Author: Zhang Ni
More general outpatient expenses will be included in the payment scope of the overall fund, personal accounts will provide family benefits, and minor illnesses will not have to run errands to see big hospitals ... Recently, the General Office of the State Council issued "Guiding Opinions on Establishing and Perfecting the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients", which will lead to major changes in the relationship between the whole family and medical treatment!
Data Map: A patient uses the face recognition system to reserve an expert number under guidance. Wang she
-More general outpatient expenses will be included in the payment scope of the overall fund.
The medical insurance for employees was established from 1998, which is a security model combining social pooling and individual accounts. Co-ordinate the fund to ensure hospitalization and outpatient service for serious illness, and personal accounts to ensure minor illness and outpatient drug expenses.
The opinions released this time put forward to establish and improve the overall guarantee mechanism for the general outpatient expenses of employee medical insurance, and gradually include the general outpatient expenses of frequently-occurring diseases and common diseases into the payment scope of the overall fund on the basis of doing a good job in medical security for chronic diseases and special diseases (hereinafter referred to as outpatient chronic diseases and special diseases) with heavy burden on the masses such as hypertension and diabetes.
In addition, the general outpatient service covers all insured employees of medical insurance as a whole, and the payment ratio within the policy scope starts from 50%. With the strengthening of the affordability of the medical insurance fund, the level of protection is gradually improved, and the payment of benefits can be appropriately tilted towards retirees.
According to Chen Jinfu, deputy director of the National Medical Insurance Bureau, the opinions issued this time mainly include three measures in establishing the outpatient economic security mechanism.
First, establish general outpatient co-ordination, and gradually include frequently-occurring diseases and common diseases in outpatient medical insurance co-ordination fund for reimbursement. These expenses are basically solved by personal accounts.
The second is to strengthen outpatient support for chronic diseases and special diseases, and gradually include outpatient expenses for diseases with high cost and long treatment cycle into the scope of outpatient support. Some special diseases, chronic diseases and serious diseases are treated in outpatient department, but they are managed according to the policy of hospitalization.
Third, in addition to seeing a doctor at a designated medical institution, the insured person can also settle accounts and purchase medicines at a designated retail pharmacy with prescriptions issued outside the hospital. Those who meet the requirements are included in the scope of payment of the overall fund, and the corresponding designated retail pharmacies are also included in such a fixed-point protection scope.
This means that more outpatient expenses will be included in the medical insurance reimbursement in the future, which will help to reduce the medical burden of the insured.
-the unit payment is no longer included in the personal account.
According to the opinion, in the future, the method of calculating and distributing personal accounts will also be improved.
The document proposes to scientifically and reasonably determine the methods and levels of personal accounts. Personal accounts of employees are included in the basic medical insurance premiums paid by individuals, and the inclusion standard is controlled in principle at 2% of the base of my insured payment, and all the basic medical insurance premiums paid by the unit are included in the overall fund; In principle, the individual accounts of retirees are allocated by the overall fund according to the quota, and the allocated amount is gradually adjusted to about 2% of the average basic pension level in the year when the reform was implemented in the overall planning area according to this opinion.
Regarding this adjustment, Chen Jinfu explained that after the personal account reform, the personal accumulation still belongs to the individual, and the rights and interests have not changed. After more than 20 years of reform, the accumulated balance of personal accounts 1 trillion is still personal rights and interests.
He emphasized that the personal account reform is not to cancel personal accounts, but to adjust the proportion of personal accounts, which is a rotation of two aspects and realizes a system transformation. The decrease of new personal accounts means the establishment, expansion, perfection and improvement of outpatient economic security system. Reducing the part does not mean losing security, but putting it into the big pool of economic security to form a new security mechanism.
Data map: A hospital outpatient building. China News Service reporter Yin She
-Personal accounts are subsidized by families.
In the document issued this time, it is also very interesting to implement family welfare in personal accounts.
The document stipulates that personal accounts are mainly used to pay out-of-pocket expenses of insured persons within the policy scope of designated medical institutions or designated retail pharmacies. It can be used to pay the medical expenses incurred by the insured and their spouses, parents and children in designated medical institutions, as well as the expenses incurred by individuals in purchasing drugs, medical devices and medical consumables in designated retail pharmacies. Explore the personal accounts of spouses, parents and children participating in the basic medical insurance for urban and rural residents.
According to the policy, the individual's out-of-pocket expenses after the reimbursement of the overall fund can be paid by himself in cash or through his personal account.
After the reform, the scope of personal accounts has been expanded. Children's personal accounts participating in employee medical insurance can be used by parents to implement welfare within the family.
Big hospitals don't have to run errands to see minor illnesses.
According to reports, the establishment and improvement of the economic security mechanism for employees' medical insurance clinics will also have a positive impact on the improvement of primary medical and health service capabilities.
Chen Jinfu said that the outpatient service guarantee mechanism has a collective effect on the allocation of primary medical resources, the improvement of primary service capacity and the general outpatient service guarantee for the masses.
Through this reform, employee medical insurance has roughly replaced 200 billion funds. According to the calculation and the current per capita outpatient medical level, it should be said that the real 80 billion yuan is invested in primary medical institutions. If individual contributions are added, at least10 billion fund resources can be increased to support primary medical institutions.
For ordinary people, there is also an institutional bonus. Minor ailments can be seen in primary medical institutions without running errands in large hospitals, and the cost of seeing a doctor will be greatly reduced. At the same time, for the national resource allocation, a better allocation has been formed under the condition that the total amount of medical resources remains unchanged.
Data Map: The elderly in a medical institution in Haidong City, Qinghai Province brushed their medical insurance cards. Photo by Zhang Tianfu
-retirees reduce the burden of outpatient expenses.
The establishment of outpatient economic mechanism has improved the security for the elderly.
According to Fan Weidong, director of the Department of Treatment and Protection of the National Medical Insurance Bureau, the opinion puts forward that the overall level of general outpatient service should start from 50%, and it is clearly required that all localities give preferential payment to retired elderly people on this basis. When the reform is implemented and the outpatient service guarantee mechanism is fully implemented, it is estimated that this system can reduce the burden of outpatient service expenses for retirees by nearly 654.38+000 billion yuan.
In addition, this time, the outpatient guarantee mechanism has been improved, and it is especially proposed to further increase the diseases that are included in chronic diseases and special diseases in outpatient clinics. The outpatient chronic diseases and special diseases paid by the overall fund have been strengthened, which is a very good thing for the elderly. In other words, in the process of reform, these people will benefit more and more.
-eligible retail pharmacies are included in the settlement scope of the overall fund.
The data shows that by the end of 2020, there will be about 390,000 designated medical pharmacies nationwide, and the annual drug expenditure of personal accounts for designated pharmacies will be about 200 billion yuan. Then, what impact will the establishment of outpatient economic mechanism have on retail pharmacies?
Fan Weidong said that this reform also attaches great importance to continuing to play the positive role of designated retail pharmacies in medical security services and has introduced some measures to continue to support the development of pharmacies.
In addition to the original personal account can continue to be used for pharmacies to buy drugs, three main support measures have been clarified: first, eligible retail pharmacies will be included in the settlement scope of the overall fund; Second, broaden the scope of personal accounts and implement family assistance; Third, qualified "Internet" medical services can also be included in the scope of basic medical security. For qualified online medical services, the fund can also pay according to regulations.
He stressed that through the above measures, it is preliminarily predicted that designated retail pharmacies can play a more important and positive role in the process of basic medical security services, which will usher in a broader development space for the pharmaceutical retail industry.