Summary of Key Points
The government is pushing forward reforms to address the challenges associated with medical treatment in different regions. The initial focus is on unifying the list of medical services covered by health insurance for cross-provincial treatments, with the goal of completing this process within two years, in order to resolve the current issue of inconsistent lists across provinces. However, the rapid growth in the scale of cross-regional medical travel (a tripling in the number of treatments from 2019 to 2024, accounting for 26.4% of total health insurance expenditures) has brought about challenges such as the concentration of resources and regional imbalances in fund distribution. Experts suggest addressing these issues through differentiated payment methods, reforms to the payment system, and improvements in the quality of healthcare services in county-level hospitals, shifting the focus from facilitating settlements to ensuring orderly medical care. Local authorities are also piloting measures for the coordinated management of cross-regional health insurance funds.
1. Why Unify the Medical Insurance Service List for Cross-Regional Treatments?
Currently, while the list of eligible medications for health insurance is fairly standardized nationwide, the specific medical services (such as examinations and surgeries) are determined by each province. When seeking treatment in a different province, the patient must rely on both the local service list and the policy of their home province. For example, if a person is insured in their hometown but goes to Shanghai for treatment, the number of eligible services may be greater in Shanghai, but the reimbursement ratio will still follow the hometown’s standards, which can lead to discrepancies where services are available but not covered by the insurance.
The government’s initiative to unify the list starts with cross-provincial treatments and aims to extend this uniformity nationwide. This move is necessary to reduce settlement disputes and facilitate better regional supervision of medical care.
2. The Rapid Growth of Cross-Regional Medical Travel and Its Challenges
Statistics show a dramatic increase in the number of cross-regional medical treatments: from 98 million in 2019 to 397 million by 2024, with annual growth rates of 12.5%. The associated costs also rose significantly, from 436.1 billion yuan to 786.7 billion yuan, accounting for 26.4% of total health insurance expenditures in 2024. Outpatient treatments across provinces have seen the fastest growth (224 million treatments in 2024, a year-on-year increase of 90%).
This rapid expansion has led to several problems:
- Resource Concentration: A large proportion of patients seeking in-patient treatment in Shanghai come from other regions, particularly those from the Yangtze River Delta area (with over 30% of cancer patients coming from Jiangsu). This has caused overcrowding in major hospitals while leaving smaller hospitals underutilized.
- Fund Imbalances: Health insurance funds flow from the patient’s home province to the larger cities, putting significant pressure on the local funds and potentially leading to overspending in those cities.
- Unnecessary Travel: With more convenient policies, some patients may travel to larger cities for minor illnesses, resulting in a waste of resources.
3. Will Unifying the List Mean Equal Benefits?
The unification of the list is just the first step; actual reimbursement still varies depending on local policies. For instance, the deductible and reimbursement ratios can differ significantly between regions. Even if the list is unified, patients may still face higher out-of-pocket costs due to differences in medical prices or varying coverage for the same conditions.
4. Expert Recommendations to Overcome These Challenges
Experts from Fudan University, such as Ying Xiaohua, have suggested the following approaches:
- Differentiated Payment for Critical Conditions: Develop specialized reimbursement policies for expensive and frequently treated diseases, such as cancer and cardiovascular diseases, by adjusting the reimbursement ratios based on local prices to reduce patients’ out-of-pocket expenses.
- Reform the Payment System: Gradually implement payment models based on the type of treatment (fixed amounts for specific procedures) or annual budget allocations to hospitals. This should be done step-by-step, starting within the same province before expanding to cross-provincial treatments, and focusing first on common and then on more complex cases.
- Coordinated Management Approaches: Establish consistent management standards for similar diseases across regions, ensuring that reimbursement rules and supervision are as uniform as possible while still taking into account local realities.
- Improving County-Level Healthcare: Strengthening the capacity of county hospitals to treat serious illnesses will encourage patients to stay in their home provinces, reducing the need for unnecessary travel.
5. Local Pilot Programs
Some provinces have already begun implementing measures to address these challenges:
- Zhejiang: Incorporates both local and cross-regional inpatient health insurance expenditures into the annual budget to prevent funding shortages due to increased demand.
- Hubei: Gradually adjusts payment standards for cross-regional treatments to align with those of the destination provinces, while also establishing mechanisms for sharing risks between regions.
These pilot programs aim to balance the distribution of funds and resources associated with cross-regional medical travel, providing valuable insights for nationwide reforms.
Conclusion
The reform of cross-regional medical care faces many challenges, including unifying the service list, addressing regional differences, and preventing waste of resources. The ultimate goal is to ensure that patients can receive timely and affordable treatment regardless of their location, while also reducing the unnecessary movement of patients between cities for both minor and serious illnesses, thus promoting more efficient use of healthcare resources.