Research On The Operation Of Urban Employees' Basic Medical Insurance In Seven Cities

BackgroudSince 1998, our country has established the urban employees' basic medical insurance. After 10 years' development, health insurance reform has made enormous progresses. The number of basic medical insurance enrollees rises continuously, the financing scale increases simultaneously, and the whole system has been improved. Urban employees' basic medical insurance has contributed a lot during the process of meeting employees' basic health services needs. Besides the progresses, we are also facing some difficulties, such as low coverage rate, risk of fund imbalance due to rapid growth of healthcare expenditures, and need of payment methods betterment. At present, both the Party and the government attach great importance to social security work. As a key domain relating people's livelihood, medical insurance draws a lot of attention recently. Urban residents' basic medical insurance program is now at the stage of experimental implementation. As a platform of urban residents' basic medical insurance, urban employees' basic medical insurance plays an important role in the process of medical insurance system construction, and its development is vital to the overall development of medical insurance system. In order to push the urban employees' basic medical insurance forward and realize the object of cover all urban workers, we must get a clear picture of current situation and define the existing problems precisely. After this we should also find out the causes of these problems and seek the best way to solve them. By analyzing the policy and operating situation of urban employees' basic medical insurance, we could summarize the experiences, find out the problems and make some countermeasures, thus provide support for the development of this system.ObjectivesThis paper tries to conduct an analysis on the status quo and the operating situation of urban employees' basic medical insurance, summarize experiences and then give suggestions to policy-makers to improve urban employees' basic medical insurance system. Contents1. Status quo analysis on urban employees' basic medical insurance policy2. Analysis on the operating situation of urban employees' basic medical insurance3. Status quo analysis on the supervision of payment of fundMethods1. Literature review2. Focus-group interviews3. Comparative study method4. Statistic analysis methods: using Excel 2003 & Spss 13.0 software to analyze medical insurance dataMain Results1. With enrollees increasing and fund growing, the scale of basic medical insurance was enlarged. But the percentage of retirees rose year after year, which caused the rise of burden coefficient.2. All 7 cities but city A adopted other payment methods besides fee for service method. Two main provider payment methods they employed were payment of an agreed sum of money for each inpatient service, and case based payment. But both the two methods are inaccurate.3. The average yearly growth rate of financing is bigger than that of spending, which leads to the decline of balance rate. Some cities even showed deficit of social pooling fund in a year.4. The balance rate of medical saving accounts showed a trend of decline, which means the accumulation speed slowed down.5. The actual reimbursement rates among different levels of hospitals were much the same., and the aim of leading patients to choose the suitable level of hospitals was not achieved.6. Analysis of sample data in city D showed that expenditures were much higher in hospitals that belonged to other districts than that of local hospitals. The authority had difficulties in supervise health agencies outside the district.7. The reimbursement of outpatient services of chronic diseases was carried out much widely, more and more chronic diseases were included. The actual reimbursement rates were above 55%, which greatly relieved the economic burden of diseases for patient with chronic diseases.8. Improvement of human resources input should be made to facilitate the development of basic medical insurance.9. There were all kinds of behaviors against the rules, and it was hard to recognize them.10. At present, punishment on inappropriate behaviors mainly depended on medical insrance authority, and it can hardly affect hospitals. We should strengthen punishment to make sure hospitals are punished properly.Suggestions1. Further expanding coverage of medical insurance and this can be done together with urban residents' basic medical insurance. We should make sure that all urban workers are included in the health insurance system.2. With the development of endowment insurance, current fund-raising mode can be changed and retirees may play a role in fund-raising. This can ease the stress brought by aging population.3. Strengthen management of referral to hospitals outside the district, and try to contain the medical expenditures.4. Make adjustment of deductibles and co-payment rate to reach the goal of leading patients to different levels of hospitals.5. Make further research on different payment methods, find out the weakness point of them and design assessing index to conquer them.6. Build high quality supervision stuff and improve the capacity of supervision.7. Make rigorous punishment on medical institutions and person in charge.8. Introduce social supervision mechanism into medical insurance fund supervision.9. Build credit archives for hospitals, doctors and enrollees. Carry out supervision work based on these records.