The medical insurance fund is the first and foremost condition to ensure the normal operation of the basic medical insurance system. Once the fund is seriously overspent, the protection function of the basic medical insurance system will be weakened or even collapsed, thus leading to the failure of the basic medical insurance reform. However, it is an objective and inescapable fact that the pooled fund faces various risks in the course of its operation. Therefore, it is of great practical significance to seriously study and discuss the various risks existing in the operation of the medical insurance fund, as well as to avoid and prevent these risks. In the current social environment, the formation of health insurance fund risk can be roughly divided into the overall social factors and local social factors.
The overall social factors are as follows:
One is the result of the characteristics of China's medical insurance system itself. China's existing medical insurance system is gradually transformed from the former public medical care. At the present stage, the payment of medical insurance is done by three parties: the insured, medical institutions and medical insurance agencies. The opacity of medical consumption makes it difficult for medical supervisory bodies to make accurate definitions of the value of medical consumption and the reasonableness of the content of the consumption, which creates great difficulties for the coordinated fund to pay for the medical expenses in a normal and accurate way. Secondly, under the current situation, the financial input of the designated medical institutions remains unchanged or is even cut, and their economic benefits mainly rely on their own income-generating capacity, which inevitably makes the medical institutions take the acquisition of economic benefits as an extremely important goal to pursue, and some medical institutions even resort to all sorts of means in order to obtain the maximum economic benefits, as exemplified in the case of Harbin's sky-high medical fees, which has become a cause for concern in the past. The Harbin incident of overpriced medical care is the best example. Thirdly, with the strengthening of medical and health conditions, the problem of population aging is becoming more and more prominent, this part of the population's medical consumption needs are also increasingly strengthened, which will inevitably also cause a substantial increase in medical costs.
Localized social factors that contribute to the risk of the fund, first, the collection of the insurance fund is greatly influenced by the economic situation. In the existing market economic conditions and social environment, in the relatively backward economic base of the region, a considerable number of units in the prescribed period can not pay the full amount of medical insurance for employees on time, and these units of insured employees still have to carry out medical consumption, which will result in a substantial reduction of the integrated fund. Secondly, with the development of medical science and technology, new medical equipments are constantly being put into clinical use, and the mentality of those who seek medical treatment makes them want to use the newest and best medical equipments as much as possible, which leads to a substantial increase in per capita medical expenses, and this will correspondingly increase the expenses of the integrated fund. At present, China's medical insurance is basically based on counties and districts as the basic unit, independent operation, temporarily unable to establish the overall coordination and balancing mechanism. Raising and spending are the two keys to ensure the safe and normal operation of the fund. Raising is the basis for the operation of the medical insurance system, and only by raising the required funds on time and in full can the normal operation of the system be guaranteed, and the proportion of the funds raised is based on the local level of living and medical consumption, and also taking into account the development trend in the future, so when determining the level of the co-ordinated fund, it is necessary to go through a meticulous investigation and analysis in order to be accurate and appropriate. Under normal circumstances, the level of financing should be slightly higher than the level of medical consumption, with a slight surplus. If there is a mistake or a poor analysis in the survey and analysis, or if the future trend of medical costs cannot be correctly predicted, and the level of financing is lower than the predetermined level of medical consumption, the operation of the fund may be at risk of overdraft.
The payment method of the fund can be roughly divided into three kinds: 1, patients pay directly with the hospital when they visit the doctor, and then the patient and the health insurance organization to settle; 2, patients do not pay directly when they visit the doctor, by the hospital and the health insurance organization to settle with each other; 3, the health insurance organization and the hospital to use a fixed amount of budgetary management, the health insurance organization allocates the medical expenses month by month, and the end of the year to sum up the calculation. In general, the fund out of danger is due to the use of ex post facto settlement, because the medical institutions in the form of medical consumption occurs before the settlement, that is to say, as the settlement itself has lost the ability to constrain the medical behavior． If the prepayment system is adopted, under normal circumstances, it will not lead to the fund out of risk. Because the medical insurance organization has been in accordance with the predetermined system of indicators for the settlement of payments to medical institutions, medical institutions are in accordance with the cost of medical insurance institutions and demand for the system of indicators of the requirements of the provision of medical services. Therefore, usually there is no risk to the fund, but often prone to another problem, i.e., under-consumption of medical care. The payment method of the combined system is precisely to make up for the shortcomings of the two by taking advantage of their strengths and combining the pre-payment system and the post-payment system, and seek to promote the advantages and eliminate the disadvantages. Firstly, it is necessary to step up collection efforts and ensure the collection rate of the fund. To ensure the normal operation of the integrated fund, it is necessary to ensure a high rate of fund collection, in particular, to prevent the problem of malicious delinquency.
The second is to establish and improve the basic medical insurance budget system and fund early warning system. Before the start of the integrated year, the total income and expenditure of the medical insurance fund of the integrated year, especially the income and expenditure of the integrated fund part of the budget, and leave a sufficient margin, do the overall budget, and then verify the individual account and the integrated fund specific income and expenditure budget. The Fund Early Warning System means that when the basic medical insurance system is being set up, the management information system is used to set up corresponding warning lines for the various funds, so as to give advance warning of the risks that may exist in the operation of the fund system. For the integrated regions that have been networked, it is even more important to make full use of the management information system and the computer settlement system to carry out online monitoring.
Thirdly, it is necessary to combine the actual situation and determine the appropriate payment ratio. Because of the income level, medical consumption level and other situations around the large differences in the payment ratio and payment methods must adhere to the principle of seeking truth from facts, according to local conditions, specific analysis of specific problems, and must not copy the so-called large and medium-sized cities, the reform of the pilot set of rules already in place.
Fourth, we must establish a coordinated fund to pay the adjustment and balance mechanism. Coordinated fund to pay for the main is the medical insurance patients hospitalization costs and special outpatient part of the cost. Usually hospitalization costs are paid in sections according to a certain percentage, and how to pay for special outpatient practices vary from place to place, which is the important part of the establishment of the adjustment mechanism. Outpatient special disease subsidies should be adopted flexible proportion, that is, the specific proportion of subsidies should be determined depending on the balance of the integrated fund at the end of the year.
Fifth, the review of major illnesses should be strict. Threshold settings and payment ratios for entry into mutual aid for major illnesses vary from place to place, but the number of people entering mutual aid for major illnesses everywhere is on the rise year by year, and the increase in costs is large. This creates considerable payment pressure on health insurance operators. The risk of the integrated fund should be proactive and preventive, and it is imperative to seriously study and explore measures and methods to resolve the risk. This will ensure the normal operation of the medical insurance system. Measures to resolve the risk usually have the following points:
One should seize the opportunity to try to nip the risk in the bud. The risk of the integrated fund usually refers to the payment of the integrated fund exceeds the amount of the account of the integrated fund. This overspending phenomenon often arises gradually and can be reflected through monthly statistical statements. Therefore, the accounting and statistical reporting system should be standardized, and the monthly income and expenditure should be carefully verified. In the event of an overspending, adjustments should be made in the following month, so that the problem of overspending can be solved as far as possible within the year of the Pool; if a serious overspending occurs at the end of the Pool year when the year-end final accounts are being finalized, the problem must be solved within the first quarter of the new year of the Pool.
Secondly, the proportionate standards should be adjusted in due course. When the amount of overspending is huge, and the overspending costs incurred are within the normal and reasonable range of expenses, and are not due to irregularities or excessive medical consumption, in this case, consideration can be given to appropriately increasing the collection ratio, thereby increasing the total amount of the integrated fund and improving the ability of the integrated fund to pay, but the crediting ratio transferred to the individual account generally cannot be reduced, otherwise, it is easy to cause imbalance in the hearts of the insured, and in addition, in accordance with the In addition, according to the situation, the collection base and payment ratio of the mutual aid for major illnesses should be adjusted appropriately, so as to solve the payment pressure of the mutual aid fund for major illnesses, and it can also be considered that it should cooperate with commercial insurance companies, so as to alleviate the pressure of the medical insurance fund through socialized channels; if the aforementioned measures still fail to solve the risks, it is necessary to increase the starting standard of the items paid by the integrated fund or reduce the payment ratio of the integrated fund, so as to enhance the sense of saving of the insured persons. Moderately reduce the overall level of medical consumption, so as to resolve the risk of overspending on the integrated fund.
Thirdly, we need to establish a fund reservation system and strive for more government funding to achieve the purpose of risk sharing. Funds set aside system is from the settlement amount of the designated medical institutions set aside a certain percentage of funds to restrain the designated medical institutions of violations, but also at the same time to establish a reward system for outstanding performance of the designated medical institutions using various forms of rewards and recognition, and to promote their legitimate business. In more economically developed regions with more financial resources, the government can be requested to increase investment in social security to provide better social security services for the insured.