Serious illness insurance cannot cover expenses Wu Yan proposes to jointly establish a risk adjustment fund

Our reporter Wang Xiaohui reports from Beijing

In 2014, "serious illness insurance" appeared in the Prime Minister's report as an independent identity for the first time.

On March 5, Li Keqiang, Premier of the State Council, pointed out that we should promote the in-depth development of medical reform when deploying the key work of 2014. We will consolidate basic medical insurance for all people, reform and integrate the basic medical insurance system for urban and rural residents, improve the financing mechanism for basic medical insurance that is reasonably shared by governments, units and individuals, raise the financial subsidy standard for basic medical insurance for urban and rural residents to 320 yuan per capita, and promote serious illness insurance for urban and rural residents nationwide.

"There is no doubt that serious illness insurance will face rapid expansion." On March 6, a researcher who participated in the drafting of serious illness insurance related proposals was interviewed by the Huaxia Times. Up to now, although 28 provinces and more than 130 cities across the country have carried out serious illness insurance pilot projects, there are many problems. Most of the insurance companies involved in such insurance types are "losing money and making calls". Therefore, how to ensure the sustainable development of serious illness insurance has become the focus of the "two sessions".

It is difficult to continue "not receiving enough to cover expenses"

On August 30, 2012, six ministries and commissions issued the Guiding Opinions on Carrying out Serious Illness Insurance for Urban and Rural Residents, and serious illness medical insurance was officially launched. After more than half a year's exploration, the CIRC issued the Interim Measures for the Administration of Serious Illness Insurance Business of Urban and Rural Residents of Insurance Companies on March 20, 2013, which standardized the specific rules for commercial insurance companies to participate in serious illness insurance.

Now, the serious illness insurance has been piloted for more than a year, and the medical security level of urban and rural residents in the pilot area has been greatly improved, reducing the problem of "poverty caused by illness and returning to poverty due to illness".

However, due to the different medical insurance or cooperative medical income in different regions, the use and balance are also different. Judging from the implementation of serious illness medical insurance schemes in many regions, local governments and insurance companies are more cautious, and many problems are gradually exposed.

As Wu Yan, member of the National Committee of the Chinese People's Political Consultative Conference and chairman of PICC, said in the proposal of the "two sessions" this year, "serious illness insurance deviates from the" risk sharing "policy in the pilot process, which affects the sustainability of the system; the low funding standard affects the financial sustainability; the low level of overall planning affects the adjustment of funds and the sustainable management and control of serious illness risks; The low degree of sharing of diagnosis and treatment information affects the sustainable use of medical resources and other issues. "

The reporter learned that serious illness insurance is a national inclusive policy, which covers the medical insurance for urban residents and the participants of the New Rural Cooperative Medical System. The main feature is that the people do not pay, and the national finance does not pay. Only the local medical insurance fund needs to pay to entrust commercial insurance companies to operate. In principle, the local and insurance companies share the risk, but in the actual operation process, In some regions, the two-way risk adjustment mechanism has become a one-way adjustment for the return of premium balance, that is, the risk is basically concentrated on the insurance company.

"Judging from the serious illness insurance business data we have collected recently, the revenue and expenditure alone has lost money, which does not include the system, personnel and bidding costs." The above researchers stressed that the low funding standards and low level of overall planning directly affect the sustainable development of serious illness insurance.

As far as the pilot areas are concerned at present, the funding standard is about 20 yuan per person per year. However, according to the calculation of the Medical Reform Office of the State Council, the per capita funding needs to reach 40 yuan to effectively alleviate the problem of poverty caused by illness. Due to the low funding standard, many insurance companies have lost money in serious illness insurance business.

Is the medical insurance fund out of money? This is not the case. At the end of last year, some media reported that the national medical insurance balance was 764.4 billion yuan, and there was a large balance every year, which was too much money to spend.

In addition, the low level of overall planning has also seriously hindered the comprehensive promotion of serious illness insurance. Wu Yan said that since the implementation of the new medical reform, most provinces and autonomous regions have implemented city level overall planning, with the exception of Shandong, Qinghai, Jilin, Gansu and other minority regions that have implemented provincial level overall planning. Some places still carry out major disease insurance pilot projects in the way of county level overall planning. The traditional geographical segmentation of social medical insurance has not been effectively improved, which is not conducive to the overall coordination of funds in a wider range, It is also not conducive to the use of the law of large numbers to disperse risks, and it will also cause regional policy differences, difficulties in cross regional settlement of mass medical insurance and other problems.

Detailed rules are required for "speeding up"

The problem has not been solved, and the expansion has shown signs of speed increase.

Just before the "two sessions", the National Health and Family Planning Commission issued the Notice of the Health Reform Office of the State Council on Accelerating the Promotion of Serious Disease Insurance for Urban and Rural Residents, which pointed out that provinces that have not yet carried out the pilot of serious disease insurance for urban and rural residents should start the pilot work before the end of June 2014. This action shows that serious illness insurance will expand rapidly.

For this reason, Wu Yan suggested that we should explore the establishment of a risk adjustment fund for serious illness insurance, reasonably distinguish responsibilities, and bear the losses caused by policy adjustment and other reasons by the fund, while the losses caused by poor management, lax control and other reasons should be borne by the insurance company. At the same time, raise the funding standard and the level of overall planning. With the basic goal of achieving provincial overall planning, provinces that have carried out county and district pilot programs for serious disease insurance should gradually improve the level of overall planning for serious disease insurance. In provinces that have not yet carried out pilot programs for serious disease insurance, make full use of the advantages of latecomers and strive to achieve provincial overall planning in system design.

In this regard, on March 6, Li Bin, director of the National Health and Family Planning Commission, made it clear at the press conference held by the News Center of the NPC and CPPCC that the next step in medical insurance work is to improve the level of overall planning, from the current majority of counties as the overall planning unit to the provincial level, and at the same time comprehensively promote serious disease insurance for urban and rural residents nationwide.

The expansion of serious illness insurance is imminent, but the reporter has consulted a large number of materials and found that, in addition to the guidance documents of individual principles, the financing standards, compliance medical expenses, high medical expenses, etc. of serious illness insurance have not been clearly defined, nor has a unified national allocation standard and proportion been set. This eventually led to the central principled provisions, but the local implementation of strange.

The reporter learned that the local government attaches the most importance to the price and the level of security, which has led to competition among insurance companies to lower the price. Finally, some professional health insurance companies with long-term health insurance operations and good qualifications have lost in the bidding, and even in the bidding of some local medical insurance for serious diseases, Because insurance companies are worried about the poor business prospects, the phenomenon of sub standard appears. In addition, there are various problems such as arbitrary charges in the process of local bidding. Some insurance companies need to pay millions of deposits after receiving the project, which will last for several years.

However, according to the reporter, shortly after the release of the Premier's report, Zhejiang and other places have arranged relevant work to include serious illness insurance in the "Ten Facts in 2014", and clearly assigned the rights and responsibilities of this work to specific responsible persons and departments. At the same time, the minimum funding standards and other indicators have been clearly defined to prepare for the expansion of serious illness insurance.