| BackgroundBefore 1980s, Cooperative Medical Scheme in China was an main medical insurance of rural residents. It made a great contribution to the safeguarding of health. Following the innovation of rural economic system, coverage rate of cooperative medical scheme in China reduced quickly. In 2003,79.1% of rural residents were not covered by any form of health insurance. Many of them had no access to health care services because of economic reason and impoverished due to disease.In order to solve this problem, the central government determined to build up a new cooperative medical scheme (NCMS), the aim is to effectively relieve rural residents'burden of disease and to help alleviate the problem of impoverishment due to disease and improve health. Since 2003, NCMS has been built up, some potential health service demands of rural residents were released, coverage rate and benefit rate of NCMS increased continually. But effective reimbursement rate of NCMS were still low and burden of disease of rural residents was still heavy. In 2008, most of enrollees still paid about 65 percent of hospitalization cost by themselves. NCMS did not yet solve the problem of impoverishment due to disease.Previous studies on effective hospitalization reimbursement rate of NCMS were less concerning the influencing factors. The research related to systemically explore causes of low effective hospitalization reimbursement rate on NCMS and analyze the influence degree of those factors through empirical research were less reported. Therefore, in order to promote the sustainable development of NCMS and release the burden of disease of rural residents, this study chooses piloted counties which NCMS developed at least 4 years as objects, tries to explore the causes of low effective reimbursement rate in NCMS, then searches influencing factors, which may provide an evidence for improve and promote the development of NCMS.ObjectivesThe aim of this study is to explore causes of low hospitalization reimbursement rate on NCMS influencing factors and influence degree of them from enrollees, hospitalization reimbursement scheme and implementation of NCMS, which may provide evidence for improve NCMS effective hospitalization reimbursement rate and promote the development of NCMS.Detailed objectives are as follows:1. Finding out problems in the development of NCMS.2. Exploring causes of resulting in low hospitalization reimbursement rate of NCMS.3. Exploring determinants and influencing factors of hospitalization reimbursement level.4. Analyzing key factors of influencing effective hospitalization reimbursement level on NCMS of sampled counties.5. Exploring the relationship of hospitalization reimbursement scheme, premium, hospitalization cost and effective hospitalization reimbursement rate in case study.6. Providing political suggestion for improving hospitalization reimbursement scheme in NCMS and increasing effective hospitalization reimbursement rate.MethodologyData Sources1. Study sites. According to geographic and economic situation, five provinces Henan, Zhejiang, Liaoning, Chongqin and Yunnan were chosen. Two counties that their NCMS were built up above 4 years were selected from each province. As a result, Changge were chosen in Henan, Anji and Xiaoshan were chosen in Zhejiang, Faku were chosen in Liaoning, Yubei and Rongchan were chosen in Chongqin, Yulong and Jiangchuan were chosen in Yunnan.2. Data collection. The first stage was from August to October in 2007, and the second was from October to November in 2008.2.1 Institution investigation. Firstly, NCMS administration offices. A questionnaire was designed by researchers and filled out by NCMS officials in NCMS administration to know about the implementation of NCMS. Meanwhile, database related to hospitalization reimbursement were provided either. Secondly, hospitals. A questionnaire was designed by researchers and filled out by hospitals to know about their revenue, expenditure and drug coverage.2.2 Household survey. To know about hospital service utilization, NCMS reimbursement and attitude towards NCMS among enrolled rural residents, household surveys were conducted in four sampled counties in 2007, with sample size as 1034.2.3 Interviews. To know about the implementation, problems in NCMS and stakeholders'attitudes, key-informant interview and focus-group interviews were conducted.2.4 Second-hand materials collection. Academic references, policy documents about NCMS in the central government and sampled counties from 2002 to 2009 were collected in order to understand research frontiers concerning NCMS.Analysis Methods1. References reviews. Summarizing second hand materials collected.2. Gray system theories. Gray relational analysis and gray GM (1, N) model were used for exploring key influencing factors of effective hospitalization reimbursement rate in NCMS and their influence degree. Gray GM (1,1) model was used for forecasting hospitalization cost, then calculating premium.3. Premium calculation. To calculation NCMS's premium in different benefit packages.4 Diagnosis tree. Finding out causes of low effective hospitalization reimbursement rate in NCMS by using diagnosis tree in health sector.5. Catastrophic health expenditure measurement. To know about the effect of NCMS. on reducing burden of disease by measuring the frequency of catastrophic health expenditure.6. Incidence of poverty measurement. Analyzing the effect of NCMS on reducing the poor by measuring incidence of poverty before and after NCMS reimbursement.7. Path analysis. Setting up path analysis model and analyzing relationships of variables and influencing level with effect hospitalization reimbursement rate in NCMS.Analysis ToolsData from institution were input and analyzed by Excel 2003. NCMS inpatient reimbursement database were analyzed through SPSS16.0 and AMOS16.0. Interviews were recorded with informant consent and analyzed by Maxqda2. Data concerning household survey were double input to Epi Data2.1 and analyzed by SPSS16.0 and AMOS16.0. Gray relational analysis, gray GM (1,1) model and gray GM (1, N) model were through Gray model software and MATLAB 6.0.Results1. Social economic development, population and health resources.During 2003-2008 in sampled counties, social economy developed quickly, income of rural residents increased gradually and the proportion of rural residents in population decreased. But rural residents'income of counties in the central and west areas was still low. And Most of local governments were deficit spending. Financial input for health sector was low in many sampled counties. Rate of financial input for health sector in financial expenditure in many sampled counties was still under 4% until 2008. Health resources were inadequate in sampled counties. Till 2008, medical doctors, nurses and hospital beds per 1000 people in most sampled counties were under the national average.2. The state quo of NCMS implementation and problems.During 2004-2008, participation rate of NCMS increased gradually and approached 100% in some sampled counties. NCMS fund ran smoothly, deficit rate of fund was reduced gradually. Benefit rate and degree of enrollees were increased. In 2008, the highest effective outpatient reimbursement rate was 100%, and the highest effective hospitalization reimbursement rate was 44.17%. Above 90% of outpatients and above 70% inpatients were treated in basic hospitals. NCMS in sampled counties had a few effect in reducing enrollee's burden of disease. It could protect 5.49% of enrollees off the occurrence of catastrophic health expenditure and reducing the severity of catastrophic health expenditure off 7.5%.94.9% of enrollees were satisfied with NCMS. The results of gray relational analysis showed NCMS in sampled counties implemented smoothly, and NCMS implementation in Yulong was the best in all sampled counties.There were some problems in NCMS implementation during 2004-2008. Firstly, the premium was low and unfired. Secondly, the effective reimbursement rate was low and enrollees still had heavy burden of disease. Thirdly, NCMS fund either had excessive surplus or deficit. Fourthly, basic medicine list and basic diagnosis and treatment list were narrow. And all of above problems finally led to low effective hospitalization reimbursement rate.3. Causation analysis of Low effective hospitalization reimbursement rate. Through diagnosis tree, causes for Low effective hospitalization reimbursement rat could be summarized as follows. Firstly, NCMS officials lacked knowledge on health insurance and administration abilities. Secondly, financial income of local government was limited. Thirdly, some rural residents'income was low. Fourthly, concept of health risk of most rural residents was generally weak. Fifthly, premium collection procedure was not reasonable. Sixthly, some of enrolled rural residents were misunderstanding of NCMS. Seventhly, low financing input of government led to low service abilities of hospitals.4. Influencing factors analysis of effective hospitalization reimbursement rate in NCMS.The result of path analysis showed hospital grade where enrollees hospitalized, hospital days, enrollees'education level were influencing factors of effective hospitalization reimbursement rate of NCMS for enrollees. The influence degree of hospital grade with effective hospitalization reimbursement rate was great and it could also influence other factors. Because all above factors could influence hospitalization cost directly or indirectly, hospitalization cost was key for increasing effective hospitalization reimbursement rate of NCMSThe results of gray relational analysis showed that benefit rate of hospitalization in NCMS, appropriation rate of fund and enrollment rate were the first three key factors with influencing effective hospitalization reimbursement rate of NCMS for sampled counties while premium of different counties was same or changed a little.5. Case study of influencing factors on effective hospitalization reimbursement rate in NCMSAccording to the results of multiple regression and correlation analysis, enrollee's age, hospital grade where enrollees hospitalized and ratio of paying by themselves in hospitalization cost were influencing factors of their effective hospitalization reimbursement rate. And shortening hospital days was significative for controlling hospitalization cost as well.According to the results of gray relational analysis and gray GM (1, N) model, utilization rate of inpatient fund, premium and hospitalization cost were the first three key factors for effective hospitalization reimbursement rate of NCMS in Jiangchuan.Results of research of pay scheme in NCMS in Jiangchuan showed could be summarized as follows. Firstly, hospitalization schemes of NCMS from 2005 to 2009 were not reasonable. When premium is stable, influence degree of hospitalization scheme with effective hospitalization reimbursement rate and fund balance of NCMS is great. Secondly, increasing deductible and decreasing ceiling had small influence to effective hospitalization reimbursement rate and fund balance. And based on increasing premium, increasing nominal hospitalization reimbursement rate was significance to increase effective hospitalization reimbursement rate. Thirdly, extending the scope of basic drug list and basic diagnosis and treatment list were significance to increase effective hospitalization reimbursement rate. Fourthly, when the other parameters were stable, effective hospitalization reimbursement rate raises 1 percentage point, premium should increase 5 Yuan RMB. Fifthly, in 2009, when effective hospitalization reimbursement rate of NCMS in Jiangchuan was 40%, premium should be 120 Yuan RMB. Sixthly, when hospitalization cost and effective hospitalization reimbursement rate of NCMS in Jiangchuan increased at the same time, the growth of premium should be higher then one of hospitalization cost.According to results of premium calculation and gray GM (1,1) model, Results of premium calculation are more precise and accurate than those of gray GM (1,1) model. Gray GM (1,1) model can use a little data to build up a model, but the result might have a big error.Political Recommendation1. Increasing the premium. Firstly, government at all levels should further increase input of NCMS, and subsidize NCMS in time and in full amount. Secondly, increasing personal premium of rural residents. Thirdly, broadening funding channels of NCMS.2. Scientifically designing and adjusting pay scheme. Based on premium and health cost, scientifically designing the pay scheme. It is impartment to increase normal reimbursement rate of county hospitals'and town hospitals'. At the same time, gradually extending the scope of basic drug list and basic diagnosis and treatment list.3. Innovating payment system for hospitals and strengthening cost containment. Firstly, developing and improving case-based payment system. Secondly, exploring other models of payment system. Strengthening supervision and management of hospitals.4. Intensifying the capacity building in NCMS administration. Government at all levels should take overhead expenditure of NCMS office into considerations, add equipment, network and position in NCMS office. Meanwhile,employing more officials, improving administration abilities and knowledge of NCMS administration officials through trainings.5. Government should increase input to basic hospitals especially rural township health centers in rural area and strengthening medical technical personnel's training to improve health service abilities of hospitals in rural area.
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