Since the 1950s, China has gradually established a medical insurance system with the characteristics of the times and played a significant role. However, with the development of the economy, the defects of the previous medical insurance system have been gradually exposed. This paper starts from the shortcomings of the current medical insurance system, analyzes the reasons for the occurrence of the problem, and proposes to make more efforts to carry out medical insurance reform and build a medical insurance system with Chinese characteristics.
1 Situation of China's medical insurance system
China's employee medical insurance system was established in the early 1950s, including public medical care and labor insurance medical care two parts. This system has been implemented for several decades and has played a positive role in safeguarding the health of employees, reducing their personal and family burdens, and improving the health of the whole nation, promoting economic development and maintaining social stability, and has played an important role in China's political, economic and social life. However, with the reform and opening up and the development of the market economy, China's medical insurance system, the existing shortcomings are increasingly exposed. The main performance of the following aspects: (1) medical costs of the state and enterprises to cover too much, heavy burden, mismanagement, the lack of effective cost control mechanism, resulting in great losses and waste; (2) health insurance coverage is narrow, the degree of socialization of services is low, part of the workers to meet the basic medical needs of the phenomenon of waste of health care resources coexist, the public health care and labor insurance medical system is not unified. As the original medical insurance system was no longer adapted to the requirements of the development of the market economy, it even impeded the further deepening of institutional reform. For this reason, the State Council issued the Decision of the State Council on the Establishment of a Basic Medical Insurance System for Urban Workers [Guo Fa (1998) No. 44] (hereinafter referred to as the Decision) in December 1998, deploying a nationwide effort to comprehensively promote the reform of the workers' medical insurance system, and calling for the establishment of a new basic workers' medical insurance system throughout the country within 1999. Since the promulgation of the Decision, provinces and cities throughout the country have stepped up the construction of a basic medical insurance system for urban workers on the principle of "low level, wide coverage, burden on both sides, and combination of accounts", and significant progress has been made. All provinces and cities have basically established the basic framework of basic medical insurance for urban workers in accordance with the actual situation, set up a social medical insurance office (social security fund office), established a social co-ordination fund and individual accounts of the basic medical insurance fund, and the social security fund office is responsible for examining and selecting designated medical service organizations and designated pharmacies, and drawing up a list of medicines, diagnostic and therapeutic items, medical service facilities and corresponding management methods for basic medical insurance. The Office of the Social Security Fund is also responsible for examining and selecting designated medical service organizations and designated pharmacies, and drawing up a list of basic medical insurance drugs, diagnosis and treatment items, medical service facilities, and corresponding management methods. In addition to basic medical insurance, a system of mutual assistance for large medical expenses has also been established in all regions, in order to deal with medical expenses above the maximum payment limit of the social insurance fund.
2 Deficiencies in the current social medical insurance system
The achievements made in the more than four years since the Decision was promulgated and put into effect are evident to all. However, with the further deepening of institutional reforms, such as changes in industrial structure, the deepening of the reform of the property rights system of state-owned enterprises, and the loosening of the control of the household registration system, some of the contradictions and problems existing in the current social health insurance system have gradually been exposed, which are mainly reflected in the following aspects.
2.1 Problem of fairness Although fairness is the primary issue to be considered for the establishment of the social medical insurance system, which is also reflected in the Decision, this problem has not been well solved due to the basic national conditions and special characteristics of China. First of all, from a general point of view, to date, less than 100 million people, or less than 1/12 of the total population, are covered by social medical insurance, and the vast majority of the population, especially the majority of peasants, are not covered by medical insurance. Although we have implemented a cooperative medical system in rural areas that is different from the urban medical insurance system, the implementation of this system is worrying because of the many constraints on farmers' incomes, township finances, and so on, and the problem of difficulties in accessing medical care has not been resolved in a good way. Moreover, in the long run, it is an inevitable requirement to break the urban-rural divide and establish a unified social security system. Therefore, the issue of social and medical security in rural areas should be considered within the overall framework of the social medical insurance system. Secondly, purely from an urban point of view, according to the requirements of the Decision, the scope of coverage of the insured population is all employers in towns and cities, including enterprises, organs, institutions, social organizations, privately-run non-enterprises and their employees, while it is up to the provinces, autonomous regions and municipalities directly under the central government to decide whether or not to participate in the participation of township and village enterprises and their employees, and the owners of urban self-employment organizations and their employees. In fact, provinces and municipalities have in principle included the latter in their medical insurance schemes. However, from the results of implementation, the actual coverage of the insured population is very limited by the willingness and ability of enterprises (including individuals) to pay, resulting in a large portion of the population's medical needs being unprotected, and those who are willing to participate in the insurance program and have the ability to pay are mainly the employees of governmental agencies, scientific research institutes and other institutions, as well as those working in the more efficient state-owned and collective enterprises, and those working in the private sector, Employees of three-funded enterprises, self-employed businessmen and urban residents, and vulnerable groups in urban areas (including laid-off unemployed, low-income workers, patients with serious illnesses, serious diseases and special diseases, and frail and sickly retirees) have a very low rate of participation in the insurance scheme, and students of universities and colleges and universities who used to be entitled to publicly-funded medical care, and immediate family members of employees who are entitled to some of the benefits of the labor insurance scheme have not yet been included in the scope of the current medical insurance scheme, and a large number of migrant laborers have also been pouring into the towns. A large number of migrant laborers have no medical insurance at all. Due to the low participation rate of social groups, the age structure of insured workers tends to age, which will make the accumulation of the insurance fund weaken and gradually shrink: on the one hand, it makes the horizontal social mutual assistance of the insurance fund poor, and can not equalize the burden of medical expenses; on the other hand, it also leads to the vertical accumulation of individual accounts to protect the role of the individual account is greatly weakened. This is not conducive to the diversification of medical risks, but also does not reflect the social health insurance **** relief and fairness, at the same time, also jeopardizes the sustainable development of the health insurance system.
2.2 Fund Balance Problems Fund balance is the key to the effective operation of the medical insurance system, and a prerequisite for the sustainable development of the medical insurance system. At present, all provinces, municipalities and urban workers' basic medical insurance funds have the same problem, namely, the imbalance between fund income and expenditure, the low degree of protection of the social coordinating fund, and the weak payment capacity of individual accounts, which cannot meet the basic medical consumption needs of the insured.
The current situation: on the one hand, due to the aforementioned low participation rate of the social groups, the structure of the aging and other reasons, the accumulation of the fund is weakening or even shrinking, and the government has not given the fund to the financial support, coupled with many units should be enrolled in the insurance does not participate in the delay in the payment of premiums for no apparent reason, omission, concealment of the wage base to avoid the payment of contributions, resulting in the fund of the fund's financing level is very low; on the other hand, from the actual consumption of medical care, even if the participation in basic medical insurance, the individual account payment ability is weak, unable to meet the basic medical consumption needs of the participants. On the other hand, from the point of view of actual medical consumption, even if one participates in the basic medical insurance and enjoys the basic medical insurance treatment, due to the "threshold" set by the starting standard of the integrated fund is too high, the risk of burdening the high medical expenses above the ceiling is high, and the high proportion of medical expenses borne by the insured person is high, coupled with the lack of reasonable and effective supply-side constraints, such as indiscriminate charging by hospitals, abuse of medicines, indiscriminate examination and pharmaceutical products, and the lack of effective supply-side constraints. The problems such as indiscriminate charging by hospitals, misuse of medicines, indiscriminate examination, and inflated pricing in the production and circulation of medicines, etc., once suffering from a major, serious or chronic disease, the payment from the coordinated fund and the individual account will be seriously insufficient and there is a large shortfall, and the insured people are forced to pay the very high medical costs in cash, which brings an unaffordable financial burden to low-income earners and the frail and sickly people.
2.3 Supplementary Medical Insurance ProblemsThe social medical insurance system includes basic medical insurance and supplementary medical insurance. China is at the current stage of the low level of productivity, the basic medical insurance can only be "low level, wide coverage", and it is in the depth and breadth of the gap in the insurance, need to rely on supplemental medical insurance, that is, commercial medical insurance to supplement. Commercial medical insurance is flexible, convenient and highly selective, which can improve the level of social medical insurance and meet the needs of different people at different levels. Its professional and market-oriented operation mechanism can also be used as a reference for the management of basic medical insurance, so as to promote the standardization and scientification of the management of basic medical insurance. Therefore, only by effectively connecting basic medical insurance and commercial medical insurance can we make the medical insurance system more scientific and perfect.
Commercial medical insurance in China started not long ago, there are still considerable obstacles to the development. Concentrated in: (1) medical reform is not in place, the relevant laws and regulations are not supporting; (2) the lack of policy support to encourage the start of health insurance; (3) the insurance company's own professional management level needs to be improved. Medical insurance is a highly specialized, technically demanding and relatively difficult to manage business. Since medical insurance started late in China and has long been treated as a subordinate business or additional insurance, insurance companies generally lack experience and technology in medical insurance, and the level of risk management and control is relatively low; there is insufficient training of talents, and a team of specialized talents has not yet been established; product innovation is not strong, and the monotonous and repetitive nature of the insurance products makes it difficult to satisfy the different requirements of the market.
2.4 Reform of Medical InstitutionsThe main problem that exists in China's medical service market at present, horizontally, is that the administrative monopoly has not been broken, and there is a lack of a level playing field. The government directly owns and manages medical institutions, puts its main focus on running hospitals, and to a certain extent consciously or unconsciously becomes the protector of the interests of public hospitals. This restricts the development of other forms of property rights in medical institutions; the market is inefficient in resource allocation because of the lack of competition; public medical institutions take advantage of their monopoly to pursue economic benefits one-sidedly, with indiscriminate charging, indiscriminate inspections, indiscriminate prescribing of medicines, and poor quality of service, directly victimizing ordinary consumers of medical services. Vertically, irrational regional health planning is the main problem. This is mainly reflected in the compartmentalization of health resource allocation, duplication of construction, structural imbalance, wastefulness and shortage of resources, high operating costs, low overall utilization efficiency, and an inability to satisfy the people's health-care needs. Therefore, medical institutions are in urgent need of reform, medical and health resources need to be reintegrated.
3Establishment of a medical insurance system with Chinese characteristics
3.1Coordination of social and economic development, scientific planning, and strengthening of the macro-guidance of the medical insurance systemThe medical insurance system, as an important social policy, involves a wide range of social activities, and has become inseparable from and closely related to the various insured persons. Therefore, it is necessary to formulate a medium- and long-term medical insurance development plan that is consistent with the level of social and economic development, and that can meet people's medical needs, in order to guide social development, coordinate the relationship between social and economic development, and make it a guide for people's social behavior. Through the medical insurance business planning, the implementation of the basic medical protection for the insured in line with the level of socio-economic development, and strive to realize the mutual coordination and sustainable development of socio-economic and medical insurance business. In the long term, based on the long-term, scientific and democratic planning of the future medical insurance business, correctly recognize and deal with the interrelationship between socio-economic development and the development of the medical insurance business, coordinate the scale, speed and proportion of the development of socio-economic development and the medical insurance business, determine the fund-raising and use of the fund, the cost-sharing and cost-constraint mechanisms in line with the requirements of socio-economic development, accurately grasp the overall situation and local, immediate and long-term, overall and unit and other types of medical insurance. In order to accurately grasp the overall and local, immediate and long-term, overall and unit indicators of various scales, speeds and ratios, correctly deal with the interests of the state, the collective and individuals, coordinate the various medical insurance relationships among medical insurance administrators, medical service providers and insured persons, and reasonably allocate social resources in accordance with the needs of the society so as to realize the rational allocation of resources and avoid wastage. Seeking balance in dynamics, seeking development in balance, seeking balance in development, so that the operation of the medical insurance system is in a virtuous circle, promoting the continuous progress of the medical insurance cause, so that more members of the community to enjoy more of the benefits brought about by medical insurance.
3.2Speeding up the pace of legislation on medical insurance and constructing a legal guarantee for medical insuranceThe reform of the medical insurance system is mandated by the state in order to safeguard the basic medical needs of all laborers, and is characterized by compulsion, mutual aid and fairness. Therefore, in order to ensure the realization of its objectives, it can only be implemented by national legislation through legal channels. The medical insurance fund is a health safety net established to provide financial protection for insured persons in the event of disease risk, and is the "life preservation money" of all insured persons, whose role is of profound significance and great importance. But now its relevant legislation is not sound, lagging behind, to jeopardize the security of the medical insurance fund, the relevant provisions of the law is not targeted, weak penalties, or even law enforcement penalties are not based on the law, it is difficult to effectively play a strong role in the law to achieve the purpose of punishment and warning. For this reason, it is recommended that medical insurance as soon as possible into the legislative program, accelerate the legislation of medical insurance regulations, so as to construct a medical insurance fund security legal protection line of defense to ensure that the operation of the medical insurance system, is the urgent task of the current medical insurance work.
3.3 Strengthening the dynamic study of medical insurance policy is an important prerequisite for scientific decision-making in the reform of the medical insurance system, social and economic development, technological advances and people's health awareness, so that people's demand for medical care continues to increase, the old medical insurance policy can only adapt to the original basic medical needs, can not solve the changing objective situation, and even to solve the previous contradictions or problems caused by new problems. New problems have been created to solve the previous conflicts or problems. There are many relationships affecting the development and change of medical insurance, various contradictions are intricate and complex, various reasons are very different, and various factors interact with each other and cause and effect each other, which makes the situation more complicated. The policy study of the health insurance system is to prevent new contradictions that may arise during the implementation of the health insurance system, to solve new situations and problems that arise during the implementation of the health insurance system in a timely manner, and it is an important prerequisite for scientific decision-making on the reform of the health insurance system. Therefore, only by strengthening the process management and dynamic research of the medical insurance system, and adjusting the medical insurance policy at an opportune moment, so as to avoid or minimize the impact and waste of the medical insurance system and the medical insurance fund due to the lagging behind of the medical insurance policy, and by constantly improving the medical insurance system, can the medical insurance policy be effectively brought into full play in order to meet the increasingly evolving and changing needs of the health care sector, and to ensure the steady operation of the medical insurance system. The system will be able to effectively play the role of medical insurance policy in order to meet the increasingly evolving medical needs and ensure the steady operation of the medical insurance system.
3.4 Open-source and cost-saving, focusing on cost-saving Rational use of the medical insurance fund is an important way to implement the strategy of sustainable development of medical insurance. The introduction of the new "Regulations on the Treatment of Medical Accidents" on the hospital in the medical safety requirements are higher, more stringent, must seriously consider the medical safety, a variety of new medical technology projects, new diagnostic and treatment equipment successive inputs, the use of new and high tech medical materials, greatly reducing the medical risk. Therefore, as a medical provider are hoping to reduce medical disputes through the safe use of high-tech equipment, at the same time, it can also bring them lucrative economic benefits. However, this has led to an increase in medical costs, an increase in the social burden of medical care, and a new pressure on the expenditure of health insurance funds. With the accelerated pace of population aging, the proportion of the elderly population in the structure of the insured population has been climbing. The income of the medical insurance fund has not kept pace with the growth of the medical insurance fund's expenditures, and it is facing the double pressure of the difficulty of raising the medical insurance fund and the accelerated growth of medical needs. This is not conducive to the smooth operation and sustainable development of the medical insurance system, and if it is not studied and resolved in a timely manner, it will inevitably lead to the emergence of the doling out of food and food, turning medical insurance into water without a source and wood without a root, and ultimately causing the entire reform of the medical insurance system to fail and lose credibility with the people. Therefore, for the time being, it is necessary to both open the source of income and reduce expenditure, open the source of income and reduce expenditure simultaneously, put the reduction of expenditure in the first place, strengthen the control of medical costs, improve the efficiency of the use of medical insurance fund, rational and effective use of medical insurance fund, to ensure the sustainable development of medical insurance.
3.5Strengthen guidance, introduce competition, rational allocation of medical resources, and promote the construction of community medical institutions due to the special characteristics of the medical services market, medical care provider to master all the medical information and medical resources, in a monopoly position, the formation of a seller's market, and thus easy to make the market failure. Market mechanism alone cannot solve the problem of rational allocation and rational utilization of resources. Therefore, in order to ensure fair competition in medical services and the legitimate interests of the insured, government intervention is indispensable. At present, the construction of community medical institutions is particularly prominent, the government departments should through macro management, improve the planning and allocation of health resources, formulate relevant policies to support community health care, encourage and guide all kinds of social funds to participate in the construction of community health care, multi-channel, multi-faceted increase in community health care institutions, and increase the training of general practitioners adapted to the needs of the community health care to improve the level of service of community health care institutions, and create a good community health care institutions, and to improve the quality of service. service level of community medical institutions, create a favorable environment for community medical care, and establish a good image among the public. The medical insurance management department, in determining the fixed points of medical institutions, formulates standards and norms for payment of fees based on the average cost or advanced cost in society, rationalizes the layout based on the actual situation of medical insurance, determines the amount of health resources needed to provide medical services to insured persons, breaks the monopoly, introduces competition, and reverses the passive situation. Guiding medical institutions through internal potential, reduce costs, improve services, improve economic efficiency, at the same time, the eligible social medical institutions to give policy support to accelerate the pace of fixed-point, and from the health insurance settlement policy, the standard on the appropriate tilt, in order to attract the insured patients close to the doctor, the convenience of the insured patients, reduce health care costs, and truly realize the "minor illnesses in the community, major illnesses in the The hospital".
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