Challenge No. 1: Can universal health insurance ease the cost of medical care?
The new health care reform program was announced. The people worry about is "expensive". Whether reasonable or not, the cost of medicine is not cheap. Many people can't afford it for a while, and some can't afford it for the rest of their lives. How to alleviate the "expensive medical treatment"? The new medical reform program points out a way, which is universal medical insurance. Everyone is covered by health insurance and becomes a participant.
The function of medical insurance is to share the risk of patients' medical expenses, i.e., to share the risk between healthy and sick people, and also to share the risk between sick and healthy times of patients. Participants usually pay premiums, and when they see a doctor for treatment, they only need to pay a small part of the cost of medicine, while the medical insurance organization pays the bulk of the cost to the medical institutions. In this way, seeing and treating a doctor is naturally less expensive.
Toward universal health insurance is the most central, clear and operational part of the new health reform program. Specific measures can be simplified as 3+1, that is, the three major public health insurance (including urban workers' health insurance, urban residents' health insurance, new rural cooperative) plus urban and rural medical assistance system. The new medical reform program has made it clear that by 2011, the 3+1 type of medical insurance will cover more than 90 percent of urban and rural residents.
What is the relationship between this and the people? The people contribute, the workplace contributes, the government subsidizes, the money goes to the health insurance organization, can the people benefit from it? How much can they benefit?
To answer these questions, you have to do the math. The family does not do the math, the day is not good; the policy does not have the account, a muddled account. Let's take a look at how much money the three major health insurances can actually raise after the new health care reform.
First, the urban workers' health insurance fund income in 2008 was 288.5 billion. As coverage expands, the level of fundraising will naturally rise. In the next three years, governments at all levels are investing 850 billion yuan in the new health care reform, a significant portion of which will be used to pay a one-time 10-year health care premium for employees and retirees of difficult, closed, and bankrupt state-owned enterprises. Therefore, after three years, 300 billion yuan a year for the urban workers' health insurance fund is definitely a conservative estimate.
Secondly, the people's participation fee for urban residents' medical insurance currently ranges from 200-300 yuan, and the minimum level of government subsidy will also reach 120 yuan, so the minimum financing per person is estimated to be up to 400 yuan.
Thirdly, the people's minimum participation standard for the New Rural Health Insurance, which is 20 yuan per person per year, is estimated to be raised to 40 yuan, and the government subsidy will be raised from 80 yuan to 120 yuan, so the minimum financing per person is estimated to reach 160 yuan.
In fact, in many places, the financing level of urban residents' health insurance and the new rural cooperative exceeds the minimum above standard.
In this way, the minimum funding scale for universal health care is estimated as follows:
Starting in 2010, the nation's urban and rural health care organizations are expected to raise at least 565 billion yuan a year. Even if 80 percent of that is spent on enrollees (and the other 20 percent on risk prevention), the health insurance organizations could pay hospitals $452 billion a year. Would that be enough money?
Currently, all hospitals in the country get about $500 billion in revenue from seeing and treating patients, which will naturally go up a bit later. But all $425 billion of the health insurance fund spent would be enough to account for more than 80 percent of hospitals' operating revenues.
In short, this payment from health insurance is enough to realize the goal of health insurance paying the lion's share and the public paying the smallest share. With universal health insurance, the proportion of out-of-pocket expenses for medical treatment is expected to drop dramatically, to an estimated 20-30 percent.
This is the new health care reform program for the people to bring real benefits. But whether these benefits can be implemented without fail is, of course, a major challenge. Health insurance organizations around the world have a long way to go. The new health care reform program proposes to reasonably control the level of the balance of the health insurance fund, pointing the way to meet this challenge.
Challenge No. 2: How to be a good broker for the insured?
With the expansion of health insurance, more money can be expected to be raised to health insurance organizations. As a result, health insurance organizations will have strong group purchasing power, and theoretically have the potential to represent the interests of enrollees by acting as group purchasers and buying pharmaceutical services for enrollees. But how can health insurance organizations buy better pharmaceutical services? To put it bluntly, it is a question of how to "spend money". This is a new challenge for the future of universal health care reform.
The purchase of medical services by health insurance organizations has two core aspects: first, from whom to buy; and second, in what way to buy.
The question of who to buy from is actually a matter of choosing a designated service organization for medical insurance. This is mainly based on two factors: first, the participants' right to independent choice, and second, the cost-benefit ratio of medical services.
From the point of view of the participants, the independent right of choice is naturally the more adequate the better. If it is arbitrary, the medical insurance fixed point will lose the necessity. Even in developed countries, public health insurance enrollees, rarely enjoy full autonomy of choice. China's existing public health insurance financing level is low, so participants to exercise unconditional, full autonomy of choice, obviously luxury, impractical. The establishment of fixed points by health insurance is mainly to set up gatekeepers to guide participants to seek medical treatment at appropriate medical institutions based on their conditions. In non-emergency cases, participants must seek treatment at pre-selected fixed-point organizations.
At present, many places have implemented the "community first-visit system", which requires participants to seek first-visit treatment only at the community health service organization near their homes. This practice creates an administrative monopoly and is not conducive to healthy competition among medical institutions. A better approach is to adopt an "open first-care system", that is, all medical institutions within a certain area can become "designated first-care institutions". Participants are free to choose, but they have to be the designated first clinic.
With the question of who to buy medical services from resolved, the next important question is how to pay.
Payers can guide the fee-payers, so health insurance organizations as a group purchaser should have the means to make the medical institutions become normal market players, that is, with a strong sense of cost-effective. Therefore, the new health care reform program proposed, "to strengthen the role of medical insurance on the monitoring of medical services, improve the payment system, and actively explore the implementation of capitation, pay per case, total prepayment and other ways to establish incentives and penalties as well as an effective constraint mechanism."
Medicare payment is a discipline, "capitation, payment by type of disease, total prepayment" these terms, not to mention the people do not understand, is that many professionals do not understand. Medical insurance is a professional service, but unfortunately, there is still a lot of room for development in the professionalization of medical insurance in our country. Do we have an occupation or profession like "medical insurance manager"?
In short, the way health insurance is paid for is a favorable lever to influence the behavior of health care organizations. When health insurance organizations are paid smartly, they will serve their enrollees well. Different payment methods have different benefits and disadvantages for different types of medical services. Therefore, the payment method of health insurance should not be a single one, but a combination of various payment methods. The exact combination depends on the contents and prices of medical services in each place, and is the result of negotiations between the health insurance and medical organizations in each place, and it is by no means possible for the higher level of government to implement a one-size-fits-all approach. Therefore, the new healthcare reform program proposes to "actively explore the establishment of a negotiation mechanism between medical insurance operators and medical institutions and drug suppliers, so as to give full play to the role of medical insurance in restraining the costs of medical services and drugs."
In any country, the improvement of the payment mechanism needs to be adjusted after two or three years or even longer, and it is impossible to accomplish it overnight. In China, how to move towards professionalization of health insurance management, how health insurance agencies negotiate with medical institutions, and how health insurance agencies themselves can achieve good governance are all big challenges facing the new health care reform, which urgently need to be actively explored around the world.
Challenge No. 3: How does the government compensate public hospitals?
Reform of public hospitals is one of the key points of the new health care reform, and also one of the difficulties. One of the difficulties lies in how the government formulates compensation policies for public hospitals. The new health care reform program has made it clear that the government should increase its investment in health care, and that the government's investment should take into account both the supply side and the demand side of health care services. The question is, how will the government spend the input from the "supply side"? This is another big challenge facing the new health care reform.
There are two common approaches to this issue: one is for the government to pay the full salaries of public hospital workers, which is a common call from public hospitals as well as health administrations; and the other is for the government to buy services and pay the service provider according to the service contract.
The first approach is commonly known as "raising the supply side". In fact, this is a kind of traditional thinking inherited from the planned economy. Compared with the planned economy era, the government now allows public hospitals to earn income from the medical services market. Many people think that as long as the Government compensates them adequately, that is, as long as they are "fed", public hospitals will not be keen on maximizing their income. I am afraid this is wishful thinking. I'm afraid that any normal person or institution that is allowed to generate its own revenue will seek to maximize it.
Public hospitals charge people to see and treat them. With the promotion of universal health care coverage, their fees for basic medical services come mainly from health insurance organizations, with a small amount coming from patients' out-of-pocket expenses; and their revenues from non-basic medical services come mainly from patients' out-of-pocket expenses and from commercial health insurance organizations. A substantial part of these incomes will of course become the wages and bonuses of their employees. If the government is allowed to pay the employees' salaries again, won't they get a double share?
Thus, the new health care reform program does not follow this practice. Regarding the government's compensation policy for public hospitals, the new health care reform program provides the following: "Gradually increase the government's investment, mainly for capital construction and equipment purchases, to support the key
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