On January 26, the National Medical Insurance Bureau released the latest national direct settlement of cross-provincial medical treatment in different places. As of the end of December 2021, there are 45,600 designated medical institutions and 82,700 designated pharmacies with direct settlement of outpatient expenses across provinces, with a cumulative settlement of 12.5144 million person-times. The improvement of direct settlement of medical treatment across provinces and places will solve the actual needs of 125 million people.
This wide-ranging effort is just one of many initiatives implemented by the National Health Insurance Authority in the nearly four years since its establishment. At the recent national medical insurance work conference, the National Medical Insurance Bureau announced the 2021 "report card", including reducing the burden of patient drug consumption, improving the experience of medical treatment in different places across provinces, reducing the cost of epidemic prevention, and improving the quality of treatment and security, each aspect of which is presented with data. Looking back at the corresponding data released at the national medical insurance work conference over the years, the National Medical Insurance Bureau has saved at least about 800 billion yuan for patients, which does not include the indirect costs saved by patients due to convenient measures such as off-site settlement.
Saving 800 billion yuan is a phased result of the National Medical Insurance Bureau's strategic planning, and after this, there must be more "small goals".
Key data released by the National Medical Insurance Work Conference over the years, source: the official website of the National Medical Insurance Bureau
4 years of reduced burden reduction
First of all, what significant measures have been taken by the National Medical Insurance Bureau in the past four years to reduce the burden on patients or the public.
■ Normalization of collection and negotiation, and the burden of drug consumption is reduced
On January 26, the seventh batch of national centralized drug procurement began to report, which means that the drug collection work in the new year has started. Prior to this, from the launch of the "4+7" collection in 2018 to the end of 2021, the National Medical Insurance Bureau has organized six batches of drug collection. In 2020, "national mining" extended from drugs to consumables, and has now carried out the collection of coronary stents and artificial joints.
By the end of 2021, the collection of drugs and consumables will save more than 260 billion yuan for medical insurance and patients.
Since the establishment of the National Medical Insurance Bureau, a normalized medical insurance drug list negotiation mechanism has been established. Since 2018, the mainland has carried out the adjustment of the national medical insurance drug list for four consecutive years, and has included 507 new drugs and good drugs in the list; the average annual decline in negotiated drug prices is about 50%-60%. According to statistics, the first three years of negotiated drugs have reduced the burden of patients by 170 billion yuan.
In 2021, the world's first precision-targeted therapeutic drug for the treatment of spinal muscular atrophy, Northinasone Sodium Injection, was negotiated into the medical insurance drug list, and one injection was reduced from 700,000 to more than 30,000, greatly reducing the burden on patients. A total of 7 rare disease drugs have entered the new version of the catalog, and as of now, there are 45 kinds of rare disease drugs in the catalog, and more and more rare disease patients can directly benefit.
■ The scope of outpatient coverage has been expanded, and outpatient expenses have been reduced
In the past, medical insurance coverage was mainly concentrated in hospitalization, and outpatient coverage was less, mainly based on personal payment or medical insurance personal account payment. In recent years, outpatient coverage is being replenished.
In terms of medical insurance for urban and rural residents, in 2019, the National Medical Insurance Bureau and other departments issued the "Guiding Opinions on Improving the Outpatient Drug Guarantee Mechanism for Urban and Rural Residents with Hypertension and Diabetes", which clearly states that relying on designated primary medical institutions at the second level and below, the cost of blood pressure and blood glucose drugs incurred in the outpatient clinics of insured patients with "two diseases" will be paid by the pooled fund, and the proportion of payment within the policy scope should reach more than 50%.
In terms of employee medical insurance, in 2021, the General Office of the State Council issued the "Guiding Opinions on Establishing and Improving the Outpatient Mutual Assistance Guarantee Mechanism for Basic Medical Insurance for Employees", which put forward two aspects of outpatient protection: First, gradually include the general outpatient expenses of multiple diseases and common diseases into the scope of payment of the pooled fund, the proportion of payment within the policy range starts from 50%, and the treatment payment can be appropriately inclined to retirees; the second is to gradually expand the scope of outpatient chronic diseases paid by the pooled fund, and some can refer to the management of inpatient treatment.
At the same time, in addition to personal use, personal accounts can also be used to pay for the expenses borne by individuals when spouses, parents and children seek medical treatment, as well as the expenses borne by individuals in the purchase of drugs, medical devices and medical consumables at designated retail pharmacies.
Since then, Sichuan, Fujian, and many provinces across the country have followed up and introduced the method of local employee medical insurance outpatient assistance, and formulated specific reimbursement ratios, quotas and implementation progress; various localities have also landed to varying degrees, and there are certain differences in the protection of diseases and reimbursement ratios. On the whole, the combination of outpatient co-ordination payment and personal account family use will jointly make up for the shortcomings of outpatient security, which will promote the transformation of outpatient security from self-protection of individual accounts to mutual security of co-ordination funds, and reduce the burden of medical treatment for patients.
■ Direct settlement of medical treatment in different places across provinces, and the efficiency of medical treatment is higher
According to statistics, the 125 million floating population in the country has the need for medical settlement across provinces and places.
As early as 2016, the national off-site medical settlement system has been launched, and patients have gradually enjoyed the direct reimbursement of off-site hospitalization, which has been greatly facilitated. However, outpatient treatment with higher frequency of use cannot achieve off-site settlement. Under the influence of the pattern of population mobility, it is more common for retired elderly people to move to another city to live with their children, and the need for off-site settlement of outpatient expenses is more urgent.
In 2020, the National Medical Insurance Bureau and the Ministry of Finance issued the Notice on Promoting the Pilot Work of Cross-provincial Direct Settlement of Outpatient Expenses, which put forward the work plan of the pilot project in the five provinces of Beijing-Tianjin-Hebei, yangtze river delta and southwest China; and simultaneously formulated the "Procedures for the Handling of Inter-provincial Direct Settlement of Outpatient Expenses (Trial)", clarifying the specific settlement rules.
As mentioned in the previous part, the outpatient security system is being accelerated and improved, which also means that outpatient off-site settlement needs to keep up with the corresponding rhythm. In 2021, the settlement of outpatient inter-provincial expenses has been accelerated, and the cross-provincial direct settlement of general outpatient expenses in all coordinated areas of 31 provinces (autonomous regions and municipalities directly under the Central Government) and the Xinjiang Production and Construction Corps has been fully covered; at least one coordinated area in each province has launched a pilot pilot of direct settlement of outpatient chronic disease-related treatment costs across provinces.
As of the end of December 2021, there were 45,600 designated medical institutions and 82,700 designated pharmacies with direct settlement of outpatient expenses across provinces nationwide, with a cumulative direct settlement of 12.5144 million person-times; of which 9.496 million were settled in 2021 alone.
The direct settlement of hospitalization expenses across provinces across the country is also continuing to advance, and as of the end of December 2021, there are 52,700 designated medical institutions in the settlement, an increase of 18.7% year-on-year. In 2021, the national hospitalization expenses were directly settled across provinces by 4.4059 million person-times, an increase of 46.8% year-on-year.
2019-2021 National Hospitalization Expenses Cross-Provincial Direct Settlement (based on cumulative quantity), source: national medical insurance bureau official website
Measures such as drug collection, medical insurance negotiation, and outpatient overall reimbursement are all directly reducing the burden on patients, while the direct settlement of medical treatment across provinces is to avoid patients running for reimbursement and indirectly reduce their medical burden under the new population flow pattern through system breakthroughs and technological improvements.
■ Vaccines are free, and the price of nucleic acid testing has dropped again and again
The protection of medical insurance for epidemic prevention and control is also closely related to the public. During the epidemic period, medical insurance and finance jointly paid for the treatment costs of new crown pneumonia patients, with a total settlement of 2.84 billion yuan for new crown patients and 1.63 billion yuan for medical insurance in 2020.
Since then, the epidemic has been sporadic in many parts of the country, in order to ensure that the social and economic operation and the epidemic "dynamic clearance" parallel, nucleic acid testing and vaccination have become the most basic two tasks, the demand is huge.
In terms of nucleic acid detection, the supply of test kits in the early stage of the epidemic was once in short supply, and the price of testing reached 260 yuan per person. In June 2020, the Office of the National Medical Insurance Bureau issued the Notice on Coordinating the Work Related to Further Improving the Testing Capacity of the New Coronavirus to improve the price policy of testing items. In 2021, the National Medical Insurance Bureau has significantly reduced the price of nucleic acid testing in the country for three rounds, and at present, the price of each single test for single person and mixed test for multiple people has dropped to no more than 40 yuan and 10 yuan respectively. For individuals, before and after travel, returning home, visiting relatives, etc., nucleic acid testing has become a routine means of guarantee for low prices.
In terms of vaccination, from the end of 2020 to the end of 2021, more than 2.9 billion doses of COVID-19 vaccination have been completed nationwide. The COVID-19 vaccine is fully free of charge, and the cost is borne by medical insurance and finance.
In fact, the medical insurance fund is mainly used for treatment, originally did not cover vaccination and other preventive services, however, according to the National Medical Insurance Bureau, medical insurance to pay for the new crown virus vaccine is a special move to deal with special events, mainly using the medical insurance fund to roll over the balance, does not affect the current medical insurance fund income and expenditure, will not affect the treatment of medical treatment.
The above measures show the effectiveness of medical insurance in reducing the burden of personal medical treatment, in addition to epidemic prevention and control, others have become or will soon become a normal measure that affects a wide range of people and involves a large amount of money.
Three steps to achieve the next step of burden reduction goals
On the basis of many achievements, what is the next goal of the National Health Insurance Bureau? In 2021, the "14th Five-Year Plan for Universal Medical Security" (hereinafter referred to as the "Plan") issued by the General Office of the State Council pointed out the direction, and the plan put forward 15 development indicators in four aspects: insurance coverage, degree of security, fine management and quality services.
The main indicators of the development of universal medical security in the "14th Five-Year Plan" period, source: "14th Five-Year Plan for Universal Medical Security"
In the chart above, the differences between the indicators indicate the focus of health insurance work. Among them, the proportion of personal health expenditure in total health expenditure has been reduced from 27.7% to 27%, which will be the result of the joint action of other indicators and can reflect the overall level of medical security. Under the guidance of this overall goal, combined with other policies involved in the National Medical Insurance Bureau in the past 4 years, the next step of medical insurance work will be carried out along such a path: expand the capital pool, reduce expenditure, optimize payment methods, and thus improve the ability to guarantee.
■ One increase: expand the capital pool
In terms of employee medical insurance, after the implementation of outpatient mutual assistance guarantee payment, part of the funds in the personal account will enter the overall account, according to statistics, the annual pooled fund will be about 200 billion yuan more than before, and this part of the funds can be used to spend the outpatient reimbursement mentioned above.
In terms of domestic medical insurance, premiums are composed of individual contributions and financial subsidies. In recent years, every year the "Government Work Report" has had requirements for raising the financing standards for medical insurance for urban and rural residents. Since the establishment of the National Medical Insurance Bureau, it has been implemented every year, and the financing standards for resident medical insurance have been raised from 490 yuan and 220 yuan per capita financial subsidy standard and individual payment standard in 2018 to 580 yuan and 320 yuan in 2021. In the future, the National Medical Insurance Bureau will explore a more reasonable financing mechanism for residents' medical insurance and optimize the structure of individual payment and government subsidies.
In addition, the Opinions of the CPC Central Committee and the State Council on Deepening the Reform of the Medical Security System and the 14th Five-Year Plan for The 14th Five-Year Plan for The Universal Medical Security plan both point out that it is necessary to adapt to the development of new business formats and improve the way of insurance payment for flexibly employed persons. This is not only a way to expand the coverage of health insurance, but also one of the channels to expand the pool of funds.
■ One reduction: reduce the cost of drug consumption
The collection and negotiation of pharmaceutical consumables is still an important way to reduce expenditure.
In accordance with the requirements of the "14th Five-Year Plan" for National Medical Security, by 2025, the number of national and provincial drugs in each province (autonomous region and municipality directly under the central government) will reach more than 500 varieties; by 2025, the number of national and provincial high-value medical consumables in each province (autonomous region and municipality directly under the central government) will reach more than 5 categories.
Recently, the national organization of centralized drug procurement work conference was held, the meeting proposed that in 2022, in the three major areas of chemical drugs, biological drugs, proprietary Chinese medicines to carry out all-round drug collection, the formation of national, inter-provincial alliance, provincial collection and multi-level coordinated promotion of the pattern. In terms of drugs, on the basis of the national organization of drug collection, the number of provincial-level collection varieties carried out in each province should reach more than 100. In terms of medical consumables, on the basis of continuing to promote the collection of high-value medical consumables organized by the state, the provincial collection varieties carried out in each province should reach more than 7, focusing on covering the main high-value medical consumables in the two major fields of cardiovascular and orthopedics, of which drug balloons and orthopedic trauma consumables should be fully covered by the provinces where they are collected. Guide and support the sichuan-led inter-provincial alliance of oral implants, and provinces that do not participate in the alliance must also carry out collection and collection independently.
Drug negotiations will be carried out with the progress of new drug research and development and listing in the mainland, in addition to reducing the burden on patients, but also coordinating to promote the innovation and transformation of the pharmaceutical industry.
■ An optimization: accelerate the reform of landing payment methods
The reform of payment methods is not only a way to finely manage medical insurance, but also a means to improve the quality of medical care and avoid excessive medical treatment, so as to benefit patients.
The "14th Five-Year Plan" for National Medical Security points out that the multi-compound medical insurance payment method based on disease type payment is widely implemented nationwide, and the reform of the regional medical insurance fund total budget point method is promoted, and medical institutions are guided to rational diagnosis and treatment, and the efficiency of the use of medical insurance funds is improved. In terms of specific indicators, in 2025, drg payment and hospitalization costs paid by disease type should account for 70% of all hospitalization costs.
In fact, in the past few years, the National Health Insurance Bureau has led the exploration of payment method reform. However, due to the complexity of the reform content and the large number of stakeholders involved, the progress of the reform needs to be further advanced.
In 2021, the National Medical Insurance Bureau issued the Notice on Printing and Distributing the Three-Year Action Plan for the Reform of DRG/DIP Payment Methods, promoting the reform of DRG/DIP payment methods to achieve development from partial to comprehensive, from partial to total, from extensive to refined. More detailed arrangements have been made for the progress of reform from 2022 to 2024, reflecting greater determination to reform.
Therefore, the next three years will be the three years of rapid implementation of payment method reform, and medical institutions will be most directly affected.
■ Improve the ability to guarantee and reduce the proportion of personal expenditure
The above points free up space through "one increase, one subtraction and one optimization", so that the medical insurance fund can provide more comprehensive and in-depth protection for the insured, and then achieve the goal of reducing the proportion of personal health expenses.
At present, outpatient protection and direct settlement of cross-provincial medical treatment have achieved certain results in reducing the burden of medical treatment for patients, but due to the large differences in the landing situation of various provinces and cities, the two will continue to expand in terms of coverage area, coverage of medical institutions, coverage of diseases, etc., to benefit more insured persons. In accordance with the requirements of the "14th Five-Year Plan" for National Medical Security, steadily improve outpatient treatment, do a good job in the overall connection between outpatient treatment and inpatient treatment, and gradually realize the online and offline integration of inpatient and outpatient expenses in different places for medical settlement services.
It is worth mentioning that with the acceleration of the aging process, long-term care insurance will become one of the important tasks of medical insurance. In the past few years, long-term care insurance has been piloted in some areas, and the National Medical Insurance Bureau and the State Civil Affairs Bureau have also formulated the "Assessment Standards for Long-term Care Disability Levels (Trial)", and a long-term care insurance system will be steadily established during the "14th Five-Year Plan" period.
In the previous pilot, the financing channel of long-term care insurance is similar to that of employee medical insurance, which is jointly borne by the employer and the individual, and during the pilot period, in order not to increase the burden on the employer, the unit payment part is transferred directly from the medical insurance fund paid by the unit, and there is no need to increase the payment standard; the individual responsibility part can be withheld and paid from the personal account of the employee's medical insurance. That is to say, the financing during the pilot period is essentially drawn from the existing medical insurance fund, which will not be a long-term solution in the case that the medical insurance fund is not "generous" in the first place. Therefore, in the process of piloting and implementing long-term care insurance, diversified financing channels will be established to achieve greater coverage.
In accordance with the requirements of the "14th Five-Year Plan" for National Medical Security, we will explore the establishment of a multi-channel financing mechanism of mutual assistance and responsibility sharing, and the financing of employees participating in long-term care insurance will be mainly based on unit and individual payment, and a dynamic adjustment mechanism for financing that is compatible with economic and social development and security levels will be formed. Introduce social forces to participate in long-term care insurance handling services. Encourage commercial insurance institutions to develop commercial long-term care insurance products.
In the nearly 4 years since the establishment of the National Medical Insurance Bureau, 124 policy documents have been formulated and gradually landed, and the main objects affected by each document are different, including insured persons, hospitals, doctors, pharmaceutical equipment enterprises, and information enterprises that provide technical support, but on the whole, the internal logic between policies is very clear, that is, as mentioned above, through the implementation of "one increase, one subtraction and one optimization" to achieve better protection. In addition, the 14th Five-Year Plan and the Outline of the 2035 Long-Term Plan propose that basic public services should be equalized. Basic health care is also a basic public service content, and the word "equalization" means to cover it in a more even way, even if the number of rare disease patients is relatively small. It is foreseeable that when medical insurance achieves the goal of reducing the proportion of personal health expenditure, "equalization" will also become an important principle in the direction of reform.