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The author:(作者)归海一刀published in(发表于) 2013/11/14 3:10:39 Medicare three insurance mergers or step by step promote ncms and residents took the lead in
Health insurance residents of three insurance mergers or step by step and ncms
Ma Xiaohua
State March issued of State reform and functions shift programme under pointed out that, will reduced sector duties Cross and dispersed, maximum to integration dispersed in State different sector same or similar of duties, straighten out sector duties relationship, town workers basic medical insurance, and town residents basic medical insurance, and new rural cooperation medical (following respectively abbreviation workers Medicare, and residents Medicare, and new agricultural collection) of duties,, respectively integration by a sector bear.
But 8 months later, "integration by parts" so far not finalized, engaged in related research, current health research center for health development, health financing and performance Director Ying Yazhen told the newspaper in an interview, three health care system completely merges are still objective obstacles, step by step, first achieving integrated management of residents ' health insurance and new rural cooperative medical.
Residents ' health and ncms combined
At present, China has formed a workers ' health insurance, healthcare, ncms, mainly residents of urban and rural residents covered by basic medical insurance system.
Which, workers Medicare from 1994 second half of started of "liangjiang pilot", to 1998 State enacted on established town workers basic medical insurance system of decided under, run time over 15 years; new agricultural collection from 2003 has walked has fast development of 10 years; 2007 started of residents Medicare run time relative more short, but overall parameter insurance (participating) rate has over 90%, related policy system also gradually mature.
"Integrated health care system, already has certain conditions. From initial system design, employee healthcare and population health insurance managed by the Social Security Department to operate, ncms is managed by health sector Manager. Run to date, has been engaging in efficiency in management, medical and health care sectors on issues such as settlements, repeated insurance showing abuses. In particular the urban and rural areas, urban and rural residents to achieve health insurance benefit equity environment, new demands on the management system reform of Medicare. "Yazhen told this newspaper that.
Yazhen explained that three of the current medical insurance system, residents ' health and ncms have many similarities, most integration Foundation. Both the voluntary medical insurance (participants), criteria for funding, funding, funding policies are basically the same, coverage of economic capacity, the current guaranteed benefit levels comparable to, the combination of the two management policy barriers hardly exist.
"The ' step by step ' strategy to integrate healthcare management system may be real and effective ways. And for repeated insurance problems, mainly between the residents ' health insurance and new rural cooperative medical groups, the combination of the two, will be able to solve this problem. "Yazhen said.
There are now many areas, jiaxing, Ningbo, Zhejiang Province in some counties, County of Jiangsu, Zhenjiang, Changshu city and xiangfen, Shanxi, Fuyang, Hefei, Wuhu, in Anhui Province, some cities and counties have implemented lay-off between residents ' health insurance and new rural cooperative medical management, funds Exchange.
Yazhen, urban workers ' medical insurance policy, the financing modalities and funding levels and other differences between the two insurance systems is large, in particular funding level difference of about 5~7 times, guaranteed benefit gap is still existent. Therefore, infrequent healthcare system completely merges three of the country's practice, even if there are a few areas to integrate the three systems in one Department management Manager, nor a place to Exchange Fund, compensation policy coherence.
"Comprehensive consideration, said at a national level, first integrated residents ' health insurance and new rural cooperative medical management, with realistic conditions, and to some extent solve problems, can actually implement two types of insurance coverage for urban and rural areas. "Yazhen said.
According to sources, current workers ' insurance and handling units remained in the Ministry. In sanming city, Fujian province has just completed this reform, established a separate "health insurance fund management center", as an institution directly under the Government. Compensation for related departments to develop, in consultation with the original Medicare reimbursement policies, unified medical insurance institutions, harmonization of regulated targets for medical institutions, harmonization and medical institutions to settle Medicare funding, unified targeted drugs in medical institutions, procurement of supplies, equipment, and so on.
Health care and medical services in parallel
Ncms achieved full coverage as early as 2008, and is available in one of three health care medical insurance the largest number of 2012 participants 805 million people, funding levels and workers ' health-care funding level 7 times times, but reimbursement levels for 55%, the workers ' health insurance, a difference of less than 10%.
Should yazhen introduced, new agricultural collection Fund run efficiency is high, limited of funds maximum to played has maintenance participating farmers health of role, and achieved has provincial range within compensation claims programme of roughly unified; 80% above of area achieved has province within instant knot reported, greatly convenient has patients, also blocked has lie insurance vulnerability; the paid way reform fast advance, effective control has medical costs growth.
With the progressive increase in funding levels, ncms also adopted gradually depending on the crowd, according to the classification of disease management, co-ordination, slower on an outpatient basis special disease, critical illness claim such compensation policies to achieve a breakthrough. At the same time as the primary comprehensive health reform to advance, in some areas, build a set of new rural cooperative medical services, public health service, for the integrated information platform, achieving health records, medical insurance compensation claims management dynamic real-time, as well as medical service regulatory fine.
"Integrated management of new rural cooperative medical and health care service delivery, compensation policy development, contracted medical institutions in healthcare regulatory process follows the regularity and characteristics specific to the medical service is to raise the efficiency of new rural cooperative medical Fund Foundation and basic guarantee. "Yazhen said.
In addition, the integrated healthcare management and medical services, you can better use of Medicare's role in healthcare and health services management.
At present, the grass-roots in the reform of the basic drug system, "fair treatment" compensation is important, generally of 80%~90% by the new rural cooperative medical treatment into the scope of reimbursement. In the reform of public hospitals at county level, paid through the new rural cooperative medical reform, development of scientific and rational criteria for payment to make up for the insufficient portion of financial assistance, lack of medical service price adjustment is not in place to ensure normal economic operations in public hospitals, but if the new rural cooperative medical management in other departments and coordination difficult, costly to coordinate issues would be difficult to avoid.
Additionally, as further towards urban hospitals public hospital reform, taking into account the impact of urban hospital resident medical insurance and employee health insurance, Medicare payments to play the supporting role of public hospital reform and reduce coordination costs, in addition to health care and medical services to residents is to achieve integrated management, creating the conditions to speed up, workers ' health care and medical services, integrated management as soon as possible. Management conditions, ultimately achieving integrated management of health care, medical and public health services, achieving integration and systematization of health management.
"Integrated health care management and medical management services, family planning Department of health to ensure the effective exercise of the duties of medical service behavior and quality and cost management. Health insurance fund management is an important economic lever, lose this means single administrative means alone, quality of the Hospital Services Act, regulatory effectiveness will be diminished. "Yazhen said.
Yazhen, for example, in 2010, residents of a municipality directly under the new rural cooperative medical and health care (collectively known as cooperative medical insurance in urban and rural areas) after the transfer of persons and social sector, the following results:
A hospitalization of actual compensation rate reduced, family reunification account for outpatient and manpower to co-ordinate efforts to decline, the Fund use efficiency decreased.
Second, healthcare management and intensification of conflict of interest among medical institutions. Medical insurance management and goal-setting fund balance amount approved less than for hospital services, resulting in total pay is too low. In this case, the hospital patient came to the hospital, admitted to no contrary medical responsibilities, treated may lose money. In addition, the hospital runs in order to maintain only a default behavior, such as drug, financial pitfalls planted.
Three were pooling funds to use Exchange rate movements. Basis due to the end of things, just merge a year, funding rates are very low, the actual compensation ratio fell sharply; and blind raise reimbursement levels for the second year, there have been annual fund overexpenditure. Medicare reimbursement of compensation policies lack stability, affect common people feel.
Four healthcare payment reform is backwards. In some districts and counties of the new rural cooperative medical payment reforms have been effective, but emphasized the social sector reform and precise, has suspended the payment reform, coordination difficulties, management, technology and other factors, but delays in the introduction of new policies, causes a full return to pay status, lack of medical service behavior controls, medical care costs surged. Source: business news
医保三险合并或分步进行居民和新农合先行
马晓华
国务院3月下发的《国务院机构改革和职能转变方案》指出，将减少部门职责交叉和分散，最大限度地整合分散在国务院不同部门相同或相似的职责，理顺部门职责关系，城镇职工基本医疗保险、城镇居民基本医疗保险、新型农村合作医疗(以下分别简称职工医保、居民医保、新农合)的职责等，分别整合由一个部门承担。
但8个月过去了，“整合由一个部门承担”至今没敲定，长期从事相关研究、现任卫生部卫生发展研究中心研究员、卫生财政与绩效研究室主任应亚珍接受《第一财经日报》专访时表示，三种医保制度完全并轨仍有客观障碍，可分步进行，首先实现居民医保与新农合的统筹管理。
居民医保与新农合合并
目前，中国已经形成了以职工医保、居民医保、新农合为主的覆盖城乡居民的基本医疗保险制度。
其中，职工医保从1994年下半年启动的“两江试点”，到1998年国务院颁布《关于建立城镇职工基本医疗保险制度的决定》，运行时间超过15年；新农合从2003年至今走过了快速发展的10年；2007年启动的居民医保运行时间相对较短，但总体参保(参合)率已超过90%，相关政策制度也渐趋成熟。
“整合医保管理体制，已经具备了一定条件。从起初的制度设计来说，职工医保和居民医保由社保部门管理经办，新农合由卫生部门管理经办。运行至今，已经在管理经办效率、医疗机构与医保部门结算、人员重复参保等问题上显示出弊端。特别是城乡统筹、实现城乡居民医保受益公平性的大环境，对医保管理体制改革提出了新要求。”应亚珍对本报表示。
应亚珍解释，现行的三种医疗保险制度中，居民医保与新农合有很多相同之处，最具融合的基础。两者的自愿参保(参合)、筹资标准、筹资主体等筹资政策基本一致，覆盖人群的经济能力、现有保障受益水平也相差不大，两者并轨管理几乎不存在政策障碍。
“采用‘分步走’的战略，整合医保管理体制，可能是现实和有效的途径。而对重复参保问题而言，主要也在居民医保与新农合人群之间，两者并轨，就能解决这一问题。”应亚珍说。
目前已有不少地区，如浙江嘉兴、宁波部分县市、江苏常熟、镇江部分县市、山西襄汾、安徽省合肥、芜湖、阜阳的部分县市都实现了居民医保与新农合之间的并轨管理，基金互通。
应亚珍表示，城镇职工在参保政策、筹资模式及筹资水平等方面与其他两个保险制度的差异较大，特别是筹资水平相差5~7倍左右，保障受益的差距还客观存在。所以，全国还鲜见把三种医保制度完全并轨的实践，即使有少数地区把三种制度整合在一个部门管理经办，也没有一个地方实现基金互通、补偿政策统一。
“综合考量，在全国层面说，首先实现居民医保与新农合的统筹管理，既具备现实条件，又能在一定程度上解决问题，也能真正实现这两种保险制度覆盖人群的城乡统筹。”应亚珍表示。
据消息人士透露，目前职工保险以及经办单位仍留在人保部。福建三明市刚完成此项改革，成立了独立的“医疗保障基金管理中心”，作为政府的直属事业单位。与原相关部门协商制定各类医保补偿报销政策，统一医保定点机构，统一对医疗机构的管控指标，统一与医疗机构结算医保资金，统一定点医疗机构药品、耗材、设备采购等。
医保与医疗服务并行
新农合早在2008年就实现了全覆盖，且是现有三种医保中参保人数最多的，2012年参合8.05亿人，筹资水平与职工医保的筹资水平相差7倍，但报销水平达55%，与职工医保相差不到10个百分点。
应亚珍介绍，新农合基金运行效率很高，有限的资金最大限度地发挥了维护参合农民健康的作用，而且实现了省级范围内补偿报销方案的大致统一；80%以上的地区实现了省内即时结报，大大方便了病人，还堵住了骗保漏洞；各项支付方式改革快速推进，有效控制了医疗费用增长。
随着筹资水平的逐步提高，新农合还采用了按人群、按疾病的分类管理、逐渐在门诊统筹、慢病特殊病、重大疾病等补偿报销政策方面实现突破。同时随着基层综合医改的推进，部分地区构建了集医疗服务、公共卫生服务、新农合为一体的信息化平台，实现了健康档案管理动态化、医保补偿报销实时化，以及医疗服务监管精细化。
“统筹管理新农合与医疗服务提供，在医保补偿政策制定、定点医疗机构监管等环节遵循医疗服务特有的内在规律和特性，是提升新农合基金运行效率的基础条件和根本保证。”应亚珍表示。
除此之外，统筹医保管理和医疗服务，可以更好地发挥医保在医改和医疗服务管理中的作用。
目前，基层基本药物制度改革中， “一般诊疗费”是重要的补偿渠道，一般诊疗费的80%~90%由新农合纳入报销范围。县级公立医院改革中，通过新农合支付方式改革，制定科学合理的支付标准，弥补了部分地方财政补助不足、医疗服务项目价格调整不到位等欠缺，保障了公立医院正常经济运行，但如果新农合在其他部门管理，协调难、协调成本高的问题势必难以避免。
另外，随着公立医院改革进一步推向城市医院，考虑到城市医院受居民医保和职工医保的影响更大，要发挥医保支付方式对公立医院改革的支撑作用，减少协调成本，除居民医保与医疗服务要实现统筹管理外，要加快创造条件，尽早实现职工医保与医疗服务的统筹管理。待管理条件成熟，最终实现医保、医疗和公共卫生服务的统筹管理，实现健康管理一体化、系统化。
“统筹医保管理和医疗服务管理，才能确保卫生计生部门有效行使对医疗服务行为、质量和费用管理的职责。医保基金是管理医院的重要经济杠杆，失去这一手段，仅靠单一的行政手段，对医院服务行为、质量等监管的有效性就会打折扣。”应亚珍表示。
应亚珍举例称，2010年，一个直辖市将新农合和居民医保(合称城乡居民合作医疗保险)移交人社部门后，出现了以下结果：
一是住院实际补偿比降低，门诊统筹回归家庭账户，统筹力度下降，基金使用效率下降。
二是医保管理与医疗机构间的利益冲突激化。医保管理的目标设定在基金平衡，存在对医院服务量核定不足，导致结付总额过低。在此情况下，医院面对前来就医的病人，不收治有悖办医责任，收治了可能赔本。此外，医院为了维持运行，只能采用拖欠药品款等行为，埋下财务隐患。
三是统筹基金使用率波动大。由于对基础情况没底，刚归并的一年，基金使用率极低，实际补偿比大幅下降；第二年又盲目提高报销水平，又出现了年度基金超支。医保补偿报销政策缺乏稳定性，影响老百姓感受。
四是医保支付方式改革倒退。该市部分区县原来新农合支付方式改革已经卓有成效，但人社部门强调改革的整齐划一，暂停了原来的支付方式改革，又受协调困难、管理技术等因素制约，迟迟不能出台新政策，导致全部回归按项目付费状态，医疗服务行为管控缺失，医疗费用增长明显。 来源：第一财经日报
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