Prop up a warm umbrella for patients with serious illnesses

In recent years, China has continued to promote the construction of a multi-level medical security system and made breakthroughs in solving the problems of "difficult to see a doctor" and "expensive to see a doctor".

In order to further make up for the shortcomings of the guarantee, the General Office of the State Council recently issued the "Opinions on Improving the Medical Insurance and Assistance System for Serious and Exceptionally Serious Diseases" (hereinafter referred to as the "Opinions"), focusing on reducing the burden of medical expenses for serious and exceptionally serious diseases of the people in difficulty.

How? Who is the target of the rescue? What are the costs of the bailout? What has changed with the support measures? In this regard, this reporter interviewed Gu Xuefei, director of the Medical Security Research Office of the Health Development Research Center of the National Health Commission.

Rescue targets

Institutional protection covers the entire population

Reporter: How to understand the scope of medical assistance mentioned in the "Opinions"?

Gu Xuefei: The object range has two characteristics: hierarchical classification and accurate determination. Since the establishment of the urban and rural medical assistance system, the number of assistance objects has been continuously expanded, and the "Opinions" have made a more accurate classification of the rescue objects, the first category is the low-income insurance objects and the special hardship cases, who automatically obtain medical assistance qualifications while receiving living assistance.

The second category is the marginal family members of the low-income family and the rural people who are easy to return to poverty and cause poverty in the scope of monitoring, that is, the lower-income groups outside the first category of people, and also consider the continuity of the medical security poverty alleviation policy from the stage of poverty alleviation to rural revitalization.

The third category is patients with serious diseases (patients with serious illnesses due to poverty caused by illness) that have serious difficulties in the basic life of the family due to high medical expenses. This is equivalent to covering the entire population within the scope of institutional protection, giving moderate assistance to those patients with serious diseases who do not belong to low-income groups but may be in trouble because of high medical expenditures, avoiding them from implementing assistance after they become low-insurance objects due to illness, and optimizing the "cliff effect" of the policy into a "slope effect", reflecting the malleability of the policy. The positioning of the system has expanded from guaranteeing basic medical and health services for those who have fallen into poverty to preventing and resolving the risk of poverty caused by large medical expenditures, that is, from guaranteed income-based poverty to reducing expenditure-based poverty.

Reporter: What is the scope of medical assistance cost protection?

Gu Xuefei: The "Opinions" make it clear that the cost of assistance is to adhere to the basics, mainly covering the cost of hospitalization incurred by the rescue target in the designated medical institution, the cost of long-term medication due to chronic diseases or the long-term outpatient treatment of serious and exceptionally serious diseases. In principle, the drugs, medical consumables, and diagnosis and treatment items paid by the medical aid fund should comply with the provisions of the state on the scope of payment of basic medical insurance.

Individual out-of-pocket expenses within the policy range below the threshold of basic medical insurance and major illness insurance shall be included in the rescue guarantee in accordance with regulations to reduce the burden of "threshold fees".

For expenses outside the scope of the basic medical security policy, overall consideration has been given in improving the multi-level medical security system system, including stabilizing and consolidating the level of security, comprehensively reducing the cost of medical treatment, and guiding the participation of social forces.

Guaranteed treatment

Promote the complementarity and convergence of the triple system

Reporter: What are the three-fold system of medical security? What is the relationship between them?

Gu Xuefei: The triple system includes basic medical insurance, major illness insurance, and medical assistance. The "Opinions" make it clear that while implementing inclusive financial subsidies for insured residents, it is necessary to ensure that the insurance should be fully insured by fully or fixedly subsidizing the low-income insurance, the extremely poor, and the return to poverty and poverty.

In fact, before the realization of comprehensive poverty alleviation, there were six, seven or even nine guarantees in some places, but it is not that the more systems there are, the higher the level of guarantees. Too many systems will lead to greater difficulty in connection, and there are excessive guarantee problems in a few places, and the sustainability of the system is worrying.

This year, the National Medical Insurance Bureau and the Ministry of Finance made it clear that the basic system includes the "triple guarantee" of basic medical insurance, supplementary medical insurance and medical assistance, and other forms of institutional arrangements will be gradually cleaned up and transitioned to the basic institutional framework of "triple guarantee".

In the institutional framework of the "triple guarantee", the basic medical insurance and medical assistance system are relatively clear, while the definition and boundary of supplementary medical insurance have always been relatively vague. In the national medical security treatment list (2020 edition), supplementary medical insurance includes urban and rural residents' serious illness insurance, employee large medical expense subsidies (including employee serious illness insurance in some provinces), and civil servants' medical subsidies are managed by reference list, while supplementary medical insurance established by enterprises and institutions themselves is temporarily excluded from the list management.

These supplementary protection systems vary considerably from basic medical insurance. For example, there is no independent financing for urban and rural residents' serious illness insurance, and the premium comes from the basic medical insurance of urban and rural residents, so it still belongs to the category of basic medical insurance in the strict sense; the supplementary medical protection established by some enterprises and institutions themselves may belong to the medical mutual aid system after the occurrence of risks in nature rather than insurance. Whether these systems are voluntary or voluntary varies from region to region.

In addition, under the framework of China's basic system, commercial health insurance, mutual insurance, medical mutual assistance, etc. also belong to the "supplementary" institutional arrangement, and the concept and institutional boundaries need to be further clarified. Other concepts, such as "basic insurance", "statutory insurance", "social insurance", etc., have similar problems.

The "Opinions" proposes to promote the complementary convergence of the triple system - to give play to the main guarantee function of basic medical insurance, strictly implement the scope and standard of payment of basic medical insurance, and implement fair and appropriate protection; major illness insurance plays a supplementary guarantee role and implements oblique protection for the rescue object; after insurance reimbursement, the support function of medical assistance is played, and in accordance with the principle of "first insurance and then assistance", the rescue targets who still have a relatively heavy burden of personal medical expenses after payment such as basic medical insurance and major illness insurance are implemented in accordance with regulations. Work together to prevent the risk of returning to poverty due to illness.

Bottom-up measures

Tilt towards patients with serious chronic diseases

Reporter: In terms of overall planning and optimization of the support mechanism, how does the "Opinions" determine the level of rescue?

Gu Xuefei: The goal of the support guarantee is to ensure that the people in need can access basic medical and health services, and to ensure that the basic life of their families is not affected by the problem of medical expenses.

In view of the design of payment tools that affect the policy benefit level of the rescue targets, such as the threshold of payment and the proportion of self-payment, the "Opinions" emphasize that on the basis of comprehensively considering factors such as the affordability of the fund and the actual needs of the masses, the treatment standards should be refined by group, and it is clearly required that the minimum payment standards for the minimum guarantee and the extremely poor people be abolished in principle, and the annual minimum payment standard that does not have the conditions for the time being shall not be higher than 5% of the disposable income of residents in the coordinated areas in the previous year. The annual minimum payment standards for marginal families and patients with serious illnesses caused by illness are determined according to about 10% and 25% of the per capita disposable income of residents in the coordinating area in the previous year, respectively.

In terms of the proportion of assistance, the low-income insurance objects and the special hardship cases shall be rescued by not less than 70%, and the other rescue objects shall be determined by various localities according to the actual situation to be slightly lower than the proportion of assistance for the minimum guarantee. The annual relief limit is also reasonably determined on the basis of the fund's actual capacity to pay.

Reporter: In what directions does the support measure focus?

Gu Xuefei: In the arrangement of the guarantee measures at the bottom, the tilt towards the patients with major diseases among the people in difficulty is more prominent. In the past, the rescue policy was mainly based on hospitalization assistance, and the "Opinions" required that the assistance guarantee for outpatient chronic diseases and special diseases be increased, and the annual assistance limit of outpatient and inpatient assistance should be shared, and the use of rescue funds should be coordinated, which will help guide patients with difficult outpatient chronic diseases to seek medical treatment reasonably and reduce the phenomenon of "outpatient transfer to hospitalization".

After the comprehensive guarantee of the triple system, the personal burden is still relatively heavy, and it can continue to give inclined assistance, provided that the standardized referral within the province is standardized, and the scope of medical assistance payment is consistent with the basic medical insurance catalogue of drugs, consumables and diagnosis and treatment items. In short, medical assistance guarantees "basic" medical and health services for people in need, and should be combined with referral mechanisms, standardized diagnosis and treatment measures, etc., to control unnecessary payments and reduce waste.

Long-term mechanism

Strengthen early warning and monitoring, and promote convenient services

[Reporter] The "Opinions" make it clear that it is necessary to establish and improve a long-term mechanism for preventing and resolving the return to poverty caused by illness.

Gu Xuefei: In the past, medical aid practice paid more attention to people who have fallen into a state of economic difficulty, and has not yet comprehensively built a "firewall" to prevent poverty caused by illness. The "Opinions" proposes to classify and improve the dual early warning mechanism of poverty caused by illness and returning to poverty due to illness, and in the era of the Internet and big data, with the help of information means, through the early warning and monitoring of high medical expenditures, the key monitoring groups that meet the conditions will be included in the scope of assistance in a timely manner; at the same time, the channels for assistance applications will be smoothed to improve the timeliness of assistance. For example, those who have been identified as low-income insurance recipients or persons in special hardship directly receive medical assistance. The "preventive" institutional arrangement and the operation support of information technology are important directions for the high-quality development of China's medical security system.

Practice has proved that "one-stop" settlement services, medical security convenience services such as first diagnosis and treatment and then payment are directly related to the public's sense of identity and satisfaction with the medical insurance system.

By promoting the integrated handling of medical insurance and medical assistance, and doing a good job of integrating services with social assistance in "one door acceptance and coordinated handling", it will help improve the convenience of medical insurance handling services for the people in difficulty. At the same time, considering that the guarantee is a "preferential" institutional arrangement for specific groups, it is more necessary to follow the basic principles of guarantee and adhere to fairness and efficiency. Therefore, the first diagnosis at the grass-roots level, standardized referral, scientific diagnosis and treatment path management, and efficient and effective payment methods should become indispensable policy arrangements for coordinated promotion of medical and health service reform.

Multi-level protection

Give play to the role of social forces such as charity

Reporter: The "Opinions" proposes to actively guide charities and other social forces to participate in rescue guarantees, how to understand?

Gu Xuefei: Charitable aid is an important part of philanthropy, an important way to play the role of the third distribution, and an important supplement to the existing triple system. Although the funds for charitable projects are very limited compared to medical insurance funds, if they are effectively linked with medical assistance and medical insurance, and give full play to the synergy of the system, they can play a multiplier effect with half the effort. For example, in some charity projects, some children with congenital heart disease have received "one-stop" reimbursement services, the treatment is completely free and the family does not have to pay medical expenses in advance, which greatly reduces the financial burden on the children's families.

For the assistance of specific diseases and specific groups of people, the level of assistance, the scope of assistance and the flexibility of charitable assistance have advantages, especially social work and volunteer service, which are services in addition to medical expenses and are beneficial supplements to government assistance.

Employee medical mutual assistance, commercial health insurance, etc. can play a complementary role in broadening the scope of protection and improving the level of reimbursement, and the system and management operation should be further improved, and the system connection with basic medical insurance should be strengthened to better meet the multi-level, personalized and differentiated health needs of the insured.

The Internet-based medical mutual aid project has developed rapidly in recent years, and is a relatively efficient and transparent after-the-fact risk mitigation mechanism based on stranger communities built in the Internet era. While regulating development, it is also necessary to prevent risks. (Reporter Wang Meihua)

People's Daily Overseas Edition (09th edition, December 7, 2021)

Source: People's Daily Overseas Edition