Health Times reporter Tan Qixin
"Where did the little money in your personal account go?" "The money in the individual medical insurance account is getting smaller and smaller, is the national medical insurance fund pool running out of money?" Recently, Jiangsu, Heilongjiang, Jiangxi and other places have successively launched the reform of employees' medical insurance personal accounts, which has caused heated discussions.
Hospital medical insurance business handling window. Xinhua News Agency photo
How much money in a personal account "shrinks"?
The Health Times reporter found that at present, all provinces in the country have issued documents on the implementation rules for the reform of employees' medical insurance personal accounts, but the requirements for personal account reduction are different, and the "shrinkage" is not completely consistent.
For the personal accounts of active employees, the general direction is basically the same in all provinces, and all (8%) of the basic medical insurance premiums paid by the employer are included in the pooled fund, that is, 3.8% of the 8% paid by the unit is also included in the pooled account, while 2% of the employee's individual contribution is still credited to the individual account.
For the transfer method of retirees' personal accounts, some provinces transfer them proportionally, ranging from 2% to 3% of the average level of basic pensions in the province and cities to their personal accounts every month, and some places, such as Guangxi, Hunan, Anhui, etc., adopt fixed amounts after calculation according to local data, and stipulate that each person will be allocated about 70 yuan to 120 yuan per month.
Previously, retirees' personal accounts were allocated to about 5% of their personal pensions.
Where does the little money in your personal account go?
"The core keyword of this reform is 'rights replacement', that is, about half of the funds originally transferred to the medical insurance personal account are put into a large pooled fund pool to jointly improve the level of outpatient protection." Professor Zhang Xiao, director of the Medical Insurance and Social Security Research Center of Southeast University and vice president of the Jiangsu Medical Insurance Research Association, told reporters that after the reform, the increased pooled fund is mainly used to establish and improve outpatient mutual aid protection, and gradually realize the unification of outpatient inpatient treatment.
According to the "Guiding Opinions on Establishing and Improving the Outpatient Mutual Aid Security Mechanism of Basic Medical Insurance for Employees", outpatient mutual assistance insurance will cover all insured personnel of employee medical insurance, and after the reform, the scope of frequent diseases and common diseases in the outpatient clinic that was directly paid by the personal account in the past will be included in the reimbursement of the medical insurance pooling fund, with a reimbursement ratio starting from 50%, in addition, the outpatient expenses of diseases with high costs and long treatment periods will also be gradually included in the payment scope of the medical insurance pooling fund.
At the same time, in addition to attending designated medical institutions, the insured can hold prescriptions outside the hospital, settle and purchase drugs at designated retail pharmacies, and meet the regulations to be included in the payment scope of the pooled fund, and the corresponding designated retail pharmacies will also be included.
Hospital medical insurance service window, photo by Cao Jianxiong
Why reform at this time?
"The mainland's medical insurance system was established in 1998 with the original intention of medical mutual assistance and mutual assistance, regardless of major and minor illnesses. In the past era without the Internet, the establishment of personal accounts is to reduce the review process of minor illnesses and pains, with personal accounts, the insured can take the medical insurance card to pay by themselves when encountering minor illnesses and pains, without going through the review process, and correspondingly, outpatient diseases are not included in the scope of reimbursement, because personal accounts are used to pay for this part of the expenses. Zhang Xiao told reporters.
According to the 2021 National Medical Security Development Statistical Bulletin, in 2021, the cumulative balance of basic medical insurance in the country was 3.615630 billion yuan, of which the cumulative balance of the personal account of basic medical insurance for employees was 1.175398 billion yuan, accounting for 32.5% of the total cumulative balance of basic medical insurance in the country, and showed an increasing trend every year.
As more and more funds accumulate in medical insurance personal accounts, problems gradually emerge.
"When the funds in the medical insurance personal account do not need to be used by individuals, others cannot use them, and the people who really need outpatient medical protection cannot be better protected, and the accumulation of this fund is increasing, which is not conducive to the efficiency of medical security." At the same time, the funds in the pooled account are too small, which directly leads to the great limitation of the reimbursement scope and reimbursement amount of medical insurance, and the protection level of serious diseases cannot be effectively improved. Zhang Xiao explained that the goal of this reform is to solve the problem of "not enough to spend if you are sick, and you can't use it if you are not sick" for the previously insured employees, revitalize the limited funds, and use them on patients who really need them.
In Zhang Xiao's view, "everyone has old age and illness, the economic risks brought by diseases will exist for a long time, and when they are old and sick, relying on medical insurance personal accounts and personal accumulation is always limited, and mutual aid protection is the key to solving the problem." ”
Did the insured lose money after the reform?
"The reduction in the new credit of personal accounts does not mean that the overall protection function is reduced, but from the institutional point of view, mutual aid protection has a more risk prevention function." In April 2021, Chen Jinfu, former deputy director of the National Health Insurance Administration, said at a press conference that the reform of personal accounts is not to cancel personal accounts, but to adjust the proportion of personal accounts, and establish, expand, improve and enhance the outpatient mutual aid security system through the transformation of the system. The reduction does not mean that the individual's protection will be lost, but put into the big pool of mutual assistance, forming a new security mechanism, this new guarantee mechanism is generally a balanced transfer of funds, and the protection efficiency is significantly amplified.
The Guangdong Provincial Health Insurance Bureau has also calculated an account of local policies. Taking Guangzhou as an example, in December after the implementation of the outpatient mutual aid reform, Guangzhou First People's Hospital benefited a total of 27,000 insured people, and the per capita reimbursement amount increased from 150 yuan to 380 yuan, an increase of 153%.
Li Hua (pseudonym), a 58-year-old retired employee in Guangzhou, went to the outpatient clinic of Guangzhou First People's Hospital in November 2022 due to rales in his breathing, and had lung CT done, with a total medical cost of more than 480 yuan. At that time, CT, MRI and other items had not yet been included in the outpatient coordination, and Li Hua needed to pay in full.
Recently, she went to the hospital for CT after "Yangkang" and found that she only gave 140 yuan for the same project, and the overall fund paid 70%.
Who are the biggest beneficiaries of this reform?
"From the perspective of the policy objectives of personal account reform and the long-term development of the system, the insured population will generally benefit from this reform, especially those insured employees and retirees who suffer from slow and special diseases, and the benefits are far more than the personal account write-down limit, because the result of mutual aid protection will often be to write down hundreds of yuan of personal accounts, but will reimburse more than 1,000 yuan or even thousands of yuan of expenses, to achieve the real role of policy adjustment reform." Zhang Xiao said.
The reporter combed and found that the specific reform plans in various places often favor retirees.
For example, in Sichuan, the minimum payment line for employees is 200 yuan, and the minimum payment line for retirees is 150 yuan, and the reimbursement ratio is 60% for employees in secondary and below medical institutions, 50% for tertiary medical institutions, and 10 percentage points for retirees. At the level of the maximum payment limit, the annual payment limit is 2,000 yuan for active employees and 2,500 yuan for retirees.
In April 2021, Fan Weidong, head of the Department of Treatment and Security of the National Medical Security Administration, said at a press conference, "Preliminary estimates suggest that this system can reduce the burden of outpatient expenses for retirees by nearly 100 billion yuan." ”