Reporters visited: a serious illness insurance, can live bottom pocket?

08:10:19 on December 18, 2015

Source: People's Daily

Zhu Huiqing draw

As the state issued "about the views of the full implementation of urban and rural residents of a serious illness insurance", serious illness insurance system started in an all-round way. A serious illness insurance, is the high medical costs occurring in patients with serious illness institutional guarantee. How to implement a complete coverage of a serious illness insurance, the people and improve the medical security level? Recently, the reporter investigation has been carried out in zhejiang, chongqing and other places. Launch "a serious illness insurance from today onwards, this new agent" series, stay tuned.

- Ed

A serious illness insurance is a serious illness

According to the definition of medical expense is the concept of a serious illness, coverage extended to all diseases, prevent disease discrimination, safeguard the fairness of policy

Reimbursement in hangzhou fuyang area social security center hall, reporter saw accompanied by her daughter-in-law to apply for reimbursement of medical expenses and source Jiang Yunying town residents. Jiang Yunying was diagnosed with subarachnoid hemorrhage, from the medical treatment of disease to August this year spent 530000 yuan. For without the source of life, by son support Jiang Yunying is astronomical.

The fuyang, so far, 680000 people live in the basic medical insurance ginseng protect, covering 99% of the population in the region. The basic realization of universal health care. However, a broad policy has certain limitations, can only cover basic, would be very serious.

Fuyang area people club bureau of sino-soviet said, urban and rural residents medical insurance policy, a natural year, within the prescribed scope of medical fees of 150000 yuan of above, cannot enjoy treatment of city house insurance reimbursement, the cap of $150000. Critically ill patients with medical expenses often far exceeds the reimbursement "seal top line". In the presence of such a large medical bills, dwarfing reimbursement costs 150000 yuan, because of sickness poor, very likely.

Fortunately, a serious illness medical insurance policy. According to the regulation, Jiang Yunying reimburse the medical expenses of RMB 330000, including 230000 yuan in the basic medical insurance reimbursement, serious illness insurance for 100000 yuan. Because Jiang Yunying belong to low-income residents, people club department also issued difficult staff medical benefits of 60000 yuan. Jiang Yunying said: "thanks to a serious illness insurance, is really saved, saved his life."

In 2014, zhejiang province issued "about to speed up the establishment and improve the system of a serious illness insurance related issues notice". The high gold content files for 50.69 million umbrella of ginseng protect personnel to hold up against a serious illness.

People club hall of zhejiang province health department, deputy director of the NiHuPing said, with a serious illness insurance system as a lever, the integration of various medical security policy, formed with basic medical insurance as the main body, serious illness insurance for extensions, medical treatment for out, other forms of security for supplement multi-level medical security system.

To start a serious illness insurance system, reduce the high medical expenses burden of the patients with serious illness, serious illness patient medical expenses proportion in original increased by 10% - 20%, based on the basic health care comprehensive reimbursement rate above 80%. For some poor family is really a nice surprise, reduced the catastrophic health spending.

Zhejiang province fu biao, serious illness insurance around last year's urban and rural residents per capita income standard reference set. When the burden of medical expenses to the local urban and rural residents in urban and rural residents per capita income, shall be deemed to be catastrophic health expenditure, will lead to poverty due to illness, Chinese happens due to illness, need to be secondary.

Antitumor medicine gleevec is many life-saving drugs, but the price is expensive, 23000 yuan per box. Fuyang area and source small wei was found in the town of leukemia, for he is the most effective drug gleevec, a family not hesitate to let him choose the medicine. In the past, gleevec belongs to own medicine. From this year, gleevec of 15 kinds of drug into zhejiang serious illness insurance to pay limits. Ginseng protect personnel, such as small wei in the fixed-point hospital or drugstore that decide a dot to buy the medicine, into a serious illness insurance payments. Province medical insurance fund is expected to take out 1 billion yuan, the special medicine to pay for the 15 kinds of serious illness, raised the policy value.

Health development planning commission of zhejiang province, deputy director of the packages to the root, said in a serious illness insurance policy, according to the definition of medical expense is the concept of a serious illness, farmers not only covers the original new shift disease rescue regulations of 22 kinds of shift, also covers the parties is a rare disease, coverage expanded to all disease, avoid disease discrimination, safeguard the fairness of policy.

A serious illness insurance will "blowing up"

According to the principle of balance of payments, the government scientific calculation, reasonable financing standard, the starting line and line of the cap, serious illness insurance fund can guarantee the normal operation

Fuyang area than the town of Shanghai man 33, patients with aplastic anemia. From 2013 to August 2013, the medical treatment of up to 2.54 million yuan. Basic medical insurance expenses 550000 yuan, 150000 yuan medical assistance, major disease supplementary insurance subsidies of 1.23 million yuan, the actual total compensation of 1.93 million yuan, the compensation rate was 88.5%. The patient's father Jane said: "a serious illness insurance solved the trouble back at home of us." As an example of this, in fuyang, 432 example, enjoy a total of 23.21 million yuan in of a serious illness.

For such a high medical expenses, serious illness insurance can afford pocket? It is reported, by economic condition, habits, disease, medical resource distribution, incidence of serious illness insurance claims are also different. In zhejiang province, serious illness insurance total financing standard in principle of 25 yuan per capita. Urban and rural residents basic medical insurance funds, in whole province at present is roughly by the government and individual 7:3 share ratio. Early one-time overall transfer from the medical insurance fund, to avoid the payment for many times.

NiHuPing said, at present, zhejiang province, the basic medical insurance coverage scale to measure 50.69 million people, the province is used in the treatment of a serious illness insurance spending will amount to 1.27 billion yuan. According to statistics, the province's incidence of serious illness insurance claims for two over one thousand. According to the principle of balance of payments, the government scientific calculation, reasonable financing standard, the starting line and the top line. The current basic can guarantee the normal operation, serious illness insurance fund will not be "broke in."

Carried out in accordance with the natural annual settlement, serious illness insurance ginseng protect personnel in a settlement occurs within the year, after reimbursement of insurance of primary medical treatment than fu biao compliance medical expenses, into a serious illness insurance to pay limits. A serious illness insurance maximum compensation limit set by 10 to 15 times the fu biao, pay no less than 50%, the higher the cost, the higher the pay scale.

NiHuPing think, set maximum reimbursement from the health point of view of economics. If a serious illness insurance expenses 400000 yuan, the annual medical in patients with total cost need to achieve 1 million yuan of above, probability, the chances of survival and therapeutic value is very small.

Uncapped in fuyang area, serious illness insurance, cancel the reimbursement cap line, bottom spirit come from? Fuyang area people club bureau deputy director of the party to keep the introduction, the medical insurance fund smooth operation, the cumulative balance of 500 million yuan. Balance of medical insurance funds, are calculated results. Implementing the total budget is given priority to, for example, to pay for health care reform, a sunlight health supervision platform, system of medical insurance agreement physicians, a series of measures such as the third party supervision, improve the medical insurance fund use efficiency, enhances the security ability, also have the power people.

Why to commercial insurance "with"

The government entrust commercial insurance to undertake a serious illness insurance, give play to the role of market mechanism, strengthen the public service ability, alleviate the contradiction between understaffed and service pressure

Fuyang district health insurance agency orgnaization only seven members formally, supervision over 200 medical establishment that decide a dot, and designated retail drug store. Due to insufficient supervision service strength, to some extent, resulting in the loss of medical insurance fund.

Sino-soviet says, the district government chooses to introduce commercial insurance, without any increase in ginseng protect personnel to individual pay cost and government financial input, on the basis of extraction of part of the medical insurance fund for the city in the health care insurance ginseng protect personnel to a serious illness insurance, insurance companies using large operation network and professional services to the refinement to create a more efficient and more three-dimensional medical security system.

In July 2012, in hangzhou fuyang region take the lead in introducing commercial insurance to participate in major disease supplementary medical insurance, and the Pacific life zhejiang branch jointly explore and try out "government leading, professional operation of" political insurance cooperation management new pattern. Insurance company specially established to third party service management agencies - fuyang area social security service center, set up 27 employees medical institutions stagnation point services, retail pharmacy management and exception and third-party supervision such as illegal investigation.

Sino-soviet introduced, such as a natural annual loss, serious illness insurance fund shall be borne by the insurance company in full; If produce a surplus, the surplus within 2 million yuan, as the operating costs of insurance company, more than 2 million yuan of above, beyond the part by area social security center and the insurance company according to the preset proportion for the distribution of profits. Area social security center will be surplus part is used to establish supplementary medical insurance risk fund major diseases, to make up for all the major disease complement medical treatment fund deficit.

"Zheng bao cooperation" is an important feature of a serious illness insurance. The province encourage commissioned to undertake a serious illness insurance, commercial insurance company entrusted business to undertake regional city divided into districts shall be the unit for to make unified bidding. This year on September 6, through public bidding taizhou government procurement center, the Chinese people's property insurance co., LTD. Taizhou branch for the price of 15 yuan/person in the winning taizhou serious illness insurance services, participate in the urban and rural residents in the 2015-2017 year a serious illness insurance agency business, ginseng protect personnel to 1.2 million.

Taizhou people club bureau Wang Rukao introduction, through the participation of insurance company, taizhou implements extend service window to remote villages and towns, raise the service ability of the masses. Ginseng protect personnel to three area in jiaojiang, huangyan, luqiao inter-district submitted claims material, need not return my census register formalities for claims. Nationwide network advantage at the same time, through the insurance company, set up the mechanism of different ground investigation, long-distance check passengers and amount are not less than 20%, to strengthen the control of medical institutions, to prevent the loss of funds.

Zhejiang protects inspect bureau supervision department, deputy director of the Lu Hang said, on the premise of guarantee insurance company guaranteed small profit, commercial insurance to ginseng protect personnel to undertake a serious illness insurance led to a more convenient and efficient service. Stagnation point claims, convenient real-time settlement services such as the expense of the masses and alleviate the medical care.

NiHuPing believes that the government entrust commercial insurance to undertake a serious illness insurance, use of market mechanism, strengthen the public service ability, alleviate the orgnaization of grassroots health care is understaffed and handling the contradiction between the service pressure.