Since the beginning of the 21st century, the aging of the population in mainland China has deepened, and in 2020, the proportion of elderly people over 65 years old increased to 13.5%. With the advent of population aging and aging, the scale and proportion of sick and semi-disabled elderly are growing rapidly. At present, about 78% of the elderly suffer from chronic diseases, and another 44 million disabled and semi-disabled elderly people. The dual demand of the elderly for pension services and medical services not only brings challenges to the allocation and supply mode of traditional medical resources and pension resources, but also puts forward new requirements for medical security policies and their governance systems and governance capabilities.
In addition to the multiple difficulties faced by the elderly, medical security is also facing a double dilemma, one is the lack of protection for the elderly in the disability and semi-disability stage, and the other is that the choice of services for the elderly will have behavioral distortions, one of the important impacts is the "social press", resulting in the waste of medical service resources and medical security funds. A large number of elderly people with medical care needs poured into the hospital to obtain long-term care services through hospitalization, and relevant data show that the average annual medical consumption expenditure of the elderly with medical insurance is 3286.97 yuan, while the annual medical consumption expenditure of the elderly without medical insurance is 2442.62 yuan.
In order to cope with the dual needs of pension and medical care, the resource allocation and supply mode should be shifted to the "combination of medical and elderly care", that is, the medical and health service resources and pension service resources are co-ordinated to achieve integrated service supply, and according to the needs of the elderly for orderly docking, the former includes chronic disease management, postoperative rehabilitation and medical care, hospice care and other services, the latter includes long-term care and other services.
1. The development and main mode of the integration of medical care and elderly care in mainland China
1.1 The development process of the integrated medical and elderly care service model
Since 2000, the mainland has entered an aging society, and in the context of accelerating the realization of "socialization of social welfare" in the same period, it has begun to establish a socialized pension service system. At the same time, with the change of the spectrum of geriatric diseases, social phenomena such as disability and chronic diseases have received attention, and the medical needs of the elderly have become an important issue that goes hand in hand with old-age care. In 2013, the state began to accelerate the development of the pension service industry, one of the important measures is to enter the medical resources into institutions, communities, families, support the conditional pension institutions to set up medical institutions. The focus of this stage of work is to increase medical services on the basis of pension services, pension service institutions are the main body, and medical institutions are more involved and cooperative. For example, hospitals above the second level are encouraged to establish referral and cooperation with pension institutions, and a series of supporting safeguard measures have been introduced, proposing that the medical institutions set up in the pension institutions will be included in the scope of medical insurance reimbursement, and should also be treated as the same in terms of professional title evaluation and technical access.
However, in the actual supply, the development of rehabilitation and medical treatment is very weak, so the functional advantages of medical institutions are increasingly valued. Since 2015, in order to further expand the supply scale of the integration of medical care and elderly care and improve the construction of the system, on the basis of "nursing" in the medical care, the design of the medical and elderly care system has continued to increase the "medical care" in the medical and community "medical care", and medical institutions have begun to serve as the sponsors, and specific measures include setting up elderly care beds in medical institutions, and gradually improving the ability of primary medical and health institutions to provide door-to-door services for the elderly at home.
In order to explore the establishment of a system and mechanism for the integration of medical care and elderly care in line with national conditions, and innovate the management mechanism and service model of the integration of medical and elderly care, in 2016, the former National Health and Family Planning Commission and the Ministry of Civil Affairs identified two batches of a total of 90 cities (districts) as national pilot units for the integration of medical and elderly care. The pilot operation has exposed some outstanding problems, one is that the compensation and guarantee of related services and their costs face institutional obstacles, so all localities have begun to explore the integration of medical care and elderly care into the scope of medical insurance reimbursement. For example, Shandong proposes to include the medical and health institutions of eligible pension institutions into the designated scope of urban and rural basic medical insurance. At the national level, in 2021, it was also stipulated that medical institutions within nursing homes and elderly care institutions that have obtained a medical institution practice license or a traditional Chinese medicine clinic record certificate can apply for medical insurance designation. In order to form a payment guarantee for the medium and long-term care services of the combination of medical care and elderly care, long-term care insurance also began to carry out a national pilot in 2016 to provide funds or service guarantees for the basic life care of the long-term disabled and medical care closely related to the basic life, which effectively solved the previous serious problem of misappropriation of medical insurance funds to pay for nursing expenses, improved the efficiency of the use of medical insurance funds, and also played a positive role in promoting the development of the medical and elderly care service industry. Second, in response to the problem of "applauding but not applauding" of medical and elderly care institutions, in order to break down the barriers to the access of market entities, in 2017, all localities began to relax the approval and registration of medical and elderly care institutions, set up "two certificates in one" for approval and practice registration, and "fully liberalized" and "non-prohibited entry" for social medical and elderly care institutions, which further activated the market vitality to a certain extent.
So far, some models of integration of medical care and elderly care have been gradually explored in the pilot areas, and the service system of integrated medical care and elderly care has been continuously developed. Since 2018, the development has been more problem-oriented, the development focus is highly targeted, and the reform mode has been continuously innovated. For example, it is required to promote the establishment of contract service relationships between primary medical and health institutions and medical personnel and the families of the elderly, establish an incentive mechanism for village doctors to participate in health care services, and encourage the transformation of primary and secondary hospitals into nursing homes, etc. The implementation of the policy has achieved remarkable results, the number of institutions integrating medical care and elderly care has increased steadily, the scale of supply has been expanding, the service mode has been continuously innovated, the service content has been continuously expanded, the service quality has been continuously improved (competition has increased), and the accessibility and sense of access to medical and elderly care services for the elderly have been continuously enhanced.
Entering the "14th Five-Year Plan" period, the goal of the integration of medical care and elderly care is more systematic, that is, to establish a medical and nursing service system covering the acute stage, chronic stage, rehabilitation period, long-term care period and end-of-life period of the elderly population, with more emphasis on continuity. In order to solve the problems of insufficient development of home-based and community-based medical care and elderly care, and to cope with the challenges of a stable long-term care payment mechanism has not yet been fully established, various localities have begun to guide the provision of home-based medical services such as family hospital beds and home visits, and improve relevant policies such as prices, and support safeguard measures have also been more diversified, including steadily promoting the pilot of the long-term care insurance system.
1.2 Model characteristics of integrated medical and elderly care services
1.2.1 "Medicine" in Yangzhong. "Medical" in the nursing system, that is, the elderly care institutions apply to open geriatric hospitals, rehabilitation hospitals, nursing homes, traditional Chinese medicine hospitals, hospice care institutions, etc., or set up infirmaries or nursing stations to provide basic medical services. Its goal is to solve the medical needs of the elderly in nursing institutions, so that the elderly can solve the problems of chronic disease management, common disease treatment, long-term care and first aid in the nursing institutions, especially for the disabled and semi-disabled elderly, and reduce the barriers to geographical and spatial transfer. According to information released by the National Health Commission at a regular press conference held in April 2021, more than 90% of elderly care facilities are able to provide medical and health services to the elderly in different forms.
The "medical care" of the Yangzhong Office still needs to be improved in terms of service supply and payment guarantee. First, the "medical care" in the nursing home has not yet become the main form of medical services provided by the elderly care institutions. In 2019, only 3,172 medical institutions were set up within elderly care institutions, accounting for only 9.23% of the total number of elderly care institutions (34,369). Second, most of the medical institutions set up are infirmaries and clinics, which can provide very limited medical services, and the level and quality of medical care cannot meet the needs of the elderly; Third, only 63.2% of them are included in the scope of medical insurance designation, and the recognition and use rate of the elderly is not high in institutions that cannot be reimbursed by medical insurance.
1.2.2 "Maintenance" in the medical office. According to the advantages of its own medical business, medical and health institutions carry out elderly care services in various forms such as geriatric hospitals, geriatric departments, rehabilitation and nursing institutions, and nursing homes for the elderly. Its service targets include the elderly with dual needs for treatment and nursing, the elderly with nursing needs who have been discharged from the hospital with delayed discharge, the elderly who have been transferred from upstream hospitals for rehabilitation, and the elderly who have undergone palliative care and hospice care. The goal of this model is twofold: one is to release medical resources in general hospitals, and the other is to make up for the lack of services in rehabilitation and medical care. In addition, there are subsidiary goals to improve the operation of primary hospitals.
At present, the most extensive form of participation of mainland medical institutions in the integration of medical care and elderly care is contract cooperation. By the end of 2022, 84,000 pairs of medical and health institutions and elderly care service institutions across the country had signed cooperative relations, but they were usually just a formality, and the actual sense of gain of the elderly was not strong. The "maintenance" of the medical office referred to below refers to the embedded service form other than the contract.
The way in which different levels of medical institutions in mainland China participate in the integration of medical care and elderly care is not uniform. By the end of 2022, there were 5,909 general hospitals with geriatric departments and above. 810 rehabilitation hospitals and 849 nursing homes have been built respectively, with 268,700 beds and 119,100 beds respectively. For example, the Beijing Municipal Government has subsidized 15 million yuan to each public hospital to transform into a rehabilitation hospital, which is specifically used for talent training, equipment and facilities procurement, or housing maintenance and transformation.
Therefore, most of the current transformation of primary and secondary hospitals is concentrated in the economically developed areas in the east. In the underdeveloped areas of central and western China, the policies of local governments to promote the transformation of primary and secondary hospitals have not yet been introduced on a large scale, and the supporting policies for transformation investment are relatively rare. At present, the secondary hospitals in the county-level cities play a very important role in the local medical service supply, so most of the transformation hospitals are the first- and second-level hospitals in the provincial capital and above. In addition, the cases of medical institutions increasing the number of elderly care beds and the establishment of rehabilitation centers in general hospitals also occur in the central and western regions, while the siphoning effect of medical resources in the eastern region is more serious, and the willingness to open elderly care services is insufficient.
1.2.3 Grassroots medical institutions run "medical care". Grassroots medical institutions run "medical care", that is, to provide long-term care services for the elderly at home in the community, as well as basic medical services such as regular physical examinations, home visits, family hospital beds, community nursing, and health management. There are three main goals: first, to meet the needs of more than 90% of the elderly at home to care for the elderly nearby, and to make up for the lack of informal care resources; the second is to achieve the purpose of hierarchical diagnosis and treatment, leaving the elderly in the community; The third is to meet the medical and health management needs of the elderly, seriously ill, disabled and semi-disabled, as well as the elderly with limited mobility or real difficulties. For the elderly who care for the elderly at home, primary medical and health institutions are the main body to respond to the needs of this group of integrated medical and elderly care services. By the end of 2021, 15,431 primary medical and health institutions had established age-friendly medical institutions across the country, accounting for about 1.58%. The signing of family doctors for the elderly has been widely carried out in various localities, but after the contract is signed, the coverage rate of health management, home diagnosis and treatment and other services provided by family doctors and village doctors for the elderly at home in the follow-up service supply is not high.
Based on the 2018 data of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) database, only 33.2% of the elderly in their communities can provide home medical treatment and medicine delivery. On the one hand, the elderly still tend to go to large hospitals for treatment when they are sick, and on the other hand, public primary medical institutions do not receive sufficient performance incentives, and the motivation in the provision of integrated medical and elderly care services is insufficient. Nursing services are mainly operated and managed by social capital, which is a market behavior, and under the constraints of the elderly's ability to pay, the effective demand for integrated medical and elderly care services is not high, and the development is still lagging behind in areas where the long-term care insurance system has not yet been implemented.
2. Challenges to the medical security system and governance system
2.1 Require a higher level of outpatient and community general practice medical services
The key to the evaluation of the guarantee effectiveness of the medical insurance governance system is to see whether it can effectively meet the medical service needs of the elderly in the elderly care service. The disease and treatment of the elderly are mainly chronic diseases and the maintenance of physical functions after serious diseases, which have the characteristics of long-term and basic, and the demand for medical services is mainly reflected in outpatient services, especially community general practice services. However, the mainland's medical security system as a whole presents the characteristics of "protecting against serious illnesses", and the realistic definition of "serious illness" is hospitalization.
Since the emergence of modern medicine, the organization of medical resources has always been centered on hospitalization, and not only the main diagnosis and treatment activities occur in the process of hospitalization, but also the main source of expenses is also inpatients. Correspondingly, the coverage of medical insurance is mainly based on hospitalization. With the continuous development and improvement of medical technology and the innovation of medical methods, some diseases can be treated without hospitalization, such as targeted drugs replacing the previous hospitalization of cancer patients. For example, the number of hospitalizations and the length of stay in OECD countries showed a slow but obvious downward trend from 2010 to 2019, so the inevitable result is an increase in the demand for outpatient and community general practice services.
Some of the original design of the mainland medical insurance system is not fully adapted to the change in the direction of the leading direction of the organization of medical resources, such as the social co-ordination in the employee medical insurance mainly pays for "serious diseases" such as hospitalization, and the personal account mainly pays for "minor diseases" such as outpatient clinics and community general practice. As a result, even if treatment can be completed on an outpatient basis, the insured person may choose to be hospitalized in order to receive reimbursement.
The level of protection for outpatient and community general practice services in mainland China is relatively insufficient. The funds in the personal accounts of employees are not enough to cope with the burden of personal self-payment, most of the outpatient co-ordination is limited to the outpatient use of hospitals, the payment for community general practice services is insufficient, and the service capacity and service level of the grassroots cannot meet the needs of the insured is also one of the obstacles to development. Due to the administrative color of the medical and health system and the influence of the system of financial allocation and support at the grassroots level in the mainland, the capacity of the primary medical and health services in the mainland is relatively weak, and there is a certain gap between the level of medical staff, drugs and facilities and that of general hospitals.
In order to solve the problem of insufficient outpatient protection, the mainland has carried out a series of reforms. For example, hypertension and diabetes (hereinafter referred to as the "two diseases") are the most common chronic diseases, and it is estimated that there are more than 300 million patients with "two diseases" among the urban and rural residents' medical insurance participants, and the long-term medical expenses have increased the burden on the insured. To this end, since 2019, the mainland has carried out a reform to improve the outpatient drug guarantee mechanism for urban and rural residents' "two diseases", and the cost of antihypertensive and hypoglycemic drugs incurred by insured patients with "two diseases" in designated medical institutions below the second level will be paid by the urban and rural residents' medical insurance pooling fund, and the payment will be made according to the capitation and disease type, and the proportion of fund payment within the policy scope will reach more than 50%, and there is generally no starting payment line in various places, and the maximum payment limit will range from 400 to 2000 yuan. In addition, in the centralized procurement of drugs organized by the state, the average price of drugs for "two diseases" has been reduced by more than 50%, and the insured have used drugs that they could not afford in the past. These reforms have had an important impact on the utilization of outpatient services for residents, and more medical treatment behaviors and medical resources have flowed to hospital outpatient clinics and primary medical institutions. However, it is worth noting that the frequency and cumulative cost of medical treatment for chronic diseases are still high, and the protection of outpatient services under the existing system needs to be further studied and explored.
In the construction of the integrated medical and elderly care service system, the problem of insufficient guarantee of hospital outpatient and community general practice services is more prominent. The average number of outpatient visits for retirees is 2.17 times that of in-service employees, and the average cost of outpatient visits is 1.15 times that of in-service employees. According to the data of the CLHLS database in 2011, 2014 and 2018, it is found that the average outpatient expenses of the elderly aged 60 and above are 5266.93 yuan/year, of which the self-payment and self-payment are 4842.10 yuan/year, and the actual reimbursement ratio of outpatient services is only 8.07%.
Of course, after the reform of outpatient security has been promoted, the security treatment has been improved, but there is still a big gap for the goal of "the elderly can afford to pay for the integrated medical and elderly care services they need". In order to reduce the burden of personal out-of-pocket payment, the elderly may exchange hospitalization for outpatient treatment to achieve reimbursement for chronic diseases and other treatments, which not only does not meet the regulations on the use of medical insurance funds, but also lacks the accessibility of medical services. In order to improve bed turnover, hospitals may pass the buck to such patients who stay in the hospital for a longer period of time, and older people may not be able to be admitted to the hospital or have a longer waiting time as a result. Therefore, in order to solve the problem of the elderly "hanging in bed" in hospitals through the combination of medical care and elderly care, it is necessary to improve the level of medical security for outpatient and community general practice services.
2.2 Challenge the ability of medical insurance governance, especially the ability to supervise
Medicare is facing challenges in regulating outpatient services and community general practice. At present, in order to expand the scope of outpatient protection, the medical insurance department has introduced a series of targeted measures. Due to the great changes in the spectrum of diseases in the mainland, chronic diseases have become the main diseases affecting the health of mainland residents, and the most effective way to treat chronic diseases is through early diagnosis and early treatment and health management in outpatient clinics. In addition, with the development of medical technology, the scope of medical services that can be provided by outpatient clinics has increased significantly, and the service function has been significantly strengthened.
Therefore, all localities have begun to carry out the reform of the outpatient mutual aid guarantee mechanism of employee medical insurance, and the specific approach is to start with outpatient chronic diseases and gradually establish general outpatient co-ordination. In most areas, the general outpatient reimbursement has been transformed from scratch, more designated retail pharmacies have been included in the scope of outpatient reimbursement, the scope of use of personal accounts has been expanded from the insured to family members, and the reimbursement "starting line" of the elderly group among employees is lower than that of in-service employees, and the reimbursement ratio and reimbursement "ceiling line" are higher than those of in-service employees, and the reimbursement treatment of primary medical institutions has been tilted. Correspondingly, the content and scope of use of the projects that need to be supervised have expanded and become more complex and diverse.
Previously, due to the impact of the payment structure, the supervision of medical insurance on designated institutions and medical treatment behavior was mainly concentrated in hospitalization, and the supervision of outpatient and community general practice services was relatively insufficient. In fact, in outpatient and community general practice services, the illegal use of medical insurance funds is more likely, the degree may be more serious, the risk points may be more, and the supervision may be more difficult. In the investigation, the research team found that with the continuous liberalization of outpatient reimbursement, in areas with different levels of social and economic development, there are some low-level hospital outpatient clinics or community health service centers in order to attract the elderly and provide integrated medical and elderly care services, and the illegal use of medical insurance funds is very common. In the context of the extensive development of the integration of medical care and elderly care in various places, in addition to the common violations of laws and regulations such as excessive examination and excessive diagnosis, the increase in support for the integration of medical care and elderly care has in disguised form led to the falsification of medical records, fraudulent use of social security cards for the elderly and other new types of fraud and misappropriation of medical insurance funds in outpatient medical treatment for the elderly, especially the false purchase of drugs, as well as the substitution, collusion and resale of medical insurance drugs have a greater impact on fund expenditure.
There is a lag in the supervision of payment methods and payment content in various places. It is mainly manifested in three aspects: first, the monitoring data of outpatient clinics, especially retail pharmacies and other designated institutions, are insufficient; Second, there is a lack of response to the new risk of using information technology such as the Internet to defraud insurance; Third, there are more and more onerous supervision tasks in outpatient and community general practice services, which fail to fully guarantee the law enforcement team and talents, so it fails to form an effective mechanism to restrain the behavior of medical institutions, doctors and the elderly. In the future, how to supervise the medical expenses in hospital outpatient and community general practice services will become an important challenge for medical insurance supervision.
2.3 Medical services, elderly care services and long-term care services need to be clearly defined
It is one of the important prerequisites to distinguish the service content related to the integration of medical care and elderly care from the theoretical and practical aspects. If multiple institutional arrangements cannot be distinguished and identified, they will fall into confusion in subsequent links such as payment guarantees. Theoretically, the integration of medical care and elderly care includes medical services, long-term care services and elderly care services, and what highlights is the continuity of the supply of the three types of services. Medical services are aimed at the elderly with chronic diseases and those recovering from acute diseases, and meet the medical needs of the elderly stage, with the means and purposes of "treatment" and "cure", and the short-term medical care contained therein is an ancillary to medical services, with the purpose of "recovery" and "cure". Elderly care services are all-round and comprehensive services for all elderly groups, mainly non-therapeutic life services and social services. Long-term care services refer to the professional nursing services provided for disabled and semi-disabled people due to illness, disability, injury, and old age, but they do not completely overlap in object identification, and the elderly are the main body, including other age groups. Different from the nursing in medical services, long-term care services reflect long-term nature, the purpose is to "maintain" physical functions, not "recovery" or "rehabilitation", the use of services can not change the trend and trend of "death", but can only minimize the impairment of self-care ability, maintain basic living needs, and improve the quality of life. Long-term care insurance is not elderly care insurance, and the insured and beneficiary are not only the elderly disabled group, but all disabled people. Therefore, long-term care insurance is not the same as old-age security, nor is it a welfare for the elderly, in the disability standard, nursing service supply, should be distinguished from old-age services, elderly care, limited to make up for the lack of self-care ability of feeding, bathing and other nursing services, can not be laundry, cooking, cleaning and other general old-age services into long-term care insurance.
The essence of the integrated medical and elderly care service is to enjoy both the pension service and the medical service in the same geographical space, which may produce the dual problems of "medicalization" and "pension" of medical services, that is, the boundary between the embedded service content and form of the medical service in the pension institution and the pension service in the medical institution is not clear and the original main business, as well as the risk of confusion of payment guarantee. In medical institutions, some elderly care services are reimbursed by medical insurance as medical services, and it is more typical for the elderly to delay their discharge from the hospital after receiving the necessary treatment, and to receive care in the hospital "hanging on the bed". According to the sample survey data, the hospitalization rate of the elderly is 20%-23%, and the probability of hospitalization for more than 30 days (3.25%) is much higher than the average (2.88%). The fundamental reason is that after the elderly are discharged from the hospital, the community and the elderly care institutions do not have cohesive medical services, rehabilitation care services or are difficult to reimburse, and it is difficult to avoid excessive occupation of hospital resources and medical insurance funds.
In the old-age institutions, part of the medical services are paid by the elderly as old-age services, resulting in the problem of not being insured, at present, only sixty percent of the medical institutions in the mainland have medical insurance reimbursement qualifications can explain the problem, the reason is that a large number of internal institutions stop at the infirmary, in the medical level and staffing and other aspects are not up to standard. At present, in some long-term care insurance pilot areas, the cost of drugs and other expenses incurred in medical care is not included in the scope of medical insurance reimbursement, but is reimbursed by long-term care insurance according to the medical insurance catalog, and there are certain risk points in the cost expenditure structure of long-term care insurance and long-term fund operation.
From a practical point of view, the two systems are not strictly separated internationally, and long-term care services are usually an important part of the integrated medical and elderly care system. This is because the disabled and semi-disabled elderly are a group with a high incidence of chronic diseases and are at risk of acute disease attacks, so the demand for long-term care services also has a need for the combination of medical care and elderly care, which is also the difficulty of differentiation. But behind it is a unified system of governance and sources of payment, such as the Integration Joint Board set up by local councils in the UK and the NHS, and the funds that are managed together. Under the current realities on the mainland, it is necessary to clearly divide the content and standards of medical services, pension services and long-term care services in the integration of medical care and elderly care, and clarify who will supervise and who will pay.
3. Conclusions and policy recommendations
3.1 Enhance the capacity of primary medical services and improve the level of protection for outpatient and community general practice services
In the report of the 20th National Congress of the Communist Party of China, General Secretary Xi Jinping pointed out that "strengthen the health management of major chronic diseases and improve the ability of disease prevention and treatment and health management at the grassroots level". In the future, efforts should be made in the two major paths of service supply and payment guarantee. On the one hand, in the promotion of the reform of the medical and health system, it is necessary to realize the sinking of general outpatient clinics, divest the above businesses and return them to the grassroots level, and let the grassroots retain doctors and patients through the tilt of talent training and reimbursement ratio, so as to form a positive cycle and improve the capacity of primary medical services. It is necessary to solve the current problems of insufficient supply of home-based community medical and elderly care services, low service accessibility, low recognition and utilization rate of the elderly, and promote the development of home-based community medical and elderly care services by stimulating the enthusiasm of family doctors to participate in the supply of integrated medical and elderly care, improving the allocation efficiency of family doctors and other resources, and realizing the innovation of supply forms such as family hospital beds. On the other hand, multiple measures should be taken to further improve the actual reimbursement level of outpatient services. In line with the general trend of the current transformation of the diagnosis and treatment model, we will ensure the smooth progress of the reform of outpatient mutual aid security for employees' medical insurance by ensuring the circulation of prescriptions. For residents' medical insurance, it is necessary to further expand the coverage of medical insurance outpatient co-ordination, study ways to reduce the self-payment and self-payment burden of individual outpatient expenses by lowering the minimum payment line and liberalizing the payment limit, and at the same time explore the reform of payment methods for chronic diseases, high-incidence diseases of the elderly or diseases that need long-term outpatient treatment, and standardize medical service behavior. In terms of community general practice services, in addition to appropriately expanding the reimbursement ratio of grassroots and high-level medical institutions, it is also necessary to establish a macro budget arrangement system for outpatient, general practice services and inpatient services to be classified by item, guide the sinking of resources through classified budgets, and build a reasonable division of labor system between specialties and general medicine.
3.2 Enhance the ability of medical insurance supervision and resource allocation, and improve the efficiency of medical insurance governance
On the one hand, it is necessary to comply with the structural change of the medical needs of the elderly, and strengthen the supervision of hospital outpatient and community general practice services. Starting from the normalization of the supervision of the use of the medical insurance outpatient pooled fund, the possible risk points in the outpatient pooled payment for the elderly are located, such as non-essential "physiotherapy and rehabilitation" projects and community day care services that belong to long-term care, and various forms of fund use supervision such as intelligent monitoring and on-site inspection of hospitals and community health service centers. On the other hand, in view of the possible problem of "medicalization" of pension services, in addition to supervising the use of medical insurance funds, we should also strengthen the guidance of medical resource allocation. The medical needs of the elderly in the mainland during the rehabilitation and stabilization period have not been fully released, and they are still stuck in upstream hospitals. In the future, it is necessary to ensure that the elderly are transferred to downstream institutions in a timely manner after the completion of treatment in general hospitals through the supply of cohesive services, and strengthen the payment guarantee of medical insurance for the supply of medical services during the rehabilitation period, stimulate the rehabilitation needs of the elderly, and fully consider the characteristics of diseases and diagnosis and treatment of the elderly in the reform of medical insurance payment methods, and improve the payment model. In addition, we should also be vigilant against the problem of "old-aged" medical services, and further increase the medical security of medical services in old-age institutions, one is to guide the elderly to flow out of the hospital, the second is to realize the full insurance, and the third is to form supervision and quality control of medical services in old-age institutions through medical insurance payment. Explore the implementation of daily payment per bed for diseases that require long-term hospitalization in medical and elderly care institutions and have a relatively stable average daily cost, so as to improve the efficiency of the use of medical insurance funds.
3.3 Promote the coordinated development of medical and elderly care, medical security and long-term care insurance
The report of the 20th National Congress of the Communist Party of China proposed to "promote the coordinated development and governance of medical insurance, medical care and medicine", and this principle also applies to the coordinated development of medical and elderly care, medical security and long-term care insurance. The integration of medical care and elderly care is a change in the supply-side service model, while the synergy between medical insurance and long-term care insurance is a change in the governance system of the payer. Medical insurance and long-term care insurance have strong strategic purchasing power, which can guide the allocation of macro resources, such as the distribution of resources between inpatient and outpatient, and the allocation of micro resources above the needs of the insured, so as to coordinate the supply of medical and nursing services and medicines, and use market means to jointly achieve the public goal of maximizing the interests of the combination of medical and elderly care.
The overall starting point of the synergistic relationship between medical and elderly care, medical security and long-term care insurance is the actual needs of the elderly, and the basic principle should be to improve the efficiency of the use of medical insurance funds and long-term care insurance funds.
First, the development of the integration of medical care and elderly care should adapt to the ever-changing situation of medical insurance governance reform, and medical insurance governance should also have the ability to respond to the payment demand of the new service resource supply model of medical and elderly care. The development of medical insurance to promote the integration of medical care and elderly care should shift from "passive payment" to value purchase, so as to guide the rational allocation of medical and elderly care resources from the macro and micro levels. It is also necessary to deal with the relationship between the basic drug system and other medical systems and the payment of medical insurance at the grassroots level, and promote the coordination of medical insurance and pharmaceutical policies, so as to provide guarantee for the implementation of the integration of medical care and elderly care.
Second, in accordance with the requirements of the report of the 20th National Congress of the Communist Party of China on the establishment of a long-term care insurance system, the implementation of the long-term care insurance system should be accelerated nationwide. Medical insurance drives the coordinated development of long-term care insurance, and the beneficial experience in the governance system should be applied to the establishment and improvement of the long-term care insurance system, and the rights and obligations within the system should be unified through an independent insurance system, so as to further reduce the burden on the elderly and the unreasonable expenditure of the medical insurance fund on the basis of medical insurance reimbursement. In terms of service model, it is inclined to home and community care, strengthen the supervision and assessment of the quantity and quality of services, and promote the construction of professional long-term care service institutions and the allocation of professional human resources with stable funding sources, so as to improve the quality of industry services and social recognition.
Third, it is necessary to adapt to the separation of "medical care" and "maintenance" in the mainland's payment security, with medical services reimbursed by the medical insurance fund, long-term care services reimbursed by long-term care insurance, and daily old-age services compensated by the basic old-age insurance and other elderly subsidy systems. Based on this, it is necessary to clarify the qualifications of the corresponding objects of basic medical insurance and long-term care insurance, the content and standards of services, the qualifications of designated institutions, the reimbursement methods and proportions, and the reimbursement methods for cross-services. It is recommended to clarify the service standards for elderly care services, long-term care services, and medical services, determine the corresponding payment guarantee subjects and payment boundaries, and then strengthen supervision in a targeted manner. （ZGYB-2024.05）
Author | Kang Rui, Institute of Social Development Strategy, Chinese Academy of Social Sciences, Wang Zhen, Institute of Economics, Chinese Academy of Social Sciences
Source | China Medical Insurance
Edit | Cui Xiujuan Gao Pengfei
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