“大病医保范围内的治疗费用报销了八九成，我很满意，但如果算上自费药物和治疗，经济压力还是有点大，希望医保覆盖的项目能再多一些。”患有尿毒症的金女士在接受《经济参考报》记者采访时这样表达她的新年期盼。但保险公司人士却对记者表示，城镇职工大病医保“一年行、两年平、三年停”是普遍现象，鉴于大病医疗基金的承担能力，让患者负担一部分费用是合理的。

"A serious illness within the scope of medical treatment expense to the into,I am satisfied with the,But if you count the at one's own expense drugs and treatment,Economic pressures or a little big,Hope health coverage project can some more."With uremic ms king in accepting[Economic reference to]A reporter to interview this express her New Year looking forward to.But the insurance company people are told reporters,A serious illness medical insurance for urban workers"A year do/Two years of flat/Three years stop"Is common phenomenon,In view of the medical treatment of a serious illness fund bear ability,Let patients burden part of the cost is reasonable.

　　对于正在铺开的城乡居民大病医保来说，这些声音无疑是最真实的存在。

For urban and rural residents is spread out of a serious illness for medical insurance,The sound is undoubtedly the most real existence.

　　《经济参考报》记者近日在太原采访了解到，以保障水平高、保费水平低、承保时间长的特点被称作全国大病医保运作“范本”之一的太原市职工大病医保，已经由中国人寿承办逾十年，期间几经波折，积累了有益经验的同时，也为居民大病医保提示了问题和风险：保障水平和范围如何设定、保费筹资标准和来源怎样确定、筹资支付动态调节机制是否有必要设立，这些问题的解决已经成为大病医保健康发展绕不开的话题。

[Economic reference to]Reporter recently interviewed in taiyuan to know,In order to ensure high level/Premium level low/Accept insurance time characteristics is called the national medical insurance operation of a serious illness"template"One of the medical insurance in taiyuan city worker a serious illness,By the China life has been more than ten years,Period after several twists and turns,Accumulated a good experience at the same time,A serious illness for residents medical insurance tip the problem and risk:Security level and scope of how to set/Premium financing standard and how to determine the source/Financing pay dynamic adjustment mechanism is it necessary to set up,The solution of these problems has become a serious illness the healthy development of medical insurance is not open around the topic.

　　保障水平仍有提升空间 Security level still have improve space

　　在职工大病医保十年来为太原带来的众多改变中，保障水平无疑最受民众关注。

A serious illness in the medical insurance for taiyuan ten years bring many of the change,Security level is the most popular public attention.

　　2000年太原市建立了城镇职工医疗保险制度，然而，由于当时筹资与保障水平较低，城镇职工个人医疗费用负担仍然较重，“因病返贫”现象时有发生。针对这一社会保障体系中的“短板”，太原市政府在2003年与中国人寿合作，采取“政府主导、商业保险公司承办”的方式，启动了城镇职工大病保险制度。

Taiyuan in 2000 established the system of medical insurance for urban workers,however,Since the financing and security level is low,Town worker individual medical expense burden is heavier,"Poverty due to illness"Is often happened.According to the social security system in the"Short board",Taiyuan city government in 2003 and China life cooperation,take"The government leading/Commercial insurance company to undertake"way,Launched a serious illness insurance system for urban workers.

　　十年间，太原市城镇职工基本医疗保险统筹基金最高支付限额经过三次调整，从2.4万元提高到8万元，与此同时，中国人寿承保的大病医保为参保职工承担了超出基本医疗保险最高支付限额以上的医疗费用，最高支付限额由10万元提高到了目前的32万元，使得参保职工每年能够享受40万元的医疗保险待遇。

Ten years,Taiyuan city urban employee basic medical insurance plan as a whole fund is top pay limitation after three times adjustment,Increased from $24000 to $80000,meanwhile,China life insurance serious illness medical insurance for ginseng protect a worker to undertake the beyond basic medical insurance highest pay limitation above medical costs,Highest pay limitation from 100000 yuan to improve the current 320000 yuan,Make ginseng protect a worker to enjoy every year 400000 yuan of treatment of medical treatment insurance.

　　目前，太原市大病医保参保人数扩展到了99.25万人，参保率达83%，给付金额也由419.8万元/年增长到了8180万元/年，大病医疗费用报销比例一直保持在90%以上，在中部六省省会城市位居前列。

At present,Taiyuan city medical illness contributors extended to 992500 people,Participating insurance rate up to 83%,Payment of the amount is 4.198 million yuan/year by up to 81.8 million yuan/year,Medical treatment of a serious illness expense ratio has been to stay above 90%,In the six provinces of central China city, capital of high achievers.

　　“要不是中国人寿的大病医疗保险给了我‘救命钱’，我可能坚持不到今天……”57岁的太原电机五金厂退休职工金竞荣对《经济参考报》记者表示，自己因尿毒症从1999年开始接受透析，由于当时没有参加医保，最初几年的高额治疗费用让家庭陷入崩溃边缘：“透析完这次，不知道下次的钱在哪儿。”

"If it weren't for China life insurance of medical treatment of a serious illness to me‘JiuMingQian’,I may persist in less than today..."57 years old taiyuan motor hardware factory retired worker to JinJingRong[Economic reference to]reporters,He has uremia from 1999 began accepting dialysis,Because at that time did not participate in the medical insurance,The first few years of high treatment costs for families in collapse:"Dialysis after the,Don't know where the money is the next."

　　但随着医保政策不算完善，金竞荣治疗费用的自付比例多次下降，加上太原市大病医保从2011年起对肾病患者取消了透析费用的总额控制，她支付的医疗费已经从最初的每月五六千元，降到现在的一千多元，“去年医疗费总共花了9万多，个人付费也就一万多元；以前每周只能做两次透析，现在已经规律地做三次，经济上可以接受。”

But as the medical insurance policy is not perfect,JinJingRong treatment costs from the pay scale down many times,With a serious illness in taiyuan city medical insurance since 2011 for kidney disease is cancelled dialysis cost of total control,She pay the medical treatment has from the initial 56000 yuan per month,To the present one thousand multivariate,"Last year a total of more than 90000 medical flowers,Individual pay is ten thousand yuan;A week before can do only two dialysis,Now regularly do three times,Economic can accept."

　　然而，另一个问题的存在仍让金竞荣有些苦恼，那就是一些应定期接受的治疗项目还需完全自费。太原市中心医院血液透析科医生王惠表示，一些有效治疗手段，如血滤、高通量透析等项目对病人非常必要，但由于费用较高患者很难负担。

however,Another problem exists still let JinJingRong some distress,That is some should be regularly accept treatment project still need to complete at one's own expense.Taiyuan city center hospital blood dialysis family doctor WangHui said,Some effective treatments,Such as blood filter/High throughput dialysis projects to the patient is very necessary,But due to the high cost of patients finding it difficult to afford.

　　事实上，随着医疗新技术的广泛应用和参保职工医疗消费能力的持续提高，这一问题越来越明显。记者在采访中发现，很多患者都表达了希望进一步扩大大病医保覆盖范围的愿望：“对政策整体非常满意，但如果算上自费药物和治疗，经济压力就大了，如果也能纳入医保就好了！”

In fact,With the medical wide application of new technologies and ginseng protect a worker to the continuous improvement of medical consumption ability,This problem is more and more obvious.Reporter in the interview found,Many patients expressed hope further serious illness medical insurance coverage wishes:"The whole of the policy is very satisfied,But if you count the at one's own expense drugs and treatment,Economic pressure is big,If can also be included in the medical insurance!"

　　对此，中国人寿相关人士指出，血滤、高通量透析这两项定期治疗项目不是门诊透析的基础治疗，鉴于大病医疗基金的承担能力，让患者负担一部分是合理的，这样有利于将有限的医保基金应用于社保目录内的治疗，确保基本医疗能得到更好的保障，也有利于确保基本医疗和大病医疗基金的持续经营。

this,China life relevant personage points out,Blood filter/High throughput dialysis these two regular treatment project is not the basis of outpatient dialysis treatment,In view of the medical treatment of a serious illness fund bear ability,Let patients burden part is reasonable,This makes the limited medical insurance fund application in the treatment of social security in the directory,Ensure the basic medical can get better security,But also to ensure that the basic medical and medical treatment of a serious illness fund of continuous operation.

　　保障水平的设定也是城乡居民大病医保政策中最引人注目的焦点。按照2012年六部委联合文件的安排，西安、昆明等地已经在本月启动了城乡居民大病保险试点，在城居保和新农合报销后，个人承担部分可以至少报销50%医疗费。

Security level is set between urban and rural residents a serious illness medical insurance policy of the most remarkable focus.According to the 2012 six ministries jointly file arrangement,xian/Kunming has been launched this month between urban and rural residents a serious illness insurance pilot,In the city in the insurance and new farming together after reimbursement,People can submit an expense account for part of at least 50% of the medical treatment.

　　业内人士指出，各地实际筹资水平和医保能力不同，但如果居民大病医保对社保目录外也提供保障，难以达到太原市职工大病医保90%的报销比例。

The personage inside course of study points out that,All actual financing level and different medical insurance ability,But if the residents a serious illness medical insurance to social security directory outside also provide security,It is difficult to meet the taiyuan city worker serious illness medical insurance reimbursement ratio of 90%.

　　卫生部医改相关负责人表示，影响一个家庭因病致贫和因病返贫的重大疾病的数量大概有四五十种。“但是目前保了大概20种。如果涵盖50种可以使因病致贫、因病返贫的问题得到有效缓解甚至是遏制。”

The ministry of health reform, officials say,Affect a family become financially-difficult or become poor again the number of major disease about forty or fifty kinds of."But now the about twenty kinds of.If fifty kinds of cover can make become financially-difficult/The problem of poverty due to illness to effectively relieve and even contain."

　　

保费标准仍有提高必要 Premium standards are still necessary to improve

　　随着保障水平的提高，大病医保的筹资水平也越来越有提高的必要。

With the improvement of security level,A serious illness health care financing level also more and more necessary to improve.

　　中国人寿太原市分公司总经理张文庆介绍，2003年中国人寿承保太原城镇职工大病医保的时候，筹资标准为每人每月5元，从2005年开始，保费标准提高到每人每月8元，其中单位缴费5元，基本医保个人账户缴费3元，之后再无调整。“七年以来保费固定在每人每年96元，但对应的大病医保支付封顶线却已经从2.4万元提高到了40万元。”张文庆说。

China life ZhangWenQing taiyuan branch general manager is introduced,In 2003, China life insurance underwriting taiyuan town worker medical insurance when a serious illness,Financing standard is 5 yuan per month,Starting from 2005,Premium standard up to eight yuan per month,The unit pay cost five yuan,The basic medical insurance individual account pay cost 3 yuan,Then no adjustment."Seven years premium fixed in 96 yuan per person per year,But the corresponding serious illness medical insurance pay for top line have increased from $24000 to $400000."ZhangWenQing said.

　　从全国大病医保实施情况看，这样的保费水平处于中低水平。

A serious illness from the national medical insurance implementation to see,This premium level in a low level.

　　此外，随着大病医保制度的迅速铺开和参保人数连年剧增，加之退休人员占参保人员比重逐年增加，以及发病率上升，重病、绝症人数增多，太原市职工大病医保受益人次十年间增长了14倍，此外，受医疗服务标准、医药价格增长等因素影响，医保赔付金额增长迅速。

In addition,Along with the rapid spread of a serious illness medical insurance system and increase the number of years of ginseng,Together with retiree accounted for the proportion of ginseng protect personnel increases year by year,And a rise,intensive/Incurable disease increase,Taiyuan city worker serious illness medical insurance benefit people ten years growth 14 times,In addition,By medical service standards/The impact of factors such as the pharmaceutical price growth,The amount of medical insurance claims the rapid growth.

　　较快增长的医疗费用与相对较低的保费水平形成了落差，到2008年，中国人寿太原市分公司大病医保业务经营出现亏损，2010年，公司大病医疗保险资金缺口超过1000万元。

Rapid growth of medical costs and relatively low premium level to form the head,By 2008,China life taiyuan branch serious illness medical insurance business appear loss,In 2010,,The medical treatment of a serious illness insurance financing gap of more than 10 million yuan.

　　中国人寿太原分公司相关负责人表示，大病医疗保险经营是世界性难题，“一年行、两年平、三年停”是国内大病医疗保险的真是写照：“事实上，中国人寿能够在太原市经办的职工大病医保维持10年在全国看非常罕见，同期承办大病医保的商业保险公司，绝大多数选择了退出，坚持下来的寥寥无几。”

China life taiyuan branch officials say,Medical treatment of a serious illness insurance business is a worldwide difficult problem,"A year do/Two years of flat/Three years stop"Is the medical treatment of a serious illness insurance is portraiture:"In fact,China life in taiyuan city to orgnaization of worker medical illness for ten years in the national look very rare,The undertaking serious illness medical insurance of commercial insurance company,Most chose to quit,Insist on down to the very few."

　　而按照中国人寿的测算，太原市96元的保费标准从长远看有提高的必要，建议以基本医疗保险相同费基的0.3%-0.5%作为大病医保保费，并与社会平均工资同步调整。

And according to the calculation of China life,Taiyuan city 96 yuan of premium standard in the long run is necessary to improve,Suggestions on the same basic medical insurance FeiJi 0.3% to 0.5% of the medical insurance premium as a serious illness,And with the social average wage synchronous adjustment.

　　与城镇职工医保类似，“保本微利”“让利于民”也是商业保险公司承保城乡居民大病保险的原则，但相比于前者，城乡居民大病医保对商业保险公司更是一个挑战。

And medical insurance for urban workers similar,"Break-even meager profit""Benefit to the people"Commercial insurance company accept insurance is the principle of a serious illness insurance for urban and rural residents,But compared to the former,A serious illness medical insurance for urban and rural residents to commercial insurance company is a challenge.

　　按照制度安排，用于城乡居民大病医保的资金将从城镇居民医保基金、新农合基金中按照一定比例或额度划出。城镇居民医保和新农合基金有结余的地区，利用结余筹集大病保险资金；结余不足或没有结余的地区，在城镇居民医保、新农合年度提高筹资时统筹解决资金来源，逐步完善城镇居民医保、新农合多渠道筹资机制。各地结合当地经济社会发展水平、医疗保险筹资能力、患大病发生高额医疗费用的情况、基本医疗保险补偿水平，以及大病保险保障水平等因素，精细测算，科学合理确定大病保险的筹资标准。

According to the system arrangement,Used for urban and rural residents a serious illness medical insurance funds from the medical insurance for urban residents fund/New farmers joint funds according to certain proportion or a line.Medical insurance for urban residents and new farming joint fund has balance area,Use balance raise serious illness insurance funds;Balance is insufficient or no balance area,In the medical insurance for urban residents/New farmers joint annual increase financing plan as a whole when solving capital source,Gradually improve medical insurance for urban residents/New farmers joint multi-channel financing mechanism.With all the local economic and social development level/Medical insurance financing ability/Suffer from a serious illness happen high medical costs/The basic medical insurance compensation level,And serious illness insurance level factors,Fine measurement,Scientific and reasonable to determine a serious illness insurance financing standard.

　　但目前看来，筹资并没有那么容易。以广东省为例，按照近日大病医保讨论会议提出的要求，“在自负盈亏前提下，遵循‘收支平衡、保本微利原则’，商业保险机构大病保险的综合费率(包括盈利与经营管理成本)原则上不超过筹资总额的5%”。也就是说，保险公司连利润带成本最多占保费的5%。

But now it seems,Financing is not so easy.In guangdong province as an example,According to the medical insurance has a serious illness discussion meeting demands,"Responsible for their own profits and losses in the premise,follow‘balance/Break-even meager profit principle’,Commercial insurance agency serious illness insurance comprehensive rate(Both profit and management cost)In principle, no more than 5% of the total amount of financing".that,The insurance company with the most cost LianLiRun accounted for 5% of the premium.

　　这一比例被各保险公司认为太低，对此一位业内人士指出，定价控制得如此紧的原因之一便是医保基金筹资困难。“模式并不是问题，问题是筹资标准。”他说，“从目前的情况来看，各地的财政支持力度确实还比较薄弱，尤其是一些不发达省份。”从青海省看，参加城乡居民医保(包括城镇居民医保和新农合)的参保参合人员，按每人每年50元的标准统筹城乡居民大病医疗保险基金，这仍大大低于职工大病医疗保险的筹资标准。

This proportion is the insurance company that is too low,A personage inside course of study points out that this,Pricing control so tight reason is one of the medical insurance fund financing difficulties."Mode is not a problem,The problem is financing standard."He said,"According to the current situation,All financial support really is relatively weak,Especially in some underdeveloped provinces."See from qinghai province,Urban and rural residents to participate in medical insurance(Including medical insurance for urban residents and new farming together)The ginseng of ginseng add up to personnel,Fifty yuan per person per year according to the standard of urban and rural residents as a whole fund of insurance of medical treatment of a serious illness,This is still much lower than the worker medical treatment of a serious illness insurance financing standard.

　　筹资、支付动态调节机制亟待建立 financing/Pay for dynamic adjustment mechanism urgently need to establish

　　对于在保费和赔付标准上的矛盾以及保险公司经营难题，业内人士指出，应建立大病医疗保险筹资与支付政策的风险预警和动态调节机制。

In the premium and compensation standard contradiction and insurance company management problem,The personage inside course of study points out that,Shall establish medical treatment of a serious illness insurance financing and payment policy risk early warning and the dynamic adjustment mechanism.

　　太原市人力资源和社会保障局副局长欧阳湘晋在接受《经济参考报》记者采访时表示，大病医保引进商业保险合作的方式，实际上是风险共担，而非把风险转嫁给保险公司。商业保险公司原则上自负盈亏，但在参保人数逐年增加和医药费用急速增长的情况下，或者当某些条款遇到特殊情况时，政府有必要按照实际情况调整政策，以保证商业保险公司在正常情况下做到保本微利。

Taiyuan city human resources and social security bureau deputy director OuYangXiangJin in accepting[Economic reference to]A reporter to interview said,A serious illness medical insurance introduction of commercial insurance cooperation way,Is actually risk sharing,Rather than the risk shifting to the insurance company.Commercial insurance company responsible for their own profits and losses in principle,But in the ginseng protect number increases year by year and medical cost under the condition of rapid growth,Or when certain terms meet special situations,The government is necessary to adjust the policy according to the actual situation,To ensure the commercial insurance company in normal circumstances do break-even meager profit.

　　但他也同时指出，因为保险公司管理不到位而造成的亏损，应该明确责任，政府不予承担。“不能盈利时利润上缴，亏损时让政府提高收费，而应建立不同于一般保险业务的模式，建立专项基金，以适当的工作经费完成任务，减轻政府压力。”欧阳湘晋说，“况且保险公司网点多，人员多，应该提供更优质的理赔服务，加强对医疗服务和医疗费用的管控。”

But he also pointed out,Because the insurance company management is not in place and cause losses,Should clear responsibility,The government shall not bear."Can't make money to profit,Losses for the government to raise fees,And shall establish different from general insurance business model,Set up special fund,With proper working funds to complete the task,Ease the government pressure."OuYangXiangJin said,"Besides insurance company more outlets,Personnel more,Should provide more high-quality claims service,To strengthen the medical service and medical cost control."

　　而按照中国人寿在太原经营职工大病医保的经验，他们是从强化风险管控入手，逐步向专业化经营转变。

And according to China life in taiyuan business worker medical illness experience,They are the risk control of strengthening,To be specialized business transformation.

　　首先是在大病医疗中实现产品、财务、系统的单独管理，建立风险备用金制度，用以调剂大病医保基金盈亏，年度结余全部进入基金池，滚存到下年度或用于提高保障水平。实时评估医保政策调整和医疗费用上涨等因素的影响，通过调整承保给付标准，实现持续经营，建立大病医疗保险长效运营机制。

The first is to realize product in the medical treatment of a serious illness/financial/System management alone,Establish the risk deposit system,To adjust a serious illness and medical insurance fund,The annual balance all into the fund pool,Cumulative to the next year or to enhance the security level.Real-time evaluation of medical insurance policy adjustment and the rising cost of medical treatment of the factors such as,By adjusting the accept insurance payment standard,Achieve sustainable business,Establish medical treatment of a serious illness insurance long-term operation mechanism.

　　其次是构建起风险预警机制，立足业务经验数据分析和政策变化研究，实时评估医保政策调整和医疗费用上涨等因素影响，及时与政府沟通协调，通过调整承保给付标准，为实现持续的健康经营打下基础。

Second is to build up the risk early warning mechanism,Based on the business experience data analysis and policy change research,Real-time evaluation of medical insurance policy adjustment and medical cost prices factors,Timely communication and coordination with the government,By adjusting the accept insurance payment standard,To achieve sustainable health management to lay the foundation.

　　中国人寿山西省分公司副总经理武建平认为，保险公司应发挥自身在账户管理、费用给付、组织效率等方面的优势，严格管控医疗机制和医疗服务，放大基本医疗的保障效用，降低大病医疗保险的运行成本。（李唐宁）

China life shanxi branch deputy general manager WuJianPing think,The insurance company should play their own in account management/Cost payment/The advantages of the organizational efficiency,Strictly control the medical system and the medical service,Amplification basic medical security utility,Reduce the medical treatment of a serious illness insurance operation cost.(LiTangNing)