It was China's largest health care reform in 24 years, and almost the most cautious.
It is a huge amount, involving 1.1 trillion yuan in the personal accounts of 350 million working employees.
It has a huge impact, and the outpatient coordination mechanism brought about by the reform of medical insurance personal accounts is an important step in ending the treatment of small diseases, saving hospitalization funds, and establishing a sound hierarchical diagnosis and treatment system, and it is also the only way for China's medical reform.
Behind it, the gap in understanding between professionals and the general public is almost the greatest.
A year ago, when the "Guiding Opinions on Establishing and Improving the Outpatient Mutual Assistance Guarantee Mechanism for Basic Medical Insurance for Employees" was issued, and faced with the document that the part of the unit that accounted for about half of the payment of the medical insurance individual account would be transferred to the overall account, public opinion asked: Is it "My money has been taken away by the state?" And the professional told Eight Point Kenwen: "At that time, the advice we put forward was to cancel all (individual accounts), what to do with this half?" ”
By April this year, the document had been issued for more than a year, and according to the statistics of Eight Points, by the time ningxia released the plan on April 26, all 31 provincial-level administrative regions in the mainland had issued local plans, and more than 100 prefectures and cities had also issued local plans, and the number continued to rise.
In the plans of more than 100 prefectures and cities released successively, Eight Point Jianwen found that although some regions can be directly adjusted, and some need to be adjusted in two steps, the proportion of personal accounts of employees in various places is basically consistent with the national plan, and its large difference is reflected in the level of outpatient security treatment.
Where the reform foundation is relatively weak, the proportion of overall payment is 50% (for active employees) and 60% (for retired employees), which is only slightly higher than the national standard; some places that have experience in reform, such as Shanghai, can directly link the reimbursement ratio with graded diagnosis and treatment, and the proportion of payment from tertiary to first-level medical institutions has reached 70% to 90%.
This is a difficult but must be completed reform, more than a decade of discussion gathered in this plan, all people are trying to find an optimal path: do you want to do one step, abolish the employee health insurance account? How to deal with the public opinion backlash that everyone thinks is "money in their own pockets"? How much should I keep if I want to? What is the ultimate mission of the individual account reform?
In 2021, a more moderate plan wins, leaving nearly half of the allocation ratio of the individual accounts of employees, all paid by individuals, calculated at the standard of 2% of wages; retirees are included in the pooled fund according to a fixed amount, which is included in the standard of 2% of the average basic pension for the year; equity replacement, reform and outpatient mutual assistance guarantee are carried out at the same time.
This time, the state stepped in to take up the baton and give support and confidence to local reforms. "When the document was issued last year, we were all very excited, and the country finally 'brightened its sword'." Ma Qing, director of the Qingdao Medical Insurance Center, said.
However, the more difficult question may lie ahead: how can the reform be carried out in such a large way, step by step? How can this half-mountain be better moved to the designated "outpatient protection" office without causing an imbalance in the pool of pooled funds? Half of the Mountain of Accounts has been removed, what about the rest?
The cautious and gentle compromise was met with the fiercest opposition
If it were not for the media interpretation, perhaps no ordinary person would have noticed what the 2020 draft of "establishing and improving the outpatient mutual assistance guarantee mechanism" means.
The "Draft for Comments", which was only open for comments for 10 days, it was mentioned that in the future, about half of the funds belonging to individuals in individual accounts will be converted to pooled accounts for sharing, and the overall treatment of outpatient clinics will be improved.
It was the most daring and cautious attempt by the National Health Insurance Bureau to this sleeping personal account fund in the past 20 years, but the reaction it provoked on social media was still unexpected.
Is the reform of the medical insurance account "my money taken away by the state"? Such problems arose frequently in the media of the time. In an endless stream, there are also: medical insurance account reform, "who moved your cheese", "who moved whose cheese"...
In a certain sense, the huge backlash from the public opinion field provoked by the draft for comments has also triggered more people to think about the big situation faced by the medical insurance fund involving more than 300 million people - on the one hand, with the continuous improvement of the level of hospitalization and reimbursement for serious diseases, the pressure on the overall fund expenditure is increasing; on the other hand, with the emergence of outpatient co-ordination, more and more medical insurance individual account funds can only sleep in their respective accounts, becoming an embarrassment that every medical insurance researcher knows its existence, but no one has a way to use it." Dead Money".
According to the China Labor Statistics Yearbook, the cumulative balance of the personal account of employee medical doctors increased from 114.2 billion yuan to 615.2 billion yuan from 114.2 billion yuan from 2008 to 2017, with an average growth rate of 20.57%, which was greater than the growth rate of the cumulative balance of the pooled fund (18.15%). By 2021, nearly 40% of the 2.9 trillion yuan of the accumulated balance of the medical insurance fund will come from personal accounts.
Another fact is that before the reform, the medical insurance account fund in many places was "upside down", and the total amount was even more than the pooled fund, such as Qingdao once reached 53%, Zhenjiang was close to 60%, and the medical insurance pooling fund was stretched, which also forced the local government to carry out relevant reforms.
However, as with all reforms, such reforms, at least for certain groups of people, appear to be detrimental. Wang Zhen, a researcher at the Institute of Economics of the Chinese Academy of Social Sciences, explained to Eight Point Jianwen that although from the perspective of security, no one suffers losses, "people who are not very sick, do not go to outpatient clinics, and young people who have a lot of money in their personal accounts will still feel that their money has been taken away and are not satisfied." ”
"Ordinary people say why are you moving the money in my personal account?" My personal account is money in my own pocket. Ma Qing recalled the voice of the people after Qingdao had lowered the proportion of accounts several times.
Looking back at the controversy at that time, many health insurance experts mentioned to us that all the problems stem from people's long-term misunderstanding that health insurance accounts are a "welfare".
In fact, the Medicare personal account is not a "personal welfare" and has a special historical mission.
In 1998, China's medical insurance was comprehensively reformed, and the paid medical insurance system came to power. The combination of social co-ordination and personal accounts, the "private" attribute of personal accounts that are only used by individuals, can better allow people to accept "paid medical insurance". After the purpose of universal insurance has been achieved, this historical mission of the individual account has been completed, but it cannot die out on its own, but it needs to spend more effort to gradually change it and strengthen its mutual assistance as a public fund.
If at the beginning of its establishment, the personal account was the lubricant for the landmark comprehensive reform of China's medical insurance, then later, this lubricant was superimposed and rigid, almost becoming the biggest "mountain" that hindered the healthy operation and development of the medical insurance system.
In 2018, the National Medical Insurance Bureau was established. In 2019, the National Medical Insurance Bureau directly proposed to "cancel the individual (family) accounts in urban and rural residents' medical insurance by the end of 2020 and make a smooth transition to outpatient co-ordination", which encountered boiling public opinion. Therefore, in the face of another employee medical insurance account that involves a wider range of areas and more funds, the relevant departments have been much more cautious.
However, no matter how carefully expressed, in the face of personal accounting problems, the gap between professionals and the general public is still huge. Recalling the introduction of the "draft for comments" in 2020 that almost triggered a storm of public opinion, a medical insurance expert bluntly said to Eight Point Jianwen that he could not understand, he said: "At that time, our opinion was to cancel all (personal accounts), what to do with this half? Isn't there an outpatient coordinator, what else do you want it to do? I can't take it out and use it, and I can't manage it when I'm really sick. ”
In April 2020, Hua Ying, an assistant researcher at the Institute of Population and Labor Economics of the Chinese Academy of Social Sciences, published a paper that also laid out the main debates about the reform. "There are two options to choose from. The first option is to advance in two steps: the first step is to stop the transfer of funds from the unit contribution to the personal accounts of the insured employees, and the second step is to record all the individual contributions into the pooled fund. Hua Ying wrote, "The second plan is to cancel the personal account in one step." ”
Under the consensus of "returning to the essence of public health insurance", in the end, the more moderate plan won. Judging from the proportion of allocations, this is precisely a "compromise" plan: first draw half, keep half, and then carry out reform in the future. There is also an attached "insurance network" added to the individual account reform: the reform of outpatient mutual assistance security is carried out simultaneously, and after the adjustment of the personal account structure is clearly adjusted, "the increased pooled fund is mainly used for outpatient mutual assistance and improves the outpatient treatment of insured persons".
In the view of experts such as Hua Ying, such a means of equity replacement is to "maximize public understanding, so as to avoid the social risks that may be caused by the cancellation of personal accounts" to the greatest extent.
However, judging from the huge public opinion reaction after the release of the opinion draft, the choice of the plan may be correct. Although it was "packaged" on paper under the plan for the reform of outpatient mutual assistance and security, as a supporting reform measure for the former, after the release of the plan, the regulations of the individual account reform were still "carried" separately, and young netizens talked a lot.
In order to cope with this kind of public opinion, Ma Qing mentioned that the former Qingdao Municipal Social Security Bureau has done a lot of public opinion response work, issued press releases explaining the purpose of reform and benefiting the insured, and using some vivid "words": turning dead money into living money, turning small money into big money, and promoting traditional Chinese culture of helping each other in the same boat.
At the national level, a series of public opinion response methods have also been used, and within a few days of the release of the draft for comments, the mainstream media took turns to carry out positive policy interpretations.
In April 2021, when the reform plan was officially released, it was titled "Your Health Insurance Card Can Be Used by Your Family!" Press releases are popping up. However, although in the past decade or so, many cities have adopted the method of family members to use individual accounts, the effect has been very limited.
On the other hand, a particularly troublesome fact is that the weakening of individual accounts needs to be combined with the strengthening of outpatient co-ordination, so that individuals feel that their interests have not been damaged. However, in many cities, especially those where the pooled fund is still facing the risk of deficit, the place where the individual account reform should be most needed has lost the grip to reduce the proportion of individual account allocation because of the inability to carry out outpatient coordination. All of this urgently needs a top-down reform.
For the newly established medical insurance institutions in the country, changing people's inherent perception of medical insurance personal accounts and removing the interest pattern that has been formed for many years is a battle that must be fought, with the purpose of sweeping the depression step by step into the "garbage heap of history". Along with the controversy, the gears of reform are still moving firmly and slowly, rolling towards the mountain of health insurance. Although there is still pressure on policy interpretation in practice, with the endorsement of national opinions, the reform of local accounts is more legitimate.
After breaking the mountain stone, how to "establish" the outpatient co-ordination?
If changing the structure of the accounts is only the first step, it is enough to change it gradually according to the established proportions of the country programme. After determining the proportion of "moving mountains", the more difficult step is, how to move the "mountains" in the direction to go? How will the local government independently establish an outpatient mutual assistance guarantee mechanism and smoothly complete the replacement of rights and interests?
With the maturity of local pilots, the transfer of individual account funds to establish outpatient pooled funds has gradually become the mainstream of this reform, and is eventually reflected in the national program.
There are rules to follow in such a design. In the past, under the plate payment method, the individual account substantially shared the outpatient medical expenses of some insured patients. However, so far, the average annual balance of each person in the mainland is only about 100 yuan, and the lack of individual account co-ordination has led to the infirm and sick people not being able to get enough protection in outpatient clinics, resulting in minor illnesses and major treatments, and the malformed medical behavior of choosing hospitalization for reimbursement has increased year after year.
Moreover, in the context of aging, medical level and the development of day surgery, the role of outpatient clinics has become increasingly prominent.
In 2018, there were more than 300 million patients with chronic diseases in the mainland, the mortality rate of chronic diseases accounted for more than 80%, and medical expenses accounted for more than 70%, and it will exceed 4 trillion yuan in 2020. If the outpatient burden is not reduced and the medical behavior does not change, with the mainland entering an aging society, the burden of disease will become heavier and heavier, and the pressure on the pooled fund will become more and more intense. In other words, because the past individual accounts did not meet the needs of outpatient medical treatment well, it is now hoped that it will be done through the reform of outpatient mutual assistance security, and the source of funds is the change in the proportion of individual accounts.
In a calculation made by Wang Zhen and Zhu Fengmei of the Institute of Economics of the Chinese Academy of Social Sciences, in a variety of scenarios, after some individual accounts and part of the pooled fund jointly paid for the outpatient freemasonry account, the decrease in the expenditure of the inpatient pooled fund due to the decline in hospitalization rate was enough to make up for the increase in the expenditure of the outpatient freemasonry fund due to the increase in the number of visits per capita. In addition, the excess savings in the inpatient pooled fund expenditure can increase the proportion of outpatient treatment protection by 3-13 percentage points (referring to Beijing) and 9-13 percentage points (referring to the international average) on the basis of 40%. In the end, no matter which scene it is, under such a reform, the medical experience of the masses has been well improved.
However, completing these changes is not an easy task. Compared with the simple change of the proportion of individual accounts, the establishment of an outpatient coordination mechanism is more like a project, with a huge volume and complex steps, and often requires multi-faceted reforms to be carried out at the same time and cooperate with each other.
The first problem is how to control the cost of outpatient treatment, compared with hospitalization, the frequency of outpatient visits is higher, the supervision is very difficult, and it constitutes a great test for local information construction. "When people do the hospitalization payment system, they think that informatization is very important, and I frankly say that when it comes to outpatient clinics, the difficulty is not an order of magnitude." Lin Feng, one of the main participants in the "Liangjiang Medical Reform" and a medical insurance researcher, said that Zhenjiang has been exploring outpatient protection for more than 20 years, and even today, informatization is still a big challenge for Zhenjiang.
Informatization is a technical means of supervision. To control fees from the mechanism, the reform of payment methods is very critical and cannot be avoided. This point has also been written into the national plan, as one of the most important supporting measures for the overall reform of outpatient clinics: primary medical services should be paid mainly per head, not by disease; at the same time, the DRG/DIP payment mechanism should be implemented for special diseases such as day surgery; some costs should also be paid by project - the next 3 payment methods are parallel, and the complexity of the reform can be imagined. The advent of the era of outpatient co-ordination has forced the grassroots to accelerate the reform of payment methods.
Third, one of the biggest purposes of establishing outpatient co-ordination is to guide graded diagnosis and treatment and strengthen the management of chronic diseases, but this is not a measure to improve outpatient treatment alone. How to improve the contracted services of family doctors, standardize long-term prescription management, promote the construction of the primary medical service system, and guide the masses to seek medical treatment at the grass-roots level also determine the final effectiveness of the outpatient overall reform.
In this sense, the reform of individual accounts not only changes the transfer of funds, but also relates to the overall thinking of the entire Chinese medical reform.
Lin Feng feels that the individual account reform should not be an action of "headache and pain", it should be regarded as an opportunity for linkage reform, and overall design is crucial, "these can make this reform go more smoothly, and all aspects can also benefit more from the reform."
However, the basis for the establishment of outpatient co-ordination varies from place to place, and therefore, the national plan only stipulates that the proportion of payment starts from 50%, leaving enough room for reform at the local level, and the minimum payment standard, the maximum payment limit, and the scope of diseases are all determined by the local government. "It is also understandable that in some places, the overall funding was originally very tight, and now it is necessary to do outpatient co-ordination from scratch, so it can only start from a low level." Zhu Minglai, director of the Research Center for Health Economics and Medical Security at Nankai University, said.
Therefore, in areas where pooled funds are relatively tight, there is no ability to improve the overall treatment of outpatient clinics, and there is great pressure to carry out individual account reform. For the experienced outpatient co-ordination reform pilot zone, deepening reform is not an easy task.
"Raise the treatment, put the fixed point, expand the catalog." Ma Qing summed up Qingdao's next plan for outpatient mutual assistance and overall reform. Among them, "letting go of fixed points" refers to expanding the scope of fixed point outpatient contracts, which may not be limited to the grass-roots level of the community, so that ordinary people can also be reimbursed for visiting outpatient clinics in large hospitals. However, this may conflict with the hierarchical diagnosis and treatment and grass-roots first diagnosis system strictly implemented in Qingdao in the past decade. Ma Qing said that the two should be comprehensively balanced, and at present, the specific plan for Qingdao is still under discussion.
In the past decade, Zhenjiang, Beijing, Chengdu, Zhuhai and other cities have directly lowered the proportion of individual accounts. The effect of this reform method is directly visible, but it will also directly face a large public opinion voice, which requires policymakers to have the wisdom and self-confidence to think holistically and implement reasonable supporting means. There are also cities that eventually give up because of excessive opposition.
According to the eight-point jianwen, some of the details of the urban reform plan that have pioneered the exploration of outpatient co-ordination have not yet been introduced, on the one hand, because these local reforms have little momentum; on the other hand, outpatient co-ordination and graded diagnosis and treatment often go hand in hand, and to further improve treatment, the original hierarchical diagnosis and treatment structure may also need to be adjusted.
Many experts said that if the outpatient coordination mechanism cannot be reasonably established, the extra money after the individual account reform will also become a hot potato, destroying the balance of income and expenditure of the pooled fund, exposing the problem of excessive financing or low treatment.
How does the remaining half of the mountain move?
The blueprint of outpatient co-ordination has been drawn, and at the other end, how to continue to use the remaining 400 billion yuan of account funds remains to be solved. After the big discussion before the introduction of the national plan, some medical reform experts believe that the cancellation of the personal account may not be put on the agenda again after 10 years, "I should not be able to see it before I retire."
This means that how to use this huge amount of money is likely to remain an important issue in the next 10 years.
Previously, in order not to deposit individual accounts into a pool of stagnant water, remain immovable and depreciate, many places learned from each other and advocated "making use of" individual accounts and expanding their scope of use, which can be used for family members to help each other, health examinations, vaccinations, etc.
However, these "consumption items" are not just needed, most of them are still voluntary, and are used by individuals on their own choice, reflecting the "privateness" of individual accounts. With the deep-seated "money in my personal account is my own money" and the tendency to save heavily, the use of it is limited. Only a few cities such as Zhenjiang, Qingdao, and Shenzhen have adopted the principle of "consent without objection" to automatically deduct from the personal accounts of employees to purchase supplementary medical insurance such as long-term care insurance, which strongly reflects the mutual assistance of individual accounts.
This has changed in recent years. With the efforts of local governments to make full use of them, individual accounts have even quietly changed the development ecology of some industries. For example, in recent years, the rapid development of the city benefits the people' insurance. Xu Erpeng, general manager of the Yuanxin Huibao City Insurance Business Center, told Eight Point Jianwen that Zhejiang Province, the "insured highland" of Huimin Insurance, is a place where the accounts are more "open". The successive implementation of relevant medical insurance policies has promoted the popularization of Huimin Insurance, including measures such as the fact that the insured can pay with a single account, coupled with the blessing of the family mutual assistance policy, the users in Zhejiang who use the individual account payment method account for a considerable part.
At present, at least more than 70 cities have allowed the purchase of Huimin Bao with individual accounts. Among them, in 2022, the total number of insured persons in the "Chongqing Yu Quick Insurance" project participated in by Yuanxin Huibao reached 4.59 million, of which the payment of medical insurance accounts accounted for nearly 44%, which "brought a qualitative impact".
Another innovative case is Ningbo Dental Implant, which in August last year solicited opinions on using a personal account to pay for dental implants, reducing the cost of dental implants of tens of thousands of yuan to 3,000 yuan to 3,500 yuan as a whole, and launched a pilot project at the beginning of this year. Dental implants are a medical project that is widely demanded in the mainland in recent years, with millions of implants per year, and the Ningbo plan is tantamount to including dental implants into the system of medical insurance control fees and supervision, forcing the supplier to reduce the price.
The national plan points out that the personal account is mainly used for out-of-pocket expenses in designated medical institutions or pharmacies, and can be used for family members to help each other, and cannot be used for public health expenses, physical fitness or health care consumption, but the specific items are not clear. Therefore, on the basis of the national plan, some innovations in the use of individual accounts are also reflected in the local plans.
For example, Guangdong supports the use of individual accounts to pay for the "treatment of diseases" of traditional Chinese medicine; Hunan and other places support the use of individual accounts to participate in long-term care insurance and large medical expense subsidies; Beijing and Yunnan also support the use of individual accounts to purchase urban commercial health insurance, which has given the industry a shot in the arm.
However, whether dental implants, which are generally considered to be consumer medical items, fall within the "scope of basic medical insurance coverage" in the latest personal account expenditure regulations, still cause some debate. The Huimin insurance industry also encountered similar problems, and relevant people noted that the national plan for the reform of personal accounts did not directly mention whether individual accounts could be used for Huimin Insurance in the future, and the future payment method of individual accounts in the Huimin Insurance industry is doubtful.
There is still a lot of room for imagination as to how personal accounts can be used better. However, some local medical personnel said that if the national policy is tightened in the future, they may consider stopping the use of individual account payments for exploration in certain fields.
In general, there are still many unknowns of where the stock of individual accounts will go in the future, including whether it will be completely cancelled as called for by experts - under the strong tone of weakening and canceling individual accounts, there is also a view that has not become mainstream, which believes that it is the right way to "return the part of the unit payment to the overall plan" in the current situation of tight pooling funds;
In the future, perhaps the mountain of individual accounts will be rebuilt, but not as an obstacle to the development of the medical insurance system, but like Singapore, the country where we first established the individual account system to learn, we levy more part of the individual account fund from individuals, and form a good division of labor with the pool fund, in addition to basic medical insurance, responsible for a richer level of medical security.
"Yugong moving mountains" is not exhausted, and "Yugong building mountains" is waiting to be launched.
Wei Xiaoning | wrote
Li Shanshan | responsible editor
This article was first published on the WeChat public account "Eight Points Health" (ID: HealthInsight)
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