Experts read │ to improve effect and decrease the people mention mass negative complete system to protect a serious illness

Interpretation of the state council general office on the opinions of the full implementation of urban and rural residents of a serious illness insurance"

The national health and family planning commission of the People's Republic of China

The 2015-08-02

General office of the state council issued "on the views of the full implementation of urban and rural residents of a serious illness insurance" (hereinafter referred to as "opinions"), and this is the national development and reform commission in August 2012 and six departments issued by the implementation of urban and rural residents of a serious illness insurance work instruction opinion ", after the state on the shift disease protection and rescue mechanism construction of another "masterpiece", to standardize and perfect the system of a serious illness insurance in our country have important guiding significance.

Nearly three years, serious illness insurance system in the pilot areas has achieved obvious results, at the same time also appeared some new problems and situations. "Opinion" against this background, on the one hand, further clear to the core principles of a serious illness insurance system and reiterated that, on the other hand on the concrete measures of the system construction, the method has made a more detailed specification and guidance. Its policy of "bright spot" is mainly manifested in the following several aspects:

First, further improve the security of a serious illness insurance, strengthen the protection function of the palm. "Opinions" clearly put forward in 2015, serious illness insurance payment ratio above 50%, and with a serious illness insurance ability to raise funds, and constantly improve the management level, further improve the pay scale, more effectively reduce the personal burden of medical expenses. The current urban and rural residents basic medical insurance (urban residents basic medical insurance and new farming) of residents in the hospital medical expenses reimbursement ratio actually big energy more than 50%, with a serious illness insurance, the future of urban and rural residents of the cost of medical treatment of a serious illness overall real reimbursement ratio over 70%, effectively relieve poverty due to illness, Chinese problem due to illness. In addition, the "opinions" in determining the security level, and special emphasis on science and fine management, one is for "according to the changes in the income of urban and rural residents, set up a dynamic adjustment mechanism", the second is "encouraging local explore appropriately directed to the difficult groups of specific measures, strive to improve the palm guarantees the precision of a serious illness insurance system". Because of a serious illness insurance direct purpose is to reduce the personal burden of ginseng protect patients and in family and fundamental purpose is to reduce the participants the probability of catastrophic health care costs, at the same time, in the face of huge shift disease medical expenses, objectively requires must strengthen the compensation mechanism of mass transfer efficiency, serious illness insurance will be limited with a serious illness insurance fund on really urgent need of the crowd.

Second, strengthen the basic medical insurance, serious illness insurance, medical treatment, disease, emergency rescue, commercial health insurance and charity relief system, the complementary linkage between security force. "Opinion" emphasized that the above system between "clear division of labor, detailed measures and policies, pay pay, management, service and other aspects as cohesion". The author thinks that, to do a good job of linking the core task is to establish information sharing mechanism, as soon as possible to provide "one-stop" instant settlement services, to ensure that the masses convenient, enjoy treatment of a serious illness insurance in time. For people to enjoy medical treatment, its qualification should not be limited to the poor identification in advance (before treatment), but should be based on standards for medical expenses after the catastrophic health care costs of a more detailed definition of "poverty due to illness", the "seamless connection" between earnestly system.

Third, further standardize to undertake a serious illness insurance services. "Opinion" reaffirmed its support commercial insurance agencies to undertake a serious illness insurance. Commercial insurance agency orgnaization of a serious illness insurance management services, its significance lies in by buying services, actively explore the government vigorously promote public affairs to the town, is a national government function transformation and a institutional innovation of social management mode reform.

In order to ensure the vital interests of the broad masses ginseng, "opinions" requirement to establish a serious illness insurance balance and the dynamic adjustment mechanism of policy-related losses. Follow the principle of balance of payments, guaranteed small profit, reasonable control profitability commercial insurance institutions. "Guaranteed small profit" principle, is decided by public welfare of a serious illness insurance, commercial insurance agencies should from the strategic perspective, serious illness insurance business is through the business handling, promote comprehensive service ability, strengthen the industry brand construction, rather than over short-term profitability.

For handling serious illness insurance, on the other hand, the anticipated cost difference with the actual operating results, should adhere to the principle of "risk-sharing", thus reasonable basic medical insurance fund balance interests of both parties and commercial insurance institutions. As the "opinions" clear: commercial insurance institutions for balance appear over the contract to undertake a serious illness insurance, basic medical insurance fund return money to the urban and rural residents; Because urban and rural residents basic medical insurance policy adjustment policy reason brings to the commercial insurance institutions losses, by urban and rural residents basic medical insurance fund and commercial insurance institutions. This is also the embodiment of the government purchasing service fairness.

Fourth, increase the commercial insurance institutions to undertake a serious illness insurance policy support. To lighten the burden of the cost of commercial insurance institutions to undertake a serious illness insurance, "opinion" rules "of commercial insurance institutions to undertake a serious illness insurance premium income, according to the current rules, shall be exempted from business tax shall be exempted from insurance business supervision fees; from 2015 to 2018, on a trial basis shall be exempted from the insurance benefit".

Fifth, emphasis on regulating the behavior of medical service. The sustainability of a serious illness insurance system, to a large extent depends on whether medical expenses got reasonable control. "Opinions" pointed out that the family planning department of public health should strengthen the regulation and quality of medical institutions, medical services. Commercial insurance institutions to social security, health, family planning and human resources department close cooperation, promote the reform of payment by macro-reforms, etc. To formulate relevant clinical pathway, to strengthen the diagnosis standard, standard medical behavior, medical expenses control. A serious illness insurance should be based on medical service system, medical security system reform and perfect global strategy, drug centralized purchasing work through the regulation of medical technology and medical services, so as to effectively prevent medical risks and unreasonable expense, it is fundamental to guarantee long-term and stable development of a serious illness insurance. Only the good medical treatment, health care, medical pattern of "3 d linkage", serious illness insurance social benefits to achieve the optimal state. (nankai university health economic and health care research center director, professor Ju Ming)

Relevant link: the general office of the state council about the opinions of the full implementation of urban and rural residents insurance of a serious illness