Health insurance reform to benefit outpatient service users

A number of Chinese cities have been implementing a reform of health insurance for urban employees and retirees.

A number of Chinese cities have been implementing a reform of health insurance for urban employees and retirees, which adjusts the amounts deposited each month into their personal accounts, while raising the reimbursement percentage for outpatient medical bills to at least 50 percent.

According to the National Health care Security Administration (NHSA), over 354 million employees and retirees had joined China's medical insurance system by the end of 2021. Experts said the reform, which is expected to be rolled out nationwide, will provide further help to citizens — especially older people — in outpatient services.

Balancing insurance accounts

China's health insurance system for urban employees and retirees consists of two parts: mandatory personal accounts with contributions from both employees and their employers that mainly pay for ordinary outpatient services; and a pooled fund contributed by employers that is used to reimburse hospitalization bills, outpatient bills for serious diseases, and expenses for some chronic diseases.

This means that ordinary outpatient medical bills can only be paid by personal accounts or citizens themselves under the current health insurance system, which has been in place for over 20 years. While some people who rarely go to the doctor have tens of thousands of yuan in their personal accounts, some others find themselves running out of personal account deposits due to frequent hospital visits.

There is an "urgent need" for a mutual-aid mechanism to enhance the ability of public medical insurance to reimburse outpatient bills and ease the burden on patients, said Jin Weigang, a professor at Zhejiang University.

After the health insurance reform, the money deposited by employers into employees' personal accounts will be directly paid to the pooled fund in order to support the reimbursement of ordinary outpatient medical bills. For urban retirees, the monthly deposit amounts will be calculated based on regional per capita pensions instead of their own pensions.

"Health insurance is primarily public insurance, in which sense it provides mutual aid on the basis of joint contributions and shared responsibility," said Wang Zhen, a public economics scholar at the Chinese Academy of Social Sciences, adding that the reform will help meet public medical demand on a larger scale.

The reform is aimed at benefiting outpatients with no need for extra payments from employers and employees, said Gu Xuefei, a medical care policy researcher at the China National Health Development Research Center.

Weighted toward elderly people

According to figures released by the NHSA, China's working population paid 2,097 yuan (306 US dollars) on average for medical expenses in 2021, whereas retirees spent 8,002 yuan, or more than 3.8 times as much.

"Obviously, elderly people are more susceptible to illness and incur higher medical expenses," said Wang Chaoqun, associate professor at Central China Normal University, adding that senior people's personal accounts are far from sufficient to cover their needs for outpatient care and pharmaceutical purchases.

To lighten the financial burden on elderly patients, the authority made it clear that local governments should weight the system more heavily toward retired people by raising the reimbursement rate of their outpatient bills based on the threshold of 50 percent.

Favorable policies for elderly people have been rolled out in the city of Hohhot, north China's Inner Mongolia Autonomous Region. Retired employees enjoy a higher reimbursement rate for outpatient bills compared with working people.

Under the new scheme, the insured are allowed to use the money in their personal account to help their elderly parents as well as other family members.

By doing so, Chinese families will be in a better position to cope with medical risks, said Gu.

How people feel matters

Highlighting the importance of how people feel about the reform, Gu said the impact on stakeholders, including the general public and medical institutions, should be taken into full consideration.

He called on all players to join hands in helping ease the process of acquiring medical treatment.

The reform is expected to be completed in three years, according to official plans. Most regions have rolled out their policies, though measures may vary from one to another due to the disparity in economic strength and the depth of insurance coordination.

It takes time for any reform to take effect, said Wang Zhen, adding that supporting measures should be taken at the same time, such as being reasonable when adjusting the payout thresholds and maximum payment limits in the reimbursement of outpatient bills, bringing more eligible pharmacies into the system where outpatient expenses can be reimbursed by the pooled fund, and incorporating Internet-based medical services into the coverage of insurance.

Optimization has been underway in some regions. In central China's Wuhan, for example, 4,065 pharmacies have been newly added to the system, supporting efforts to cover outpatient expenses through unified accounts, in addition to the more than 1,000 pharmacies previously brought in under a pilot scheme.

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