How Does the 14 Measures Leverage Health Insurance to Solve the Problem of Difficult Access to Medical Care: From "Unwilling to Go" to "Happy to Stay" at the Grassroots?

For a long time, China's primary healthcare institutions have been trapped in a dilemma of patient distrust, lack of motivation for doctors, incomplete drug availability, and difficulties in controlling medical insurance expenses.

Recently, the National Healthcare Security Administration, together with the National Development and Reform Commission and the National Health Commission, issued the "Guiding Opinions on Medical Insurance Support for the Development of Grassroots Medical and Health Services" (hereinafter referred to as the "Opinions").

To address the key issues in grassroots medical treatment and healthcare security for the public, the "Opinion" explicitly proposes 14 specific measures focusing on total fund management, designated point management, price management, benefit guarantees, family doctor contracts, payment reforms, medication supply, settlement and clearance, handling services, and expanding long-term care services. These measures aim to better support strengthening services at the grassroots level, promote reform initiatives taking root at the grassroots level, and achieve convenient and high-quality services at the grassroots level.

At the policy interpretation event held by the National Healthcare Security Administration on April 10, VCBeat learned that this "Opinion" accurately addressed the public's concerns about grassroots medical services: First, ensuring stable healthcare security fund support at the grassroots level, reasonably allocating surplus retention within medical consortia, and increasing倾斜towards grassroots healthcare institutions; Second, improving the three-level drug linkage mechanism, promoting the alignment of drug lists between grassroots facilities and large hospitals, enabling chronic disease patients to access commonly used medications in the community; Third, projects such as home service fees, family sickbed fees, and hospice care fees have received clear billing codes and healthcare security payment support, allowing the services needed by the public to be accessible close to home; Fourth, mechanisms linking healthcare security payments with health management and personalized service package filing charges are driving family doctors to transition from "signing without fulfilling" to truly "signing with fulfillment and a sense of engagement."

Is it cost-effective to use medical insurance for reimbursement when seeing a doctor in the community? How long a supply of medication can a chronic disease patient get at one time?

When people choose whether to seek medical treatment at the grassroots level, the first thing they may calculate is such an economic account.

In the past, some grassroots institutions may have been concerned that if they admitted more patients, the total amount of medical insurance would exceed the limit and result in fines; for the convenience of chronic disease patients to issue long prescriptions, they were also worried that the average cost per visit would be too high, affecting their assessment.

To make medical reimbursement more cost-effective and medication access more convenient for patients at the grassroots level, while also incentivizing primary healthcare institutions to admit patients, the "Opinion" proposes optimizing the regional total management of medical insurance funds. On the basis of ensuring the stable operation of the fund, support for primary care can be reasonably reflected by optimizing the structure of total budget allocation. The annual increase in medical insurance funds can be appropriately tilted towards primary healthcare institutions to stabilize expectations for grassroots development.

This means that the incremental portion of the medical insurance fund can be appropriately tilted towards township health centers and community health service centers.

Miao Yanqing, Deputy Director of the Department of Health Strategy and Service System Research at the Health Development Research Center of the National Health Commission, pointed out that this breaks the rigid constraints of traditional total amount management, giving grassroots institutions a stable funding expectation. They no longer have to worry about survival and can confidently develop new departments and introduce new talent.

At the same time, the "Opinions" promote "total amount payment" for the closely-knit county medical consortium. The medical insurance funds saved by the consortium through strengthening health management and standardizing diagnosis and treatment behaviors are allowed to be retained and will not be used as the basis for reducing the total amount in the next year.

This mechanism fundamentally changes the behavioral orientation at the grassroots level — from "more examinations, more prescriptions, more revenue" to "better health management, fewer illnesses, fewer hospitalizations."

Wu Hao, Dean of the General Practice and Continuing Education College at Capital Medical University, pointed out that this means the healthier the patients are and the less they seek medical care, the higher the income for grassroots institutions and doctors may be, truly realizing a shift from treatment-centered to health-centered care.

Regarding the issue that chronic disease patients care most about — "how much medication can be prescribed at one time" — the Opinion clearly supports grassroots healthcare institutions in issuing prescriptions for up to 12 weeks for eligible chronic disease patients, and explicitly states that this will not be included in the "average cost per visit" assessment.

This means that the tight restrictions on long-term prescriptions for chronic diseases have been further lifted.

Wuhu City, Anhui Province, Medical Insurance Bureau Director Han Yongqiang revealed that the practical results of the local medical insurance bureau have confirmed the actual effect of this policy. By implementing a pilot program for common chronic diseases paid per capita, the hospitalization rate in the pilot areas decreased by 2.68%, and the medical insurance fund achieved a surplus. For patients, this means they no longer need to visit the hospital every month for medication, saving them both the trouble of traveling and registration fees.

At the same time, the "Opinions" encourage the exploration of combining per capita payment for outpatient services with chronic disease management, strengthening the linkage between primary outpatient payment and family doctor contracting, and exploring the per capita allocation of outpatient funds for contracted residents to primary care or family doctor teams.

It is worth noting that the reimbursement for medical treatment at grassroots medical institutions is expected to be further guaranteed.

The "Opinion" clarifies that the payment ratio for ordinary outpatient expenses under the employee medical insurance scheme shall be no less than 50% within the scope of policy provisions, and the outpatient overall planning under the resident medical insurance shall mainly rely on primary-level medical and health institutions, with a payment ratio of no less than 50% within the scope of policy provisions. In places with conditions, the treatment payments may further tilt towards primary-level medical and health institutions.

Can the medications prescribed at large hospitals be obtained at community health centers? Will there be shortages of chronic disease drugs that have undergone centralized procurement and price reductions at primary care facilities? Are services like home injections, family sickbeds, and palliative care reimbursable?

This is the most realistic concern for families of patients with chronic diseases and disabled elderly people. At the same time, as the degree of aging deepens, the public's demand for home-based medical services such as house calls, family sickbeds, and rehabilitation nursing is becoming increasingly urgent.

In terms of drug supply, the "Opinions" require the establishment of an integrated management mechanism for drug procurement, distribution, and use within medical communities, achieving alignment in drug catalogs between primary healthcare institutions and lead hospitals. This also implies "drugs follow diseases," realizing "same disease, same drugs, same quality."

Chen Xinmei, Director of the Jimei Street Community Health Service Center in Xiamen City, shared the practical results: With the support of medical insurance policies, the center now stocks 1,052 types of medicines, including 498 essential national drugs, 516 non-essential drugs, 38 nationally negotiated drugs, and 455 types of Chinese herbal pieces, resolving the issue of drug shortages at the grassroots level.

In terms of price management, clearly pricing specialty services. This is one of the most attention-grabbing breakthroughs in the recent "Opinions" for grassroots medical staff and elderly patients.

The "Opinions" encourage grassroots medical and health institutions to make good use of home visit fees, hospice care fees, family bed establishment fees, internet follow-up consultation fees, as well as TCM and rehabilitation-related price items. The home visit fee is determined autonomously by the medical institution and reported to the medical insurance department for record.

At the same time, optimize the price management of grassroots institutions, clarify that the general diagnosis and treatment fee is generally around 10 yuan, classify and optimize the medical service price system, and promote hierarchical diagnosis and treatment in a targeted manner. For example, appropriately narrow the price gap between different levels of institutions for first and second-level surgeries, nursing, imaging examinations, and tests, and promote regional price coordination for projects with a high degree of homogenization.

With a clear basis for charging fees, family doctor teams can design diversified personalized service packages to meet the differentiated health needs of the public. For example, home visits for elderly patients, rehabilitation guidance for postpartum women, and dietary and exercise interventions for diabetes patients, with voluntary payment by residents.

The multi-party sharing of family doctor contract service fees also reduces the burden on residents. The practice in Xiamen City provides replicable experience, with an annual contract fee of 120 yuan per resident. Of this, 70 yuan is covered by the medical insurance fund, 30 yuan is subsidized by union funds, and individuals only need to pay 20 yuan out-of-pocket, which can be paid through personal or family-shared medical insurance accounts. This "medical insurance + government funding + individual" sharing mechanism significantly lowers the threshold for signing contracts, promoting a gradual increase in the contract rate among the local resident population.

In response to the public's concerns about referrals between different levels of healthcare, more solutions have been introduced. To further promote the efficient allocation of medical and health service resources and meet the demand for convenient and nearby medical treatment, the General Office of the State Council recently issued the "Several Measures on Accelerating the Construction of a Tiered Medical Treatment System," proposing 13 targeted measures in four aspects.

It explicitly mentions guiding the public to seek primary care at the grassroots level, focusing on common and chronic diseases. Strengthening the diagnosis and treatment of common illnesses and the management of chronic diseases at the grassroots level can be achieved by establishing outpatient services for common and chronic diseases in primary healthcare institutions through closely-knit medical alliances with higher-level hospitals. Additionally, extending general outpatient services provided by expert teams to the grassroots level offers patients integrated medical and preventive services for chronic diseases.