On February 28, 2019, the National Health Insurance Bureau issued the "2016 Medical Insurance Development Statistics Express". The Express News showed that the accumulated balance of the medical insurance fund has reached 2,323.4 billion yuan. Last year, the Ministry of Human Resources and Social Security released According to the "Statistical Bulletin on the Development of Human Resources and Social Security in 2017", the accumulated balance of medical insurance funds was 193.86 million yuan. According to this calculation, the balance of medical insurance funds in 2018 increased by 384.8 billion yuan compared with 2017, an increase of 19.8%.
The medical insurance fund balance has exceeded 2 trillion yuan, which is not a small amount. But in 2018, the medical insurance bureau issued a number of control measures, the biggest shock to the industry is the announcement on December 6, 2018. 4+7 results of centralized drug procurement in cities. As a result, many people have questions: Why is the Health Insurance Bureau still trying to control expenses when the balance of the medical insurance fund is so large?
Cause 1: The growth rate of medical insurance expenditure is fast
The medical insurance expenditure in 2018 is 1,760.8 billion yuan, and in 2017, it is 144.2 billion yuan. According to this calculation, the medical insurance expenditure in 2018 has increased by 3186. 100 million yuan, the growth rate is 22.1%. Although the increase in medical insurance expenditure is less than the medical insurance balance in absolute terms, the growth rate is higher than the latter.
If you compare the medical insurance fund balances and expenditure data over the years It can be found that the medical insurance management agency controls the number of years of medical insurance savings (medical insurance balance / current medical insurance expenditure) to be above 1.3.
Comparing the growth rate of medical insurance income and expenditure can also be found, the medical insurance management agency Let the growth rate of expenditure not be higher than the growth rate of income:
Although we do not know which specific indicator of the medical insurance management agency is responsible for maintaining the balance of medical insurance and having a balance, these data clearly show On the whole, the medical insurance system is based on the management principle of “receiving the balance. Ensuring the balance. It can resist the risk without bottoming out”.
Cause 2: The pressure on financial subsidies is large
The current domestic medical insurance is divided into two. Class, one is employee medical insurance, and the other is resident medical insurance.
Employee medical insurance The employment unit and the employee themselves pay together, and the local rates are slightly different, but the proportion of the total paid employment units and employees is mostly between 10% and 12% of the employee's monthly salary. This ratio is very high, so the employee's medical insurance Expenditure can basically be covered by premium income and interest generated by employee medical insurance balance, and less dependent on financial subsidies. According to the Ministry of Finance's "Note on the 2017 National Social Insurance Fund Final Account", the income of employee medical insurance in 2017 was 1,213,465 million yuan. Among them, the basic medical insurance premium income was 112.243 billion yuan, and the financial subsidy income was 10.353 billion yuan. The expenditure was 929.836 billion yuan. However, the coverage of employee medical insurance was narrow. The number of participants in 2018 was only 317 million.
Note : In the "Description of the National Social Insurance Fund Final Account" of the Ministry of Finance over the years, the financial subsidy data from 2009 to 2013 has not been published, so the figure shows zero.
Resident medical insurance includes medical insurance for urban and rural residents and new Nonghe. In 2008, the number of participants was 1.027 billion, covering most of the nationals. However, according to the Ministry of Finance’s “Notes on the 2017 National Social Insurance Fund Final Account”, 2017 residents The expenditure is 61.216 billion yuan, far lower than the employee medical insurance. In addition, the income of residents' medical insurance is greatly dependent on financial subsidies. In 2017, the income of residents' medical insurance is 683.833 billion yuan, of which the income from payment is 181.272 billion yuan and the income from financial subsidies is 491.868 billion yuan. That is, 71.9% of the income comes from financial subsidies.
Note: The “National Social Insurance Fund Final Account Statement” before 2014 does not specify the specific financial subsidy income figures of residents’ medical insurance income, but considering Other incomes in subsequent years are lower, so the calculation assumes that the income other than personal contribution income is financial subsidy.
Because the amount of financial subsidies is not always announced, in order to estimate the entire basic medical insurance (ie employees) The amount of financial subsidy in medical insurance plus resident medical insurance, simply assume that the annual interest rate of the medical insurance balance is 4%, and assume that the total income minus the premium income of the employee's medical insurance. After the income of the resident medical insurance and the interest income of the medical insurance balance, The next part is the financial subsidy, and the calculation results are as shown below:
Note: According to the Ministry of Finance, the National Social Insurance Fund’s final account statement The data is calculated, and the original data is slightly different from the Medical Insurance Bureau's “Development Statistics Express”.
Cause 3: Leave room for medical reform
CCTV on February 24, 2019 The "Focus Interview" column broadcasted a program "Auxiliary Drugs: From Abuse to Rules", which mainly talked about "disuse and even abuse of auxiliary drugs, which increased the burden on patients and increased medical insurance expenses." It became the hardest hit area for over-medication and benefit transmission. The use of the auxiliary medicines controlled by the Anhui Provincial Health Planning Commission was a positive case, and the official’s words were quoted as “squeezing out the cost of this part.” “The space for this kind of expenses, It is used to adjust the price of medical services for the reform of the salary system, and at the end of the program, “a national catalogue of auxiliary medicines is coming out.”
The pricing of medical services for medical staff is too low. Even the price of medical services used more than ten years ago, so that medical personnel must pass the medicines to get a reasonable reward, that is, the so-called "medication by medicine", which is a dysentery of the domestic medical system. This not only makes a big The amount of "grey zone" also brings high but unnecessary friction costs.
From the perspective of this issue of "Focus Interview", the health care committee officials may look forward to improving medical services in the future. The price of the medical staff is raised so that the reasonable remuneration of the medical staff can be achieved directly through the salary. At the same time, after eliminating the high friction cost, the medication will be more reasonable and the drug price will be cheaper.
In fact, in 2018, the Health and Health Insurance Commission and the Medical Insurance Bureau paid significant attention to the control fees for auxiliary drugs. According to the IQVIA data quoted in a public company announcement, as of November 2018, the pharmaceutical market of the big hospital increased by 3.3% year-on-year, but auxiliary The medication decreased by 7.4%, while the therapeutic medication increased by 11.0%. The control was very significant.
After the remarkable effect on the control of the adjuvant medication, in December 2018, the medical insurance bureau passed the "4+ 7 episodes of mining, significantly reducing the price of some therapeutic drugs, eliminating the high friction costs of these varieties. If the future "collection" mode is promoted, then this will leave a huge operational space for medical service price reform The era of "medication with medicine" may end.
Cause 4: Pressure brought about by demographic changes
The above three points are short-term factors for medical insurance control fees, population The structural changes are long-term variables. The statistical data of our neighboring countries in Japan is perfect and can be used for reference.
According to the data in the “National Medical Expenses” report issued by the Ministry of Health, Labor and Welfare every year, the data can be calculated. The per capita medical expenses of people aged 65 and over and those under the age of 65 are generally about 4 times that of the latter.
According to the 2016 National Medical Expenses report, all age groups The distribution of per capita medical expenses is shown in the following figure:
So, assuming that the distribution of per capita medical expenses at all age levels in the country is the same as that in Japan, how much pressure will there be for medical insurance in the future?
The prediction of the long-term population structure involves many variables and is relatively complex. The median data of the United Nations population prediction for China is used here. However, it must be pointed out here that some scholars, such as Dr. Yi Fuxian, The United Nations has different opinions and believes that the UN's forecast is too optimistic. In the following set of figures, the first picture is the actual data of the 2010 census, and the subsequent figures are predictions.
To 2010 Based on the year, it is assumed that the parameters other than the population and age structure do not change (the drug price does not rise. The structure of the drug does not change, etc.), and the future national medical expenses are calculated as multiples of 2010, as shown in the following figure: p>
At the same time, it must be taken into account that the number and proportion of the working population between the ages of 15 and 65 will decline. This has a huge impact on the medical insurance of employees, because it will reduce the number of people who pay the premiums, and the use of medical insurance. Increase.
Therefore, in the long run, in order to ensure that under the “full coverage” of the nationals, the medical insurance can still provide payment guarantee for higher quality medical services and medicines, and the control fees will always be in progress.
and for In the pharmaceutical industry, the medical insurance bureau uses the drug rationally. The continuous attention to reasonable prices will lead to earth-shaking changes in the pharmaceutical market. In the future, the status of the Chinese pharmaceutical market will increasingly converge to mature overseas markets.
1. Ministry of Finance: Explanation of the National Social Insurance Fund Final Account
2. Medical Insurance Bureau: Medical Insurance Development Statistics Express
3. Ministry of Social Affairs: Statistical Bulletin on the Development of Human Resources and Social Security Services
4. Ministry of Health, Labour and Welfare: Overview of National Medical Expenses
5. CCTV Focus Interview: Auxiliary Medication: From Abuse to Rules used
6. United Nations: World Population Prospects