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The &#34;14th Five-Year Plan&#34; outlines the goal of &#34;reducing the personal financial burden on insured individuals&#34; for the first time. Will personal medical expenses further decrease in the next five years?
On March 13, the &#34;Outline of the 14th Five-Year Plan for National Economic and Social Development of the People's Republic of China&#34; (hereinafter referred to as the &#34;14th Five-Year Plan&#34;) was released, requiring the establishment of a coordinated development and governance mechanism for medical care, medical insurance, and pharmaceuticals. It also proposed deepening the reform of medical insurance payment methods, optimizing the use of surplus funds, improving differentiated payment policies for medical institutions at different levels, reducing the personal financial burden on insured individuals, and enhancing the efficiency of medical insurance fund utilization.
Jin Chunlin, director of the Shanghai Health and Health Development Research Center, told a reporter from Yicai that reducing the medical burden on insured individuals requires multiple measures, including expanding outpatient coverage, controlling unreasonable medical expenses and waste through centralized procurement, and exploring the establishment of a cap on personal out-of-pocket expenses.
Comparing the previous &#34;13th&#34; and &#34;14th Five-Year Plans,&#34; Yicai reporters found that the &#34;14th Five-Year Plan&#34; changed the original &#34;improving the universal medical insurance system&#34; in the section on &#34;accelerating the construction of a healthy China&#34; to &#34;improving the coordinated development and governance mechanism for medical care, medical insurance, and pharmaceuticals.&#34;
In the &#34;14th Five-Year Plan,&#34; the reform of the medical and health system and the universal medical insurance system were placed in two relatively independent chapters. The most critical change in the &#34;14th Five-Year Plan&#34; is that medical care, medical insurance, and pharmaceuticals are no longer viewed as isolated system modules but are included in a unified framework, deepening the reform of the medical and health system, emphasizing &#34;unified goals, policy coordination, information connectivity, and regulatory linkage.&#34;
In terms of medical care, the &#34;14th Five-Year Plan&#34; proposes to deepen the reform of public hospitals with a public welfare orientation, establish a dynamic adjustment mechanism for public hospital staffing, improve a fee structure led by medical services, enhance the compensation system, standardize the professional behavior of medical institutions and personnel, and strengthen legal protections in the medical and health field. It also aims to guide and standardize the development of private hospitals.
In terms of medical insurance, it aims to deepen the reform of medical insurance payment methods, optimize the use of surplus funds, improve differentiated payment policies for medical institutions at different levels, reduce the personal financial burden on insured individuals, and enhance the efficiency of medical insurance fund utilization.
In terms of pharmaceuticals, it aims to improve the drug pricing formation mechanism, enhance centralized procurement policies for drugs and medical consumables, optimize the review and approval of innovative drugs and clinically needed drugs, establish a mechanism for medical insurance to support the high-quality development of innovative drugs and medical devices, improve the catalog of innovative drugs, and encourage commercial insurance to expand the payment scope for innovative drugs.
Another factor for the explicit inclusion of &#34;reducing the personal financial burden on insured individuals&#34; in the &#34;14th Five-Year Plan&#34; is the slight increase in the proportion of personal health expenditures in the total health expenditure in recent years.
According to the annual statistical bulletins from the National Health Commission, the proportion of personal health expenditures in the total health expenditure in China decreased for five consecutive years from 2017, dropping to 27% in 2022, rising to 27.3% in 2023, and increasing to 27.5% in 2024, which is higher than the expected target of 27% set in the &#34;14th Five-Year Plan for Universal Medical Security&#34; for 2025
Jin Chunlin believes that establishing a personal out-of-pocket cap is an effective measure to alleviate the financial burden on insured individuals. Currently, China's medical insurance system generally has a cap on insurance payments, while developed countries set a personal out-of-pocket cap. In reality, the vast majority of patients cannot afford to pay for medical expenses beyond the cap, and this shortcoming should be addressed as soon as possible. During the 14th Five-Year Plan period, exploration can begin in areas with relatively abundant medical insurance funds.
The personal out-of-pocket cap mechanism sets the highest limit for individual expenses, reducing the economic burden of medical costs on individuals. This mechanism helps prevent poverty caused by illness and the return to poverty due to illness. Currently, some regions in China have implemented policies for personal out-of-pocket caps for disadvantaged groups.
In recent years, several experts and representatives have suggested during the Two Sessions to shift the medical insurance protection mechanism from &#34;fund cap&#34; to &#34;personal out-of-pocket cap&#34; to strengthen financial protection for seriously ill patients.
Zheng Gongcheng, a representative of the National People's Congress and president of the China Social Security Society, suggested in an interview to change the current cap on medical insurance fund payments to a cap on personal out-of-pocket medical expenses. This means that regardless of the medical costs, the proportion borne by individuals can be controlled within 30%, 20%, or 10%, allowing insured individuals to have stable expectations of medical insurance.
Jin Chunlin believes that the current difficulty in establishing a personal out-of-pocket cap mainly lies in the inability of the medical insurance fund to bear it, but this difficulty can be resolved through methods such as centralized procurement, where savings are made where possible and funds are utilized where needed.
In addition to the cap reform, Jin Chunlin believes that reducing personal burdens also involves the issue of insufficient outpatient coverage. &#34;Currently, outpatient coverage is very weak; medical insurance is primarily focused on inpatient insurance, and only major illnesses or specific diseases can be covered in outpatient settings, while other illnesses have limited outpatient coverage.&#34; Jin Chunlin suggests expanding the coverage of outpatient coordination, improving outpatient coverage levels, while controlling unreasonable medical expenses and reducing waste, as these are important ways to alleviate personal burdens.
(This article is from Yicai)

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The "14th Five-Year Plan" outline first proposed to "reduce the personal cost burden on insured individuals," requiring the deepening of the coordinated development of medical care, medical insurance, and pharmaceuticals, reforming the medical insurance payment methods, optimizing fund usage, and improving payment policies. Experts suggest measures such as expanding outpatient coverage, controlling medical costs, and exploring a cap on personal payments to alleviate the burden. The plan emphasizes the unified reform of medical care, medical insurance, and pharmaceuticals, promoting the standardized development of public and private hospitals

The "14th Five-Year Plan" first proposes to "reduce the personal cost burden on insured individuals," how to achieve this