Study On The Rational Use Of Basic Medical Insurance Expenses

China has now established "a health insurance system with national coverage", a combination of medical insurance for urban workers, urban residents’ medical insurance and new rural cooperative medical system. But in the process of using medical insurance funds, the issue of seriously excessive usage and rapid usage growth has affected the economic and social benefits of the basic medical insurance fund, sometimes resulting in a medical insurance fund crisis with a balance in red. There are mainly five contributing factors:one is concerning the responsibility of the government. The reform of medical system and the medicine circulation system is lagging far behind with a serious shortage of financial input; two, problems of the medical institutions. Because the government compensation is inadequate, the medical organizations are market-oriented, taking advantage of the information asymmetries to pursue profits, resulting in excessive diagnosis and treatment behavior like large amount of prescription, big project check, deliberately prolonging or shortening hospitalization time. Three is the factor of the insured. Participating in the medical insurance, the insured person’s medical needs are massively released. They become less thrifty, and take advantage of the current policy of low pay-high return proportion and easy referrals, seeking intensive treatment of minor diseases. The consulting and hospitalization rates rocket up. Four is the social factor. One is the aging the population is accelerating and various senile diseases increased; two is the change of the living environment and way of life leads to structural change of disease spectrum. The incidence of malignant tumors, cardiovascular, diabetes is growing rapidly. Three is the game among medical institutions and insurance agencies and the insured, which is the unity of opposites, with the insured person to obtain the best treatment, the medical institutions to increase fees, and the agencies to control costs. At present the outcome of the game is a dominant position in the medical institutions. These factors have led to the excessive use of insurance fund, resulting in the rapid growth of the insurance cost. Through the analysis of these phenomena, and the public nature of the basic medical insurance, we deem basic physical insurance a public product and we should put first the long-term interests and the overall interests of the insured, embodying the fairness and rationality of the basic medical expenses. Two is to establish the concept of covering basic medical "demand", not for the basic medical "expenditure", scientifically understanding the scope and extent of the medical insurance. At the same time, SWOT analysis of the basic medical insurance system suggests the advantages and opportunities of strengthening the reasonable use of basic medical insurance funds are:government leading, more incentives; continuous accumulation of experiences. the deepening of reform. perfection of the system, the setting up the reasonable market competition system. Disadvantages and challenges lie in:the unreasonable scope and degree of the current basic medical insurance; inadequate policy design offering poor guidance to medical institutions and the insured; moral risks of the insured difficult to control; coexistence of government failure and market failure; no full play of the role of health education and disease prevention system; population aging and disease spectrum change accelerating further, the basic medical insurance cost pressures increase.Therefore, this paper puts forward suggestions:one is to clarify the responsibility of the government. Increase the medical input, determine the government’s annual medical investment in terms of a GDP ratio; speed up the medicine circulation system reform, reduce the price of drugs; strengthen the supervision of medical institutions in the industry, contain irregular medical behavior. Two is to improve the design of the system of medical insurance. Properly determine the starting point of payment standard for the hospitalized and the self-payment ratio, perfect a reasonable cost sharing mechanism; adjust the pooling account and the individual account proportion, increase the proportion of personal account, and gradually explore medical insurance acting at the same time as a saving account; establish annual reward system to give incentive to the non-user of medical insurance funds; regulating the level-three hospitals two-way referral system. Three is the policy design to save medical insurance funds. Implement annual "transfer" system, strengthen medical institutions competition; transfer our focus from the "treatment" to "prevention", set aside a special fund to strengthen health education and disease prevention, reduce the incidence rate, outpatient, hospitalization and re-hospitalization rate; strengthen the moral risk prevention and supervision of insurance and medical insurance agencies and the insured to prevent the abuse of medical funds.