The ＂tax collectors＂ who broke into medical care and the ＂huge waves＂ of medical reform in the past five years.

(The author of this article is Jianwen Consulting, a cross-border insight into the medical industry)

On the morning of November 28th, the responsible comrades of the Organization Department of the Central Committee attended the meeting of leading cadres in State Taxation Administration of The People’s Republic of China, and announced the central decision: Comrade Hu Jinglin was appointed as the Party Secretary of State Taxation Administration of The People’s Republic of China, and Comrade Wang Jun was removed from the post of Party Secretary of State Taxation Administration of The People’s Republic of China.

A short news of personnel appointment has aroused the attention of practitioners in the entire medical industry.

The Medical Insurance Bureau, whose administrative level is only the deputy ministerial level, has been deeply embedded in the medical and health field of China by virtue of its frequent medical insurance policies in the past five years, and even transformed and reshaped the behaviors of patients, hospitals, enterprises and other multi-stakeholders, and has become the leader of the linkage among the three hospitals in medical reform.

For Hu Jinglin personally, he was born in the financial system, and this time he can be said to return to the fiscal and taxation circle. As the first director of the National Medical Insurance Bureau, if you understand Hu Jinglin, you can understand the work of the National Medical Insurance Bureau in the past five years.

In the eyes of many medical insurance policy observers, the National Medical Insurance Bureau, as a super payer, has successfully completed the phased historical task of "controlling medical insurance fees" in the past five years with a number of policies, such as national talks, centralized procurement, payment mode reform, outpatient co-ordination and individual account reform. Today, the balance of medical insurance funds has exceeded 4 trillion yuan.

But at the same time, the relationship between medical insurance and pharmaceutical industry innovation still needs to be straightened out; After "changing cages for birds", the pace of medical service price reform is slightly delayed; Although medical insurance is forced to go upstream, which can generate great impetus, it is obviously unrealistic to rely solely on medical insurance.

All these call for the National Health Insurance Bureau to make greater achievements in the next five years.

The "tax collector" who broke into the medical system

According to the website of State Taxation Administration of The People’s Republic of China, Hu Jinglin is the Party Secretary of State Taxation Administration of The People’s Republic of China.

Time goes back to five years ago. On May 31, 2018, with the official unveiling of the National Medical Insurance Bureau, Hu Jinglin, who was born in the financial system, became the party secretary and the first director, and entered the medical field.

This appointment has surprised many people in the industry. Looking back now, in the early days of the establishment of the National Medical Insurance Bureau, in order to complete the task of "managing the medical insurance fund", it can be said that it is appropriate for the financial system official to serve as the director of the National Medical Insurance Bureau.

Zhu Hengpeng, director of the Public Policy Research Center of China Academy of Social Sciences, once pointed out that the raising of social medical insurance funds has a quasi-fiscal color, and at the same time, finance is responsible for the funds.

Before joining the National Medical Insurance Bureau, Hu Jing Lin had been deeply involved in the financial system for 20 years, and served as deputy director of the Property Appraisal Department of the Ministry of Finance, deputy director of the Economic Construction Department, director of the Economic Construction Department, chief of staff, assistant minister and deputy minister.

The experience of more than five years in the National Medical Insurance Bureau laid the foundation for Hu Jinglin to return to the fiscal and taxation system.

The aforementioned scholars in the field of public management said that the administrative leaders of various departments belong to policy posts, and they pay more attention to political quality and personal ability than familiarity with the industry, so that the incumbents can fully exercise their decision-making ability.

During his tenure as director of the National Medical Insurance Bureau, Hu Jinglin’s work style was also recognized by the outside world. A researcher in the field of medical insurance told Jianwen Consulting that Hu Jinglin was willing to listen to and absorb opinions from all sides, and his attitude was modest and polite, "unlike those technocrats".

He also revealed that he received many WeChat greetings from the director during the holidays. "This is absolutely not among the officials at the same level I have contacted."

Some observers believe that in the past five years, after the National Medical Insurance Bureau completed the task of "vacating cages", the core of the next step is to promote the task of "changing birds"-the reform of medical service prices. Shi Zihai, the current deputy director of the National Medical Insurance Bureau, is an expert in this field. He has been engaged in policy research in the National Development and Reform Commission for a long time and was once the director of the price department.

Not limited to "controlling fees", supporting innovation is the future direction.

"Through the coordinated development and governance of medical insurance, medical care and medicine, the win-win situation of’ people enjoying benefits, funds ensuring safety, hospitals developing and enterprises growing’ is taking shape."

In May of this year, Hu Jing Lin once commented on the work in the past five years at a series of news conferences on the theme of "the beginning of authoritative departments" held by the State Council.

Look carefully, medical insurance, medical care, medicine; The masses, funds, hospitals and enterprises, as the payer, the Medical Insurance Bureau, traced back to the lower reaches of the industrial chain and used the logic of managing money to connect the whole medical and health system in China, reshaping the medical and health pattern, just like throwing a big stone into an ancient well, which not only caused ripples, but also caused stormy waves.

Before the establishment of the National Medical Insurance Bureau, China’s medical care faced some problems: the adjustment time of medical insurance catalogue was not fixed, and it was only adjusted three times in 18 years, which was difficult for innovative pharmaceutical companies to predict; The drug price is artificially high, and the people’s medical burden is heavy; The logic of supporting doctors with medicine distorts the income structure of doctors; Payment by project is too extensive, excessive medical care is hard to avoid, and medical insurance funds continue to be under pressure.

This chaotic situation was gradually broken after the establishment of the National Medical Insurance Bureau, relying on frequent policies.

There are policies such as medical insurance negotiation, centralized procurement with quantity, reform of medical insurance payment method, individual account reform and outpatient co-ordination, all of which have not caused widespread debate and discussion in the industry and society. However, only by breaking the old system can we rebuild the new system on the ruins.

Specifically, there are some changes worthy of writing: promoting centralized procurement with quantity, the average price reduction of 333 drugs organized by the state is over 50%, and the average price reduction of 8 high-value medical consumables such as heart stents and artificial joints is over 80%; Together with local alliance procurement, the cumulative burden reduction is about 500 billion yuan. At present, the ninth batch of national procurement has included 41 drugs in the list, and the average price of the drugs to be selected is reduced by 58%. It is estimated that the annual drug cost can be saved by 18.2 billion yuan, and the fourth batch of consumables will also be opened this week.

The medical insurance catalogue has achieved "one adjustment per year", and 618 drugs have been added in five years. More than 80% of new drugs can now be included in medical insurance within two years of listing. The expenditure of medical insurance on new drugs increased from 5.949 billion yuan in 2019 to 48.189 billion yuan in 2022, an increase of 7.1 times. Among them, a considerable part of them are anticancer drugs and drugs for rare diseases. In addition, after reimbursement, the cumulative burden reduction for patients exceeds 500 billion yuan, which benefits thousands of families.

By November, 2023, there were 282 overall planning areas in China, accounting for 71% of all overall planning areas. The results are also quite remarkable. The data show that from January to March 2023, the average hospitalization expenses of tertiary public hospitals nationwide were 13,822.9 yuan, down by 0.8% at comparable prices, and the average hospitalization expenses of secondary public hospitals were 6,756.3 yuan, down by 1.4% at comparable prices.

After careful consideration of the above policies, we can find that the underlying logic is the efficient use of medical insurance funds, and a more rude summary is "controlling fees."

Under the control of Hu Jinglin, who was born in the financial department, the National Medical Insurance Bureau has done an excellent job in the management, use and control of medical insurance funds in the past five years. "The most important function of medical insurance is to manage the medical insurance fund", and Zhong Chongming, a medical insurance policy researcher, pointed out that this will also be the red line and safety line of the medical insurance bureau for a long time to come.

At present, although "controlling fees" is still the most basic requirement, it is not enough to complete it, and the constraint of simply controlling fees on the innovation and development of the medical industry has gradually emerged. Therefore, the next work of the National Medical Insurance Bureau may no longer be limited to simply "controlling fees".

In fact, this weather vane has begun to appear-the propaganda slogans such as "soul bargaining" commonly used in the early years have gradually withdrawn, the national mining cycle has been extended to four years, and the new national talks have also been described as "moderate". In the contact between Jianwen Consulting and industry professionals, it is also noticed that promoting the high-quality development of the pharmaceutical industry is now the direction that the medical insurance department wants to highlight.

Shanghai may have come to the front. At the end of July, Shanghai issued "Several Measures to Further Improve the Multi-payment Mechanism to Support the Development of Innovative Medical Devices" (referred to as "Several Measures"), which aroused heated discussions among practitioners in biomedicine, medical devices, commercial insurance and other fields and became the hottest topic in the medical device market in Shanghai at that time.

Xia Kejia, director of the Shanghai Municipal Medical Security Bureau, once said that the introduction of "Several Measures" is not only to promote the construction of a multi-level medical security system in Shanghai, to meet the diversified security needs of citizens, and to reduce the burden of medical treatment for the masses; It is also to improve the multi-payment mechanism of innovative medical equipment, guide good development expectations, and promote the high-quality development of biomedical industry and insurance financial industry in this city.

The industry hopes that the more such policies, the better.

In the next five years, how can medical insurance continue to "do its best"?

The industry expects that the funds saved by fee control should not only be used to support industrial innovation, but also be used to rationalize the price of medical services and correct the distorted income structure of medical staff.

Xu Yucai, a well-known medical reform expert, pointed out that "the biggest shortcoming of medical insurance reform in recent years is that the price reform of medical services is seriously lagging behind, and the price reform of medical services under the leadership of the Medical Insurance Bureau needs to be accelerated."

Previously, the state identified Ganzhou, Suzhou, Xiamen, Tangshan and Leshan as pilot cities for medical service price reform. Jianwen Consulting noted that in recent months, many places outside these five cities have also frequently adjusted the prices of medical services. However, compared with thousands of medical service price systems, there are still a few adjustments at present.

More importantly, it is an important link to be explored next whether we can shed the part of "rule by man" in medical service price adjustment and hand over the adjustment or not to the mechanism related to medical service price adjustment.

The price of medical services has remained unchanged for many years, which gave birth to the soil of selling with gold. The two have formed a fragile balance in practice, but now one end of the balance has been shattered and stands after breaking, and the other end needs to keep up quickly.

The five years since the establishment of the National Medical Insurance Bureau are also five years when the decision-making power of local medical insurance has been gradually weakened.

On the surface, the local medical insurance catalogue will gradually withdraw, and the local medical insurance equipment catalogue will gradually be unified in the future. The overall level of medical insurance funds has been continuously improved, and many provinces such as Jilin, Liaoning and Sichuan have shouted the slogan of provincial overall planning.

In the future, national overall planning may not be impossible. The authority of the local medical insurance department has been tightened continuously, and it has gradually changed to the agency.

Some scholars believe that the current reform direction is to improve the focus of medical insurance decision-making, standardize the decision-making power of governments at all levels, and establish a unified national medical insurance system.

From a deeper perspective, in recent years, conflicts and even lawsuits between private hospitals and local medical insurance bureaus are common. The contradiction between the two sides is also typical. Some local medical insurance bureaus think that private hospitals buy drugs and consumables at low prices and then report them to medical insurance at high prices, which actually reflects the different understanding of the authority of different local medical insurance bureaus. Nowadays, it has gradually become a consensus that medical insurance "cannot be stretched too long", and the law has also proved this with judgments.

The standardization of medical insurance information system provides objective conditions and possibilities for the concentration of medical insurance power, which is beneficial to the coordination of policies at all levels to some extent, but excessive concentration of power also weakens the regulatory power of local medical insurance in disguise. There are both advantages and disadvantages. Finally, judging whether the medical insurance power is concentrated in the central government is good or bad may be left to the future and reality.

In Zhong Chongming’s view, with the gradual development of medical insurance services and the continuous exploration of the direction of health insurance, medical insurance will inevitably go through the process from "managing money" to "managing some things and cooperating with more things", and in this process, corruption and inefficiency are still huge challenges.

The road to medical reform is long and arduous, although medical insurance has played a key and fundamental role, and even played a leading role in the process of joint reform of the three hospitals. However, limited by the scope of power of the medical insurance department, the medical insurance department can only "appeal", "guide" or even "force" the implementation of some specific medical reform policies, but the real executor is "someone else".

In some places, it is difficult for the medical insurance department and the health care department to work together. In the absence of a strong and effective coordination mechanism, as the medical reform enters the deep water area, the road of "crossing the river by feeling the stones" has become more challenging.

"No matter how the linkage between the three hospitals evolves and how healthy China develops, we should always uphold’ reform is the brightest background of the medical insurance banner’." Zhong Chongming said.

(The author of this article is Jianwen Consulting, a cross-border insight into the medical industry)

This article only represents the author’s point of view.