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2023 is an "extraordinary" year for the medical insurance fund. The demand for medical treatment suppressed by the three-year epidemic was released this year, and the number of people enjoying benefits, total medical expenses, and hospitalization rates all exceeded 20%. Benefiting from the reform of the outpatient mutual aid system, the employee medical insurance pooling fund also increased by more than 20%, providing a guarantee for the soaring medical expenses this year.

On the 25th, the National Healthcare Security Administration released the "2023 National Healthcare Security Development Statistical Communiqué" (hereinafter referred to as the "Communiqué"). The communiqué shows that the scale of participation in basic medical insurance nationwide is generally stable, with 1.33 billion participants; the fund operates smoothly, with a total income of 3.35 trillion yuan, a total expenditure of 2.82 trillion yuan, and a cumulative balance of 3.4 trillion yuan for the national basic medical insurance (including maternity insurance) fund.

Employees' pooling fund revenue and expenditure increased significantly

my country's basic medical insurance consists of employee basic medical insurance (hereinafter referred to as "employee medical insurance") and urban and rural residents' basic pension insurance (resident medical insurance).

The communiqué shows that as of the end of 2023, 370.95 million people will be covered by employee medical insurance, an increase of 8.52 million people, or 2.3%, from the previous year. Among them, 270.99 million are employed workers, an increase of 1.9% from the previous year; 99.96 million are retired employees, an increase of 3.7% from the previous year, and the ratio of employed to retired is 2.71.

In terms of fund revenue and expenditure, in 2023, the employee medical insurance fund (including maternity insurance) will have revenue of 2,293.165 billion yuan, up 10.3% from the previous year, and fund (including maternity insurance) expenditure will be 1,775.073 billion yuan, up 16.4% from the previous year.

The employee medical insurance fund consists of a pooling fund and personal account funds. In 2023, the employee medical insurance pooling fund (including maternity insurance) had an income of 1,658.03 billion yuan, an increase of 26.0% over the previous year; the pooling fund (including maternity insurance) had an expenditure of 1,165.277 billion yuan, an increase of 21.9% over the previous year. The current balance of the pooling fund (including maternity insurance) was 492.753 billion yuan, and the accumulated balance (including maternity insurance) was 2,631.605 billion yuan.

Compared with 2022, the income and expenditure of the employee medical insurance pooling fund have increased significantly. The data for 2022 is that the income of the employee medical insurance pooling fund (including maternity insurance) is 1,316.017 billion yuan, an increase of 10.9% over the previous year; the expenditure of the pooling fund (including maternity insurance) is 955.84 billion yuan, an increase of 2.5% over the previous year.

Relevant personnel from the National Health Insurance Administration told reporters that the rapid growth of the pooling fund income benefited from the reform of the outpatient mutual insurance mechanism of employee medical insurance. After the reform, the funds allocated to the pooling fund increased, and the current balance of the employee medical insurance pooling fund accounted for more than 90% of the total current balance of basic medical insurance, greatly enhancing the risk resistance of the medical insurance fund.

While the income of the unified fund has increased, expenditure has increased even more significantly, from 2.5% in 2022 to 21.9% in 2023. An important reason for the increase is the further expansion of outpatient treatment.

The report shows that in 2023, the number of employees who received benefits increased rapidly, reaching 2.53 billion, an increase of 20.2% over the previous year. Among them, 2.18 billion people visited ordinary outpatient and emergency departments, 270 million people visited outpatient departments for chronic and special diseases, and 80 million people were hospitalized. In addition, 2.3 billion people enjoyed the purchase of medicines in pharmacies.

The report also shows that in 2023, the total medical expenses of employees covered by the medical insurance will be 1,987.979 billion yuan, an increase of 21.3% over the previous year. In 2023, the hospitalization rate of employees covered by the medical insurance will be 21.86%. Among them, the hospitalization rate of employees in service is 11.93%, and the hospitalization rate of retirees is 49.02%. The data for 2022 is that the total medical expenses of employees covered by the medical insurance will be 1,638.240 billion yuan, an increase of 9.2% over the previous year, and the hospitalization rate of employees covered by the medical insurance will be 17.6%, among which the hospitalization rate of employees in service is 10%, and the hospitalization rate of retirees is 38.6%.

Jin Chunlin, director of the Shanghai Health and Health Development Research Center, said in an interview with Caixin that 2022 is a "mask abnormality" year and the growth rate of total medical expenses is meaningless, but it should be noted that the hospitalization rates of both employee medical insurance and resident medical insurance are over 20%, which is indeed too high.

The data in the bulletin showed that the hospitalization rate of employees covered by medical insurance was 21.86%, an increase of 4.2 percentage points over the previous year, and the hospitalization rate of residents covered by medical insurance was 20.7%, an increase of 4.4 percentage points over the previous year.

Residents’ medical insurance “tight balance”

China Business News learned from the National Healthcare Security Administration that my country's medical insurance in 2023 showed the characteristics of "three stability and two progress", namely, the overall insured scale was stable, the fund operation was stable, the hospitalization benefits were stable, and the outpatient benefits were further expanded and the services were further optimized.

The communiqué shows that in 2023, the proportion of fund payments within the employee medical insurance hospitalization expenses list was 84.6%, which remained basically stable as in previous years; the proportion of fund payments within the resident medical insurance hospitalization expenses list was 68.1%, which was slightly lower than 68.3% in the previous year, but generally stable.

In 2023, the number of employees and residents who received benefits increased by more than 20%, among which the growth rate of outpatient benefits was faster. 2.61 billion people participated in the resident medical insurance and received benefits, an increase of 21.1% over the previous year. Among them, 2.08 billion people received ordinary outpatient and emergency treatment, 340 million people received outpatient treatment for chronic and special diseases, and 200 million people were hospitalized.

Relevant personnel from the National Healthcare Security Administration stated that in terms of residents, various regions have continuously optimized and improved the policies for the coordinated use of ordinary outpatient and emergency care for residents. Some places will increase the reimbursement ratio at the grassroots level and lower the reimbursement deductible, and some places will increase the annual maximum payment limit for residents' outpatient care. Based on various policies, the benefits enjoyed by residents in ordinary outpatient and emergency care have been greatly improved.

The report shows that by the end of 2023, 962.94 million urban and rural residents will be covered by basic medical insurance. The residents' medical insurance fund has an income of 1,056.971 billion yuan, an expenditure of 1,045.765 billion yuan, a current balance of 11.206 billion yuan, and a cumulative balance of 766.370 billion yuan.

"Tight balance" is the judgment of the National Medical Insurance Administration on the current operation of the resident medical insurance fund. Jin Chunlin said that the financing of resident medical insurance is tight, and the medical insurance management department needs to strengthen supervision and strictly manage overspending, which will also be transmitted to medical institutions. Medical institutions need to strengthen the cost management of resident medical insurance and avoid overspending.

In terms of service optimization, the number of out-of-town medical treatment visits, the number of out-of-town medical treatment visits, the number of direct settlements across provinces, and the number of out-of-town medical treatment visits ... in-town medical treatment visits will reach 243 million in 2023, an increase of more than 100% compared to 110 million in the previous year.

The communiqué shows that in 2023, the national medical expenses for general outpatient and emergency departments, outpatient chronic and special diseases, and inpatient medical treatment outside of places were 711.105 billion yuan, of which 280.651 billion yuan was medical expenses for out-of-town medical treatment under employee medical insurance, and 430.454 billion yuan was medical expenses for out-of-town medical treatment under residents' medical insurance.