Department of Health Service, Naval Medical University, Shanghai, 200433, China.
BMC Health Serv Res. 2022 Mar 25;22(1):392. doi: 10.1186/s12913-022-07783-z.
Urban and rural residents' basic medical insurance (URRBMI) is an institutional arrangement for rural residents and unemployed urban residents in China. The serious illness medical insurance system (SIMIS) was established to provide additional medical cover. At present, the SIMIS payment method in China is based on large expenses, and only a few areas, such as Shanghai, pay according to the treatment of serious diseases. This study aims to simulate and analyse the effect of the two payment methods on SIMIS in Shanghai.
We developed a micro-simulation model to predict the number and characteristics of SIMIS participants among urban and rural residents in Shanghai and to simulate the process of medical treatment, medical consumption, and medical insurance payments for each insured person from 2020 to 2025. We then summarised and analysed the payment compensation effect, and compared it with Shanghai's current policies.
The payment of SIMIS according to high expenses, the total medical expenses of seriously ill patients show an increasing trend, with an average annual growth rate of 3.56%. The URRBMI fund payment covers 56%-58% of total medical expenses, and the SIMIS fund covers 5%-7% of the total medical expenses. Both cover 62%-63% of total medical expenses. Self-payment under SIMIS covers 22%-23% of the total medical expenses, total self-payment covers 14%-15% of the total medical expenses, and the medical expenses borne by individuals cover 36%-38% of the total medical expenses.The fund expenditure is 213 million yuan and average annual cost borne by individual patients ranges from 40 000 to 60 000 yuan.
The policy of designing SIMIS according to national guidelines does not meet the development needs of Shanghai. Shanghai should take the current policy of paying compensation according to the treatment of serious illness as the policy basis, consider the security needs of patients with large medical expenses outside the scope of protection, and adjust policies appropriately to prevent poverty caused by illness.
城乡居民基本医疗保险（URRBMI）是中国为农村居民和城镇失业居民设立的制度安排。大病医疗保险制度（SIMIS）的设立是为了提供额外的医疗保障。目前，中国的 SIMIS 支付方式基于高额费用，只有少数地区，如上海，按照大病治疗进行支付。本研究旨在模拟和分析这两种支付方式对上海 SIMIS 的影响。
我们开发了一个微观模拟模型，以预测上海城乡居民中 SIMIS 参保人数和特征，并模拟每位参保人从 2020 年到 2025 年的治疗过程、医疗消费和医疗保险支付。然后我们对支付补偿效果进行总结和分析，并与上海现行政策进行比较。
按照高额费用支付 SIMIS，重病患者的总医疗费用呈上升趋势，年均增长率为 3.56%。URRBMI 基金支付覆盖总医疗费用的 56%-58%，SIMIS 基金覆盖总医疗费用的 5%-7%。两者共同覆盖总医疗费用的 62%-63%。SIMIS 下的自付费用覆盖总医疗费用的 22%-23%，总自付费用覆盖总医疗费用的 14%-15%，个人承担的医疗费用覆盖总医疗费用的 36%-38%。基金支出为 2.13 亿元，个体患者年均负担从 4 万元到 6 万元不等。
按照国家指南设计 SIMIS 的政策不符合上海的发展需求。上海应以现行按大病治疗进行补偿的政策为政策依据，考虑保障范围外高额医疗费用患者的安全需求，适当调整政策，防止因病致贫。
