Personal account money is less than half, medical insurance reform is blocked, experts: vested interests are difficult to touch again

Text / Xin Ying

Ed. / Wang Xiao

Photo/Visual China

Now that the money put into the medical insurance personal account every month has become less, is it a loss? This is the doubt that everyone has had since the release of the medical insurance personal account reform plan in 2020.

The most touching thing about this adjustment with the theme of "outpatient mutual assistance" is that 30% of the unit's medical insurance contributions are no longer included in the personal accounts of active employees. This led to a "shrinkage" of cash in the personal account, and this money was fully credited to the Medicare pooling fund.

After some operation, how much has the personal account shrunk? The Wuhan Municipal Medical Insurance Bureau took a 68-year-old cerebral infarction patient as an example, whose annual pension income after retirement was 50,000 yuan, after the medical insurance personal account was transferred to 2,400 yuan per year, and after the reform, it was reduced by 1,404 yuan, which was transferred to the outpatient coordination account.

It is equivalent to 350 million employees in the country who have taken out a little money and put it in an account, and whoever is sick in this account will use it. For those who really need to see a doctor, the risk of "poverty due to illness" is reduced.

However, in its third year, the focus on changes to Medicare personal accounts reached a climax, with the expected resistance "coming as promised." Recently, medical insurance departments in Wuhan, Sichuan, Heilongjiang, Xi'an and other places have spoken out intensively to explain the pros and cons brought by the reform.

On February 9, 2023, the Wuhan Municipal Medical Insurance Bureau issued a document in response to questions from all parties, saying that from the current period, the personal account transfer of most insured employees will decrease; In the long run, all insured employees have increased the general outpatient treatment that was not available before, especially the sick and the elderly have benefited more.

"Finance and Health" learned that in order to not affect patients' drug purchase habits and other issues as much as possible, the National Medical Insurance Administration is studying and promoting the implementation of corresponding supporting measures, and specific policies still need to be adjusted according to local conditions.

Any reform is a redistribution of benefits, and the risks it needs to face are also a test for policy implementers. An industry insider deeply involved in the reform lamented before the release of the consultation draft, "There is no turning back after taking this step." ”

Under "Freemasonry", who benefits?

This reform touches the interests of every employee and is equivalent to taking "personal money" to pay for unknown health risks in advance.

Taking Wuhan as an example, the problem to be solved through the reform of personal accounts is that more than 60% of the city's personal account funds are lying in the accounts of young and healthy people; On the other hand, the personal account balances of retired and sick people are not enough to use, and outpatient individuals have a heavy burden of outpatient out-of-pocket expenses.

Therefore, "Freemasonry" is proposed. In order to make this concept more acceptable to individuals, some regions adopt a "easy first, then difficult" model, opening outpatient reimbursement first, and then adjusting personal accounts.

In Wuhan, like many regions, most of them have just started implementing outpatient reimbursement in early 2023. In the above response, the Wuhan Medical Insurance Bureau clearly stated that the reform of personal accounts will benefit the sick and the elderly more.

The above-mentioned Wuhan cerebral infarction patient spent 7,150 yuan on outpatient visits in a local tertiary hospital. Before the reform, this money had to be completely self-expense. If reimbursed according to the existing outpatient coordination policy, minus the threshold fee of 500 yuan, according to the 60% reimbursement ratio of the tertiary hospital, he can reimburse 3990 yuan this time, and he only took out the annual income of 1404 yuan and put it into the co-ordinated outpatient account.

However, not everyone will become a beneficiary of this medical insurance reform, and due to the different conditions of medical insurance funds in different places, the outpatient coordination treatment is different, and the "profit and loss" is their own account.

Hua Ke (pseudonym), a 59-year-old hypertensive patient in Heilongjiang Province, noticed that he had recently spent more money on medicine. "I usually don't go to the hospital, I mainly go to the pharmacy," he took in the hospital for more than 7 yuan a box, less than 30 yuan a month, and nearly 360 yuan a year. The local hospital opened medical insurance outpatient coordination on January 1, 2023, and the minimum payment line was 400 yuan, which means that he could not enjoy medical insurance reimbursement when he went to the hospital to prescribe medicine.

In fact, in order to keep patients with chronic diseases in community hospitals. According to the Heilongjiang outpatient coordination standard, the annual minimum payment line for employees is 400 yuan, the annual limit is 3,000 yuan, and the reimbursement ratio in tertiary hospitals, secondary hospitals and community hospitals is increasing, which is 50%, 60% and 70% respectively.

However, the community hospital at his doorstep has never had this cheap antihypertensive drug commonly used by Huake, he can only take a bus to a third-class hospital 3 kilometers away, the round-trip fee is 4 yuan, plus the outpatient registration fee of 7 yuan, "Calculate that it may be a loss, simply buy it at the pharmacy at the door, 14 yuan a box." Hua Ke said.

Communicate with the surrounding family and friends, many elderly people have this confusion, the money into their account is less, the money saved in the hospital has nothing to do with themselves?

Not long ago, because he suddenly felt some discomfort in his heart, Hua Ke rushed to the cardiology department of the best local third-class hospital, "did a color ultrasound, checked dozens of blood items, spent more than 300 yuan himself, and reimbursed 140 yuan." He felt, "This time it really benefited." ”

The significance of the social insurance system is to share the risk and try not to let a person be completely crushed when a serious illness comes.

This is the same as the well-established inpatient co-ordination. According to data from the National Health Insurance Administration, in 2021, the hospitalization rate of employee medical insurance participants was 17.7%. The remaining 82.3% can be said to be contributors, and then, who can guarantee that they will not one day become a member of this 17.7%, need to alleviate the financial pressure caused by the disease.

Such a risk-sharing mechanism, which was previously hospitalized, is now established in an outpatient clinic.

Personal accounts are fading

Why do I have to use the money in my personal health insurance account?

In fact, as early as the stage of soliciting opinions on the reform, some people in the pharmacy industry publicly suggested that the funds for the establishment of outpatient pooling should be allocated from the original pooled fund, rather than individual accounts.

Indeed, there are areas that used the money from the pooled account when establishing outpatient mutual aid in the early years, and a medical reform expert introduced that on the one hand, the local pooling fund is relatively strong and has this ability; On the other hand, they really dare not touch the deep waters of this reform.

Since the establishment of China's employee medical insurance system in 1998, it consists of pooled accounts and individual accounts, and the money comes from individual contributions and unit contributions. The money in the personal account can be used for out-of-pocket expenses incurred within the policy of designated hospitals and pharmacies. The funds in the pooled account are used to pay for hospitalization expenses, which are settled by medical insurance and hospitals and pharmacies.

Personal accounts, borrowed from Singapore's Central Provident Fund system. The difference is that China has long implemented publicly-funded medical care under the responsibility of the unit, which means that it does not cost employees to see a doctor. After the medical insurance is coordinated, not only do you have to pay the premium, but also only part of the reimbursement for medical treatment, and you have to pay again.

At that time, a problem similar to this personal account reform was encountered, because the benefits of paying "premiums" were not immediately visible to everyone, so the low willingness to participate in insurance became the biggest problem at that time.

So, as a "transitional" policy, individual accounts that incentivize public participation were born. Wang Zongfan, director of the medical security research office of the Chinese Academy of Labor and Social Security, said that first of all, let the premiums paid by employees be visible, and the money in their own accounts must be spent carefully, so as to avoid "running to the hospital if you have nothing to do" and restrict the excessive release of medical demand.

The second is the accumulation role, the personal account implements the accumulation system, the funds are used by individuals, and the money is saved when you are young, and you will not have no money to see a doctor when you are old.

However, these missions have faded away. Today, when medical insurance coverage reaches 95%, there is no longer a need for insurance incentives. The biggest dilemma faced by today's patients is that some patients have a heavy burden of outpatient visits, while a large amount of money sleeps in "personal accounts", which reduces the risk co-financing ability of insurance itself.

More than 60% of the funds deposited in Wuhan's personal accounts lie in the accounts of young and healthy people. According to the above-mentioned medical reform personnel, in some areas, the funds in the personal account have exceeded the pooled account.

"Internationally, few countries can rely on the personal account model to solve the problem of medical security. Singapore's system has its advantages, but for a large country of 1.4 billion people, it is difficult to directly apply a city-state's health care system. Wang Zongfan said.

The United States has a similar system, the Health Savings Account (HSA). Individuals do not pay taxes on putting money into a health savings account, and the money in the account can be used for medical expenses permitted by insurance, such as medicine, dental, ophthalmology, etc. Funds in a health account can be accumulated, but if a member wants to withdraw the money, they will need to pay taxes.

According to industry analysts, HSA is a combination of commercial insurance with high deductibles. According to a 2019 data report on HSAs published by platform Lively, 93% of HSA funds are used to pay for daily medical expenses.

At least according to policymakers' thinking, China's personal account reform is only to make a sum of money that should have borne the burden of public health care play its due role.

"In fact, from the beginning of the design of the system, we knew that there was no way for personal accounts to resolve the risk of universal medical care, but we may not have expected that this reform would be delayed until more than 20 years later." Wang Zongfan said.

Why did the "outpatient mutual assistance" reform begin?

Why did it take more than 20 years to start promoting personal account reform now?

"The biggest difficulty is that the personal account that already exists, which is a vested interest for everyone, is difficult to touch again." Wang Zongfan introduced that when they are really sick and spend money, everyone hopes to have a higher level of protection, and when they are not sick, they do not want to give the money in their personal accounts to others. That's the constraint.

Unlike the public suddenly discovering that there is less money in personal accounts, this reform has been slowly pushing.

As early as 2010, the revision of the Social Insurance Law mentioned that "basic endowment insurance implements a combination of social pooling and individual accounts", while in basic medical insurance, there is no mention of medical insurance personal accounts. The move is seen as a sign of reform of employees' health insurance personal accounts.

Subsequently, local governments successively tested the water reform. In April 2012, Qingdao Municipal Employee Medical Insurance Urban Employee Medical Insurance was fine-tuned, the proportion of funds transferred to personal accounts decreased by 0.3-0.5 percentage points, while the ceiling of outpatient medical expenses was raised to 1,600 yuan, and the reimbursement ratio increased by another 10 percentage points.

Some regions have changed the original fixed ratio to a fixed amount, for example, retirees are credited with 100 yuan per month. At the same time, local pooling funds began to try to cover outpatient medical needs, and successively reimbursed outpatient serious diseases and outpatient chronic diseases.

In order to fundamentally reduce the burden of outpatient medical treatment in terms of system, it is necessary to comprehensively establish an outpatient pooling fund and start it. After years of careful promotion, after the establishment of the National Health Insurance Administration in 2018, the "fast forward button" was pressed.

After the 2020 medical insurance personal account reform plan was released, a local medical insurance system official told Caijing Health that the local medical insurance pooling foundation increased by about 20%.

In the end, there was no step in canceling personal accounts, because it was hoped that the public would enjoy the benefits and reduce the resistance to progress.

At this time, the progress of medical insurance fund supervision technology also solved some problems exposed in the previous local pilot, and the outpatient pooling fund was abused, resulting in the loss of the pooled fund.

"Due to the high frequency of medical treatment, the medical insurance control of outpatient services is a problem in the world, and technical improvement is a guarantee, but how to manage outpatient coordination in the follow-up is also a test of the medical insurance ability of various places." Wang Zongfan said.