1. Establish a reasonable level of access and security for basic medical insurance. The traditional dual-track medical insurance has many disadvantages, the biggest of which is the strict access standard, which clearly defines the beneficiary's occupation and the nature of unit ownership. Reforming the traditional medical insurance system is to change the dual-track medical insurance system for urban workers into a single-track system, lower the access standard, establish a unified basic medical insurance system for urban workers, and achieve wide coverage. The system can be expressed as follows: according to the inherent requirements of the socialist market economy, the basic medical security mechanism for urban workers is constructed, and all urban workers are included in this safety net to prevent urban workers from affecting the production and reproduction of the labor force because the basic medical care is not met, thus causing a huge impact on the operation of the market economy. The defining standard of basic medical insurance should be the affordability of finance, enterprises and individuals. Under the realistic needs and possible circumstances, the policy choice of reform must be to solve the most basic medical needs of urban workers. This is entirely determined by China's social situation and economic development level, which conforms to the basic characteristics of China's primary stage of socialism. The history of China's medical insurance development tells us that medical needs are the basic living conditions of workers, and the state must provide them with such needs, which is the inevitable trend of social development. This medical insurance system should be based on breaking the original barriers of ownership and units, with the goal of establishing a unified medical insurance system. However, as far as China's reality is concerned, at this stage, medical insurance supply is restricted by all aspects of finance and can only be basic, and the satisfaction of medical insurance demand can only be basic, that is, low level, wide coverage and guarantee of basic medical needs.
2. Choose a scientific basic medical insurance fund model. Fund is the core of medical insurance, and the determination of fund model is the key to the success or failure of medical insurance system reform. The choice of China's medical insurance fund model is based on the reform experience of other countries and their own countries. On the basis of emphasizing the obligations of employers, personal responsibility is linked to medical insurance benefits, which is both an incentive and a constraint. Social pooling fund embodies the "law of large numbers" of social medical insurance mutual assistance, which is conducive to realizing the overall adjustment of medical insurance fund in a certain social scope, balancing the burden of medical expenses, dispersing medical risks and realizing social equity. Personal account embodies the responsibility that individuals should bear, which is conducive to enhancing employees' awareness of health investment, prompting employees to accumulate medical insurance funds when they are young and healthy, and establishing a vertical personal accumulation guarantee mechanism; At the same time, personal accounts are owned by individuals, which improves the sense of personal responsibility, urges employees to be self-disciplined in medical consumption, and strengthens the cost restraint mechanism. The basic medical insurance fund combines social pooling with individual accounts, realizing the combination of the horizontal social mutual aid function and the vertical accumulation guarantee function of the medical insurance fund, giving consideration to fairness and efficiency, which is conducive to dispersing medical risks. In recent years, the reform practice in various places has fully proved this point. According to the regulations, the basic medical insurance premium for employees is paid by both employers and employees. The employer's contribution rate should be controlled at about 6% of the total wages of employees, and the employee's contribution rate is generally 2% of his salary income. With the development of economy, the contribution rates of employers and employees can be adjusted accordingly. The basic medical insurance combines social pooling with individual accounts, all individual contributions are included in individual accounts, about 30% of unit contributions are included in individual accounts, and the rest are established as a pooling fund. The principal and interest of an individual account are owned by the individual and can be carried forward and inherited. Pooled funds and individual accounts should define their respective payment ranges and be managed separately, with the purpose of defining their respective responsibilities and avoiding the overdraft of individual accounts by pooled funds. It is necessary to formulate the minimum payment standard and the maximum payment limit of the overall fund. Qifubiaozhun is controlled in principle at about 10% of the average annual salary of local employees, and the maximum payment limit is controlled at about 4 times of the average annual salary of local employees. Medical expenses below Qifubiaozhun shall be paid by personal account or borne by individuals. Medical expenses above Qifubiaozhun and below the maximum payment limit are mainly paid from the overall fund, and individuals also have to bear a certain proportion. Medical expenses exceeding the maximum payment limit can be solved through commercial insurance and other means.
3. Realize the effective management of basic medical insurance. Socialization is the basic principle of the reform of basic medical insurance system. It broke the traditional pattern of compartmentalization, decentralized management and decentralized decision-making, straightened out the basic medical insurance management system, and eliminated the unfair and unreasonable treatment caused by the differences in ownership and occupation in the unified basic medical insurance system for urban workers. To realize socialized management of basic medical care, it is necessary to establish a system of separating government affairs, execution and supervision. The main tasks of the government are planning, decision-making and policy guidance, and social insurance agencies are specifically responsible for fund collection, management and treatment payment. The supervision organization composed of the government, mass organizations and individual employees shall effectively supervise the behavior of social insurance agencies. The socialization of basic medical insurance also includes the socialization of basic medical services, the socialization of treatment payment and the socialization of quality community services.
4. Build a low-cost, high-efficiency drug and medical support system. The distribution of medical institutions in drug production and the efficiency of diagnosis and treatment are directly related to the level of medical expenses, and then directly related to the reform of medical insurance system. According to relevant newspapers and periodicals, since 1978, China's pharmaceutical economy has been growing at an annual rate of about 18%. Its growth rate ranks first in all industries in China, and it is also higher than that of major pharmaceutical countries in developed countries. In terms of drug production, as of 1997, there are 639 1 companies in China, including more than 700 foreign-funded enterprises, producing more than 350 kinds of raw materials 1350, over 4,000 kinds of preparations and over 8,000 kinds of Chinese patent medicines. Among more than 6,000 pharmaceutical manufacturers, more than 300 enterprises (workshops) meet the requirements of good manufacturing practice (GMP), of which only 59 enterprises, 38 workshops and 13 varieties have obtained GMP certificates. China's pharmaceutical production enterprises are small in scale, with a large number of enterprises, repetitive products, low technical level, poor economic benefits, featureless products, similar varieties, few brand-name products and low-level repetitive production. Take norfloxacin as an example. According to incomplete statistics, there are currently 828 enterprises producing norfloxacin in China, including 75 in some provinces. From the operating situation, by the end of 1998, there were 165 19 pharmaceutical wholesale enterprises and more than 60,000 retail enterprises in China. In the United States, there are only 13 pharmaceutical wholesale enterprises, of which 5 wholesale enterprises account for 85% of the total business in the country. There are only 13 pharmaceutical wholesale enterprises in France, of which the largest one accounts for 45% of the total national business. According to the usage, from 1998, hospitals above county level 152 19, township and street hospitals 5 1535, individual clinics 125264. There are 309,007 sanatoriums, specialized clinics, maternal and child health stations (institutes), health stations (institutes), clinics and other medical institutions in China, with more than 5.27 million employees. From 65438 to 0997, there were 4045 general hospitals of health departments in China, with a total income of 8265438+78 million yuan. Drug revenue was 42.394 billion yuan, accounting for 565.438+0.59% of the total revenue. Among them, 6 1.36% of outpatient income and 49.69% of hospitalization income came from drugs. The difference income from the annual sales of drugs in medical units is 65.438+06.56 billion yuan, and the profits and kickbacks of drug trading enterprises are about 8 billion yuan, totaling 24.56 billion yuan. According to the statistics of the health department, the national drug consumption in 1997 was 83.8 billion yuan, and the per capita drug consumption was 6.65 1 yuan, including 175 yuan in cities and 25 yuan in rural areas. In the same period, the per capita drug consumption in moderately developed countries was 40 to 50 dollars, that in western European countries was about 160 dollars, and that in the United States exceeded 300 dollars.
China's medical and health system has been unable to meet the needs of medical insurance system reform in many aspects for decades. The structure of medical and health service system is unbalanced, and medical and health resources are over-concentrated in big cities and over-concentrated in big hospitals in cities. However, community medical services that are close to employees' lives, convenient for employees to seek medical treatment and low in service cost are underdeveloped, and employees need to go to large hospitals for minor injuries and illnesses. The unreasonable distribution of medical and health resources increases the cost of medical services, which is an important reason for the waste of medical insurance funds. The structure of medical service is unreasonable, and the proportion of medical service in medical service is too large. Some medical institutions unilaterally pursue profits, focusing on providing pharmaceutical services and high-tech large-scale equipment inspection. Irrational examination and irrational drug use are serious, which is another important reason for increasing the expenditure of medical insurance fund; At the same time, the drug circulation system is chaotic, with high discount and high pricing, which encourages irrational drug use. The internal management mechanism of medical institutions is not perfect, and there are a large number of redundant staff, which increases the labor cost of medical services and directly leads to the increase of medical expenses. This high medical expense is finally converted into medical insurance fund expenditure, which makes the financial budget constraint of medical insurance soften continuously. Therefore, the reform of drug production, sales system and health system must be coordinated with the reform of medical system. Focusing on the reform of the medical insurance system, we should straighten out the system of drug production, sales and health management, formulate the drug list, diagnosis and treatment items and service facilities standards of designated hospitals, designated pharmacies and basic medical insurance in a timely manner, and standardize the drug market and medical behavior. This is an important link to optimize the allocation of medical resources, reduce medical costs, reduce the waste of medical resources and ensure the smooth reform of medical insurance system.
5. Actively and steadily establish a supplementary medical insurance system. The State Council's decision on establishing the basic medical insurance system for urban workers aims at establishing a social medical insurance system to ensure the basic medical needs of urban workers. This basic medical demand is defined by the maximum payment limit, and the medical demand beyond this limit is not a basic demand, which can only be solved by means of commercial insurance. Theoretically, the basic medical insurance is universal, that is, it is generally implemented in the whole society, aiming at ensuring the basic needs of workers' health, and the government enforces it in the whole society through legislation. Supplementary medical insurance refers to the basic medical insurance that ensures the basic medical needs of employees, and the employer or individual appropriately increases medical items and selects more advanced treatment technologies according to its own characteristics and financial resources. Its insurance level can be high or low, insurance items can be more or less, and insurance forms are flexible and diverse. At present, some places have made some attempts. Zhenjiang City, Jiangsu Province stipulates that insured employees and retirees each pay 30 yuan every year as a large medical expenses pooling fund. Medical expenses exceeding the maximum payment limit of 30,000 yuan and 6,543,800 yuan will not be paid by individuals, 20% by insured units and 80% by pooling funds. The individual pays 10%, and the insured unit pays 90% of the 65,438+10,000 yuan. The characteristic of this model is that supplementary medical insurance is directly managed by social insurance agencies, and the risks are shared by social insurance agencies, employers and individuals. According to the regulations of Xiamen, each person withdraws 18 yuan from his personal account every year, and 6 yuan from the social pooling fund to apply for insurance with an insurance company. If the medical expenses exceed the maximum payment limit of 40,000 yuan, the individual pays 10%, and the insurance company pays 90%. The annual maximum payment limit is150,000 yuan. The characteristic of this model is that the social insurance agency collects fees and then reinsurance with the insurance company, and the risks are shared by the insurance company and the individual. In fact, the supplementary insurance for workers' well-being and mutual assistance organized by Nanjing Federation of Trade Unions is also a kind of supplementary medical insurance. It is characterized by self-management by mass organizations, aiming at mutual assistance and economic assistance, not for profit, voluntary participation of employees, and independent determination of payment standards, insurance items and treatment levels.
The above-mentioned supplementary medical insurance models have their own advantages and disadvantages, which need to be constantly supplemented and improved in the process of reform. Basic medical insurance is the basic content and core of medical insurance system, and supplementary medical insurance is also an important content of medical insurance system. In the process of implementing the basic medical insurance system, we should actively carry out multi-level and flexible supplementary medical insurance according to the diversified characteristics of medical consumers' needs, enhance employees' ability to resist the risk of serious illness, meet their higher-level medical consumption needs, and truly establish a medical insurance system with basic medical insurance as the leading factor and commercial insurance as the supplement, which reflects the characteristics of our country at this stage. At the same time, we should actively study and explore the specific forms and ways to realize medical insurance for rural residents.