| ObjectivesAn investigation on the operation of the New Rural Cooperative Medical System (NRCMS) in Hunan was made to obtain relevant data and further analyze the status including existing problems of NRCMS in Hunan, rural residents'health status, hospitalization expenses and the influencing factors in order to explore the possible solutions for the problems in NRCMS and provide the basis for reasonable allocation of the health resources in Hunan to promote the sustainable development of NRCMS.MethodsWith multistage clusters random sampling, one county (city and district) from each of 11 prefectures in Hunan where NRCMS pilot programs were implemented was randomly selected to build the study sample. Data analysis was used for the study of NRCMS participants' hospitalization, reimbursements by the NRCMS fund and design of the reimbursement scheme. Detailed information is as follows:1) Descriptive analysis was used for the demographical data and hospitalization of the sample and chi-square test was used for comparison of the quantitative data of two and more groups; 2) single factor and ordinal multi-category logistic regression model was used for analysis of NRCMS participants' hospitalization expenses and the influencing factors; 3) descriptive analysis was used for the operation of the NRCMS fund in the sampled counties in Hunan in 2006, including financing, fund utilization and reimbursement and fund distribution; 4) based on the above study and in combination of the NRCMS policy a reasonable expense reimbursement scheme was designed and a model of expense reimbursement calculation was established. Meanwhile an empirical study on them was made.ResultsNRCMS was implemented in forty-three counties (cities and districts) in Hunan, covering a population of about 24,635,000 rural residents, among which about 18,572,000 joined in NRCMS and the average participation rate was 75.39%. Eleven counties (cities and districts) were chosen with a total of 694,376 participants, among which 365,014 (52.57%) were men and 329,362 (47.43%) women.1) Analysis of hospitalization service. The average hospitalization rate in the NRCMS contracted hospitals was 7.02%; the hospitalization rates in Sangzhi, Shuangpai, Huitong, Shimen and Yueyang were high:11.93%,10.57%,.80%,.26%,7.23%, respectively; women participants'hospitalization rate was higher than men's:8.01% and 6.13%, respectively; The distribution of the hospitalization rate of the participants at different age was like the letter V:the hospitalization rate of the group of 15-29 years old was the lowest (4.29%) and of the group of aged 60 and above was highest (12.96%); the top five diseases of the hospitalization rate were respiratory system diseases (22.91%), digestive system diseases (16.77%), urinary and reproductive system diseases (10.20%), poisoning and injury (9.6%), circulation system diseases (8.44%); The analysis of the distribution of hospitalized patients showed that 67.67% of the NRCMS participants were hospitalized in township medical institutions.2) Analysis of hospitalization expense. The analysis of hospitalization expenses through single factor and ordinal multi-categroy logistic regression analysis showed that all six variables including gender, age, days of hospitalization, level of hospitals, economic level of the counties and types of diseases influenced hospitalization expenses. The average hospitalization expense per visit for men was higher than that for women; The hospitalization expense increased as age increased:The hospitalization expense per visit for the group of the age below 15 was the lowest:1038.12 yuan while the hospitalization expense per visit for the group of above 60 years old was highest:2017.17 yuan; The duration of hospitalization was positively correlated with hospitalization expense:the longer the duration of hospitalization was, the higher the hospitalization expense per visit was; the higher the level of the hospitals were, the higher the hospitalization expense per visit were; hospitalization expense per visit in the contracted provincial hospitals was highest:9070.67 yuan, and hospitalization expense per visit in township hospitals was lowest:781.52 yuan; hospitalization expense was related with the economic development level in the county:hospitalization expense per visit in the county of the high economic development level was highest: 2311.20 yuan, the hospitalization expense per visit in the county of the low economic development level was lowest:1249.16 yuan. Ordinal multi-categroy logistic regression analysis showed that hospitalization expense per visit for tumor was highest, that for congenital anomaly, screening and postoperative radio chemotherapy and rehabilitation, neural and behavioral disorder, and perinatal diseases took the second place, that forrespiratory system diseases, ear and mastoid diseases,dermatological and subcutaneous tissue diseases was lowest.3) Operation of NRCMS in the sampled counties (cities) in Hunan in 2006. The total of raised fund was 33,086,000 yuan, among which NRCMS participants made contribution of 6,943,800 yuan,20.9% of the total fund, and public finance at all levels paid 26,142,300 yuan as allowance,79.01% of the total fund. The total of fund used for hospitalization reimbursement was 25,109,500 yuan, which is 75.89% of the total of raised fund, and 48,500 visits were reimbursed for hospitalization expense. The beneficiary rate was 6.98%. The beneficiary rates of Sangzhi, Shuangpai, Huitong, Shimen, and Yueyang were higher than the average provincial beneficiary rate. The beneficiary rates of Sangzhi and Shuanpai were highest:11.87% and 10.52%, respectively; the beneficiary rates of Wangcheng, Huayuan, Yanling, Xiangxiang, Guiyang and Changning were lower than the average provincial beneficiary rate; the beneficiary rate of Changning was lowest:3.19%. The actual hospitalization expense that the NRCMS participants paid was 83,442,200 yuan, reimbursement was 25,109,500 yuan; hospitalization expense per visit was 1711.25 yuan, and the expense per visit that could be reimbursed was 1492.61 yuan, reimbursement for each visit was 514.95 yuan, and the average provincial reimbursement rate was 30.09%. The reimbursement rates of Sangzhi, Shimen, Changning, Huayuan, and Huitong were higher than the average provincial reimbursement rate while the reimbursement rates of the other 6 counties (cities) were lower than the average provincial reimbursement rate. The highest and the lowest reimbursement rates were that of Huayuan (38.68%) and that of Xiangxiang (22.16%), respectively. In the year 2006 hospitalization reimbursement mainly concentrated on the hospitalizations in township and county hospitals that consisted of 86.99% of the reimbursed visits. Correspondingly, the proportion of the reimbursement for hospitalization in township and county hospitals was fairly big, but disproportionate. The reimbursement for hospitalization in the township hospitals consisted of 60.63% of the total reimbursed visits, but the proportion of reimbursement distribution was 39.32%. The reimbursement for hospitalization in county hospitals consisted of 26.36% of the total reimbursed visits, but the proportion of reimbursement distribution was 35.13%. There were difference among reimbursed visits and reimbursement distribution in the counties (cities) and the proportion of some counties'hospitalizations that went to prefecture level and provincial hospitals was fairly big.4) Design of expense reimbursement scheme. According to the basic principles of the calculation of the NRCMS fund, that is, "payout depends on income and balance of payments", and based on the payment system of "deductible coverage plus coinsurance and ceiling" major considerations was given to NRCMS participation rate, the total of hospitalization co-ordination fund, rate of hospitalization, hospitalization expense per visit in the hospitals at all levels, patient distribution, and harm done to family and society by diseases and other factors. Four reimbursement schemes were designed. The deductible coverage for the medical institutions at the first, second and third levels were 100 yuan,300 yuan, and 500 yuan, respectively and the ceiling for all was 60,000 yuan. A specific proportion of reimbursement for the expenses for specific diseases in the hospitals at different level was designed. The results of the empirical study and evaluation showed that the 2nd scheme was the best:the rate of hospitalization reimbursement was actually 49.68% and the reimbursed expense was 99.44% of the hospitalization fund. The 2nd reimbursement scheme was as follows: the rate of reimbursement for the hospitalization expense for tumor, infectious diseases, delivery, diseases with average hospitalization expense per visit of one thousand yuan or more, and diseases with average hospitalization expense per visit of less than one thousand yuan were 85%,80%,55%,75% and 70%, respectively in the hospitals at the first level; 80%,75%,65%,70%and 65%, respectively in the hospitals at the second level; 70%,65%,70%, 60% and 55%, respectively in the hospitals at the third level.5) A convenient and practical model of expense reimbursement calculation was made:M=N×ΣPij×Eij×Rij×(1+F) (i=1,2,3,j=1,2,3,4,5). ConclusionsThe following conclusions have been drawn in the study:1) The utilization level of hospitalization service by NRCMS participants was high, and women of childbearing age, and participants of 15 years and below, and 60 years and above were the key population of hospitalization service; the majority of the diseases for which the NRCMS participants were hospitalized were infectious diseases (of respiratory system, digestive system and urological system). But at the same time prevalence of chronic non-infectious diseases increased obviously.2) The influencing factors for hospitalization expense included gender, age, days of hospitalization, level of hospitals, economic level, and type of disease.3) The participation rate of NRCMS in Hunan increased annually ever since the pilot program of NRCMS started in Hunan in 2003. The enthusiasm for participation in NRCMS needs to be further promoted. The level of financing was low. The rate of use of NRCMS fund was slightly lower than that required in the policy and too much surplus was left over. The majority of the NRCMS participants did not benefit from the fund; the rate of reimbursement was low; the level of reimbursement was not balanced so that the role and effect NRCMS in many counties (cities and districts) played in reducing medical burden was not achieved. However, the reimbursed visits to hospitals and distribution of reimbursement were generally reasonable, mainly concentrated on township and county medical institutions.4) To explore a scientific and reasonable expense reimbursement scheme according to the conditions in specific counties (cities and districts), to set up deductible coverage, ceiling and the proportion of reimbursement for hospitals at different levels and for specific type of diseases can help maximize the reimbursement effect of NRCMS and facilitate the reasonable use and allocation of health resources. It is vital that the burden of farmers'medical expense be reduced through reimbursement.5) The model of expense reimbursement calculation made in this study was convenient and practical. It was proved in the empirical study that the 2nd reimbursement scheme established in the study was most scientific and reasonable so far for the present level of NRCMS financing. |
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