In recent years, China has continued to promote the construction of a multi-level medical security system and made breakthrough progress in solving the problems of "difficult to see a doctor" and "expensive to see a doctor". In order to further supplement the weakness of basic security, the general office of the State Council recently issued the opinions on improving the medical insurance and relief system for major and serious diseases (hereinafter referred to as the "opinions"), focusing on reducing the medical cost burden of major and serious diseases for people in need. What exactly? Who is the target? What are the relief costs covered? What changes have taken place in the supporting measures? In this regard, our reporter interviewed Gu Xuefei, director of the Medical Security Research Office of the health development research center of the National Health Commission. Rescue object System protection covers all people Reporter: how to understand the scope of medical assistance objects mentioned in the opinions? Gu Xuefei: the object range has two characteristics: hierarchical classification and accurate determination. Since the establishment of the urban and rural medical assistance system, the objects of assistance have been expanding. The opinions has made a more accurate classification of the objects of assistance. The first category is the objects of subsistence allowances and the extremely poor, who automatically obtain the qualification of medical assistance while obtaining life assistance. The second category is the marginal family members of the subsistence allowances and the rural people who are easy to return to poverty and cause poverty included in the monitoring scope, that is, the lower income groups outside the first category. At the same time, the continuity of the medical security poverty alleviation policy from poverty alleviation to Rural Revitalization is also considered. The third category is seriously ill patients (seriously ill patients who are poor due to illness) whose basic family life is seriously difficult due to high medical expenses. This is equivalent to covering the whole population within the scope of system protection, giving appropriate assistance to those seriously ill patients who do not belong to low-income people but may be in trouble due to high medical expenditure, avoiding them from implementing assistance after becoming the object of minimum living security due to illness, and optimizing the "cliff effect" of the policy into "slope effect", reflecting the scalability of the policy. The orientation of the system extends from ensuring the basic medical and health services of the poor objects to preventing and resolving the poverty risk caused by large medical expenditure, that is, from ensuring income poverty to reducing expenditure poverty. Reporter: what is the coverage of medical assistance cost guarantee? Gu Xuefei: it is clear in the opinions that the relief expenses are basically guaranteed, mainly covering the hospitalization expenses incurred by the relief objects in designated medical institutions, the expenses for long-term medication due to chronic diseases or long-term outpatient treatment due to major diseases. Drugs, medical consumables and diagnosis and treatment items paid by the medical assistance fund shall, in principle, comply with the provisions of the state on the payment scope of basic medical insurance. Within the policy scope below the starting line of basic medical insurance and serious illness insurance, the expenses paid by individuals shall be included in the relief guarantee according to regulations, and the burden of "threshold fee" shall be reduced. For expenses beyond the scope of the basic medical security policy, overall consideration has been given to improving the multi-level medical security system, including stabilizing and consolidating the security level, comprehensively reducing medical costs, guiding the participation of social forces, etc. Guaranteed treatment Promote the complementary connection of triple systems Reporter: what are the triple systems of medical security? What is the relationship between them? Gu Xuefei: the triple system includes basic medical insurance, serious illness insurance and medical assistance. The opinions clearly states that while implementing inclusive financial subsidies for insured residents, the insured shall ensure that all insured persons shall be insured through full or fixed subsidies for the insured objects with economic difficulties such as subsistence allowances, people living in extreme poverty and returning to poverty. In fact, there are six, seven or even nine guarantees in some places before the comprehensive poverty alleviation is realized, but it is not that the more systems, the higher the level of guarantee. Too many systems will make it more difficult to connect, and there are excessive security problems in a few places, which makes the sustainability of the system worrying. This year, the national medical insurance bureau and the Ministry of finance made it clear that the basic system includes the "triple guarantee" of basic medical insurance, supplementary medical insurance and medical assistance. In addition, other forms of institutional arrangements will be gradually cleaned up and transferred to the basic institutional framework of "triple guarantee". In the institutional framework of "triple security", the basic medical insurance and medical assistance system are relatively clear, while the definition and boundary of supplementary medical insurance have been relatively vague. In the list of national medical security benefits (version 2020), supplementary medical insurance includes serious illness insurance for urban and rural residents, large medical expense subsidies for employees (including serious illness insurance for employees in some provinces) and medical subsidies for civil servants, which are managed with reference to the list, while supplementary medical insurance funded by enterprises and institutions is not included in the list management temporarily. Compared with basic medical insurance, these supplementary security systems are quite different. For example, there is no independent financing for serious illness insurance for urban and rural residents, and the premium comes from the basic medical insurance for urban and rural residents, so it still belongs to the scope of basic medical insurance in a strict sense; The supplementary medical security established by some enterprises and institutions with their own funds may belong to the medical mutual assistance system after the risk, rather than insurance. Whether these systems participate automatically or voluntarily varies in different regions. In addition, under the framework of China's basic system, commercial health insurance, mutual insurance and medical assistance also belong to "supplementary" institutional arrangements, and the concept and institutional boundary need to be further clarified. Other concepts, such as "basic insurance", "statutory insurance" and "social insurance", also have similar problems. The opinions proposes to promote the complementarity and convergence of triple systems - give full play to the main guarantee function of basic medical insurance, strictly implement the payment scope and standards of basic medical insurance, and implement fair and appropriate guarantee; Serious illness insurance plays a supplementary role and provides preferential protection for relief objects; After insurance reimbursement, give play to the basic guarantee function of medical assistance. According to the principle of "insurance before assistance", provide assistance to the relief objects who still have a heavy burden of personal medical expenses after payment, such as basic medical insurance and serious illness insurance, so as to jointly prevent the risk of poverty caused by illness. Underpinning measures Tilt towards patients with serious and chronic diseases Reporter: how does the opinions determine the level of relief in terms of overall planning and optimization of the support mechanism? Gu Xuefei: the goal of basic security is to ensure that people in need can access basic medical and health services and that their basic family life will not be affected by medical expenses. With regard to the design of payment instruments that affect the policy benefit level of relief objects, such as the starting line and self payment ratio, the opinions emphasize the need to refine the treatment standards by groups on the basis of comprehensive consideration of factors such as fund affordability and the actual needs of the masses, and clearly require that the starting payment standards for low-income and extremely poor people be abolished in principle, The annual starting payment standard that does not meet the conditions for the time being shall not be higher than 5% of the disposable income of residents in the overall planning area last year. The annual starting payment standards for marginal families with minimum living security and seriously ill patients due to illness shall be determined according to about 10% and 25% of the per capita disposable income of residents in the overall planning area last year respectively. In terms of the relief proportion, the relief proportion for the minimum living standard and the extremely poor shall not be less than 70%, and the relief proportion for other relief objects shall be determined by all localities according to the actual situation. The annual relief limit is also reasonably determined according to the actual payment capacity of the fund. Reporter: what are the key aspects of supporting measures? Gu Xuefei: in terms of the arrangement of supporting measures, it is more prominent to favor patients with major diseases among the poor people. In the past, the assistance policy focused on inpatient assistance, while the opinions required to increase the assistance guarantee for outpatient chronic diseases and special diseases, share the annual assistance quota for outpatient and inpatient assistance, and co-ordinate the use of assistance funds. In the long run, it will help to guide difficult outpatient patients with chronic diseases to seek reasonable medical treatment and reduce the phenomenon of "outpatient transfer to hospitalization". After the comprehensive guarantee of the triple system, if the personal burden is still heavy, preferential assistance can continue to be given, provided that the standardized referral within the province and the scope of medical assistance payment are consistent with the catalogue of drugs, consumables and diagnosis and treatment items of basic medical insurance. In short, medical assistance guarantees "basic" medical and health services for people in need, which should be combined with referral mechanism, standardized diagnosis and treatment and other measures to control unnecessary payments and reduce waste. long-term mechanism Strengthen early warning and monitoring and promote convenient services Reporter: the opinions clearly states that we should establish and improve a long-term mechanism to prevent and resolve poverty caused by illness. What should we do in practice? Gu Xuefei: in the past, the practice of medical assistance paid more attention to the people who have fallen into economic difficulties, and the "firewall" to prevent poverty due to illness has not been fully built. The opinion proposes to improve the dual early warning mechanism of poverty caused by illness and poverty returned due to illness by classification, and timely include qualified key monitoring groups into the scope of assistance through early warning and monitoring of high medical expenses with the help of information means in the era of Internet and big data; At the same time, unblock the channels of rescue application and improve the timeliness of rescue. For example, those who have been identified as the objects of subsistence allowances and those in extreme poverty will directly receive medical assistance. "Preventive" institutional arrangement and operation support at the level of information technology are an important direction for the development of China's medical security system to high quality. Practice has proved that "one-stop" settlement services, medical security and convenience services such as diagnosis and treatment before payment are directly related to people's identity and satisfaction with the medical insurance system. By promoting the integrated handling of medical insurance and medical assistance and doing a good job in the service integration of "one acceptance and collaborative handling" with social assistance, it will help to improve the convenience of medical insurance handling services for people in difficulty. At the same time, considering that the guarantee is a "preferential" institutional arrangement for specific groups, we should follow the basic principle of guarantee and adhere to fairness and efficiency. Therefore, the first diagnosis at the grass-roots level, standardized referral, scientific diagnosis and treatment path management and efficient and effective payment methods should become indispensable policy arrangements to promote the reform of medical and health services. Multi level guarantee Give play to the role of charity and other social forces Reporter: the opinion proposes to actively guide charitable and other social forces to participate in relief and security. How should we understand it? Gu Xuefei: charitable assistance is an important part of philanthropy, an important way to play the role of the third distribution, and an important supplement to the existing triple system. Although the funds for charitable projects are very limited compared with medical insurance funds, if they are effectively connected with medical assistance and medical insurance and give full play to the joint force of the system, they can get twice the result with half the effort. For example, in some charity projects, some children with congenital heart disease have received "one-stop" reimbursement services, the treatment is completely free, and families do not need to pay medical expenses in advance, which greatly reduces the economic burden of children's families. For the relief of specific diseases and specific groups, the level, scope and flexibility of charitable relief have advantages, especially social work and voluntary service. It is a useful supplement to government relief. Mutual medical assistance for employees and commercial health insurance can play a complementary role in broadening the scope of protection and improving the reimbursement level. We should further improve the system and management operation, strengthen the connection with the basic medical insurance system, and better meet the insured's multi-level, personalized and differentiated health needs. The Internet-based mutual medical assistance project has developed rapidly in recent years. It is a relatively efficient and transparent post risk resolution mechanism based on the stranger community in the Internet era. While standardizing development, we also need to guard against risks. (reporter Wang Meihua) (outlook new era)