The Strategy Study On Irregular Behaviors' Regulation Of Certified Medical Institution Of New Rural Cooperative Medical System

Certified medical institutions play an important role in the New Rural Cooperative Medical System (NCMS).They are not only the suppliers of health services, but also the headstream of medical expenditure and the goalkeeper of NCMS fund payout. The qualification, quality and behaviors of suppliers influence the development of NCMS directly. Since 2003, NCMS has made prominent progress. However, with the development of trial work, there also exist many irregular behaviors in certified medical institutions. However, the study on behaviors' regulation of certified medical institutions is limited and inconclusive. Some researches have been done about big hospitals in China, but these studies are only descriptive study or case study and not prevalent. Thus it really needs some further study on certified medical institutions.On the basis of above-mentioned background, six areas including Qingzhou city, Ningyang county, Linqing city, Qufu city, Jiaxiang county of Shandong province and Zhen'an county of Shan'xi province have been selected as investigative field. The goal of the study includes the following: Firstly, to summarize the expressive form of irregular behaviors; Secondly, to conclude the existing feasible measures and deficiency of behaviors administration and cost controlling; Thirdly, to analyze the reason, motivation and rule of irregular behaviors forming from policy, mechanism, system and operation aspects; Lastly, to design the process and ways of monitoring and management for certified medical institutions according to the expressive form and reasons of irregular behaviors. The research acquires plenty of quantitative data and qualitative data through literature review, interview, exit-survey, field-notes and field-investigation. We induce and analyze data by descriptive study, single-factor analysis, multifactor analysis, optimal scaling, case-study, Delphi and specialist review.Main findings:1) Since NCMS began, the trend of person-time of out-patient and in-patient is reasonable. The portfolio and income of hospital increase.Nevertheless, the benefit rate of in-patients is lower than that of out-patients. So the benefit level enjoyed by many people who take part in NCMS is low, and also NCMS fund is overspend or deposited in some places.2) The irregular behaviors exist in diagnosis and treatment, medical service charge and other aspects.3) Despite all the experimental counties constitute perfect system ,for example, qualification censor, democracy supervision, drug using, check-up, cost control and soon, there are many deficiencies of management system, supervision system and punishment rules and also they attach over-importance to technologic supervision at present.4) According to the investigation, the NCMS has strong impact on doctor's prescribing behaviors in township and village medical institution. The average cost per prescription, the average number of drugs prescribed, the percentage of prescription using antibiotics, the percentage of prescription using hormone and average days of using drug are different between NCMS members and non-members. The percentage of patients receiving injections is high in township and village medical institution. The optimal scaling results show that age, medical institution, average days of using drugs , the average number of drugs prescribed, the percentage of prescription using antibiotics and payment of medical cost have significant impact on the prescription expenses.5) From the results of in-patients investigation, after new rural CMS implemented, the average medical expenses and the average hospitalized days for inpatients of county level are more than before, while those of inpatients of township hospital decrease. The average medical expenses for patients who take part in NCMS are higher than that of those who do not take part in NCMS. It is also true for the average hospitalized days. The portion of drug expenses decreased after NCMS, while the fees for operation rise. For both county and township medical institution, the actual compensative portion of medical expenses is very low. The optimal results show that age, medical institution, taking part in NCMS or not, the average hospitalized days, surgery, check-up, payment code and economy have significant impacts on medical expenditures.6) Case study on Zhen'an county shows that: the average medical expense is 1437.09 and 3145.12 yuan for single sickness and not respectively. The portion of medical expense which overruns the compensative range for single sickness patients who were switched to out-county hospitals and work in other places is 51.82% and 48.37%, however the portion is 63.55% and 42.34% for patients who have not single sickness. Medical expenses of non-single sickness and out-county hospitals are not easily controlled.7) Problems which include office of NCMS subjecting to health bureau, deficiency of regulation mechanism, non-effective execution of management rules and the subjective intent and objective ignorance of certified medical institutions afford benefit motivation to certified medical institutions.Advice: 1) establishing subject and object of monitoring and management, forming the effective supervision chain; 2) setting up separated system between management and service supplying; 3) combining technologic supervision, diagnostic related groups and gross revenue controlling to urge certified institutions restricting behaviors self-consciously; 4) strengthening the punishment system; 5) adopting multi-supervision ways to enhance efficiency; 6) improving the providing ability of certified medical institution; 7) constituting reasonable supervision process on certified medical institutions.