees' medical expenses and as the medical base for each employee's outpatient service. It embodies the principle of fairness in the distribution and use of medical expenses, overcomes egalitarianism, embodies the self-adjustment of employees, embodies the adjustment of non-sick employees to sick employees, and the adjustment of young employees to old sick employees, and embodies the overall use of medical funds within enterprises and mutual assistance among employees. The third is to reform the current turnkey mode, impose a small amount of personal burden on employees who exceed the medical expenses, and save some rewards. If the medical expenses exceed the fixed subsidy, the employee shall bear 10% of the outpatient expenses, 5% to 15% of the self-funded medical expenses for hospitalization, and 10% to 30% of the bed expenses. If several people in a family work in the same unit, the medical expenses subsidy can be used together, and the personal overspending part will be offset in the family's total medical expenses subsidy balance to prevent overspending. The maximum amount of medical expenses borne by outpatients and inpatients shall not exceed 5%~ 10% of the annual average salary of retired employees of the enterprise within one year, and the retired employees shall not exceed 5% of the annual average retirement expenses of retired employees of the enterprise, and the excess shall be reimbursed by the enterprise. If there is a balance, I can be rewarded with cash at the end of the year according to 50% to 70% of the balance, and the remaining 50% to 30% will be carried forward to the next year, and I will continue to use it. It not only shows that the state, units and individuals share the medical expenses, but also considers the actual situation of the use of medical expenses within the family, eliminating the loophole of one person seeing a doctor and taking medicine for the whole family, and saving medical expenses equally. Fourth, medical expenses for certain serious diseases such as work-related injuries, occupational diseases, family planning operations, etc., which exceed the medical expenses subsidies, will be reimbursed according to the facts, and some care will be given to those who are engaged in underground, high-altitude, high-temperature, toxic and harmful work in the personal burden of medical expenses. To encourage people to devote themselves to the socialist cause, encourage people to work in special posts and encourage the implementation of family planning. Fifth, strict system and strengthened management. Strengthen the management of enterprise medical units, strengthen the management of external diagnosis and referral and the management of medical expenses. In particular, establish medical cards (managed by the unit) and medical certificates (kept by the employees) for employees. When an employee falls ill in a designated medical unit, he will write a double prescription. After examination, the employee will submit the prescription and invoice to the unit for reimbursement, and make the same record on the medical card and medical certificate, and announce it to the public regularly or irregularly.
The above reform measures have achieved initial results. First, it not only effectively guarantees the basic medical care of employees, but also overcomes the situation that some enterprises can't guarantee the basic medical care in order to reduce the medical expenses (that is, all medical expenses are paid to employees according to the quota, and they are overspent to take care of themselves, or all outpatient medical expenses are paid to employees to take care of themselves), which turns the medical care of employees into a new egalitarianism or can't guarantee that basic medical care will affect the health of employees, relieve their worries and promote social stability and stability. Second, it has promoted enterprises to establish and improve the labor insurance medical management system, eliminated some loopholes, better overcome the phenomenon of drug waste, alleviated the unreasonable increase of medical expenses to a certain extent, and saved funds. Third, a small amount of medical expenses should be borne by employees, so that employees can gradually establish a sense of expenses, change the long-standing old concept of no payment for labor insurance medical care, greatly reduce the waste of drugs in the past and save medical expenses. Taking Xichong County as an example, after the implementation of the reform measures, the medical expenses of 1990 employees decreased from 14.56 yuan per month of 1989 to 7.87 yuan, and the medical expenses of retired employees decreased from 16 yuan to10. Fourth, the number of outpatients has been greatly reduced, so that medical staff in enterprises have more time and energy to learn business technology and improve the quality of medical services, which is conducive to strengthening and doing a good job in disease prevention and control.
In recent years, although we have made unremitting efforts in this reform, it is difficult to deepen the reform due to various reasons, especially the serious shortage of medical funds and the lack of comprehensive reform measures (such as price, drug production, hospitals, medical system, medical quality, medical ethics, etc.). ).
Second, serious illness medical expenses and its impact
The method of serious illness co-ordination includes the principle, object, scope and organization of serious illness co-ordination, the scope, source, payment method, disbursement method and management system of serious illness medical fund. (1) Principle of overall planning for serious illness: help each other and help each other, guarantee basic medical care, set aside funds with support, have a slight surplus, strictly regulate the system, and overcome waste. (2) The object and scope of serious illness co-ordination: state-owned enterprises, self-supporting institutions managed by enterprises, employees of collective enterprises in cities and towns at or above the county level (including formal employees in cities and towns, contract workers and farmers) and retired employees. (3) serious illness co-ordination organization: initially implemented by industry organizations; After a trial period, it will be extended to all counties in time and organized and implemented by social insurance institutions. (4) Expenditure scope of medical fund for serious illness: female workers' continuous or one-time medical expenses in emergency rescue exceed those in 300 yuan (or hospitalization exceeds those in 500 yuan) due to complications caused by visceral diseases, malignant tumors, severe trauma and planned dystocia. (5) The source of the serious illness pooling fund: the on-the-job employees pay from the after-tax retained profits or welfare funds; Retired workers are still included in the "non-business" items of enterprises. (6) Payment method of serious illness co-ordination fund: calculate the amount of serious illness medical fund to be paid according to the industry co-ordination, the independent accounting unit of the company and various economic entities with separate accounts, and the number of registered employees and retired employees in the current month 10, and pay it to the co-ordination department at one time; The implementation of county-level co-ordination, serious illness medical fund withheld by the enterprise bank or entrusted by the bank from the bank account of each unit. If the recovery period co-ordination fund does not pay, 1% of the payable amount will be charged for each day of recovery period, and the overdue fine will be transferred to the employee's serious illness medical fund. If there is no reason to refund the fee for three consecutive months, the right to refund the fee shall be suspended in principle. (7) Allocation method of serious illness pooling fund: starting point of serious illness pooling fund is 300 yuan (hospitalized in 500 yuan); The medical expenses exceeding the deductible point shall be allocated to the units participating in the overall planning by the competent department of serious illness coordination according to the method of subsection calculation and cumulative payment. The amount is: 30 1(50 1) yuan ~ 1000 yuan, with 80% allocated by the overall fund; 85% of 100 1500 starts from 0 yuan, 90% from 150 1 yuan to 2,000 yuan, and the rest is borne by employees' units and individuals: 100% over 2,000 yuan. The current trend is that 100 1~2000 yuan will be allocated 85% gradually, and 90% will be allocated above 2000 yuan, and the rest will be borne by the employees' units and employees. 90% of the medical expenses within 300 yuan and the rest except the serious illness medical fund shall be borne by the enterprise, and the personal burden of the employees shall be 10%. The expenses of artificial organs, artificial joints, pacemakers and organ transplantation shall be handled according to the special provisions of the state (including provinces). (8) serious illness fund management. First, except for the nearest emergency department, employees should be treated in the hospital designated by the unit (only for initial diagnosis); Need to be transferred for treatment, subject to consultation and issue a certificate; Transferred to other places for treatment should be negotiated by the local people's hospital at or above the county level and issued a certificate; Medical expenses in violation of the above provisions do not belong to the scope of serious illness co-ordination and will not be reimbursed. Second, in line with the scope of serious illness as a whole, the medical expenses shall be applied by the unit to which they belong, on the basis of hospitalization certificate, transfer certificate, discharge procedure and receipt issued by the hospital. , and approved by the Department in charge of disease coordination fee of Jiaotong University. Third, the deposit paid in advance by employees in hospital is paid by the unit or individual, and will be submitted for approval after the medical treatment is over. If a few people do have practical difficulties, they can also borrow a part of the deposit from the competent department of serious illness coordination first, and the credentials that meet the reimbursement conditions will be partially disbursed. Fourth, the initial amount of the overall scope of serious illness and the amount of medical expenses allocated by stages are determined for one year with the adjustment range of national medical expenses and the actual income and expenditure. Fifth, the collection and disbursement of funds from the serious illness pooling fund are all solved by the pooling office and corporate finance. Sixth, the serious illness pooling fund is stored in a special account set up by the competent department of burden pooling. Special funds shall be earmarked and shall not be misappropriated. The year-end balance should be carried forward to the next year. The expenses required by the overall planning department to handle the overall work of the serious illness medical fund shall be extracted from the collected overall planning fund as a management service fee. The practice of social pooling of medical expenses for serious illness proves that social pooling of medical expenses for serious illness is a good way to ensure the medical care for serious illness of employees in small and medium-sized enterprises, especially in commercial, grain and supply and marketing enterprises, which is well received by enterprise leaders and employees and has achieved good results. First, it ensures the serious illness medical treatment of employees, relieves their worries, is conducive to mobilizing the enthusiasm of employees, promoting the development of production, and is conducive to the stability of the workforce and society. Second, mutual assistance has solved the problem that small and medium-sized enterprises can't afford serious illness medical expenses, eased the imbalance of medical expenses among enterprises, and promoted the reform of lease contract responsibility system. The third is to explore a new way to reform the labor insurance medical system. The implementation of serious illness medical expenses as a whole, a small amount of scattered medical expenses will be centralized and used uniformly, so that the risks borne by individual enterprises will be transferred to the insured units to share; Social pooling of medical expenses for serious illness paves the way for establishing medical insurance fund and implementing social pooling of medical expenses in the future.
From the perspective of the implementation of serious illness medical expenses co-ordination in Sichuan Province, to do a good job of serious illness medical expenses co-ordination, the specific operation needs to do the following work.
First of all, we must adhere to the principle that the state, units and individuals should bear medical expenses reasonably. This principle has been reflected in the areas and units that have implemented serious illness co-ordination in our province. Most of the medical expenses are borne by the serious illness medical fund, and a small part is borne by enterprises and individuals. The implementation of this method has not only solved the difficulty of paying for serious illness and serious illness of enterprises and employees, but also changed the disadvantage that medical expenses were all borne by the state and enterprises in the past, taking into account the interests of the three. Workers are seriously ill and can be treated in time, which protects the labor force and promotes the development of production.
Secondly, it is necessary to expand the overall coverage of serious illness and unify on-the-job employees and retired employees. In terms of scope, in order to facilitate the organization and implementation in enterprises, it is not easy to make it too big at the beginning, but it can be carried out in the industry first, and all employees and retired employees will be included in the overall planning scope. Generally, it is advisable to start with 2000 to 3000 people and gradually expand. In the stage of consolidation and development, qualified counties (cities, districts) will gradually transition from the industry as a whole to the industry within a county (city, district). In this way, both on-the-job workers and retired workers can ensure basic medical care and fully embody the superiority of socialism.
Third, the overall planning method should be scientific and reasonable, easy to operate and easy to push in the enterprise. Scientific methods and reasonable standards are important prerequisites to ensure the smooth implementation of serious illness planning. In the range of serious illness, it is necessary to determine the cost according to the disease and cost. The minimum starting point of medical expenses for continuous or one-time medical treatment is 300 yuan and above, and hospitalization is 500 yuan and above. If the determination is too high, the low-profit loss-making enterprises can't afford it and can't play the superiority of social overall planning; If the determination is too low and the overall fund is not enough to pay, the contributions of enterprises and individuals will inevitably be too high. As for the standard of pooling funds, according to the basic calculation, according to the principle of "fixed capital by expenditure, with a slight surplus", employees and retired employees are accrued separately for a certain period of one year. Considering that retired employees are old and sick, the accrual standard is higher than that of on-the-job employees. In other words, we should consider whether we can pay for serious illness medical expenses, especially to deal with sudden risks, and we should also consider not having too much surplus funds and not adding too much burden to enterprises. In terms of funding channels, the on-the-job employees are charged in the after-tax profit retention or welfare fund, while the retired employees are still charged outside the business, ensuring the source of funds. Individuals are encouraged to pay appropriate fees, but it is not easy to pay too much. Need to consider the economic and psychological endurance of employees. At first, it can be named 0.5 yuan, which is symbolic, psychologically adapted, and then gradually paid appropriate fees, so as to open up sources of funds and cultivate employees' awareness of self-protection. In the level of serious illness expenses, it is necessary to comprehensively consider the economic situation of small enterprises and the ability to pay as a whole, and it is appropriate to allocate funds at the second to fourth levels, and coordinate the burden ratio of competent departments, enterprises and employees, taking into account the interests of the three, and reasonably determine.
Fourth, individuals should be encouraged to pay fees appropriately, and employees' awareness of expenses should be enhanced, so as to reduce waste and curb excessive medical consumption. At present, in pengshan county, Zizhong County, Dazhu County, Qingchuan County, Huili County and other places. On-the-job employees in our province have a per capita 0.5 yuan per month, and retired employees in some counties also have a per capita 0.5 yuan, which is deducted from wages or retirement expenses. The development of serious illness medical fund from symbolic payment to appropriate or small payment embodies the "taste" of medical social insurance and the law of large numbers. On the other hand, individuals should pay appropriate fees, so that employees can gradually establish a sense of cost and change the long-standing old concept of paying medical expenses without labor insurance. It is conducive to overcoming unnecessary waste and making employees feel that although some money has been paid now, it will not affect their lives, and a serious illness is also guaranteed and worth it.
Fifth, we should expand the social adjustment function in a timely manner. Small-scale overall planning of industrial units is a good form in the early stage of serious illness overall planning, which does not affect the distribution of interests between industries and is easy to start. However, it still can't solve the imbalance of medical expenses among industries, with limited guarantee ability and poor stability. Therefore, industry co-ordination should be gradually transformed into county-based co-ordination and managed by social insurance institutions. This is the objective requirement of medical social insurance, and it is also the inevitable trend of the overall development of medical society from low level to high level, so that all employees can finally guarantee basic medical care. Only in this way can we strengthen the adjustment function, alleviate the contradiction between enterprises and industries caused by the sudden increase or decrease of medical expenses in a certain period of time, and enhance the ability to bear risks. Centralized and unified use of the less scattered funds of the unit also reflects that the employees of the disease-free or less sick units are transferred to the employees of the sick units and become socialized.
Sixth, we should vigorously strengthen and improve management services and improve the degree of socialized management as soon as possible. From the industry unit of 1989 to the second half of 1990, it gradually developed from the whole industry to the serious illness directly managed by social insurance institutions, which improved the degree of social management. This is the development direction of medical social insurance. This not only reduces the working hours of enterprise financial personnel, but also enables enterprise leaders to concentrate their energy and time on production and operation. ……
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