Study On The Management Mode Of Pooling Funds Of Outpatient Service

Outpatient pooling fund refers to the management range that integrates some outpatient treatments, and their outpatient treatment expenses will be paid by the risk-pooling fund to a certain proportion. Now, outpatient pooling fund has two modes in China, the one is the outpatient services pooling fund for special diseases (OS-PFSD); the other is the outpatient services pooling fund for general diseases (OS-PFGD). With the development of medical insurance in China, developing outpatient pooling fund of basic medical insurance has been on the agenda. In the promotion of a series of policy documents issued, New Rural Cooperative Medical Scheme(NCMS), Urban Residents-Basic Medical Insurance(UR-BMI) and Urban Employee-Basic Medical Insurance(UE-BMI) are gradually try to build Outpatient pooling fund in many places in our country. Relatively, outpatient management is more difficult and complex than hospital management, therefore, it is an urgent need to standardize the management system of outpatient pooling fund.PurposeBased on the above background, this thesis is mainly to research the management mode of outpatient pooling fund, follows the technical route of document research, empirical studies and theoretical studies. In document research respect, study its relevant theoretical foundation and the guidance, the policy, experience and reference from abroad, the present situation of our country. And through empirical study, study the system of outpatient pooling fund from typical areas in our country, analyze their experience, achievements, insufficiency, implementation effect and influence. In theory, preliminarily establish a management mode of outpatient pooling fund that can share risk of disease effectively, and conforms to ours national conditions from the functional orientation, the overall internal management, and cohesion of external related system, which can provide the reference for the policy-making department.MethodsThe paper collects and analysis literatures which related with the policy of outpatient insurance in typical developed countries and the present situation of outpatient pooling funds in our country by methods of literature research, induction and comparison. To analyze the experience, achievements and the insufficiency of the system of outpatient pooling fund in the typical areas in our country, study the impact of OS-PFSD and the reform of payment way on service utilization for inpatients by method of case study and interview. The survey collected the data in medical institutions from2009to2012, which included1county level hospital and6township health centers (Community Health Centre),18village health stations in Shuangliu and Xinjin county in Chengdu city; In Henan, collected the statistical reports from Qingfeng and Xi county cooperative medical service office, it included the outpatient funds of financing, allocating and usage from2009to2012. Hospitalization expenses, insurer reimbursement data collected from the Changsha HMO (health maintenance organization) and social insurance agencies on the care of people with schizophrenia covered by UE-BMI and UR-BMI in Changsha in2010. Data were analyzed using SPSS for Windows(Version17). Based on consulting relevant experts, design the management mode of pooling funds of outpatient service by method of system associated.Result1. Comment on the related theory of outpatient pooling fund:the related theory including risk of illness theory, the law of large numbers, health management theory, public economics and health economics etc. The first two are the comprehensive theoretical and methodological guidance, the others provide a basic theory framework for the management mode of outpatient pooling fund. The paper assimilated the core ideas and basic connotation of the above theories, so designed the management mode of outpatient pooling fund.2. Review domestic present status:In general, although some positive significance was performed, but the financing and treatment level are low in most place. For example, the funding lines is mostly30～50yuan per person per year, reimbursement ratio only at around50%, annual ceilings are mostly under300yuan; Some policymakers are very vague about functional orientation of outpatient pooling fund, which lead to biased in policy making; The coverage still follow the three catalog of Urban Employee-Basic Medical Insurance(UE-BMI) in many cities, insurance coverage lacked specific aim. Provider’s "per head" is not the meaning in traditional significance, so the service management system of outpatient pooling fund need for continual and detailed development. The present payment way is not the capitation in the true sense, and it is need to continue elaborate the management system of outpatient pooling fund.3. Case analysis:(1) In Chengdu, for both sample township health centers and village health stations, the average of the outpatients compensation numbers of people and total costs were increasing year by year from2009～2012, the payment proportion of outpatient pooling fund rose from29.8%to45.1%in township health center, and rose from29.8%to58.3%in village health station. It showed that more and more participants knew the policy and benefit from the policy, and the compensation ratio was increasing gradually. For sample township health centers, annual outpatients numbers, annual income and annual outpatient income increased steady in the past4years, but for village health stations, annual income increased slowly, annual outpatients numbers and annual outpatient income was decreasing in recent years, it showed that the basic medical function of village health station had shrinking tendency.(2) In2009, the savings rate of outpatient fund in Qingfeng and Xi county in Henan Province achieve74.58%and61.6%under the family account management mode, while, after implementing the system of outpatient pooling fund from2010～2012, the savings rate of outpatient fund of the two counties both decline to less than48%in the case of the total outpatient fund increased more than two times. On the range of outpatient benefits, two counties gained a large growth respectively from66%and71%in2009to319%and314%in2010, at the same time, the range of total benefits were increased by4.5and4.2times, but the security level is relatively low in two counties, for example, the benefit degree of outpatient pooling fund was less than40%, annual ceilings was only60yuan, the savings rate of outpatient fund was still high. From the view of compensation scheme, two counties were still affected by family account mode, and the policies tended to be degenerated to the family account mode in Qingfeng county.(3)UE-BMI integrated schizophrenia management into the OS-PFSD and introduced some new reimbursement methods while UR-BMI made no provision for financially supporting outpatient care of these patients. Compared with inpatients covered by UR-BMI, the inpatients of UE-BMI were admitted to higher level medical institutions and were prescribed expensive second generation antipsychotics (SGA) medicines. Nevertheless, the hospitalization service utilization and cost of inpatients’ hospitalization under UE-BMI were far less than that of inpatients under UR-BMI.4. Experience and enlightenment provided by typical developed countries on outpatient security policy:medical insurance system in almost typical developed countries cover outpatient service; Whether implement community first diagnosis system due to the local conditions; Due to the community first diagnosis system is a necessary condition for capitation, so whether implement community first diagnosis system is closely related to compensation methods and the elaborate degree of outpatient treatment catalog; Classified supervised outpatient service and respectively formulate payment policy, firstly, classified supervised and respectively pay the expense of medical service and drug, secondly, classified supervised general practitioners and specialist; There are two supervision modes about outpatient service:external supervision and self supervision, but the key is manage outpatient doctor; Patients need to pay outpatient treatment expenses to a certain proportion, some assistance should be given to members of disadvantaged groups.Conclusions1. With the development of medical insurance system and the improvement of the security capability, it is necessary to implement outpatient pooling fund at proper time. Because the OS-PFGD is propitious to improve the usage rate of outpatient fund, and make more residents beneficial from outpatient compensation, it can also expand the range of medical insurance system benefits. The OS-PFSD can appropriately reduce hospitalization utilization, which, together with the payment way reform and the prescription of reasonable medications, can significantly reduce the overall hospitalization cost for patients.2. At the initial stage, OS-PFSD is the preferred form. With the improvement of financing ability and management level, gradually implement OS-PFGD which as a supplementary form of OS-PFSD. Not recommended use the form of small subsidies.3. The functional orientation of outpatient pooling fund is security of economic risks of illness. It is a misunderstanding that integrates public health and prevention service into outpatient pooling fund pay limits, and place security emphasis on mild illness.4. Specific catalog of outpatient pooling fund should be formulated on the provincial level. The specific catalog should including national essential drug and clinics projects from the class A catalog of basic medical insurance, which accordance with the contents and characteristics of outpatient medical.5. Whether implement community first diagnosis system due to the local conditions and the characteristics of medical service. If the conditions are not mature, it should not be enforced. However, designated management system should be insisted, and the range can be expanded to first-level and secondary-level medical institutions. 6. At the initial stage,"Capitation fee" can only be used to pay outpatient treatment expenses occurred in first diagnosis institutions, after establishing standardized system of two-way referral,"Capitation fee" can pay outpatient treatment expenses occurred in referral hospital. If referral to the higher hospital and hospitalization, hospitalization treatment expenses should be pay by hospitalization funds.7. In most parts of our country, due to not implement the policy that classified supervised and respectively pay the expense of medical service and drug, so it do not has the preconditions to implement the Capitation, so service package should including national essential drug and clinics projects from the class A catalog of basic medical insurance, which accordance with the contents and characteristics of outpatient medical. Payment way can adopt fee for service under total amount control. In the case of absence of basic data, the average per capita outpatient fund budget can be as a basis for temporarily calculating total amount control of medical institutions, but medical insurance agencies should accumulate data in ordinary time, and prepare for formulating scientific Capitation fee.8. Treatment management policy is closely related to payment way. Some control measures for demand-side including deductible, reimbursement ratio and ceilings are needed if employ payment way of fee for service. OS-PFGD is also need to employ deductible, because deductible can define the economic risk of illness, this study suggest employ annual deductible. Reimbursement ratio is not less than50%when outpatient treatment expenses more than deductible. Annual ceilings should be significantly higher than average funding lines. More effective management to supplier can be employed if implement the policy that classified supervised and respectively pay the expense of medical service and drug.Innovations1. Theoretical innovation:The research defined the function and responsibility of three main responsible party:government, insurance and personal, provide some ideas to solve the problem in the operation of outpatient pooling fund2. Put forward the management mode of outpatient pooling fund which conforms to ours national conditions:this study preliminarily establish a management mode of outpatient pooling fund by the methods of theoretical studies combined with empirical studies. In the system design, this study put forward the point of view both considering the reality and the direction of the reform.3. To provide reference for the improvement of medical insurance system:This study reviewed domestic present status, analyzed the experience, achievements and insufficiency in the typical areas in our country, sum up experiences of typical developed countries, which is conducive to form a normative management system and provide the reference for the policy-making department.