| BackgroundIn order to reduce the number of the rural residents who became poverty due to diseases and make them be covered by a health insurance system, Chinese government made a decision to reestablish cooperative medical system (new cooperative medical system, NCMS) in rural areas in 2003. Before NCMS was piloted in some counties, central government and local government paid high attention to it and supported it financially and organizationally. It's the first time for the central government to contribute to establishing a health insurance system for the rural residents in mid-west China. At the same time, the central government demanded the local government contribute to establishing NCMS financially. With the support from central government and cooperation from local governments, NCMS was established in the first pilot counties in 2003. With enlargement of pilot counties, NCMS was expanded to the rural areas gradually.During the first pilot year, NCMS played an active role in reducing poverty caused by diseases. But some problems such as difficulty in financing, unreasonable payment system, more surplus rot the NCMS fund, low percentage of beneficiary and lack restriction with hospitals were found that would make NCMS develop unsustainably. In order to make NCMS develop sustainable, some projects were committed with the financial help from UNICEF. Most of these projects paid more attention to payment system adopted in pilot counties and wanted to find the problems in payment system and give some comments to develop NCMS smoothly. Based on these findings, some measures would be intervened to the payment system in NCMS in pilot counties. Through interventions, some comments were given to improve the payment system and promote NCMS sustainable development. Many researches indicate that whether the payment system is reasonable will affect whether the demands can use medical services rationally and the suppliers can provide medical services reasonably. Furthermore, a reasonable payment system can alleviate the rapid growth of medical expenditure. Therefore, it's a critical task for us to pay attention to payment system in NCMS.Objectivesâ… . Analyze the status quo of NCMS in pilot counties in western areas and find obstacles that prevent NCMS from sustainable development.â…¡. Explore a reasonable payment system in NCMS and analyze deductible, ceiling and reimbursement rate theoretically and practically.â…¢. Analyze the feasibility and premise of payment system of diagnosis related groups in NCMS.â…£. Some policies and comments were given to improve the sustainability of NCMS development.MethodsSome qualitative and quantitative methods are applied together in this study, mainly including references analysis, expert consultation, focus group interview method, in-depth interview, stakeholder analysis, sensitivity analysis, health statistics method, health policy analysis method and health policy assessment and other relevant knowledge. The study use the methods above try to find the problems of NCMS and explore the reasonability of payment system in it, use it as follows concretely:â… . With the existing data from pilot counties, some problems were found through the focus group interview method and in-depth interview method.â…¡. With the stakeholder analysis method, we analyze the responses of different stakeholders.â…¢. With the sensitivity analysis, we forecast the reimbursement rate of hospitalization expenditures for the rural residents covered by NCMS.â…£. Based on the existing data analysis, the deductible and ceiling of hospitalization expenditure for the rural residents were defined through qualitative analysis.â…¤. With the pre-post analysis, we assess the intervention measure of payment system in NCMS.ResultsThere're some problems in NCMS as following:â… . Shortage of staffs in NCMS office and insufficiency in management ability.â…¡. Lack in social marketing skill for financing and some rural residents can't perceive NCMS adequately.â…¢. The payment system adopted in pilot counties is unreasonable. On the one hand, the surplus of the NCMS fund is too much; on the other hand, the reimbursement rate for the beneficiaries is low. The deductible and ceiling for the rural residents is much high, the reimbursement rate is much low, and the process of reimbursement is too complex.â…£. The rule for restricting the suppliers'behaviors is not enough.Through the intervention on the payment system in NCMS, some findings are as following:â… . The reasonable deductible, ceiling and reimbursement rate adopted in NCMS can increase the number of beneficiaries and the utilization rate of the fund as well.â…¡. The suppliers' unreasonable behaviors sacrifice the beneficiaries' benefits. Hospitals are the biggest beneficiaries from NCMS. When they provide services for rural residents, they prescribe more to them than to other rural residents uncovered by NCMS. Therefore, their behaviors forfeit the beneficiaries' benefits.â…¢. There're some premises for DRGs: strong information systems, effective management ability and regulation power, perception and support from hospitals and powerful supervision measure on providers' behaviors.Conclusions and commentsâ… . There're still some rural residents who are not willing to join in NCMS. On the one hand, the social marketing skills for financing should be improved and make them perceive the connotation of NCMS; on the other hand, some rural residents can't be covered by NCMS because they leave their hometown and make a living in other areas.â…¡. The competence of providers can't meet the rural residents' demand and the reimbursement mechanism for the hospitals is distorted. Both of them will affect the sustainable development of NCMS.â…¢. The competence of staffs in NCMS office can't meet its development. The overhead expenditure is to low to mobilize the staffs' initiatives.â…£. The staffs in NCMS office lack in project design, modification and accomplishment. The reimbursement rate is too complex to express to the rural residents. Most of the pilot counties had a higher deductible, lower reimbursement rate and higher ceiling. The reimbursement the rural residents got was not enough and their burden of disease was still very heavy.â…¤. There're not enough supervision measures for providers. The rapid growths of medical expenditure for the enrollees lower their benefits from NCMS.Finally, some comments were given to related policymakers as the following:â… . Improve the competence of the staffs in NCMS office, pay attention to the network building of NCMS, enhance the staffs' training and improve their competence gradually.â…¡. Better the social marketing skills in financing for NCMS and induce the rural residents join in NCMS voluntarily. Enlarge the contracted hospitals and meet the demand of the rural residents.â…¢. Define the reasonable deductible, reimbursement rate and ceiling that are compatible with the development of local economy and medical services. Simplify the process of reimbursement and make the beneficiaries get the reimbursement conveniently. Simplify the reimbursement rate and make the enrollees understand them and support them.â…£. Increase the inputs to basic health institutions, improve the competence of the providers and meet the demands of the enrollees. Lower the rapid growth of medical expenditure and make the enrollees benefit more from NCMS.â…¤. DRGs implementation has some premise: strong information systems, effective management ability and regulation power, perception and support from hospitals and powerful supervision measure on providers' behaviors. If the premises can be met, DRGs can be implemented in western areas in China. â…¥. DRGs, as a measure to regulate providers' behaviors and alleviate the rapid growth of medical expenditure, didn't get an expected effect in western areas in China. Therefore, it shouldn't expand to other areas very soon. In order to control the rapid growth of medical expenditure, some other measures should be explored.Innovative points of this studyIt's the first time to explore the reasonable deductible, ceiling and reimbursement rate in NCMS theoretically and practically. It's the first time to explore the feasibility and premises of DRGs implementation in NCMS in China.
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