Recently, many departments issued the "Guidance Opinions on Developing Major Urban and Rural Residents' Illness Insurance Insurance," and clarified the policy of compensation for serious illness insurance. In the exploration path of the medical care insurance policy for serious illnesses, it is necessary to continue to practice how to ensure the fairness of medical care for major illnesses, but also to correctly encourage the behavior of patients and the behavior of doctors and doctors. This is the top priority of the current reform. Recently, medical observers conducted an exclusive interview with Zhu Hengpeng, director of the Public Policy Research Center of the Institute of Economic Research of the Chinese Academy of Social Sciences, on issues related to major medical insurance.

Difficulties in financing channels

Medical observers: According to the Guiding Opinions on Major Disease Insurance, medical insurance funds for major illnesses should be allocated a certain percentage from the urban residents' medical insurance fund and the new rural cooperative fund. For areas with surpluses, it is necessary to use balances to raise funds. According to the current actual situation, is this reasonable? why?

Zhu Hengpeng: The balance is only the status quo if the current conditions do not change. In terms of NCMS, the balance in 2010 was less than 10%. Although the balance in 2011 was 17%-18%, this trend is not sustainable: First, the reimbursement of new rural cooperative medical insurance will continue to increase, and the second reason is that The actual fund utilization rate of the new rural cooperative medical system is still not very high. The actual compensation rate for 2011 was 48%. At this time, the balance of funds actually meant that the funds had already been precipitated and did not play a reasonable role; and the urban residents' medical insurance plate was To be small, there have been deficits in some places. It is not very safe to allocate funds from these two areas.

In addition, if it is expected to use urban workers' medical insurance balance funds as one of the sources of funding for medical insurance for major illnesses, this is also unrealistic, although this opinion does not mention this aspect. In fact, many regions such as Shanghai and Beijing have already incurred deficits. According to the topic we are now working on, the deficit situation will be even more severe. After 2017, urban employees’ medical insurance will even have a large deficit in the current period.

Medical Observer: In view of this, from the perspective of the Medicare Fund's share of illnesses for major illnesses and medical insurance, the feasibility is not as good as expected. Can other channels be implemented?

Zhu Hengpeng: Yes, personally think that this is a typical “three-fours”, from the medical insurance fund to share the share of the disease to the medical insurance, the insured enjoy the medical insurance funds as a whole did not increase, but there have been some changes in the structure only. Even if there have been places where pilot public funds are used for medical insurance, this is still using the people’s own money for medical treatment. No substantive adjustment has been made.

In addition to the “three directions” channel, there are three other channels for the financing of major medical insurance: raising the proportion of individual contributions, increasing local government subsidies, and increasing central government subsidies. In these three channels, individuals think that the most important thing to open up is the first one. This not only eases financial tensions, but also stimulates the sense of supervision of the participants. The third method is also feasible but needs to be solved by the Central Government Finance Bureau. The question of how to increase the allocation of funds among the localities; and the second channel is not particularly appropriate, because the financial resources in many places are now very tight. It can be said that the local finances cannot help.

The practice of compressing outdated medical insurance funds from medical institutions is not very much shared by individuals. This involves the negotiation and bargaining of health insurance institutions and medical institutions. It also involves deep-level medical system issues. Under the current system, it is not difficult to encourage hospitals and doctors to save money.

Medical Observer: As you just mentioned, the share from the Medicare fund only changes the structure of medical insurance funds. Then, what kind of negative impact will this structural adjustment have?

Zhu Hengpeng: A rational medical insurance system should cure minor illnesses and prevent major illnesses. However, this will take some time to explore. Therefore, it is still too early to draw conclusions on the final effectiveness of major illness medical insurance. However, it is certain that patients with major diseases can get more protection from it. From the point of view of ensuring fairness and ensuring safety, it is a good system choice to increase the proportion of reimbursement for serious illnesses to vulnerable groups. It can prevent poverty caused by illness and return to poverty due to illness; however, the actual compensation rate for patients with minor diseases will certainly be reduced. The cost of small and medium-sized diseases can be borne by most families. However, the reduction in the proportion of reimbursement of small and medium-sized diseases may be a big burden for low-income residents, especially rural residents, and they will fall into the “rich subsidies for the poor” cycle.

After long-distance running to correct the fruit

Medical observers: It should be said that the basis for the implementation of major medical insurance is to achieve equal opportunities in medical insurance. In the design and implementation, which principles should it grasp?

Zhu Hengpeng: The design of serious medical insurance must consider both fairness and incentive effects. First of all, the medical insurance for major illnesses is based on the premise of protection and is close to vulnerable groups. Therefore, fairness must be reflected. The reality also shows that it is really necessary to continue efforts to achieve fairness. Take Taicang, Jiangsu for example. Taicang Medical Insurance is based on the standard of 50 yuan per employee per year and 20 yuan per person per year. On the surface, it seems that medical insurance for urban workers subsidizes local farmers. However, according to statistics, Taicang’s household registration population is 470,000, and the permanent population is about 810,000. The local urban employees’ medical insurance participants are mainly migrant workers, which means that it may actually be migrant workers who subsidize local farmers and residents. Just stay on the surface.

Second, any change in the health insurance system or payment methods will affect the behavior of doctors and patients. Therefore, for the impact of the major medical insurance system on the doctor's diagnosis and treatment behavior and patient's visit behavior, relevant departments need to be expected, especially considering how to produce the greatest incentive effect. The illness medical insurance must also be able to play an active role, and these need to be demonstrated before the implementation of the policy. It cannot be determined by merely taking the initiative.

The relationship between doctors and patients is also a major illness medical insurance need to consider. From the doctor's point of view, if he is reimbursed for high expenses, he will certainly spend more money, which will inevitably increase medical expenses. From the perspective of the patient, he is willing to spend more under the current policy. Under the partial payment system, how to guide doctors and patients in their diagnosis and treatment and medical needs is a difficult problem. However, with the further maturity of the medical insurance system, it is believed that the doctor-patient relationship will be greatly improved.

Medical observers: In order to alleviate or even solve the current problems, but also in order to achieve the original intention of serious illness and medical insurance, before the implementation of major medical insurance, which issues need to be resolved?

Zhu Hengpeng: I am afraid we must first clarify the concepts and division of labor of basic medical insurance and major medical insurance. I have always disagreed with the government from entering the category of medical care for illnesses, because the government should have more of a function of “guaranteeing basics”. The diseased health insurance must work hard at outpatient services, such as how to transform the existing medical system, how to implement primary care and treatment, and how to establish a system of general practitioners and family doctors, rather than having to wait until the minor illnesses become serious. The reform must be made step by step, and reform of the supplier is the first priority.

Medical observers: There are views that in the area of ​​serious medical insurance, commercial insurance should play the role of medical control fees. How do you interpret this? For commercial insurance to enter this field, are you optimistic?

Zhu Hengpeng: This is an innovation in major illness insurance. Commercial insurance can be used to obtain the right to manage major illnesses in all parts of the country. Next, commercial insurance will consider winning the right to handle basic medical insurance. Once it is implemented, it will be able to exert its role as a medical control fee. At this time, the government is only a policy maker and a regulator, and management and management may be implemented separately.

It should be noted that commercial insurance will encounter many challenges in this area because medical fees, payment methods, and medical insurance fund management are all very strong. At the same time, the medical insurance experience of commercial insurance is not necessarily more abundant than that of the social security department. Therefore, commercial insurance must truly experience a sweetness and is destined to go through a long process. This is also the process that disease-ridden medical insurance must undergo.