Study on the operation mechanism of insurance for major diseases: based on domestic and foreign experience (1)

"Author's Profile" Qiu YuLin, female, Chinese Min University School of Labor and Personnel, doctoral tutor, Beijing 100872; Huang Guowu, male, doctoral student of the Chinese Min University School of Labor and Personnel, Beijing 100872 "Content Summary" in the initial establishment of the universal health insurance system, the people have a basic guarantee to see a doctor, China's medical expenses burden is increasingly prominentIn 2012, China launched the work of urban and rural residents insurance for major diseases, to the patients of the high medical costs to further protectFor more than a year, the insurance for major diseases has formed a variety of models, such as Taicang, Xiamen and HangzhouThese models have some differences and cause some controversy on the issues of starting payment standard, capping line, quality of the development of major disease insurance and the main body of operationIn this regard, China's major disease insurance should be removed from the cap line, and in the economically developed areas to pilot individual self-payment limitThe main body of the operation to implement diversification, some areas and other conditions mature before the commercial insurance, in order to facilitate the stable development of the systemIn the operating mechanism, a special and independent review body shall be set up to audit medical expenses in accordance with the standards agreed upon by all parties, and to pay medical institutions according to the results of the audit.In August 2012, six departments, including the National Development and Reform Commission, jointly issued the Guidance on the Development of Major Illness Insurance for Urban and Rural Residents (hereinafter referred to as "Opinions")Under the guidance of the Opinion, various parts of Our country have carried out the pilot work of major disease insurance according to their own actual situation, and formed a variety of models, such as Taicang mode, Zhanjiang model, Xiamen model, Xinxiang model and Hangzhou model, and accumulated many useful experiencesHowever, in the course of the operation of major disease insurance, there are some disputes about the setting of the starting line and the cap line, the characterization of major illness insurance, and the main body of operationThis paper compares the operation mechanism of the representative Taicang model, Xiamen model and Hangzhou model, learns from the experience of foreign countries of social medical insurance, combs and analyzes some disputes in the operation of major disease insurance, and hopes to provide reference for the further development of China's major disease insurance.First, the operation mechanism of major disease insurance analysis 1Taicang big disease insurance operation mechanism Taicang mode operating mechanism see figure 1 (1)Taicang City, Jiangsu Province, is an economically developed area, the difference between urban and rural areas is not large, has achieved the basic coverage of health insuranceIn 2012, in order to alleviate the pressure of people's major illness payment, Taicang City in accordance with the standard of 50 yuan per employee per year, urban and rural residents 20 yuan per person to raise funds, a total of 2277.27 million yuan, to establish a coverage of all workers and urban and rural residents of the major disease insurance systemIn this system, commercial insurance companies obtain qualifications through competitive bidding and participate in the related matters of major illness insurance The medical insurance operators shall make strict rules and supervise the operation activities of commercial insurance In terms of expense compensation, Taicang City for the insured personnel within a year personal burden of more than 10,000 yuan of medical expenses, according to the cost segment, according to the proportional increase in the way of reimbursement, the amount of reimbursement is not capped, can break through the basic catalog, but there are strict restrictions In the reimbursement process, the insured person himself or entrusts others to carry the relevant materials such as hospital certificate to the designated place for reimbursement, which shall be paid by the commercial insurance company after examination Commercial insurance companies recruit eight staff, except for two who are fixed to engage in claims, the rest of the health insurance center dispatch, to assume the supervision of medical services At the same time, the insurance company hired 18 medical experts, set up an expert review team, the case in question for external expert review The medical insurance operating institution shall deal with the cases of violation in accordance with the relevant provisions in accordance with the results of supervision In terms of responsibility-sharing, the base profit-and-loss ratio is set at 4.5% (2), and for the excess, regardless of the profit or loss, 50% is shared by the health insurance center and the insurance company The health insurance center evaluates the insurance company annually and decides whether to return the 5% pre-deducted reinsurance fund to the insurance company based on the results of the assessment Judging from the current operation of major disease insurance funds, in 2012, 3,086 insured persons in Taicang City received compensation, the total compensation amounted to 19.2 million yuan, the compensation rate was 84.3% For the actual reimbursement ratio of in-patient medical insurance, urban and rural residents increased by 11.87 percent, and workers increased by 6.05 percent Commercial insurance institutions withdrew 1.02 million yuan for basic services, or 4.47 percent of the total fund-raising, and $950,000 for performance services, or 4.17 percent of the total funding The balance of more than 1.6 million yuan is returned to the "big disease reinsurance" fund account, as a risk adjustment fund (3) On the whole, Taicang City's insurance model of major diseases effectively alleviated the economic pressure of patients and improved the universal health insurance system Figure 1 Taicang Big Disease Insurance Operation Figure 2 The operating mechanism of Xiamen Major Disease Insurance Xiamen Mode Operating Mechanism is shown in Figure 2 In 2010, Xiamen City, Fujian Province, learnfrom the supplementary medical insurance system for workers, the establishment of urban and rural residents major disease insurance system In 2012, urban and rural residents will be financed at 10 yuan per person per year, accounting for 2% of the basic medical insurance financing standard for urban and rural residents (the basic medical insurance financing standard for urban and rural residents is 500 yuan per person per year) In terms of the main body of operation, commercial insurance companies obtain the qualification by bidding, xiamen insurance regulatory bureau to regulate the bidding behavior of insurance companies The social security department does not directly interfere with the specific operation of the commercial insurance company except to formulate policies that restrict the commercial insurance company and pay the premium for major illness insurance according to the contract of competitive bidding The medical expenses of the insured person's outpatient and inpatient accumulation exceeding the maximum payment limit of basic medical insurance of more than 100,000 yuan in a social security year are included in the scope of the reimbursement of major illness insurance, and the link between basic insurance and major illness insurance is realized, and the proportion of employee and resident major illness insurance reimbursement is 95% and 80%, respectively In 2012, the maximum payment limit for Xiamen major disease insurance was 400,000 yuan for employees, plus the maximum payment limit of 100,000 yuan for basic medical insurance, which actually reached 9.5 times the average wage of social workers; In terms of the reimbursement process, the insured person to the designated medical institution to see a doctor, only pay the out-of-pocket part, the other part by the medical service institutions to the commercial insurance company, the commercial insurance company according to the review of the payment of medical expenses For the insured person who seeks medical treatment in another place, the medical insurance agency shall provide information and bills, and the commercial insurance company shall pay the medical expenses of the insured person for medical treatment in another place after examination Insurance companies set up a special medical audit and inspection team, on-site audit and real-time monitoring, social security agencies rely on the basic medical insurance information system, through the online early warning audit testing platform for supervision In terms of responsibility sharing, Xiamen City set up a dynamic adjustment mechanism for risk profit and loss, the social security department commissioned a third-party audit of the direct profit ability and loss rate of insurance companies, direct profit rate of more than 3% of the funds returned to the insurance fund by the insurance company, the direct loss rate of more than 3% of the funds by the health insurance fund compensation to the insurance company From the current operating situation, Xiamen major disease insurance system since the establishment of a total of 363 million yuan, a total of 11,000 people enjoy the treatment of major disease insurance, to obtain compensation of 308 million yuan (4), greatly reducing the financial burden of the people suffering from major illness, effectively resolved the risk of poverty due to illness, disease and return to poverty Figure 2 Xiamen Major Disease Insurance Run Chart (Responsible Editor: Wang Jinbao) 5
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