1. national unit guarantee: institutional choice to adapt to planned economy
At the beginning of the founding of New China, the central government inherited a riddled mess from the old Kuomintang government: industrial shrinkage, agricultural depression, hyperinflation, serious damage to production facilities, a large number of factories shut down, a large number of workers lost their jobs, commercial order was chaotic, and people's lives were difficult. At that time, the primary task of the central government was to stabilize the society, and at the same time, to develop production and economy rapidly, so as to ensure the people's decent life and guaranteed survival. This is a severe test faced by China's * * * production party at the beginning of its administration, and it is also a hurdle that must be overcome to appease people's hearts, stabilize society, demonstrate its ruling ability and consolidate its ruling foundation.
Because the new China has chosen the road of socialist development, there is no practical experience to follow in the specific institutional model. The only thing we can learn from is the national security model implemented by the former Soviet Union relying on the planned economic system, and the former Soviet Union also achieved good results at the beginning of the system implementation. To this end, the central government assumed the national responsibility with a strong posture, and quickly organized the construction of social security systems such as social relief and labor insurance through grass-roots units such as enterprises and institutions, forming the basic pattern of the state-unit security system model from the beginning. By 1956, China has initially established a relatively complete social security system that is compatible with the planned economic system, with the state as the main responsibility and urban and rural areas as the unit to organize and implement specific policies. The state (through the government) and units are increasingly closely integrated in the implementation of the social security system.
1August, 966, the "cultural revolution" began, and the country entered a period of ten years of turmoil. From the end of 1968, when the Ministry of Internal Affairs was revoked by the state, the labor union in charge of labor protection was paralyzed and the functions of the labor department were weakened. The state cannot effectively control the implementation of the social security system, and the social security system can only be maintained and continued by various units and organizations. The phenomenon of unit-run society has expanded rapidly, and the national-unit security has largely moved towards self-enclosed unit security.
Starting from 1978, China ended its ten-year turmoil and entered the stage of bringing order out of chaos. Although the social security work was improved during the period of 1978- 1986, it was mainly to solve the problems left over from history and restore the retirement system, free medical care and labor insurance medical care system destroyed by the Cultural Revolution. Although some areas have carried out reform experiments on labor insurance medical care and retirement expenses, they have not touched on the foundation, essence and significance of the national unit security system.
Second, the combination of social pooling and personal accounts: the objective need of institutional transformation
With the transformation of China's economic system from planned to market, enterprises have become independent economic entities, and a large number of foreign-funded enterprises, private enterprises and other non-public enterprises have emerged one after another. The incompatibility between the original system and the new system is becoming increasingly prominent: first, the medical security system for employees in non-public units is lacking; Second, the medical treatment between different units is very different, and the medical burden is light and heavy; Third, the self-management of medical insurance by enterprises increases the social burden of enterprises and limits their market competitiveness; Fourth, the supply and demand sides of medical care lack effective cost restraint mechanism, medical resources are wasted seriously, and medical expenses are increasing unreasonably and too fast; Fifth, under the condition of market economy, enterprises independently undertake business risks, and it is normal to close, break, stop and change, and the unit guarantee model is objectively unsustainable and unsustainable. All this shows that it is imperative to reform the original medical security system model.
Throughout the world today, there are mainly four medical insurance system models, namely, the national medical insurance system model represented by Britain, the social medical insurance system model represented by Germany, the commercial medical insurance system model represented by the United States and the savings medical insurance system model represented by Singapore.
The main problems existing in the British national medical insurance model are the rigid operation, low efficiency and poor service quality of medical service institutions, and the situation of waiting in line for surgery for months or even half a year often occurs. At the same time, due to the lack of cost awareness between doctors and patients, the level of medical consumption has increased too fast, medical resources have been wasted seriously, and the financial burden is too heavy. In the past, China's labor insurance medical care and free medical care, and in recent years, the policy of free insurance and high treatment for poverty-stricken households who have set up a file card, are constantly verifying this fact. We don't need to repeat the story of yesterday. Those experts and scholars who always stand at the highest moral point and are keen to advocate that China should learn from the so-called free medical care in Britain, either forget the history or ignore the facts.
The United States is a country that advocates freedom and emphasizes individual self-help, from which an institutional model with commercial medical insurance as the main body is derived. The main problem is: based on the profit-seeking nature of commercial insurance companies, some people with poor payment ability and high disease risk are shut out, which cannot reflect social fairness and mutual assistance. Although the government has established a medical care plan for the elderly and a medical assistance plan for low-income people, there are still more than 50 million people without any medical insurance. As a socialist country, seeking happiness for all the people is the fundamental purpose of our party. It is the government's responsibility to achieve universal health insurance. Our persistent goal is to ensure that no one is left behind. The combination of fairness and efficiency, mutual assistance and self-help should be the basic principles of our system design.
The model of savings medical insurance system, represented by Singapore, emphasizes self-protection and personal responsibility, and weakens individuals' trust in the government. The main problems are lack of social mutual assistance, poor fairness and weak social risk function.
The main characteristics of the social medical insurance system model represented by Germany are: First, compulsory participation. All qualified personnel must attend; The second is to establish a fund. The fund consists of employees and employers who pay the same fees, and is raised according to the principles of "pay as you go" and "balance of payments"; Third, only provide basic medical services; The fourth is to adopt the "third-party payment" mechanism and set up a specialized agency to manage the receipt and payment of funds in a unified way.
The main problems to be solved in China's new medical insurance system are: first, to meet the needs of China's market economic system reform and development, to establish a medical security system covering all employers, independent of employers and implementing socialized management; Second, the responsibility of medical security has changed from being fully borne by the state and units in the past to being shared by the state, units, society and individuals, and a restraint mechanism for medical behavior has been established to control the unreasonable increase of medical expenses; Third, the system design adheres to the unity of fairness and efficiency, the corresponding rights and obligations, and the combination of mutual assistance and self-help. Therefore, the establishment of social medical insurance system with reference to the German model has become the choice of new medical insurance system. Before China's system reform, the national unit security model was implemented, which is the logical starting point and path dependence to be followed in China's medical insurance system reform. Therefore, the biggest challenge facing the system reform is to change from the past personal free to insurance payment and cost sharing. If there is no perfect system design, it will inevitably affect the employees' acceptance of the new system, thus hindering the advancement of the medical insurance system reform. Fortunately, before the implementation of the new system, all localities generally carried out pilot explorations such as linking medical expenses with individual users and reforming the management mode of public medical care, which laid the foundation for the system design of individual payment and cost sharing. Considering that the mainstream understanding of economic system reform at that time was to break the "big pot", the implementation of complete social planning of medical insurance may form a new "big pot". In order to enhance the awareness of personal expenditure and control waste, the personal account system in Singapore and other countries is undoubtedly worth learning. The design of personal account can not only reduce the payment burden of the unit, but also solve the medical expenses burden of the insured for minor illnesses and common diseases to a certain extent, thus solving the psychological gap before and after the reform of the medical insurance system. Therefore, the combination of social pooling and individual accounts is undoubtedly the best choice for the new medical insurance system.
Looking back now, the combination of social pooling and personal account has successfully resolved the social contradictions in the economic system transformation, and at the same time realized the smooth transformation of employee medical insurance from public expense and labor insurance to social medical insurance system, in which the design of personal account contributed a lot. However, the personal account system has not fully realized the original intention of alleviating the aging problem, and with the basic completion of the historical mission of personal account, its unique shortcomings and internal defects have become more and more prominent, which has brought a lot of trouble to the management of medical insurance and also caused a discussion on the retention and abolition of personal account in society. Some individuals even deny the correctness of taking the road of social medical insurance with personal account problems, which deserves high vigilance.
Third, the gradual deepening of institutional reform: the difficult practice of developing countries
According to Wang Dongjin, former vice minister of labor and social security and president of China Medical Insurance Research Association, the reform of China's medical security system can be roughly divided into the following four periods.
The first is the exploration pilot period (from the mid-1980s to the end of 1998).
This period can be divided into three stages:
1. 1994 is preceded by the stage of local spontaneous experimental exploration. Some places (such as Siping City, Jilin Province, Huangshi City, Hubei Province, etc. ) Witnessed the increasingly prominent drawbacks and unsustainable situation of the medical system of public expense and labor insurance, and spontaneously explored reforms, mainly focusing on the appropriate linkage between medical expenses and individuals, in order to curb the unreasonable increase of medical expenses and the serious waste of medical resources.
2. 1994- 1996 is an organized and leading pilot stage of the reform of the basic medical insurance system for urban workers. The State Commission for Economic Restructuring and other four ministries and commissions issued the Guiding Opinions on the Pilot Project, set up a leading group and office for medical insurance reform in the State Council, and organized and guided the pilot projects in Zhenjiang City, Jiangsu Province and Jiujiang City, Jiangxi Province (known as the "Two Rivers Pilot Project" in history). Explore how to establish the basic medical insurance system for employees.
3.1April 1996 to1February 1998, expanding the pilot phase. Guided by the Opinions of the General Office of the State Council on Expanding the Pilot Reform of Workers' Medical Security System, the pilot scope has been expanded from "Two Rivers" to more than 40 cities across the country. The main purpose is to test the results of the "Two Rivers Pilot Project" in a wider scope, conduct in-depth research, find problems, sum up experience, grasp the law, improve policies, and determine the institutional model.
The second is the period when the basic medical insurance system for urban workers was established (1999 to 2003).
After more than four years of pilot and expanded pilot exploration, all departments and parties have basically formed a * * * understanding of major issues such as the direction of reform, the importance and urgency of reform, the tasks, objectives, paths, institutional models and policy frameworks of reform. On this basis,1From June 5 to February 6, 1998, the State Council made the Decision on Establishing the Basic Medical Insurance System for Urban Employees, which officially initiated the historic change of establishing the basic medical insurance system for urban employees in China. Circular 44 also clearly stipulates that enterprises are encouraged to establish supplementary medical insurance, implement medical subsidies for civil servants, and support the development of commercial health insurance as supplementary and supporting measures for the new system. As a result, the medical system of public expense and labor insurance, which has been implemented for more than 40 years, has been terminated, and the unit (enterprise) security system has been transformed into a modern social security system ("unit person" has become a "social person"). It has achieved a historic transformation and leap.
Third, the period of establishing universal medical security system (2003-20 17).
Thanks to the experience of establishing employee medical insurance and the medical insurance team experienced in practice, this period is also the period with the fastest progress, the fastest development and the most remarkable results in the construction of universal medical insurance system. Generally can be divided into six stages:
1. The stage of establishing a new rural cooperative medical system (hereinafter referred to as the "new rural cooperative medical system") (from 2003)
Mainly through government financial subsidies, the past rural cooperative medical system has been transformed into a "new rural cooperative medical system", which has solved the basic medical problems of rural residents.
2. The stage of establishing social medical assistance system (from 2003)
Mainly to solve the basic medical security problems of poor people (such as urban "low-income households", rural "five-income households" and severely disabled people). ), and reflect the overall function of social policies and government responsibilities.
3. The stage of establishing the basic medical insurance system for urban residents (from 2007)
Starting from the State Council's Guiding Opinions on Piloting the Basic Medical Insurance System for Urban Residents (Guo Fa [2007] No.20), it was fully launched one year later. It mainly solves the basic medical security problem of urban unemployed people (commonly known as "one old and one small").
4. The stage of establishing the system (mechanism) for guaranteeing and rescuing serious diseases (from 20 12)
The 18th National Congress of the Communist Party of China clearly put forward the establishment of a system for guaranteeing and rescuing serious diseases, and the Decision of the Third Plenary Session of the 18th Central Committee was further clarified. Later, it evolved into a "serious illness insurance system" in practice, which has different understandings in terms of concept connotation, functional orientation and implementation methods, and needs to be further corrected and improved.
20 13 premier the State Council officially announced in the "government work report" that China's national medical insurance system was basically established. Basically, a national medical security pattern has been formed, with basic medical insurance as the main body, supplemented by supplementary medical insurance for enterprises, medical subsidies for civil servants and commercial health insurance, and based on social medical assistance.
5. Integration stage of basic medical insurance system for urban and rural residents (from 20 13)
After the 18th National Congress of the Communist Party of China, the central government put forward the requirement of integrating the medical insurance system for urban and rural residents. In 20 13, the State Council also determined the "timetable" for integration (it was put in place at the end of June of that year). However, due to various obstacles and interferences, it was not until the State Council released No.3 document on 20 16 that it "entered the fast lane". By the end of 20 17, most provinces (24 provinces and cities in total) had handed over their business management to the human and social departments, realizing the "six unification", and only a few provinces and cities still had the "new rural cooperative medical system" in the health department.
6. Explore the stage of establishing long-term care insurance system (from 20 16)
According to the spirit of the Fifth Plenary Session of the 18th CPC Central Committee, Ministry of Human Resources and Social Security issued the Guiding Opinions on Piloting the Long-term Care Insurance System. Starting from 20 16, the pilot project was carried out in 15 cities nationwide. At present, it has achieved initial results, explored the path and accumulated experience for establishing a new security system, improving the social security system and resolving the risks of an aging society.
Fourth, the period when China's medical security system was fully established (from 20 17).
With the implementation of the "Healthy China" strategy as a symbol, the reform of China's medical insurance system has entered a new development stage with national health as the core. Marked by the 19th National Congress of the Communist Party of China, China's medical insurance reform and development has entered a period of building a medical security system with China characteristics in an all-round way.
Fourth, enhance the sense of access to medical insurance: the requirements of the times to deepen reform
After more than 30 years of unremitting efforts, the reform of "medical insurance" has made brilliant achievements, established a medical insurance system covering the whole people, and initially solved the problem of people's difficulty in seeing a doctor. However, the problem of difficult and expensive medical treatment has not been fundamentally alleviated, and the people's sense of medical security needs to be further improved. The medical insurance department is faced with the dual pressures of tapping the potential internally, improving the efficiency of fund use and external assistance to incite medical reform to develop in depth. The effective function of medical insurance needs to be solved urgently.
Externally, first, due to the administrative monopoly formed by the slow reform of public medical institutions and the separation of management and operation, public medical institutions cannot respond sensitively to social needs and the role of medical insurance payment, resulting in the disconnection of "three medical linkages" and the inability of medical insurance to effectively balance medical service providers. The medical insurance fund, which holds most of the compensation funds for medical expenses, basically loses the ability to guide the allocation of medical resources and the diagnosis and treatment behavior of both doctors and patients, and degenerates into the second finance that only provides financial compensation for public medical institutions. Second, public medical institutions have not become real market players, unable to obtain sunshine income through healthy competition and standardized operation, and the medical service value of medical staff has not been truly reflected, leading to the prevalence of kickbacks, red envelopes, large prescriptions, excessive inspections and other distortions. As a result, the rapid growth of medical insurance financing not only did not reduce the medical burden of urban and rural residents, but also induced the rapid expansion of public hospitals, and the people's sense of gain declined instead of increasing. Third, it restricts the smooth progress of the graded diagnosis and treatment system. The current hospital grading system urges high-quality medical resources to gather in high-grade hospitals. With the improvement of people's living standards and medical insurance benefits, patients tend to seek authoritative experts from high-level hospitals. The original way of adjusting patients' medical treatment destination through the price difference of medical services has gradually failed, and the trend of patients gathering in high-level hospitals has intensified, resulting in "the third-level hospitals are crowded and the primary hospitals are scarce".
Internally, first, because medical insurance projects and funds are managed by different departments, there are great differences in the levels, standards and levels of protection, and the design of information systems, fund operation and management methods and policy objectives are also different. This decentralized management mode reduces the handling efficiency, increases the operating cost of the system, and also makes it difficult to coordinate and connect various systems. Second, due to the limitation of the number of staff, the serious shortage of supervision and law enforcement personnel, the lagging construction of supervision team and the lack of supervision ability have not been well solved, and the phenomenon of over-medical treatment and insurance fraud caused by fancy renovation has not been effectively curbed, resulting in improper loss and inefficiency of medical insurance funds, which not only affects the treatment guarantee of insured personnel, but also affects the sustainable development of medical insurance system.
Therefore, it is imperative to integrate medical insurance resources, set up specialized institutions, give full play to the power of third-party buyers of medical insurance, and promote the reform of medical and health system. Because of this, the state announced the establishment of the National Medical Insurance Bureau at the first session of the 13th National People's Congress, and medical insurance departments specialized in medical insurance came into being.
As Comrade State Councilor Wang Yong pointed out in his explanation of the State Council's institutional reform plan, the establishment of the National Medical Insurance Bureau is intended to achieve two goals: first, to improve the unified medical insurance system, improve the level of protection, and ensure the rational use, safety and controllability of funds; The second is to promote the "three-medical linkage" reform of medical care, medical insurance and medicine as a whole, and better ensure that patients have medical treatment. This passage clarifies the role of the medical insurance bureau in medical reform, that is, by integrating the medical insurance system, aggregating management power and coordinating fund payment, the reality of decentralized and extensive management can be changed, thus improving management efficiency, preventing fund risks and ensuring the sustainability of the system; At the same time, let the medical insurance department use the medical insurance fund in its hands to become a powerful resource allocator based on the market mechanism, thus becoming the key instigator of medical reform.
Specifically, it is mainly reflected in three aspects: First, after the establishment of the Medical Insurance Bureau, the medical insurance foundation is highly aggregated. Previously, employees' medical insurance, residents' medical insurance, maternity insurance and medical assistance funds scattered in human society, health planning commission and civil affairs departments were centrally managed by the Medical Insurance Bureau, which gave full play to the purchasing power of the group and provided strong economic support for effectively guiding the rational allocation of medical resources and standardizing the diagnosis and treatment behavior of both doctors and patients. The second is to integrate the long-term decentralized management authority. The Medical Insurance Bureau has concentrated the functions of catalogue determination, price management, drugs, medical consumables and medical service procurement, as well as the functions of signing contracts, payment of fees and service supervision of designated medical institutions. It is expected to solve the problem of "multi-specialty wrangling" caused by overlapping functions and decentralization, thus improving administrative efficiency, giving full play to the strategic procurement role of medical insurance funds, and providing strong organizational guarantee for realizing the reform goal of rational use of funds and continuously improving the level of security. Third, under the condition of centralized demand side, the key to deepening the reform will focus on implementing the separation of management and operation of the medical service system, breaking the administrative monopoly of public medical institutions, and thus achieving effective competition among suppliers. This is the key to realize the rational allocation of medical resources oriented by medical insurance, promote the rationalization of diagnosis and treatment behavior of both doctors and patients, and is also an important lever to promote the reform of medical and health system.
Fifth, play the role of strategic buyers: an important issue facing the medical insurance department.
The so-called strategic purchase, in the words of Deputy Director Chen Jinfu, is "recent system improvement and trend optimization: improving the performance of medical insurance group in purchasing funds in quantity and price; Win by quality and lead the value orientation of medical service system; Compatible with students and build a coordinated, healthy and innovation-driven development pattern in the future. " The first is to "establish an efficient medical insurance payment mechanism and improve the efficiency of fund use". Through the continuous improvement of medical insurance payment methods, it has a strategic impact on medical behavior, hospital management and medical system operation, and promotes the transformation of hospitals from extensive management to refined management. The second is to strengthen the purchase direction of medical insurance with the strategic thinking of future investment, and regard the current purchase as the future strategic investment. For example, at present, the improved service level of family doctors is difficult to meet the needs of basic medical services, but the current purchase is an investment in future growth; Buying the services of private medical institutions focuses on more full competition. Third, strengthen the strategic purchase function of medical insurance fund, steadily improve the level of overall planning, implement municipal overall planning of medical insurance, pilot provincial overall planning, improve the direct settlement of medical treatment in different places, cancel the separation of unified accounts, reduce management levels, realize data concentration, continuously strengthen the strategic purchase function of medical insurance fund, and promote the synchronous reform and coordinated development of medical insurance, medical care and medicine.
From the specific implementation point of view, we should give full play to the strategic purchasing role of medical insurance funds by improving the medical insurance system, strengthening fund management, promoting the "three-medical linkage" and improving service capabilities, so as to provide more fair and accessible medical insurance services for the people and further improve the people's sense of medical insurance acquisition.
Improve the medical insurance system. First, make clear the basic connotation and extension of basic medical insurance, clearly define the responsibility boundary, strengthen the management of medical insurance treatment payment by formulating the management system of medical insurance treatment payment list, and realize the sustainability of medical insurance system. The second is to further improve the unified basic medical insurance system for urban and rural residents and establish a stable and sustainable financing mechanism for basic medical insurance for residents. Third, comprehensively promote the overall work of general outpatient service for urban and rural residents; Explore and improve the management mechanism of employee medical insurance personal accounts, steadily promote the transition of employee medical insurance personal accounts to outpatient co-ordination, and enhance the mutual aid ability and economic ability of individual account funds. The fourth is to actively build a multi-level medical security system that organically connects basic medical insurance, serious illness insurance and medical assistance. The fifth is to further deepen and expand the pilot of long-term care insurance system.
In strengthening fund management. The first is to strengthen agreement management.