On June 5438+ 10, 2009, the new rural cooperative medical system and urban residents' medical insurance in Zhanjiang were operated in parallel, which solved the problems of disparity in payment standards between the two medical insurance systems, low enthusiasm for participating in insurance and weak fund adjustment ability caused by different levels of overall planning. In order to further improve the complicated medical insurance reimbursement procedures, uneven allocation of medical resources and high government management costs after the merger, Zhanjiang City decided to introduce commercial means to provide integrated management and services for basic medical insurance and supplementary medical insurance for urban and rural residents. Insurance companies provide policy consulting services including basic medical care, supplementary medical care, health management, commercial health insurance, etc. to residents of this city by establishing a "comprehensive consulting service platform". By establishing an "integrated payment and settlement platform", the information of patients' medical expenses settlement can be shared among insurance companies, social security departments and designated hospitals.
Zhanjiang model was selected as one of the top ten insurance news in China on 20 10 and the top ten insurance news in China on 20 10, which was released in February. As a typical sample, China PICC Healthy Zhanjiang Model was selected as the top ten news. The jury evaluated that in the process of the government actively improving people's livelihood and further strengthening the construction of social security system, "Zhanjiang Model", "Yixing Model" and "Jinjiang Model" emerged in the insurance industry. Local governments actively cooperated with commercial insurance institutions and played an indispensable and important supplementary role in basic medical insurance, new rural endowment insurance and new rural cooperative medical care. The essence of Zhanjiang Model is co-location. Through co-location, a one-stop management service platform integrating basic medical insurance and supplementary medical insurance will be established. Health insurance companies provide professional services such as medical management and document review for basic medical insurance, which reduces the management personnel and operating costs of social security departments, improves administrative efficiency and public service level, optimizes the management of medical and health resources, and improves operational efficiency and service quality. The limited medical resources have been reasonably and fully utilized, and the "complementary advantages, seamless links and win-win cooperation" among social security departments, companies and designated hospitals have been realized, which can be called the successful practice and typical sample of the insurance industry serving the construction of the national medical security system. The central government fully affirms the value and significance of Zhanjiang model in transforming government functions, relying on the professional and efficiency advantages of third parties, and innovating the way of providing public services, which will undoubtedly guide all sectors of society to pay more attention to the positive role of studying the new medical reform of insurance services from the aspects of system and mechanism, and strive for greater policy support for the promotion of Zhanjiang model.
Since Zhanjiang cooperated with Zhanjiang Central Branch of China People's Health Insurance Co., Ltd. in July 2008 to promote the reform of urban and rural medical security system, the "Zhanjiang Model" has achieved remarkable results after more than three years of operation. First, it has improved the efficiency of medical insurance management and standardized medical behavior. The integrated management service platform enables the insured to obtain one-stop service. Through the restraint and supervision of medical services, in 2009, the "leakage" funds were reduced by 69.08 million yuan. The second is to improve the efficiency of resource allocation and reduce the medical expenses of the masses. Through differentiated Qifubiaozhun and reimbursement ratio, the insured can be guided to seek medical treatment reasonably, the distribution of disease sources can be balanced, and the rational utilization of medical resources can be promoted. From 20 10 to1-September, the number of inpatients in the city was 367,000, an increase of 69.9% over that before the system was merged. The per capita hospitalization expense within the basic medical care scope is 30 19 yuan, which is 628 yuan lower than that before the system was merged. The per capita payment of the overall fund is 1.748 yuan, an increase of 24.3% over that before the merger; The average reimbursement rate reached 57.9%, which was higher than before the system was merged 19.3%. Third, through the comprehensive information platform, the mechanism of direct settlement of medical expenses of insured persons and prepayment of medical insurance fund has been innovated. The latter has reduced the long-standing phenomenon of arrears in medical expenses, especially the primary medical institutions such as township hospitals and community hospitals have obtained stable sources of funds. Fourthly, the administrative cost of the government has been reduced and the service level of the government has been improved. Zhanjiang City has reduced the relevant staff, which can save the government expenditure by more than 8 million yuan every year. "Zhanjiang Model" has achieved a win-win situation for the government, hospitals, the masses and commercial insurance companies.
The Essence of Zhanjiang Model
The specific mode of cooperation between Zhanjiang City and PICC Health Zhanjiang Branch is to continue to use 85% of the original individual contributions of basic medical insurance for urban and rural residents for basic medical insurance expenses (managed by the social security department), and withdraw 15% to purchase large supplementary medical insurance services for PICC Health. Under the condition that the individual payment standard remains unchanged, according to the different payment grades (the payment grades are divided into 20 yuan and 50 yuan), on the basis of the original basic medical insurance limit of 1.5 million yuan, the amount of protection has been greatly increased, and the accumulated reimbursement amount has reached 80,000 yuan and 1.5 million yuan.
The first is the government's promotion. First, set up the "Office of the Leading Group for Basic Medical Insurance for Urban and Rural Residents" to coordinate social security, health, finance and other departments to plan and design a new medical insurance system model; The second is to integrate government management resources, establish the main body of supervision of urban and rural overall medical insurance system, and continuously improve the efficiency of medical insurance management; The third is to promote social security departments, designated hospitals and insurance companies to establish a new cooperation mechanism, guide social security departments and insurance companies to actively explore the reasonable rate level of supplementary medical insurance, and promote medical insurance reform to achieve sustainable development. Secondly, it is driven by commercial mechanism. After China People's Insurance Company Zhanjiang Branch intervened in the basic medical insurance system, driven by its own profit-seeking motivation, it should not only review the large supplementary medical insurance, but also put the monitoring before the basic medical insurance, effectively prevent the unreasonable overflow of the basic medical insurance to the supplementary medical insurance, such as excessive medical treatment, false medical treatment, hospitalization and bed hanging, and ensure reasonable treatment and reasonable expenses. This "deep participation" is another key to the "Zhanjiang Model".
The advantages of "Zhanjiang model" are: on the one hand, "government-led" to resolve hospital resistance. As we all know, hospitals are the hard bones of medical reform. Hospitals are used to making their own decisions, and commercial insurance companies want to "intervene" and supervise their medical behavior, which is a horizontal intervention in the vertical hospital management system. Without the overall leadership of the government, it is almost an "impossible task" for insurance companies to enter hospitals. In the first half year of its implementation, the "Zhanjiang model" met with the uncooperative and resistance of the hospital in the process of entering the hospital. If it weren't for the coordination and communication of the government, it would have almost died. Of course, the hospital will only be glad that the insurance company has entered. Because insurance companies not only bring economic benefits to hospitals, improve the relationship between doctors and patients, but also contribute to information construction. For example, the standardized, standardized and data-based supervision of insurance companies based on their unique actuarial ability will help to improve the informatization level of hospitals and establish a regional modern medical informatization system that "breaks the fragmented system". In addition, it will be the general trend to set up a hospital authority with "separation of management and operation". Then, the professionalism of medical supervision of insurance companies can be combined with the professionalism of hospital administration, so as to realize the establishment of modern hospital management system in China.
On the other hand, the incentives of participants are compatible. Led by the Party Committee and government, social security departments, commercial insurance companies, designated hospitals for medical insurance and insured persons ("1+4") participated together, realizing structural optimization and system upgrade, and achieving a win-win situation for all parties. The goal pursued by the government and the social security department is to ensure the healthy operation of the medical insurance system with low financial input and high security level; The goal of insurance companies is to expand customer resources and enhance brand influence without losing money in undertaking business; The goal of designated hospitals is to make full use of medical resources, maximize medical income and settle medical insurance expenses in time. The goal of the insured is to improve the level of medical security, reduce the proportion of self-payment, and facilitate the reimbursement and settlement of medical expenses under the condition of unchanged payment.
How to improve Zhanjiang model
Zhanjiang Model is not without challenges. First, Zhanjiang City used 15% of individual contributions in basic medical insurance to purchase large supplementary medical insurance (commercial insurance) to improve the level of protection, which is suspected of violating the regulations on the management of medical insurance funds. According to the current regulations, the new rural cooperative medical fund needs to be "stored in a special account, earmarked for special purposes, and strictly closed to ensure that the cooperative medical fund and interest are all used for medical subsidies for participating farmers". The basic medical insurance fund for urban residents can only be used to pay medical expenses within the prescribed scope.
In fact, the merger of urban medical insurance and new rural cooperative medical system in Zhanjiang City is an innovation in itself. To evaluate it, we should not only calculate small accounts, but also large accounts, such as the income and expenditure of funds, the operation of funds and other small accounts, as well as people's livelihood issues, government management and other big accounts. The new medical reform plan puts forward that "under the premise of ensuring the safety and effective supervision of the fund, we should actively advocate the way for the government to purchase medical security services and explore entrusting qualified commercial insurance institutions to handle various medical security management services". It can be seen that the practice of Zhanjiang municipal government does not violate the essence of "earmarking" of medical insurance funds, and is in line with the general direction of the new national medical reform. It is a basic business law that insurance institutions need the lowest profit to participate in handling. Moreover, the newly promulgated "Social Insurance Law" has no prohibition on this, and puts forward the purpose of "maintaining and increasing the value under the premise of ensuring safety".
Secondly, Zhanjiang, as an underdeveloped area, draws a certain proportion from the insured's basic medical insurance payment to purchase supplementary medical insurance. This practice reflects the urgent desire of the local government to improve the level of medical security and promote the reform of medical security, but it is suspected of compulsory insurance. In fact, according to the experience of American medical insurance reform, compulsory medical insurance is inevitable, and in the long run, the advantages outweigh the disadvantages. Because under the compulsory insurance system, according to the "law of large numbers" of insurance, payout ratio will be limited to an acceptable and predictable range, and the level of insurance premium will tend to be stable. Coupled with government intervention, it will reduce the phenomenon of insurance companies profiteering from it, thus to some extent, it can curb the rise of premiums. Moreover, under the compulsory medical insurance system, people's enthusiasm for medical treatment will be enhanced, which is conducive to the early detection and treatment of diseases, not only to reduce medical costs, but also to improve the overall health status of the whole people.
In view of the above two problems, it is suggested that Zhanjiang City adopt the following two schemes in the next pilot: First, change the source of commercial insurance payment, from the burden of the insured to the financial burden of the government. The government can adjust the basic medical insurance payment subsidy to ensure a reasonable financial burden. The second is to introduce the decision-making mechanism of local people's congresses to avoid violating the voluntary principle of commercial insurance. The local people's congress departments decide whether to purchase commercial supplementary insurance and determine the final level of medical security. In addition, "Zhanjiang Model" should continue to expand the interests of the insured.
How to popularize "Zhanjiang model"
The next step for the relevant departments in Guangdong Province is to study the specific measures for refinement and promotion. The first stage: set up a leading body to promote the pilot work. You can set up a leading group for the pilot and promotion of Zhanjiang model of medical insurance; Choose one or two underdeveloped areas and cities as pilots for promotion. The second stage: timely and comprehensive promotion, using the "Zhanjiang model." First, write the "Zhanjiang Model" operation manual to guide the promotion of "Zhanjiang Model" in other regions. Second, combined with the practice of pilot cities such as Zhanjiang, the policies, attitudes and institutional arrangements for commercial insurance companies to participate in medical insurance management were further clarified by formulating provincial-level guiding documents. The third is to formulate supporting policies to solve the problems of commercial insurance participating in basic medical insurance and enjoying tax reduction and exemption.
In addition, the integration of urban and rural areas, municipal co-ordination, government-led, commercial insurance mechanism (rate determination) and other aspects of "Zhanjiang Model" are an organic whole, and one-sided and fragmented understanding and practice should be avoided when promoting it in various places. In addition, the medical security system is a systematic project with great influence, wide coverage and complex mechanism. Local governments should have strong leadership and coordination to establish a win-win cooperation mechanism. Finally, all localities should adhere to the principle of "adapting to local conditions and promoting by classification". (2 1 Century Business Herald)