What is medical insurance control fee?

Medical insurance fee control, as its name implies, refers to controlling the insurance expenditure for medical services, reducing medical waste and improving the efficiency of medical insurance funds.

Who dominates the medical insurance control fee?

The medical insurance system of a country or region determines the expenditure structure of medical insurance expenses.

Specifically, in the game between the government, commercial insurance companies, doctors, hospitals and pharmaceutical companies, which party occupies the dominant position in the process of medical service flow and price, and then dominates the control of medical insurance costs.

Research model of medical physique

Advantages under different medical systems

Cost control of medical insurance under different medical systems

Britain: government-led medical insurance cost control model

The government forcibly raises funds from the society through taxes to provide medical expenses for the whole population. The government directly operates hospitals, employs medical staff and directly provides medical services. In terms of drug list, the government has formulated a free drug list, stipulated the profit rate of pharmaceutical companies, and the government has centralized drug purchase.

Germany: government regulation and social group-led medical insurance cost control model

1. fund-raising: members of society can choose all kinds of foundations independently, and employers and individuals share 50% of the funds. The rates of different foundations are different, and the medical insurance rate is related to the personal income level. The higher the income, the higher the proportion of contributions, but the same medical services as other members of the foundation. The federal government is only responsible for the macro-control of all foundations and does not interfere in their specific operations. At the same time, according to the policyholder structure, rate difference and insurance project difference of different foundations, the income of each foundation is adjusted and distributed to adjust the income gap of each foundation and promote fair competition.

2. Provision of medical services: The distribution of medical resources in Germany is very scattered and uniform, and the outpatient service and hospital are separated. Community doctors play a very important role in the local area. Community doctors are mainly general practitioners, some of whom are specialists, and 80% of common diseases can be solved in community hospitals. The number of general hospitals is small, and more hospitals are strong in a certain field. The foundation is responsible for linking doctors and various medical service institutions through contracts to provide flexible medical services for members. Ordinary members can choose their own general doctors, specialists need to make an appointment and follow the arrangement, and they need to pay for their own choice of specialists.

3. Drug pricing: Germany has established a strict drug reference pricing system. Each foundation negotiates with pharmaceutical companies according to the reference pricing of drugs, and the logistics and distribution of drugs is also the main responsibility of each foundation. Because Germany has a reference price set by the government, the foundation has a slight advantage in price negotiation. This medical system in Germany makes the leading role of medical insurance control fees in the hands of the foundation and subject to government supervision.

1) The dominant position of medical services-"pay as you go". At present, Germany adopts the system of "capping departmental budget and expenditure", and all aspects of medical services are basically supported by income: hospitals and outpatient doctors pay independently, hospitals pay in advance, and the excess is shared by hospitals and foundations; The foundation's payment to doctors is mainly divided into two steps: first, according to the number of participants, the head fee is paid to the doctors' association as agreed, and the doctors' association manages the doctors nationwide in a unified way; Second, the doctors' association pays doctors' service fees according to the services paid by doctors. Doctors don't touch medicine, and medicine is separated.

2) Drug pricing-drug reference pricing system and drug payment limit system. Reference pricing is based on the price of alternative drugs. Patients can only get medical insurance reimbursement if they buy drugs below the reference price, which leads to full price competition among pharmaceutical companies, reducing drug prices and transferring drug profits to the foundation. In addition, Germany implements a payment quota system for doctors' prescription drugs and over-the-counter drugs purchased by individuals, strengthening the awareness of individuals and doctors to control medical expenses.

United States: medical insurance companies dominate medical insurance control fees.

Controlled medical insurance system means that insurance companies limit the scope of doctors and hospitals selected by plan members through different insurance plans, control the specific process of medical services, strictly control the various expenses of medical services, and control the overall medical expenses through standardization and systematization of diagnosis and treatment processes.

1) Patients choose insurance products provided by commercial insurance companies: In principle, American citizens who can afford the premium are free to choose various insurance products provided by various insurance companies; Because most of these products are commercial insurance, when choosing different insurance products, you need to know which services to insure, which services not to insure, the rate and the self-payment ratio (generally, the higher the self-payment ratio, the lower the rate);

2) Insurance companies provide corresponding catalogues: after customers purchase insurance products, insurance companies will provide customers with an online list of primary doctors, and customers will choose one of them to be their health care doctor or family doctor, who will be responsible for their initial diagnosis, annual physical examination and simple medical treatment when they are sick; This relationship will accompany this customer for many years, and the health care doctor of this customer generally knows the physical condition of this customer best;

3) Suggestions after the initial visit: If the customer is sick, he should go to his own health care doctor first. If the health care doctor feels that he can't handle it, he will issue a referral form to the patient and recommend the patient to the medical practitioner in the corresponding hospital for further treatment. Of course, the recommended specialties should also be on the network list provided by insurance companies;

4) Medical treatment: If a patient needs hospitalization after receiving the recommendation form and being diagnosed by a doctor appointed by a designated hospital, the doctor must first apply to the patient's insurance company for hospitalization, and then apply to the hospital for hospitalization procedures after approval. Without the permission of the insurance company, the hospital can't accept patients unless all patients pay their own expenses; If a prescription is required, the doctor will prescribe a prescription for the patient. Of course, the list and price of prescription drugs should be selected from the list of drugs provided by insurance companies, and patients take prescriptions to retail pharmacies to buy them; At the same time, the doctor uploads the electronic data of the patient's diagnosis and treatment process and prescription to PBM(PharmacyBenefitManager) company.

5)PBM Company completes the settlement: PBM Company makes the settlement according to the electronic data of prescription and the corresponding reimbursement level. At the same time, the details of each treatment are recorded and data processing and analysis are provided to commercial insurance companies.

1) medical service dominance: medical insurance companies will recommend the best treatment process for the corresponding diseases according to the needs of different diseases, and pay the doctors according to the national unified rate. Doctors charge according to the number of treatments, and the more they do, the higher their income; For the hospital, the insurance company will pay the total amount according to different diseases, and the part beyond the reimbursement of the insurance company will be borne by the hospital itself. The hospital strives to improve the use efficiency of facilities and reduce the hospitalization time of patients;

2) Pricing power of drug prices: The formulation of drug prices in the United States has nothing to do with drug costs, and the formation of drug prices is mainly the result of mutual consultation between pharmaceutical companies and commercial insurance companies. The chip of commercial insurance companies is the drug list of each company. This process involves the participation of PBM companies of various commercial companies, and some wholesalers need to participate in each other. This is a negotiation process. The biggest chip in the game of pharmaceutical companies is the market monopoly position.

Singapore: a social security system based on savings, with public hospitals leading the control of medical insurance costs.

In Singapore, hospitals providing medical services are mainly public, forming a medical service provider with hospitals as the core. In terms of medical service prices and drug prices, Singapore emphasizes the role of the market, and the burden borne by individuals is relatively large.

1) Raising funds: It is stipulated in Singapore that employees earning more than S $6,000 need to deposit 6%-8% of their monthly income into their personal accounts, and the individual and the employer should bear half of it. Savings in personal accounts are used to pay for education, housing, old-age care and medical expenses of individuals or families. The Central Provident Fund Bureau is responsible for the specific management of these personal accounts to maintain and increase the value. For citizens under S $6,000, the government provides minimum protection.

2) Provision of medical services: There are 29 hospitals and medical institutions in Singapore, of which 13 are public institutions, and more than 72% of beds belong to these public institutions, and the ownership of these institutions also belongs to the government, so the overall market of medical service institutions is basically dominated by the public. In management, the government adopts the management mode of private enterprises, sets up the board of directors and hires the chief operating officer to ensure the implementation of various government systems in hospitals. At the same time, all public institutions are divided into "western group" and "eastern group", and all groups can cooperate with each other to form scale effect, encourage mutual competition and reduce medical costs.

3) Formulation of drug prices: All hospitals purchase drugs through public bidding and bulk purchasing, so the overall formation of drug prices is the result of market-oriented games. Public hospitals have played a leading role in controlling medical insurance costs, but the overall price is determined by the market and the reimbursement threshold is high, which leads to more responsibilities being placed on individuals and families.

1) The leading position of medical services: As most hospitals are public, coupled with the management of private enterprises and the competition between the two groups, the overall cost of medical services has been effectively controlled;

2) Drug price is dominant: due to the mode of negotiation between hospitals and pharmaceutical factories, drug prices are basically market-oriented, and the government has weak control over them;

3) Individuals should bear more medical responsibilities: individuals should balance housing, pension, education, medical care and other expenses in savings accounts. At the same time, the government has set a deductible line and a cap line for medical expenses. Individuals should bear most or all of the expenses below the deductible line and above the capping line, and 50% of the expenses between the deductible line and the capping line.

conclusion

By comparing different medical insurance systems, it can be found that different medical insurance systems determine different medical insurance schemes, different insurance schemes determine the pricing mechanism of medical services and drug prices, and then determine the structure of medical expenses in a country, which ultimately leads to which party in different countries has the initiative to control medical expenses.

Judging from China's situation, China's medical insurance system is still not perfect, and the proportion of medical expenses in GDP is still at a low level compared with other countries, and the aging process has just begun; Judging from the current medical expenditure in China, personal expenditure still accounts for a considerable proportion, and the formulation of hospital clinical pathway and prescription right has a great influence on medical insurance expenses. In the future, the dominance of medical insurance control fees will be carried out among hospitals, governments and commercial insurance companies.

Compared with the growth of medical expenses at home and abroad, the control ability of medical insurance expenses in China is relatively weak.

Every one percentage point increase in China's aging rate will increase the medical expenses by 13%, and the control of medical insurance expenses in China has a long way to go.