Medical Insurance Payment Method Of Grass-roots Public Hospital Based On Case Classification

1. Research Background and SignificanceIn 2012 the 18th National Congress of the Communist Party of China pointed out that the reform of public hospitals should be deepened and the social public welfare nature and people should be highlighted. In 2011 public hospitals pilot reform meeting pointed out that county hospital reform is the sally port, which means a new round of "medical reform" policy in gradually tilts at the grass-roots level. The current phase of the public hospital appeared many problems embodied in uneven distribution of medical resources and all levels of hospital strength gap. In order to solve the problems, Medical and health system reform in our country did a lot of trying for many years. One of the most important is building a medical insurance system to reform the medical cost payment method. We should guide patients "A serious illness to go to the hospital, slight illness in the community" in order to relieve the pressure on hospitals at all levels by layered drainage way.The medical insurance payment method is one of the most important factors of the medical insurance system. The current commonly used payment methods in the world are total budget payment, single disease payment, case mix payment, capitation payment, service items payment, mix payment and so on, which all have their own advantages and limitations. Among those methods, case mix means a method classified for hospital diseases according to characteristics of patient characteristics, diagnosis, medical service path, resource consumption and so on. Case mix technique represented by Diagnosis Related Groups, DRGs, can bring reasonable compensation for hospital costs through the combination with Prospective Payment System, PPS, which widely applied and researched in developed countries.The development of case mix technique has a rather late start in our country. In recent years it makes payment by disease experiments in partial area. But due to the differences of environment, resources, technology and case structures, it is still hard for the national cost measurement model to be set and also hard for wider promotion at the grass-roots level. In the previous, part of the pilot hospitals has implemented relatively simple case classification quality cost management method as transition. It possesses the advantages of diagnosis related group (DRG) in the method, and also adapts the technical route of the actual situation in our country. It can be tried to expand the scope of pilots for the easy processing,This research provides a scientific basis for case classification application in grass-roots hospital and providing a case for promoting grass-roots hospital quality management and the medical care payment method reform.2. Research MethodOpinions are demonstrated by using the case study methods such as document research, case analysis, quantitative research and qualitative interview. Through the collection of the related literature at home and abroad, case mix and the development history of case classification are concluded. This paper puts forward the ideas of application of case classification in grass-roots hospital. Taking some first-class public hospital as an example, through the use of the new medical record home page in the hospital medical record data analysis, the hospital in case classification characteristics of the medical cost are concluded; based on a questionnaire on the inpatient clinical doctors and an interview to the main working head in related administrative functions, the usage of the hospital case classification and the feasibility of the implementation of case classification quality management are understood.Statistical approaches include frequency statistics, one-sample Kolmogorov-Smirnov Test, Kruskal Wallis Test, Mann-Whitney Test, Wilcoxon Signed Rank Sum Test, Fisher’s Exact Test, inspection level α=0.05 and statistical software is SPSS20.0.3. Research Content(1) Medical Record Analysis.① Data Source and PretreatmentRegarding the 2013 full-year effective discharged patients medical record home pages (totally 16,527 copies) of Class One Level One Public Hospitals from some municipal town in Guangdong Province as the sample,100 pieces of medical records were chosen at random. The case classification of the records is manually checked by the method of Homepage Classification. The coincidence rate is 93%.② General Hospitalized Cases and Case ClassificationMost age groups of patients are concentrated in the children, youth and the elderly. The majority of cases are the medical records with short hospitalization days. The occupational categories of patients are mainly employees of enterprises or institutions, and the unemployed people. There are around 30% medical records involved in three social basic medical insurance; surgeries occupy 47% of the total proportion. The results of the case classification rate as high as 96.9%, which indicate the hospitalized patients are mostly with simple medical records. The intractable cases are very uncommon.③ Case Classification Medical Cost AnalysisOverall medical cost per patient in A, B, C, D four case classifications are received descriptive statistics and comparative analysis. Through the Chi-square Test, there exists statistical differences between four models of per-patient overall medical cost. Pairwise comparison results show that these differences are all statistically significant, apart from the combination of B-type & C-type and C-type & D-type. Major components of per-patient overall medical cost are the "nursing cost" and other six charges. Upon examination, the itemized cost of four classifications is statistically different, showing characteristic factors different from the large scale hospital.④ "Medical insurance Patient" is defined as the patient settling under one of three basic medical insurance; and "Non-Medicare Patient" is defined as the patient settling in other ways. The case classification medical cost of both of the above are studied through descriptive statistics and analysis. By comparison, the cost of "medical insurance patients" under the four case classifications is higher than "non-medical insurance patients". It illustrates that the inefficient and wasteful use of medical insurance funds may still exist under the current item-division and postpaid system.⑤Taking the classification medical cost of the number of discharged patients with top five major-cause deceases in statistics, it is counted by choosing each Percentile 25 as the expense lower limit, Percentile 50 as the Median, Percentile 75 as the expense upper limit. Based on that, cost range can be considered as the standard range of medical cost. And the median can be referenced as the point of the standard expense. This range can be used to develop medical insurance reimbursement criteria to social medical insurance sector, providing the reference towards Case Mix and other payment models; it can be used for the hospital’s own medical quality cost management as well.(2) Quantitative Research.Select 50 doctors from the clinical section of each inpatient department for the survey. Try to figure out the comprehension and the ability of the clinicians to master case classification, which refers to the new version of medical record home page. After investigation,54% of doctors said they can understand the correct concepts and the classification criteria of the fore models during judging the case classification on home page; 54% of doctors expressed they would like to classify the cases when the patient was discharged; most doctors determine what classification of cases according to admission diagnosis, illness history, and treatment process; 82% of doctors will change the case classification as the patient’s condition changes; 94% of doctors believed that the significance of the case classification is to prompt severity of the illness and helpful in treatment processing.By Fisher exact probabilities analysis, doctors with different educational levels and different length of service has no significant difference statistically in the cognition of case classification, indicating that the clinician can understand the general concept of case classification and master classification standards. The doctors with senior titles could hold the better cognition of the case classification, which related closely to their higher level of medical technology and perennial clinical experience. All in all, the case classification which can be determined by the doctor in clinical is much more accurate and credible.(3) Qualitative Interview.Selected quality control department, record room, information department, medical department, social security office and other five which are closely related to the case classification quality management of administrative departments, do an interview with main working head of every administrative function.The investigation discovered that hospital of middle managers and administrative functions of the advanced management concepts are not exclusive but due to the short time development, many basic problems are to be solved in the management and the concept of medical quality management has yet to accept.Although the hospital has the information basic condition and managers are also interested in case classification quality management, when it comes to real execution, more concerns are existing with related provisions, institutional guarantee and concrete operation. This suggests the reform of medical insurance payment system must consider more in the feasibility of execution at the grass-roots level and improve grass-roots hospital development environment and the health resources practically.4. ConclusionTheoretical study of case classification has been carried out for many years. It also has a considerable range of experience. But research for hospitalized cases in grass-roots hospital is still in its infancy and has its deficiency.First of all, due to differences medical services which offered by medical institutions at all levels, the grass-roots hospitals has facing the main problem that standardize the diagnosis and treatment of simple cases, identification difficult and critical cases, concerned about the quality of medical care, improve the efficiency of medical resource consumption. Secondly, the limitations of database resources and information technology in grass-roots hospitals, case classification and case-mix model structure lacks sufficient data to support; finally, under the influence of traditional systems, coupled with series of problems which brought by the earlier reform in advance, many grass-roots medical institutions hold suspicion and a wait-and-see attitude to the new medical insurance payment system. In fact, they do not accept it subjectively.In response to these issues, this research making recommendations on the following aspects:Government, the social security agency should set the pace, for example,extend to the grass-roots pilot, proposal appropriate policies and support measures; perfecting the species composition, combined with case classification, establish reasonable standards of disease cost; strengthen this grass-roots hospitals development, establish case-management philosophy, promote the use of quality information resources; case classification quality combined with incentives to upgrade their existing performance appraisal system.These grass-roots hospitals push the quality management model of case classification will effectively improve the efficiency of medical insurance fund, promote the distribution of health resources rationally among these grass-roots medical institutions; develop the usage of quality information resources in hospital, impartial assess the value of medical staffs work. On the next stage, we should take into account the differences in economic, factors such as level of hospital to design implementation of case classification system in the grass-root. So that to lay the foundation for establishment of case-mix and payment by disease.5. Innovations and deficienciesThe innovation of the paper as follows:As the background of medical system reform currently, combine with the history of medical insurance system, as well as the present situation of China’s basic medical insurance system reform, we put forward the application of the method of case classification to the grass-roots public hospital, demonstrate the applicability and feasibility of the idea.The main deficiency of the paper is the limitation of sample selection and sample size. Part of the data of cases including type C and type D has missed, which make an impact on the integrity of this research. Additionally, the result lacks the horizontal comparison to the large 3A hospitals. Consequently, results of these data are so far not in much better. Hope that I will have an opportunity to expand the scope of research in the further study, presenting the characteristics of medical payment result from the difference of case structure in different regions and different levels hospitals. Further evidences should be raised to proof the applicability and feasibility of case classification method in our grass-roots hospitals.