| There are medical and economic explanations for the concept of serious diseases.Medically,malignant tumors and other diseases with relatively serious damage to human health are identified as major diseases according to the classification criteria of diseases.Economically,medical expenses are regarded as the classification criteria.It can be identified as a serious disease when the medical expenses after illness exceed the economic affordability of patients,and then seriously affect patients and families.In the paper,we have absorbed the above two explanations for the definition of serious diseases,that is,when there are some specific diseases,or when the cost of medical treatment exceeds a certain standard,they are considered to have occurred serious diseases.Medical security system for serious diseases refers to a system in which the state raises medical funds through reasonable means to ensure equal access of citizens to appropriate medical services when suffering from serious diseases.Relying on the existing medical security system,the medical security system for serious diseases is to reexamine the medical security system of our country from the perspective of solving serious diseases.From the aspect of medical financing,it includes basic social medical insurance,serious diseases insurance,commercial health insurance,medical assistance and charitable assistance,etc.At the same time,it is necessary to design the system modules to ensure the rational use of the medical funds raised.To control the waste of medical resources and realize the effective supply of medical services,it involves the level of medical and health service,including public health,medical services and drug production and distribution system modules.Our country has initially established a medical security system that covers the entire population,but it is an indisputable fact that a small number of social members and families suffer from catastrophic health expenditure due to serious diseases.The phenomenon of poverty caused by illness and returning to poverty due to illness still occurs from time to time in real life.In the historical process of accelerating population aging,under the realistic challenge of serious disease risk becoming more and more severe,how to solve the problem of people's strong reflection of poverty caused by illness and returning to poverty caused by illness has become one of the most concerned problems in society at the critical time of building a welloff society in an all-round way.The research value of the medical security system for serious diseases lies in the reexamination of the medical security system,the establishment of a sound medical security system for serious diseases,the completion of the shortcomings of the national health insurance system in preventing catastrophic health expenditure,the solution of the problem of poverty caused by illness and the return to poverty caused by illness,and the effective guarantee of the whole population.The institutional effect of the right to health of citizens will affect all aspects of social and economic life.There are two innovations in this paper: Firstly,the paper breaks through the limitations of previous studies on single medical security system module,such as medical insurance or medical assistance.Focusing on solving the problems of difficult and expensive medical treatment,the paper extending the scope of research into multiple system modules of medical service system and medical financing system.Secondly,focusing on solving the catastrophic health expenditure risk caused by serious diseases,referring to the mature practices of Germany,Japan and other countries,the paper innovatively put forward the self-paid top of the high medical expenses supplementary insurance system,as an important group of the medical security system for serious diseases.At the same time,based on the sample data of China Health and Retirement Longitudinal Study(CHARLS)in 2015,this paper calculates the financing level and treatment standard of the high medical expenses supplementary insurance system,and verifies the feasibility of the system assumption.This paper attempts to clarify three core questions,what are the components of China's medical security system for serious diseases and how to evolve into today's form? How is the current status of China's medical security system for serious diseases and how effective is it to solve catastrophic health expenditure? What are the references to the medical security system for serious diseases of the developed countries? Where should we go for the medical security system for serious diseases? Based on these issues,this paper follows the logical way,"basis of theoretical research-assessment of domestic institutions-international experience-key system design-top level design",which is based on the two major institutional systems of medical service and medical financing,and includes disease prevention,medical insurance,medical assistance and charity assistance.This paper consists of nine chapters:Chapter 1,introduction.This chapter mainly introduces the background of the topic,clarifies the purpose and significance of the research.On the basis of reviewing the existing research,it clarifies the content of this study,the main problems to be solved,the research methods,and illustrates the possible innovations and shortcomings.Chapter 2,the theoretical basis of medical security research for serious diseases.Theory is the forerunner of practice,and thought is the guide of action.By reviewing and combing the related theories of risk management,supply and demand,government and market,fairness and efficiency,we find that health care products are in the field of public goods and quasi-public products.The health care market is a typical market failure field.The medical security system for serious diseases needs the active involvement of government and market,and needs the comprehensive apply of disease risk management strategies such as prevention,buffering,compensation and coping,whose goal is to achieve equality in an efficient economic system.Chapter 3,the development of medical security system for serious diseases in China.The concept of medical security system for serious diseases is formally proposed along with the needs of the reform and development of China's basic social medical security system,but in fact the idea of "protecting big illness" has always been embedded in the design of China's medical security system.The concept is given different definitions and connotations in different periods based on specific historical backgrounds and actual needs.The research on the medical security system for serious diseases is actually to examine,interpret and rationalize China's medical security system from the perspective of solving the burden of serious diseases.Looking back on the development of the medical security system in the past seventy years since the founding of the new China,in the long historical periods,as a typical country with dual economic structure,it is inevitable that the government implements different medical security systems in urban and rural areas.With the improvement of urbanization level and the increase of labor mobility,the government of China has integrated the basic medical security system for urban and rural residents,which means the security system has gradually shifted from geographical division to job division,from urban and rural parts to staff and resident parts.In general,the focus of the construction and development of China's medical security system has always been the financing system on the demand side.Under the national security model consisting of public medical security and labor medical security systems during the planned economic period,individuals did not need to worry about medical expenses,and the real problem was left to the supply level.In the period of the market economy system,in order to solve the problem of the medical burden of ordinary people,the government has introduced a number of institutional modules for different groups,such as social medical insurance,critical illness insurance,medical assistance,which are all financing system on the demand side."Path dependence is a constraint imposed by past historical experience on the current set of choices." Reconstructing the medical security system for serious diseases requires us to break through the path dependence.Supply and demand are the two sides of the economy,which are divided into two ends of economic activities,and can be described as "one body and two sides." The essence of expensive medical treatment is that high-quality medical and health services are in short supply,and which is caused by the superposition of the medical service resource allocation on the supply side and the medical service cost allocation on the demand side.To construct and improve the medical security system for serious diseases requires both the efforts from the supply side and the demand side,and also from the medical service system and the medical financing system,simultaneously.Chapter 4,analysis of the operation of medical security system for serious diseases in China.China has made a lot of efforts to improve the medical security system for serious diseases,and has also achieved outstanding results.From the perspective of the supply and demand of medical service,the demand of urban and rural residents for health services continues to increase.With the strengthening of the medical and health service system,the utilization of medical and health services,the health level and the life expectancy of residents have increased significantly.The average life expectancy of residents in 2017 has reached 76.7 years old,and the overall health level is better than the average of middle-and high-income countries.From the perspective of medical financing,the financing structure of medical and health expenses in China has gradually become more reasonable.In 2017,government,social and personal health expenditure accounted for 28.91%,42.32% and 28.77% of the total national health expenditure.The overall participation rate of the social medical insurance system reached 94.23% which covers the urban employees,urban and rural residents.The scale of commercial health insurance continued to grow,while the charitable foundations developed rapidly.The social health expenditures,which includes of social medical security,commercial health insurance and social donation assistance,have become the main fundraising subjects,and the proportion of personal cash health expenditures has been declining year by year.This also indicates that the socialized medical expenses financing system has been actively built.The medical insurance and rescue system for serious diseases,which consists of social medical insurance for urban employees,urban and rural residents,critical illness insurance,commercial health insurance,medical assistance and charity assistance,has set up a five-fold line of defense against the risk of catastrophic health expenditures.From the institutional level,it is basically possible to ensure that a seriously ill patient does not fall into desperation.However,the hospital outpatient expenses and per capita hospitalization expenses have increased year after year.There is still a certain proportion of people who need to see a doctor for treatment without seeing a doctor,need to be hospitalized without hospitalization.The restrictions on medical insurance reimbursement system such as deductible lines,capping lines,reimbursement ratio,and the compliance medical expenses in the catalogue make residents,especially some poor groups,still exposed to the risk of catastrophic health expenditure.According to the sample data of China Health and Retirement Longitudinal Study(CHARLS)in 2015,with cash health expenditure accounting for 40% of household's ability to pay as the criterion of catastrophic health expenditure,about 16.5% of households suffered from catastrophic health expenditure,the intensity of catastrophic health expenditure was 24%,and the poverty rate of catastrophic health expenditure was 8.6%.The incidence of catastrophic health expenditure decreased with the increase of economic level.For example,the incidence of catastrophic health expenditure in urban and rural areas was 12.6% and 18.2%,respectively.The incidence of catastrophic health expenditure in economic quintile groups(from the poorest families to the richest families)was 20.8%,17.6%,16.8%,14.0% and 13.1%,respectively.The differences of the intensity of catastrophic health expenditure is relatively small between urban and rural areas and between economic quintile groups.At the same time,empirical research shows that families with small size,poor health status,weak economic strength and living in rural areas are more vulnerable to catastrophic health expenditure.A laid-off worker in Beijing break the law of "carving chapter to save his wife",a Hebei villager painfully cut off his ulcerated right leg with a steel saw,a Chongqing peasant woman cut her abdomen with a kitchen knife to release water.,the Zhejiang old parents made their own ventilators to save their son's life,a Jiangsu uremic patient made his own hemodialysis treatment at home by old method et al.These embarrassing cases raises the questioning of the level of medical security in our country and highlights the task of promoting the construction of the medical security system for serious diseases is still arduous.Chapter 5,the problems and challenges faced by medical security system for serious diseases in China.Based on the review of the evolution of the medical security system for serious diseases in China and the analysis of its operation,this paper argues that the medical security system for serious diseases in China is facing the following five problems: Firstly,from the perspective of the evolution of the system,the population covered by the medical security system has experienced the evolution from the minority to the majority,but the catastrophic health expenditure risks are still not be fully dispersed,and the special difficulties of a few members become more prominent,which is a hot issue related to social stability and national image.Secondly,from the perspective of the implementation of the financing system,the multilevel medical financing system has not really been established,while the basic social medical insurance and major illness insurance system play a major role.The basic social medical insurance system for urban workers in China is compulsory,and the basic social medical insurance system for urban and rural residents is voluntary.A certain proportion of residents,especially the vulnerable groups in society,are still outside the safety net of social medical security.Thirdly,from the perspective of the implementation of the service system,the marketoriented medical service system promotes the centralization of medical service resources to high-end services and high purchasing power areas,the medical accessibility in rural areas and remote areas is poor,and the problems of difficult medical treatment are prominent when suffering from serious diseases.Fourthly,from the perspective of the operation of the whole system,the medical financing department representing the demand side has not formed an effective restriction and cost control mechanism for the medical service institutions representing the supply side,and the financing pressure of medical security for serious diseases will be enormous in the future.Fifthly,from the perspective of the operation mode of the specific system,the innovative exploration of the "public-private cooperation" of the serious diseases insurance is not mature.It is necessary to deal with the relationship between social security agencies and commercial insurance institutions and other parties,and the specific rules and operational details still need to be standardized and refined.Chapter 6,analysis of the causes of the problems faced by medical security system for serious diseases in China.The paper has discussed the following reasons: the reform lacks toplevel design,and there is no one complete and definite plan for the target model of medical security system,which makes the generalized system of preferences and the preferential safeguard system have not been established;the functions of medical and health management are decentralized,and the system fragmentation and the governance fragmentation coexist,resulting in the insufficient horizontal and vertical integration of medical service,and the insufficient complementary connection of medical insurance,supplementary insurance,social assistance and social welfare systems;the incentive mechanism of medical institutions is unreasonable which exists the inherent motivation to raise costs,resulting in the concentration of medical resources and excessive growth of medical expenses;the management foundation and ability of medical security agencies are weak,which makes the failure to implement strategic purchasing functions.It shows that the medical service system and the medical financing system fail to form a situation of mutual checks and balances and promote each other,and the input of national medical and health resources fails to translate into the reduction of the burden of patients' medical expenses.Chapter 7,international reference of medical security system for serious diseases.The reform of medical security system is a global issue.Although it is not possible to simply copy the experiences of other countries with the doctrine of "transplanting flowers and grafting trees",it can inspire and guide our system design.The medical security system for serious diseases in the United States,Britain,Germany and Japan is representative in the world.The American medical security model is a typical representative of market orientation.The low coverage and poor fairness of the American medical security system fully shows that the medical and health services formed under the free competition of the market have insurmountable fatal weaknesses,while its managed medical treatment and DRGs based on disease diagnosis are advanced.The British medical security model is a typical representative of the welfare state.The government directly pays for medical services,and British citizens can enjoy almost free medical and health services.By restricting residents' first-visit places and graded referral system,the efficiency of the allocation of medical and health resources has been improved.Germany and Japan have some commonalities in their medical security models,which achieve universal coverage and give consideration to fairness and efficiency;emphasize that family is the unit of joint and several insurance,and the cost reimbursement can be calculated according to the total value of the family;medical supply agencies and medical insurance institutions are dispersed,giving the insured the right to choose freely among different institutions,allowing the individual to see a doctor freely without setting up graded medical treatment,to ensure the efficiency of the supply system by the competition mechanism between the contractors;set up the maximum limit of individual self-paid medical expenses to ensure that the national will not fall into poverty because of the economic burden of disease.There are differences in the population coverage and development priorities of the basic medical insurance,commercial health insurance,medical assistance and other system modules in China.We can learn from the advanced experience of different countries.For example,the American commercial health insurance industry is mature and worthy of learning from its product design,actuarial technology,to building the ecological circle of the medical health industry,implementing managed health care,and formulating the rules of medical fee payment.The British healthcare system NHS has realized free medical care for all people with relatively low investment.Its general practitioners system and the hierarchical referral system have important reference significance for the optimization of the medical supply system in China.The system design of setting the maximum limit of individual self-payment fee in Germany and Japan provides a useful reference for the transition of the medical security system from the top of fund payment to the top of individual self-payment.Chapter 8,the financing and payment calculation of high medical expenses supplementary insurance.The self-capped high medical expenses supplementary insurance system is an innovative attempt.Based on the sample data of China Health and Retirement Longitudinal Study(CHARLS)in 2015,this paper estimates the financing level and treatment level of high medical expenses supplementary insurance to demonstrate the feasibility of this system.After calculating,it is suggested that the main objective of the system is to prevent the risk of poverty caused by illness at the start.According to the local per capita disposable income of less than 60%,60%-300% and more than 300%,the system can be divided into three categories.Different starting standards are set for different income classifications.The starting standards can be set as 50%,250% and 500% of the local per capita disposable income,respectively.The maximum limit of individual self-payment is the 5% of the medical expenses in the quasi-part catalogue above the starting standard.Chapter 9,the design of medical security system for serious diseases in China.After sorting out the problems faced by the medical security system for serious diseases in China,and drawing on the experience of the medical security system in the United States,Britain,Germany and Japan,the paper believes that the medical security system for serious diseases in the new era should adhere to the "three combinations",namely,the combination of prevention and treatment,the combination of cost compensation and service supply,the combination of general system construction and key system design,and adhere to the concept of medical and health work based on disease prevention during the planned economy period and highlight the principle of public welfare medical and health work,and continuously improve China's basic social medical insurance system,commercial health insurance system,medical assistance and charitable assistance system.The critical illness insurance system in operation should be transformed into the supplementary insurance system of high medical expenses,the capping line of medical insurance fund payment should be transformed into the capping line of personal or family medical expenses,and so on.We should promote the "three medical linkages" through the reform of medical insurance payment mode,and finally reshape the patient-centered medical service system to achieve the goal of appropriate medical security for everyone.Innovation is a challenge.In this paper,disease prevention,medical services,medical insurance and medical assistance are integrated into the unified framework of the medical security system for top-level design,which is still a forward-looking attempt and needs solid theoretical basis and knowledge breadth.The theoretical analysis of this paper,especially for some subdivisions,needs to be deepened.At the same time,the system design of medical security for serious diseases is mainly a framework recommendation.At present,the payment standards and treatment standards of the basic social medical insurance system vary from province to province.There are also differences in the connection between the basic social medical insurance system which bears the main responsibility,and the rescue system which bears the bottom responsibility,and the supplementary insurance system of high medical expenses which bears the top responsibility.Due to the difficulty of obtaining relevant data,this paper only makes a rough calculation on the high medical expenses supplementary insurance system.It is worth further discussion and improvement in the future research. |
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