On December 1st this year, a major reform will be ushered in in the personal accounts of Shenzhen employees’ medical insurance. The amount included in the personal accounts of the first-class insured will be reduced from 5% of the payment base to 2%, and the difference will be used to improve the reimbursement level of outpatient services after being included in the overall fund.
In the interpretation of relevant policies, Shenzhen said that the core of this reform is to change the medical expenses of the medical insurance outpatient service of employees who are "unified accounting" from the individual accumulation guarantee model to the social mutual assistance guarantee model.
Liao Zangyi, an associate professor at the School of Politics and Public Administration of China University of Political Science and Law, told CBN that for Shenzhen, outpatient mutual aid reform is a system adjustment made in response to the national and provincial reform trends, and there is no risk of medical insurance funds. Like the national reform, the reform of outpatient mutual aid security in Shenzhen is essentially a kind of rights replacement, which replaces the funds in personal accounts with pooling funds, establishes an outpatient pooling system, and uses the law of large numbers to solve the problem of outpatient expenses burden of insured people.
It is an established goal of deepening China’s medical insurance reform to establish and improve the outpatient mutual aid guarantee mechanism of employee basic medical insurance. After the State Council issued relevant guidance in April last year, various provinces successively issued provincial-level guidance documents, which made arrangements for the progress of promoting the reform of outpatient mutual aid security mechanism in the whole province. At present, the reform of outpatient mutual aid is being accelerated nationwide.
Shenzhen promotes the outpatient treatment of the first-class insured
On the 15th, the General Office of Shenzhen Municipal Government issued the Notice on Implementing the Measures for the Implementation of the Basic Medical Insurance for Employees in Guangdong Province (hereinafter referred to as the Notice), which was officially implemented on December 1, 2022.
The specific contents include: adding general outpatient treatment as a whole, reducing the funds transferred to personal accounts, standardizing and expanding the scope of use of personal accounts, etc.
One of the focuses of this reform is to adjust the funds transferred to personal accounts. According to the notice, the first-class insured person of basic medical insurance for employees who pay the basic medical insurance premium at 8% of the payment base will be included in the monthly personal account at 2% of the payment base, and the rest will enter the basic medical insurance serious illness pooling fund (hereinafter referred to as the "pooling fund"). For retirees who stop paying fees and continue to enjoy the first-class treatment of basic medical insurance, their personal accounts are allocated by the overall fund according to the quota, and the monthly allocation standard is 2.8% of the average monthly amount of basic pension in this city in 2021.
Due to the current policy, the first-class insured person pays the basic medical insurance premium at 8% of the payment base, of which 5 percentage points are included in the personal account and 3 percentage points are included in the overall fund. Compared with the old and new policies, the funds transferred to personal accounts have decreased by 3 percentage points, which is the part where the insured thinks the rights and interests have been damaged.
On the 23rd, the reporter consulted the Shenzhen 12345 hotline about the advantages and disadvantages of this reform for the insured. The hotline staff said that for the first-class insured, the disadvantage is that the money in the personal account is less, and the advantage is that the outpatient service can also be reimbursed. On the whole, for people who see more clinics, the treatment is getting better; If you don’t look at the clinic, you will feel a little disadvantaged if you have less funds in your personal account.
Liao Zangyi believes that the reform of outpatient mutual aid has not reduced the medical treatment of the insured, but has carried out institutional structural reform through a kind of equity replacement, further strengthening and expanding the efficiency of the use of personal accounts. "The insured believes that the benefits will be damaged after the personal account amount is reduced. One reason is that it involves welfare perception, and the other reason is that there is a certain understanding of this reform." Liao Zangyi said.
Judging from the effect of the policy, for on-the-job employees, the insured who usually don’t use or use less, don’t have the allocation of 3% of the social pooling fund, and it seems that less money has entered the personal account, but in fact, the reimbursement has not changed. In the past, the personal account was swiped into the "personal account+pooling fund" for joint payment, and the use scope of the personal account was expanded, which benefited the whole family.
For on-the-job insured people who usually rely on personal accounts to buy medicines in spite of illness, the money in personal accounts was not enough in the past. Now, due to this system reform, with the payment of the overall fund, the treatment level of these insured people has been improved, and their personal burden has been effectively reduced.
The notice proposes that on the basis of outpatient treatment and medical treatment such as personal accounts and outpatient specific diseases, the general outpatient treatment of the first-class insured person with basic medical insurance for employees will be added. The first-class insured person of employee’s basic medical insurance can select a social health institution or other primary medical institutions, a second-class hospital or a specialized hospital as a designated medical institution for general outpatient co-ordination and medical treatment within the scope of designated medical institutions in the city.
The staff of the Shenzhen 12345 hotline specially reminded that on December 1st, the first-class insured should try to select a designated medical institution, so as to enjoy the outpatient reimbursement treatment of the first-class and second-class hospitals. If not selected, they will still be reimbursed according to the original policy, that is, the first-class hospitals will pay 70% for individuals and 30% for co-ordination funds. After selection, the co-ordination funds of the first-class hospitals will pay up to 75%, and retirees can be higher.
Shenzhen reform has nothing to do with the risk of medical insurance fund
Because the outpatient mutual aid reform involves the adjustment of individual account funds, some insured people will think that it is because the medical insurance fund has no money, or the increase in the expenditure of the medical insurance fund on epidemic prevention has increased the pressure on the fund. In this regard, Liao Zangyi made it clear that the reform of Shenzhen medical insurance fund personal account system and outpatient mutual aid system has nothing to do with the risk of medical insurance fund, but is an institutional adjustment in response to the policy reform of the state and Guangdong Province.
According to the Table on Budget Implementation of Shenzhen Medical Insurance Fund from January to October 2022 published by Shenzhen Medical Insurance Bureau, as of October this year, the current balance of basic medical insurance for urban employees in Shenzhen was 20.749 billion yuan, with a cumulative balance of 177.075 billion yuan.
On April 14th, 2021, the Guiding Opinions of the General Office of the State Council on Establishing and Perfecting the Outpatient Mutual Aid Security Mechanism for Employees’ Basic Medical Insurance (Guo Ban Fa [2021] No.14) required that the provincial people’s governments should issue implementation measures before the end of December 2021 to guide the overall planning areas to promote implementation, and a transition period of about three years can be set to gradually realize the reform goal.
On December 31, 2021, the Notice of the General Office of the People’s Government of Guangdong Province on Printing and Distributing the Implementation Measures for the Basic Medical Insurance for Employees in Guangdong Province (Guangdong Government Office [2021] No.56) requires all localities and cities to issue the implementation rules and implement them before July 1, 2022.
According to Li Juan and Wang Zongfan, Chinese Academy of Labor and Social Security, published in lanzhou academic journal on 15th, the current situation analysis and countermeasures and suggestions on the reform of mutual aid guarantee mechanism for workers’ medical insurance outpatient service sorted out 31 provinces and cities in China. The time of issuing documents in each province was concentrated in the end of 2021 and the beginning of 2022, and the issuing unit was basically the general office of the provincial people’s government. Most provinces have issued guidance documents for local governments, and made arrangements for the progress of the province’s reform of the mutual aid guarantee mechanism for employees’ medical insurance clinics. However, as of the end of July, most of the overall planning areas have not yet issued the landing documents on the reform of the mutual aid guarantee mechanism for employees’ medical insurance clinics, and some cities have issued implementation rules under the guidance of national and provincial documents.
At present, many places in the country have accelerated the reform of outpatient mutual aid. The Liaoning Provincial Medical Insurance Bureau said that it is making efforts to establish and improve the outpatient mutual aid guarantee mechanism for employees’ basic medical insurance. Before the end of this year, all the overall planning areas in the province will start to implement reforms.
From December 1st, 2022, Beijing started to provide medical insurance individual account funds for family members to help each other.
The Hunan Provincial Medical Insurance Bureau recently announced that the province will comprehensively establish a general outpatient co-ordination system for employee medical insurance before the end of the year. From January 1, 2023, personal accounts will be credited in a new way. After the reform, family members will be allowed to help each other to use personal accounts.
