Disease screening reimbursement policy

Basic medical insurance only includes the screening of statutory infectious diseases required by the state and the early screening of high-incidence cancers/chronic diseases in some coordinated areas into the scope of reimbursement. The individual out-of-pocket proportion of screening items that meet the requirements fluctuates between 0-70%. Commercial early screening and special screening items that are not included in the catalog temporarily require self-pay. Special groups such as low-income households, pregnant women, and seniors over 65 years old can enjoy exclusive free screening policies.

Last week, I accompanied Aunt Zhang from my community to the community health service center for a low-dose CT screening for lung cancer. She originally had more than 300 yuan in cash ready to pay in full, but in the final settlement, she only paid 128 yuan, and the reimbursement ratio was just 60%. Uncle Li, who went with me, did a full set of early tumor gene screening worth thousands of dollars, and didn't pay a penny. I was a little confused on the spot. He pulled me and asked why it was also a "cancer screening" but the treatment was so different.

In fact, to put it bluntly, this is the "priority selection" of the medical insurance fund. After all, the money in the medical insurance pool is like the living expenses shared by a large family. It must be spent first on the most urgently needed and cost-effective projects. When I was helping at a grassroots medical insurance agency, I would meet about a dozen people every day who came to ask for reimbursement with screening forms. There were many scams: some people went to private beauty institutions to get Helicobacter pylori screening, and they didn’t even have the qualifications to be designated by the medical insurance. You definitely can’t apply for it; some people made an appointment with a special number of a tertiary hospital for screening, and they went through the special service channel and were not covered by the reimbursement; some people had screening done across provinces, and the insured place didn’t include this item in the catalog at all, so naturally they couldn’t apply for it.

As for the controversy over the scope of screening reimbursement, the industry has actually been arguing for many years without reaching a unified conclusion. Most scholars in the field of public health tend to expand coverage. After all, there is data showing that taking Shanghai as an example, after the early community-based gastric cancer early screening was fully included in the medical insurance in 2021, the local late-stage gastric cancer detection rate dropped by 23%. 1 yuan spent on early screening can save 10 yuan on subsequent treatment, which is cost-effective for both patients and medical insurance funds. However, the staff responsible for the calculation of medical insurance funds have different concerns: the pressure-bearing capacity of medical insurance funds in different regions is inherently different. If all early screening projects are blindly included, the reimbursement limit for serious illness hospitalizations will be squeezed, but instead the watermelon will be lost. Many people in the industry have taken a middle-of-the-road approach: it is better to go in stages. Henan, which has a high incidence of esophageal cancer, will first include early screening for esophageal cancer in local reimbursement. Guangdong, which has a high incidence of nasopharyngeal cancer, will give priority to covering nasopharyngeal cancer screening. High-risk groups (such as those with family medical history and smokers all year round) will apply first. The general population will voluntarily pay for themselves. This takes into account practicality and will not put too much pressure on the fund.

To be honest, I have encountered people before who came in with a tumor gene screening form worth nearly 10,000 yuan, saying that other people's low-dose CT can be reported but their own can't. There is really no way. After all, that kind of screening is still a "high-end consumption", and the accuracy has not been clinically verified on a large scale. It will definitely not be included in the inclusive reimbursement catalog. However, the signs of loosening policies in the past two years are actually quite obvious. For example, last year Guangdong expanded the scope of reimbursement for two-cancer screening for women of childbearing age from rural households to all insured women. Hangzhou included full reimbursement for early colorectal cancer screening for people over 45 years old. I made an appointment for my aunt a while ago. It really didn’t cost a penny and I paid 10 yuan for the registration fee.

Finally, I would like to give you some practical advice: If you want to be screened and want to save money, don’t rush to private institutions to buy expensive packages. First, go to the community hospital near your home and ask a few questions to see what free/reimbursed screening programs there are this year and whether there are any that meet your conditions. For example, patients with high blood pressure and diabetes have free complication screening every year. Many people don’t know it at all and spend their money to do it. In fact, the balance of screening and reimbursement will definitely be adjusted slowly. After all, it is necessary to control fund risks while increasing the early diagnosis rate. This is a matter that needs to be slowly polished. But at least the current direction is that more and more practical early screening projects are entering the reimbursement catalog. Let us pay more attention to the notices posted in the community and don’t miss out on the benefits we deserve.