Study On The Effect Of The Family Doctor Co-ordination Mechanism And The Outpatient Expense Copayment Scheme In QingDao City

BackgroundTo promote the establishment and improvement of the health care system, to meet the basic medical service needs, according to the central unified department, Shandong Province has preliminarily established the social medical insurance system which covers all urbans and rurals including the basic medical insurance for urban workers, basic medical insurance for urban residents and the new rural cooperative medical system, to provide basic medical insurance through different systems for different social groups. But with the rapid development of economy and society, social medical insurance faces the expansion of surface, and anti-risk ability of the fund is facing a threat, especially in the current case of "medical treatment is difficult and expensive". The effective mechanism of controlling unreasonable medical expenses for is not perfect. The medical expense grows faster. The medical insurance only covers the hospital, so that the out-patients'needs are not fully met. In this regard, reference to the practices and experiences of some countries and regions, Qingdao social medical insurance management carried out the family doctor co-ordination mechanism and the outpatient expense copayment scheme in some communities since 2007, in accordance with the principles of "First pilot, Then ameliorate, Gradually popularize", Seeking to solve the current health insurance major issues.The family doctor co-ordination mechanism guides patients to community-based treatment first, then to the hospitals above the county level if necessary. Local residents determine the family doctor by choosing fixed-point community medical services. The system implements family doctor first visit system, grading treatment and two-way referral, and actively guides the reasonable medical treatment pattern of "minor illness into the community, serious illness to the hospital". The outpatient expense copayment scheme focuses on improving the urban basic medical insurance benefits.The system establishes outpatient co-ordinate account for part of the volunteer pilot group in addition to the medical insurance fund and manpower account and the personal account on the basis of the family doctor co-ordination mechanism. The system improves the relevant policies and incentive mechanisms, guides patients to community treatment, solves the problem of "medical treatment difficult and expensive". There is no systematic survey and evaluation about its effect on guiding residents to community health services, interest change of all groups and problems after the trial. There is few literatures about using the medical insurance policy to run medical insurance system, promote the rational allocation of health resources, improve health care services, and reduce the medical burden of insured. This research project was designed according to the requirements of Qingdao medical insurance management. There was a systematic study about the situation and Effect of the trial to, provide the basis for decision-making of further promotion.Research Purposes And ContentThis paper mainly does In-depth study in the policy design, implementation and results, objective reflection of participate in the program and other aspects of officers and problems. Qualitative and quantitative methods, and some systematic analysis of statistical analysis were used to get relatively objective and accurate conclusion to help determine whether the two pilot projects should promote and how to improve and strengthen. It provided scientific policy basis and theoretical research results for more in-depth development of community health services. Research MethodsThe combination of literature and field research, Quantitative and qualitative survey were used. This paper had extensive literature review, collecting the social health insurance fund of Shandong Province and Qingdao City, Shandong Statistical Yearbook, Health statistics and financial statements of Shandong Province, sample of community health services building materials of Qingdao, and so on. It carried out questionnaire survey to 400 households of 4 community,576 outpatient of community health services and 432 outpatients of 3 hospitals in Qingdao city. Focused interviews were done to some of the administrative staff of medical insurance management, handling, financial and health management in Qingdao. Comparison between households surveyed and out-patient survey, different groups of people of patient internal survey to participate in the pilot two systems, structure analysis,χ2 test and logistic regression were used to analysis the affect of the two systems in the choose of medical institutions of community residents, and satisfaction of community residents to pilot implementation of the results and community health services. Analysis of the causes and purposes of outpatients to the hospital for treatment, the age structure, funds expenditure structure, raising and use of out-patient co-ordinate fund of workers participating, construction of community health services were done to form the preliminary conclusions.Results And ConclusionsAccording to qualitative and quantitative analysis, this paper gets those conclusions.1. Two systems have achieved results. The family doctor co-ordination mechanism has been expanded to all institutions of community health service include health insurance. Outpatient co-ordinate system is also gradually expanded. Participation in the pilot has further increased, and two systems have reduced the medical burden of the participants. The wise of the first diagnosis of community health services of the participants was promoted, and affirmative to the service of community health services Institutions. The build of community health service institutions also promote in a greater degree. Qingdao Medical Insurance Management adjusted the pilot policy to promote the pilot.2. The effect of guiding nearby residents to Community health services is significantly. According to the results of the analysis of patients preferred medical institutions and community health services satisfaction, patients with severe cases of non-emergency choose community health service institutions. Most of the patients had comparative satisfaction to community health services. In addition, State and Shandong Province issued a series of policies and regulations which conducive to the development of community health services and enhance its provision of basic health services capacity.3. Community health service institutions have a big gap to the require of two-way referral system. Whether community health services or hospitals above county level, the implement of two-way referral system were not well. Hospitals do not take the initiative to these patients to the referral community health service organizations:This is mainly because the community; health service institutions have gap with hospital, and doctors generally do not believe the level of community clinics or do not understand the two-way referral system.4. Pilot policy implementation was poor and failure to achieve expected results. Respondents generally believe that community health services didn't provide free medical and health services for participates actively, and seldom had home visits for patients. The establishment of the first consultation and community health record system were not been done well. So that relevant policies and regulations become a mere formality, and can not play an active role in guiding. Many people believe that Community health services have less medical equipments, doctor's attitude is rather poor. We found that if community health services didn't provide free medical and health services for participates, they got no return only to pay, so that the initiative is not strong. Management did not show a clear regulatory approach just like for that, and did not take administrative or economic instruments to guide. In addition, there were more problems that the survey also reflects. Although the medical burden in community health services was lower than hospitals, the drug prices of community health service organizations were still higher than Retail Pharmacies. The pattern of drug dependent doctors has not been changed.5. The pilot did not keep up with complementary measures, and implement efforts was not enough. Some surveys reflected that they did not understand the pilot of the two systems and the policy was not clear either. This is mainly because propaganda of policy design and purpose was not well. Because medical insurance administration lack check and constraints, it was difficult to achieve full real-time inspection and supervision. It was difficult to prevent fraud in policy implementation. It needs optimal control methods continuously, and improves medical insurance management system in the next step in the deepening of the pilot, to ensure the important role of medical insurance system meeting the basic insured health services.6. The pilot policy should be further optimized. It shows that the preferential level of policy is not high enough. It need consider improving the treatment, but it can not improve the treatment only for the pilot, because it may damage the health insurance system. Under the existing policy framework, most of the participants are retirees, so the operation of the fund faces potential risks. It need explore to reform the fund management pattern of Basic medical insurance for urban workers. It should reduce the proportion of individual account funds or cancel the personal accounts. A single co-ordinate fund management should be carried out. Inpatient, outpatient and other related medical expenses of the insured persons should be appropriate solved.Policy Recommendations1. Two systems which had achieved significent effect and should be popularized need to be ameliorated. Based on reality, long-term planning, gradually establish community health services with two important elements of family doctor system and general out-patient trial co-ordination system. It must do further investigation and study, develop detailed construction plans, on stages, planned, step by step, to promote community health service system building and reform of the system stably. Highlight the key points, close to people's needs, contact the system of family doctors, outpatient co-ordinate system, the first community clinic system, two-way referral system, serious illness co-ordinate system as the main content, further improve health care management, promote the effectiveness of key health services reform.2. Enhance the quality and establish a good image, continuously improve the self-construction of community health services, enhance the service capabilities. Focusing on GP, Medical self-study, units sent to school, actively participate in the GP Training Program organized by Shandong Province. Developing featured specialist services, stick to the road of development characteristics, focus on developing a number of new projects,new technology, especially Traditional Chinese Medicine. Improving health care services attitude, Always provide dedicated, warm and thoughtful service.3. Strict system, strengthened management, improving standardized and scientific of:community health services. Scientific development, implementation of system, guided by the conditions favorable instead of forcing the community residents to the community health service by blunt policy provisions. Both of hospitals and community health services should conscientiously implement the regulations.Strengthen health care management, Standard the behavior of medical staff, strengthen examination and assessment of various medical institutions to implement the pilot program, the specific circumstances of the system.4. Plans for the building, taking into account equitable, forming a new positive development pattern of Government-led, market regulation, multiple participation, fair competition. Improve community health service system, encourage and support private capital access to community health services market. Gradually establish community health service system of government-sponsored and social, private as auxiliary. Establish reasonable compensation mechanism, use government purchases, establish and guide government funding mechanism for all community agencies, guide fair competition, equitable development for various institutions.5. Propaganda, policy guidance, effectively create a social atmosphere to make community residents understand and believe community health services and take the initiative to community medical care treatment. First, further develop preferential policies guiding the insured to the community. Second, propagate what quality-assured services community health services can provide. Education, organization, support, supervision, management of community health services should be done. Improve community health service quality. Focus on disease prevention and control. Promote feelings of community residents. Establish a good new doctor-patient relationship, to attract more community residents to the Community health services.