Du Xin, director of the Management Center of Beijing Medical Insurance Affairs Management Office, systematically expounded the requirements and challenges faced by China's medical insurance management under the new situation, and put forward some thoughts on the basic medical insurance work in the future.
Requirements of the new situation on the management of basic medical insurance in China
From the perspective of the basic medical insurance manager, there are two main requirements for the management of basic medical insurance.
First of all, the question that medical insurance managers need to consider is whether the fund can achieve balance of payments. On this basis, we should further consider how to better improve the efficiency of the use of medical insurance funds and seek a higher level of protection for the insured. From the management point of view, the most fundamental requirement to measure whether the medical insurance managers are qualified is to see whether the medical insurance fund can achieve balance of payments. Because the key to the sustainability of the basic medical insurance system is whether the medical insurance fund can reach a balance. Otherwise, no matter how big the cake is, it will not only burden the enterprise and finance, but also protect the interests of the insured.
In addition, the standard to measure the level of protection that medical insurance can provide for the insured population is not a simple policy provision, but a number of related factors need to be considered as a whole, including the level of national economic development, the level of population dependency rate, the expected level of protection and the overall medical level. At the same time, medical insurance managers need to judge what kind of protection the state can provide to the people through actuarial calculation according to the funds raised. Managers need to consider whether limited funds can maximize economic benefits. At the same time, medical insurance needs effective management to form checks and balances among medical insurance managers, insured persons and medical service providers.
Challenges faced by current medical insurance
Under the new situation of institutional reform, the medical insurance industry in China is facing four major challenges.
First, the expectations of the insured for medical insurance are getting higher and higher, and the demand and expenditure for medical insurance funds are increasing. The report of the 19th National Congress clearly pointed out that "Socialism with Chinese characteristics has entered a new era, and the principal contradiction in our society has been transformed into the contradiction between the people's growing need for a better life and the unbalanced development". Ordinary people have higher requirements for a better life, so the demand for medical security of the insured is also increasing. The insured's high demand for medical insurance also includes some inducing factors, such as health guidance and education, and the indoctrination of the current imperfect medical security system, which also causes the insured's demand for basic medical insurance to be incompatible with the current level of economic and social development in China.
Second, in recent years, new technologies in the medical field have developed faster and faster, including drug treatment and medical service treatment. In this process, how to achieve a good balance between the rapid development of medical technology and the supply capacity of the entire basic medical insurance fund is another major challenge facing China's basic medical insurance. Whether it is a pharmaceutical manufacturer or a medical device supplier, everyone is considering whether the company's products can be included in the payment scope of basic medical insurance. However, due to the limitation of the basic medical insurance fund, the basic medical insurance will face great pressure.
Thirdly, with the current economic downturn in China, many enterprises have expressed increasing pressure. At present, China's basic medical insurance is changed to tax collection. Theoretically, it seems that the collection of medical insurance will be stronger, and the actual foundation will be bigger. However, from the perspective of government management, if the current funds are basically enough, the state will consider reducing the burden on enterprises and further reducing the rate at this stage. However, in this case, the financing of basic medical insurance will face great challenges.
Fourthly, at present, the pressure of medical insurance fund in China is increasing, and how to keep the balance of medical insurance fund is a common practical problem. Medical insurance managers need to maintain the balance and continuity of the medical insurance system, and the first problem to be solved is how to achieve the balance of payments of medical insurance funds.
Reflections on the work of basic medical insurance
Under the new situation, the orientation and focus of China's basic medical insurance need to be adjusted according to the requirements of the current era, mainly including two directions.
First of all, the state should reasonably guide the people's expected demand for basic medical insurance. Medical insurance managers should focus on how to guide reasonable expectations at the whole social and national level and let the public form a healthy cognitive concept. Since the establishment of China's basic medical security system, the guidance of medical insurance to the public has been in a state of lack or insufficiency. In the next step, the state needs to give the insured an objective understanding and evaluation of social security and medical security through correct and comprehensive publicity and guidance.
Secondly, in the face of various pressures and challenges of medical insurance, medical insurance managers need to study how to improve the effectiveness and efficiency of existing funds. So how to do a good job in the overall planning of medical insurance funds? At the macro level of system development, it is basically impossible for medical insurance to achieve "open source" in a certain period of time. On the one hand, it is difficult for the state to increase taxes and fees, on the other hand, it has achieved full coverage at the institutional level. Therefore, the current medical insurance mainly considers how to "cut expenditure", especially under the premise of ensuring the basic interests of the insured. The country needs to reduce waste, so as to improve the efficiency of the use of medical insurance funds. For medical insurance "throttling", there are mainly the following considerations.
The first is to further deepen the reform of medical insurance payment methods. Although under the current medical system and framework, the management measures that medical insurance can take are extremely limited, the payment method, as a means directly linked to the economic lifeline of medical institutions, is the main way for medical insurance to effectively manage fund expenditures.
Second, reform and improve the current centralized drug procurement. Recently, the State Council passed the pilot program of centralized drug procurement organized by the state, and the state will improve the procurement mode of exchanging quantity for price, which plays an important role in effectively squeezing out the water with inflated drug prices. However, if centralized procurement with quantity is implemented, it needs the linkage of "three doctors", including the reform of compensation mechanism of medical institutions, the reform of medical insurance payment method and the reform of drug circulation system. The state encourages the innovative development of drugs, constantly improves the quality of drugs and promotes the formation of reasonable drug prices. In this process, the reduction of price will affect the original medical insurance payment standard, and the reduction of payment standard will also affect the initiative and enthusiasm of medical institutions to participate in the reform. Therefore, the next step of medical insurance needs to systematically think about how to better balance the interests of all medical parties, so as to realize the benign operation of the whole management mechanism.
Third, fully consider the management relationship between medical insurance and designated medical institutions and doctors. At present, China's medical insurance still adopts the mode of agreement management for medical institutions, and some provinces and cities have carried out forward-looking exploration, that is, the management of designated doctors. By adopting some policies or administrative intervention measures, these provinces and cities have bound and restricted the unreasonable diagnosis and treatment behavior of designated doctors. From the perspective of medical insurance management and design, it is certainly more intuitive to manage specific designated doctors. But in China, there is a very real problem, that is, doctors in China are not freelancers and need to practice based on medical institutions. So in the whole medical insurance management design, how should the subject relationship between designated medical institutions and designated doctors be reflected? As the designer and manager of the medical insurance system, we should have a clearer understanding and judgment on this in the next step.
Fourth, continue to deepen and promote medical insurance informationization and big data applications. At present, with the gradual improvement of the universal medical insurance system, the aging population, the rapid release of medical needs and the rising medical expenses, China's medical insurance is facing many challenges, such as the pressure of fund balance and frequent medical service violations. Therefore, how to make full use of big data is also a key research topic of current medical insurance.