What is Cost Containment?
Health insurance cost control, as the name suggests, refers to controlling the insurance expenditure spent on medical services, reducing medical waste and improving the efficiency of the use of health insurance funds.
Who is leading the charge for health insurance?
What determines the structure of a country's or region's health insurance spending is the country's or region's health insurance system.
Specifically, in the provision of medical services, the government, commercial insurance companies, doctors, hospitals, pharmaceutical companies and other parties in the game process, which party dominates the process of medical services, prices, and thus dominate the health insurance premium control.
Model of Medical Physique Research
Dominance under Different Medical Systems
Control of Health Insurance under Different Medical Systems
UK: Government-led Health Insurance Controlling Mode
The government mandatorily raises funds from the society through taxation to provide the whole population with healthcare costs, and the government directly operates hospitals, employs medical personnel, and directly provides medical services. services. In terms of drug catalogs, the government establishes a list of free drugs, sets profit margins for pharmaceutical companies, and centralizes the procurement of drugs.
Germany: government-regulated, social organization-led health insurance fee-control model
1, fund-raising: members of the community can independently choose from various types of foundations, and the employer and the individual each share 50% of the funds, the rate of different foundations have a certain degree of difference, and the rate of health care insurance is related to the level of income of an individual, the higher the income has to pay the higher proportion, but enjoy the medical services are the same as other members of the foundation. The higher the income, the higher the contribution rate, but the medical services are the same as other members of the foundation. The federal government is only responsible for the macro-control of all the foundations, and does not intervene in their specific operations. At the same time, according to the structure of the policyholders of different foundations, the rate difference, the difference between the insurance programs, etc. to regulate the income of various types of foundations, allocation, adjustment of the income disparity between foundations, and to promote fair competition;
2. Provision of health care services: Germany's health care resources are very dispersed and evenly distributed, and the implementation of the system of separation of outpatient and hospitals. and hospitals are separated from each other. Community doctors play a very important role in the local community doctors to general practitioners, but also some specialists, 80% of the common diseases can be solved in the community hospitals; the number of general hospitals is relatively small, more hospitals in a certain field of strength, the foundation is responsible for the doctors and various types of medical services through the contractual way to link up, to provide members with flexible health care, general members can choose their own general practitioners, and the general members can choose their own general practitioners. In general, members can independently choose a general practitioner for consultation, while specialists need to make appointments and follow the arrangements, and they need to pay for the specialists they choose;
3. Pharmaceutical pricing: Germany has established a strict reference pricing system for pharmaceuticals. Various foundations negotiate with pharmaceutical companies based on the reference pricing of medicines, and the logistics and distribution of medicines are also the main responsibility of the foundations. Due to the reference prices set by the government in Germany, the foundations have a slight advantage in the price negotiations.
1) The dominance of medical services -- "pay-as-you-go". At present, Germany adopts the system of "sectoral budgeting and expenditure capping", which basically determines expenditure by income in all aspects of medical services: hospitals and outpatient doctors are paid independently, and hospitals are paid in advance in total, with the excess being shared by the hospitals and foundations; the foundation pays the doctors in two main steps: firstly, the capitation fee will be paid to the physicians' association in accordance with an agreement in accordance with the number of participants, and the physicians' association will pay the capitation fee to the physicians' association in accordance with an agreement in accordance with the number of participants. The foundation pays doctors in two main steps: first, the capitation fee is paid to the physicians' association according to the number of insured people, and the physicians' association unifies the management of doctors in the whole country; second, the physicians' association pays the labor fee of doctors according to the labor paid by doctors. Doctors do not have access to medicines, and medicine is separated.
2) Drug Pricing - Drug Reference Pricing System and Drug Payment Limit System. Reference pricing is based on the price of substitutable drugs, patients can only buy drugs below the reference price to get reimbursed by health insurance, and the excess part has to be paid out-of-pocket, which leads to full competition in the price of pharmaceutical companies to reduce the price of medicines, and transfer the profits of medicines to the Foundation; in addition, Germany has implemented a payment limit system for doctors' prescription drugs and over-the-counter drugs purchased by individuals to strengthen the awareness of individuals and doctors in controlling health care costs.
The U.S. has a system of payment limits for doctors' prescriptions and over-the-counter medicines purchased by individuals to strengthen individuals' and doctors' awareness of controlling medical costs.
USA: Controlled health insurance companies dominate the health insurance cost control
Controlled health insurance system, that is, the insurance company through the different insurance plans, limited to the scope of doctors and hospitals chosen by the plan members to control the specific process of medical services, strict control of the cost of medical services, through the standardization of diagnosis and treatment processes, systematic methods to achieve control of the overall medical costs. The plan is designed to control the overall medical expenses by standardizing and systematizing the treatment process.
1) Patients choose insurance products provided by commercial insurance companies: In principle, as long as the ability to afford the premiums of U.S. citizens can freely choose from a variety of insurance products provided by various insurance companies; because most of these products are commercial insurance, so when choosing different insurance products, it is necessary to be clear about what services are insured, what services are not insured, the rate is high or low, and the proportion of out-of-pocket payments (generally, the proportion of out-of-pocket payments is high, the premium rate is low). The insurance company will provide the corresponding directory: after the customer has purchased the insurance product, the insurance company will provide the customer with a network list of primary doctors, and the customer will select one of them, who will be the customer's health care doctor or family doctor, and will be responsible for the customer's initial diagnosis of the disease, the annual physical examination, and the simple medical treatment; this relationship will be accompanied by the customer for many years, and this customer's health care doctor will be responsible for the customer's medical treatment, and the customer's health care doctor will be responsible for the customer's health care services. This relationship will be with the customer for many years, the customer's health care doctor generally knows the customer's physical condition best;
3) Recommendation after the initial diagnosis: If the customer's body is sick, it is the first to go to their own health care doctor to deal with, if the health care doctor feels that he or she can't deal with it, he or she will give the patient to issue a referral (Referral) to the patient, recommending that the patient go to the appropriate hospital to do further treatment, of course, the recommended this doctor to do further treatment. further treatment, of course, the recommended specialist is also to be provided by the insurance company's network list;
4) the handling of the licensed doctor: when the patient to get a referral to the designated hospital to accept the designated doctor's diagnosis, if you need to be hospitalized, the doctor should first of all to the patient's insurance company to submit an application for hospitalization, to get approval before applying for hospitalization procedures with hospitals without the insurance company's permission, hospitals can not accept patients. Without the permission of the insurance company, the hospital cannot accept the patient unless the patient pays all the expenses; if prescription drugs are needed, the doctor will issue a prescription to the patient, of course, the catalog and price of the prescription drugs have to be selected from the catalog provided by the insurance company, and the patient will go to a retail pharmacy to buy the drugs with the prescription order; at the same time, the doctor will upload the patient's electronic data on the current medical treatment process and the prescription to the PBM (PharmacyBenefitManager). PharmacyBenefitManager) company;
5) PBM company completes the billing: the PBM company settles the bill based on the prescription electronic data and the corresponding reimbursement level. It also records the details of each treatment and provides data processing and analysis to commercial insurers.
1) Dominance of medical services: medical insurance companies will recommend to doctors the optimal treatment process for the corresponding diseases according to the needs of different diseases, and pay the doctors according to the national uniform rate, the doctors will charge according to the number of treatments, and the more they do, the higher their income is; for the hospitals, the insurance companies will pay the total amount of money according to the different diseases, and the part exceeding the reimbursement of the insurance company will be borne by the hospitals themselves, the hospitals Ideas to try to improve the efficiency of the use of facilities to reduce the length of hospitalization of patients;
2) the pricing power of drug prices: the United States of America drug price setting has nothing to do with the cost of medicines, the formation of drug prices is mainly the result of mutual negotiations between the pharmaceutical companies and commercial insurers, commercial insurers negotiating chips are the drug catalogs of the various companies, the process of each commercial company's PBM companies to participate in, and in some cases, need the participation of mutual supporting wholesalers. Need to support each other's wholesalers to participate in, is a *** with the negotiation process; drug companies game the biggest chip is the market monopoly position.
Singapore: savings-based social security system, public hospitals dominate the health insurance fee control
In Singapore, the hospitals that provide medical services are mainly public, and the formation of hospitals as the core of the health care provider. In terms of medical service prices and drug prices, Singapore places more emphasis on the role of the market, with individuals bearing a larger proportion of the burden.
1) Mobilizing funds: Singapore requires employees earning more than S$6,000 to save 6-8% of their monthly income in a personal account, with the individual and the employer each bearing half of the burden. The savings in the personal account are used to pay for the individual's or family's education, housing, pension and medical expenses. The Central Provident Fund Board (CPFB) is responsible for the management of these individual accounts and the preservation and enhancement of their value. For citizens with less than S$6,000, the Government provides a minimum guarantee.
2) Provision of healthcare services: There are 29 hospitals and healthcare institutions in Singapore***, of which 13 are public institutions. More than 72% of the beds belong to these public institutions, and the ownership of these institutions is also attributed to the government, so the overall healthcare market is basically dominated by the public sector. In terms of management, the government adopts the management style of a private enterprise, setting up a board of directors and hiring a chief operating officer to ensure the implementation of the government's systems in the hospitals, and at the same time dividing all the public institutions into the "Western Group" and the "Eastern Group," so that cooperation and scale effects can be formed among the groups. This will allow them to cooperate with each other, creating a scale effect, and encouraging competition among them to reduce health care costs.
3) Setting of drug prices: Hospitals purchase drugs through open tenders and bulk purchasing, so the overall formation of drug prices is the result of market-oriented games. In terms of health insurance control, public hospitals play a leading role, but the overall price is determined by the market, while the threshold for granting reimbursement is higher, resulting in more responsibility being placed on individuals and families.
1) dominance of medical services: since most hospitals are public, coupled with private enterprise-style management and competition from the two major groups, the overall cost of medical services has been effectively controlled;
2) dominance of drug prices: since the mode of negotiation between the hospitals and pharmaceutical companies is adopted, the prices of medicines are basically market-driven, and the government's control over them is weaker;
3) individuals bear more responsibility for the cost control of medical insurance. p>3) Individuals take on more responsibility for medical care: Individuals have to balance the expenses for housing, retirement, education, and medical care in their savings accounts, and at the same time, the government has set a starting line and a ceiling for medical expenses, with individuals having to bear most, if not all, of the expenses below the starting line and above the ceiling, and individuals having to pay 50 percent of the expenses in the period between the starting line and the ceiling.
Conclusion
By comparing different health care systems above, we can find that different health care systems determine different health insurance plans, and different insurance plans determine the pricing mechanism of medical services and drug prices, which in turn determines the structure of a country's health care expenditures, and ultimately leads to which side of the different countries holds the dominant position in controlling the costs of health care.
From China's situation, our health insurance system is still unsound, the proportion of medical expenses to GDP is still at a low level compared to other countries, and the aging process has just begun; from the current medical expenditure in China, personal expenditure still occupies a considerable proportion, and the formulation of clinical pathways and prescribing rights of hospitals has a greater impact on health insurance costs. In the coming period of time, the dominant power of medical insurance cost control will be in the game between hospitals, the government and commercial insurance companies.
From the comparison of the growth of medical expenses between China and foreign countries, China's health insurance fee control ability is relatively weak.
China's aging rate increased by one percentage point, medical expenditure increased by 13%, China's health insurance fee control is a long way to go