Medical insurance co-ordination refers to the remaining part of medical insurance premiums paid by all employers for employees in a co-ordination area after being deducted from personal accounts. The medical insurance pooling fund belongs to all insured persons, and is managed centrally by social insurance agencies and used uniformly. It is mainly used to pay the medical expenses, operation expenses, nursing expenses and basic inspection expenses of the insured employees. The medical insurance fund shall be stored in a special account for special purposes, and no unit or individual may misappropriate it.
The overall planning fund includes: the remaining part of the total payment of all insured units in the overall planning area after deducting individual accounts; Financial subsidies; Social donation; Bank interest; Late payment fees, etc.
The medical insurance pooling fund belongs to the insured, which is stored in a special account and earmarked, and no unit or individual may misappropriate it. The overall fund is mainly used for medical expenses such as hospitalization of insured persons, emergency rescue in non-designated hospitals, referral from different places (hospitals), resettlement in different places, and special disease clinics.
Risk prevention of medical insurance pooling fund
The medical insurance pooling fund is the primary condition to ensure the normal operation of the basic medical insurance system. Once the overall fund is seriously overspent, the guarantee function of the basic medical insurance system will be weakened or even collapsed, which will lead to the failure of the basic medical insurance reform. However, it is an objective and unavoidable fact that the whole fund faces various risks during its operation. Therefore, it is of great practical significance to seriously study and discuss various risks existing in the operation of medical insurance funds, and to avoid and guard against these risks.
First, the formation of risks
In the current social environment, the formation of medical insurance pooling fund risk can be roughly divided into overall social factors and local social factors.
The overall social factors mainly include the following points:
First, the characteristics of China's medical insurance system. The existing medical insurance system in China is gradually transformed from the former public medical care. At present, the payment of medical insurance is completed by the insured, medical institutions and medical insurance agencies. The opacity of medical consumption makes it difficult for medical supervision institutions to accurately define the value of medical consumption and the rationality of consumption content, which makes it very difficult for the overall fund to pay medical expenses normally and accurately. Second, under the current situation, the financial input of designated medical institutions is unchanged or even reduced, and its economic benefits mainly depend on its own income-generating ability, which inevitably makes medical institutions regard obtaining economic benefits as an extremely important pursuit goal, and even some medical institutions do not hesitate to take various measures to obtain the maximum economic benefits. The recent uproar over the sky-high medical expenses in Harbin is the best example. Third, with the strengthening of medical and health conditions, the problem of aging population is becoming increasingly prominent, and the medical consumption demand of this group of people is also increasing day by day, which will inevitably lead to a substantial increase in medical expenses.
The local social factors that cause fund risks are as follows: First, the collection of insurance funds is greatly affected by the economic situation. Under the existing market economy and social environment, in areas with relatively backward economic base, a considerable number of units cannot pay medical insurance for their employees in full and on time within the prescribed time limit, and the insured employees of these units still have to pay medical expenses, which will lead to a significant reduction in the overall fund. Second, with the development of medical science and technology, new medical equipment has been put into clinical application. Due to psychological reasons, medical staff want to use the latest and best medical equipment as much as possible, which leads to a substantial increase in per capita medical expenses and a corresponding increase in the expenditure of the overall fund. At present, China's medical insurance co-ordination is basically based on counties and districts, and it is impossible to establish a co-ordination and balance mechanism for the time being.
II. Fund Raising and Expenditure
Raising and spending are two keys to ensure the safe and normal operation of the fund. Raising is the basis of the operation of medical security system. Only by raising the required funds on time and in full can the normal operation of the system be guaranteed. The financing ratio is based on the local living and medical consumption level, and the future development trend is considered. Therefore, when determining the overall level, we must carefully investigate and analyze it to be accurate and appropriate. Under normal circumstances, the level of financing should be slightly higher than the level of medical consumption, so as to achieve a slight surplus. However, if there are mistakes or poor analysis in investigation and analysis, or if the future trend of medical expenses cannot be correctly predicted, and the financing level is lower than the predetermined level of medical consumption, there may be the risk of overdraft in fund operation.
From the perspective of cities that have implemented the basic medical insurance system, the fund payment methods can be roughly divided into three types: 1. When patients see a doctor, they pay directly to the hospital, and then the patients settle accounts with medical insurance institutions; 2. Patients do not pay directly for medical treatment, and hospitals and medical insurance institutions settle accounts with each other; 3, medical insurance institutions and hospitals to adopt fixed budget management, medical insurance institutions to allocate medical expenses month by month, year-end summary. Under normal circumstances, the fund is out of danger because of the way of settlement afterwards, because the medical consumption form of medical institutions occurs in the front and the settlement is behind, that is to say, as settlement itself, it has lost its ability to restrain medical behavior. If the prepayment system is adopted, under normal circumstances, the fund will not go out of danger, because the medical insurance institutions have settled and paid the medical institutions according to the predetermined index system, and the medical institutions provide medical services according to the requirements of the cost and demand index system provided by the medical insurance institutions. Therefore, it is usually not the fund that is in danger, but another problem that is often prone to occur, that is, insufficient medical consumption. The combined payment method is to learn from each other's strong points and combine the prepaid system with the post-paid system, so as to foster strengths and avoid weaknesses and make up for their respective shortcomings.
Third, risk prevention.
First, it is necessary to increase the intensity of collection and ensure the rate of fund collection. In order to ensure the normal operation of the overall fund, we must ensure a high fund collection rate, and pay special attention to prevent malicious arrears.
The second is to establish and improve the basic medical insurance budget system and fund early warning system. Before the start of the overall planning year, we must budget the total revenue and expenditure of the medical insurance fund in this overall planning year, especially the revenue and expenditure of the overall planning fund, leaving enough room. After the overall budget is completed, we will separately approve the specific revenue and expenditure budgets of individual accounts and overall funds. Fund early warning system refers to the establishment of a basic medical insurance system, through the management information system, set up corresponding warning lines for various funds, and give early warning of possible risks in the operation of the fund system. For the integrated area that has been networked, it is necessary to make full use of the management information system and computer settlement system to implement online monitoring.
The third is to determine the appropriate payment ratio according to the actual situation. As the income level and medical consumption level vary greatly from place to place, we must adhere to the principle of seeking truth from facts, adapting to local conditions and analyzing specific problems in terms of payment proportion and payment method, and we must never completely copy the existing routines of so-called large and medium-sized cities and reform pilots.
Fourth, it is necessary to establish an adjustment and balance mechanism for overall fund payment. Judging from the current practice in various places, the overall fund mainly pays most of the hospitalization expenses of medical insurance patients and part of the expenses of special clinics. Usually, hospitalization expenses are paid by stages according to a certain proportion, but how to pay for special outpatient services varies from place to place, which is also an important part of establishing an adjustment mechanism. Outpatient special disease subsidies should adopt flexible proportion, that is, according to the year-end overall fund balance to determine the specific proportion of subsidies.
The fifth is to strictly review serious diseases. At present, the threshold setting and payment ratio of mutual aid for serious illness vary from place to place, but the number of people entering mutual aid for serious illness is increasing year by year, and the cost is also increasing greatly. This has caused considerable payment pressure to medical insurance agencies.
Fourth, resolve risks.
It is necessary to plan ahead, nip in the bud, and seriously study and explore measures and methods to resolve risks. Only in this way can we ensure the normal operation of the medical insurance system. Measures to reduce risks usually include the following:
First, we must seize the opportunity and try our best to resolve the risks in an outbreak. The risk of pooling funds usually means that the payment amount of pooling funds exceeds the account amount of pooling funds. This kind of overspending often occurs gradually, which can be reflected by monthly statistical statements. Therefore, it is necessary to standardize the accounting statistical report system, carefully check the income and expenditure situation every month, and adjust immediately next month if there is any overrun, so as to solve the problem of overrun as far as possible throughout the year; If there is a serious overrun in the year-end summary of the overall planning year, it must be solved in the first quarter of the new overall planning year.
The second is to adjust the relevant proportional standards in a timely and appropriate manner. When the amount of overspending is huge, and the overspending expenses are within the normal and reasonable expenditure range, which is not caused by violation of regulations or excessive medical consumption, in this case, we can consider appropriately increasing the collection ratio to increase the total amount of the overall fund and improve the payment ability of the overall fund, but the proportion included in the personal account can not be reduced generally, otherwise it will easily lead to psychological imbalance of the insured. In addition, the collection base and payment ratio of mutual aid for serious illness can be appropriately adjusted according to the situation to alleviate the payment pressure of mutual aid for serious illness. If the above measures still can't solve the risk, it is necessary to raise the minimum payment standard or reduce the payment proportion of the overall fund, so as to enhance the saving consciousness of the insured and moderately reduce the level of overall medical consumption, thus solving the risk of over-expenditure of the overall fund.
Third, it is necessary to establish a fund reservation system, strive for more government funds, and achieve the purpose of sharing risks. The fund reservation system is to reserve a certain proportion of funds from the settlement amount of each designated medical institution to restrain the illegal activities of each designated medical institution. At the same time, an incentive system can be established to reward and commend outstanding designated medical institutions in various forms to promote their legitimate operation. In areas with developed economic level and sufficient financial resources, you can apply to the government to increase investment in social security and provide better social security services for the insured.
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