2025年德州市医疗保障工作的主要进展和成效： 齐鲁晚报·齐鲁壹点 李梦晴 12月30日，德州市举行2025年德州市医疗保障工作专题新闻发布会，介绍2025年德州市医疗保障工作的 主要进展和成效，并回答记者提问。 2025年，对德州医保而言，是乘压奋进、砥砺前行、卓有成效的一年。在市委、市政府的坚强领导下， 秉持"医保为民"宗旨理念，按照"守牢底线、夯实基础、改革创新、提质增效"工作思路，立足"省内有 位置，全国有影响"的工作定位，扎实推进全市医疗保障事业创新发展，医保钱包国家试点、医疗救助 等多项工作取得显著成效，获得国家卫健委、中央政法委、国家医保局等13个部委联合表彰的"全国平 安医院建设表现突出集体"荣誉称号。 医保基金总体运行平稳，趋势向好。1－11月，德州市医保基金总收入86.22亿元，总支出75.22亿元，当 期结余11亿元，累计结余91.73亿元。其中，职工医保基金收入44.41亿元，支出35.32亿元，当期结余 9.09亿元，累计结余55.98亿元。居民医保基金收入41.81亿元，支出39.9亿元，当期结余1.9亿元，累计 结余35.75亿元。职工医保基金运行平稳，居民医保基金运行压力减缓。 ...

德州居民医保基金今年已支出40亿余元，惠及近196万人 针对"银发族"和"数字困难群体"，一支支帮办队伍开展"敲门行动"，上门提供服务。针对大学生， 推出一系列优惠政策：缴费标准降至240元、可按学制趸交、门诊报销限额提高、学校卫生室纳入定点 等。聚焦困难群体，通过与民政部门数据共享，低保对象、特困人员等资助群体在系统中被精准标识， 由财政资金直接缴纳，实现"免申即享"，确保困难群众"一个不漏"。目前，全市高标准建成基层医保工 作站（点）1864家，实现了市、县、镇、村四级医保服务网络全覆盖，27项高频事项市域通办。 谢春华一家经济条件有限，巨额医疗费主要依靠亲戚帮扶。幸运的是，全家常年坚持缴纳居民医 保，且2023年生病前便已参保德州惠民保，2025年谢春华还因大病被纳入低保，享受医疗救助、起付线 降低、报销比例提高等政策优惠。"以前总有人说医保'白交钱'，但真到生病时才知道，这是最实在的 保障。"于春花感慨，如今谢春华病情趋于稳定，后续复查、用药仍能享受医保门诊慢病报销政策。 从日常参保的"小投入"到重病时的"大保障"，医保为像谢春华这样的家庭筑起了抵御疾病风险的坚 固防线。 "医保一定要有，但不一定要用 ...

Core Insights - The transition of Huiminbao from "post-compensation" to "prevention" is highlighted, indicating a shift in focus towards proactive health management and risk reduction in the insurance sector [1][4] Group 1: Market Dynamics - The payment paradox between insurance companies and pharmaceutical firms is discussed, where insurers aim to cover healthy individuals to control costs, while drug companies focus on medication usage for market value [1] - The expected market size for innovative drug sales in 2024 is projected to reach 162 billion yuan, with commercial health insurance expenditures estimated at 12.4 billion yuan, contributing only 7.7% [1] - Huiminbao's share in the compensation for innovative drugs is 15%, which is lower than disease insurance and million medical insurance, accounting for 47% and 22% respectively [1] Group 2: Product Development and Challenges - The proportion of normally operating Huiminbao products decreased from 74.3% in 2023 to 66.68% in 2024, indicating ongoing challenges in market performance [3] - The decline in Huiminbao product numbers is attributed to lower-than-expected participation rates and difficulties in expanding the risk pool [3] - New product offerings are being introduced, such as health check management services, to enhance participant engagement and address operational pressures [3] Group 3: Health Management Integration - The integration of health management into commercial health products is emphasized as a means to reduce the risk of major diseases through early detection and intervention [4] - The model of "health management + Huiminbao" aims to shift the focus from post-event compensation to preemptive measures, enriching risk management strategies [4] - The combination of preventive health checks and innovative drug coverage is seen as a significant advancement in insurance, potentially lowering the disease burden on the population [4] Group 4: Industry Trends - The rise of health management services in insurance has been noted since 2016, although growth remains slow due to a lack of experience in managing medical models [5] - The potential of commercial health insurance in the innovative drug payment sector is yet to be fully realized, with ongoing exploration needed for deeper integration of technology, payment, and value [5]

Core Viewpoint - The medical insurance system in Dezhou has shown significant progress in the first half of 2025, with various initiatives enhancing the public's sense of security regarding medical insurance [3][4][12]. Group 1: Medical Insurance Fund Performance - In the first half of 2025, the total income of the city's medical insurance fund was 3.886 billion, while total expenditure reached 4.607 billion, resulting in a cumulative balance of 7.352 billion [4]. - The employee medical insurance fund generated an income of 2.349 billion, a year-on-year increase of 6.68%, with expenditures of 1.991 billion, up 3.54% [4]. - The resident medical insurance fund had an income of 1.537 billion and expenditures of 2.616 billion, with a budget execution rate of 54.81% [4]. Group 2: Healthcare Reform and Initiatives - The city has implemented a "Three Medical Linkage + Traditional Chinese Medicine" reform, resulting in savings of 755 million from drug and consumable procurement [5]. - The "Dezhou Huimin Bao" commercial insurance program has seen participation from 334,800 individuals by the end of June [5]. - The city has expanded the number of designated medical institutions for traditional Chinese medicine from 81 to 115 [5]. Group 3: Service Capability Enhancement - The medical insurance settlement process has been optimized, reducing the settlement cycle to 15 working days [6]. - The city aims to cover 5.074 million insured individuals by 2025, with an additional 49,500 new participants this year [6]. - The online processing of medical expense reimbursements reached 12.2045 million cases in the first half of the year [6]. Group 4: Fund Supervision and Management - The city recovered and returned 22.1135 million in medical insurance funds and imposed administrative penalties totaling 3.4545 million in the first half of the year [8]. - A credit and joint supervision system has been established to manage the qualifications of personnel in designated medical institutions [9]. Group 5: Ongoing Reforms and Innovations - The city has implemented reforms in major disease medical insurance and assistance systems, benefiting 110,100 individuals with a total expenditure of 43.0352 million [10]. - The average hospitalization cost has decreased by 6.57% compared to the previous year, with personal hospitalization burdens reduced by 6.84% [10]. - The city has introduced a unified major disease insurance fund, saving 85 million in resident fund expenditures [11]. Group 6: Future Directions - The medical insurance bureau plans to continue deepening reforms and ensuring comprehensive coverage for the population, aiming to enhance the quality of medical insurance services [12].