The Study On Medical Care Cost And Economic Burden Of Disease Covered By Medical Insurance In Guangzhou City

Background and objectivesThe subjects and population of basic urban employer medical insurance have been increasing continually, and the management and regulation of the medical insurance system have been improved obviously since "Principle of Establishing Urban employers Basic Medical Insurance System Developed by the State Council" was issued in December 1998. Up to 2007 year's end, the number of basic urban employer medical insurants was 180 million. The medical insurance fund received 221.42 billion yuan, and disbursed 155.17 billion yuan, so the fund depositions massively. Guangzhou basic urban employer medical insurance was implemented from December 1, 2001. The insurants increased 2569.7 thousands in 2007 from 1069.7 thousands in 2002. In term of the national policy titled with "The key implementation plan for the reform of medicine health system in near future (2009-2011)", one of five reform issues suggests that the basic medical insurance must be expanded its coverage to all citizen graduately. How to formulate the strategy of basic medical insurance reform should be firmly founded on if the basic medical insurance system in operation is effective and reasonable.The objectives of this study are to analyze the present situation of implementation of basic medical insurance system, explore the active impact of the system on descending disease burden, assess its efficacy and rationality, and provide the foundationg for decison and policy making in the reform of medical insurance system.Data sourceâ‘ The 689305 pieces of records, composed of the 219579 from the admission department and the 469726 from outpatient department separately, came from patient's individual information documented by Guangzhou basic urban employer medical insurance system from July 1,2005 through December 31, 2006.â‘¡Records of 42942 inpatients from a hospital of grade three and level A in Guangzhou in 2007.â‘¢Expenditure of the fund managed by the Guangzhou medical insurance administrative center from July, 2004 to December, 2008.MethodsThe linear regression analysis was applied to explore the effects of potential factors on inpatients' cost paid by medical insurance. The descriptive analysis, standardization adjusted by the kind of medial insurance, stratified analysis, two-sample t test, Pearson chi-square test, ANOVA, sensitivity analysis, were used to comparison between hospitals, cities, kinds of insurance. The life table and exceptive life time were used to estimate the financial burden of disease. The ARIMA model and exponential smoothing model were employed for time series data fitting and forecasting. Statistical analysis was conducted by software SPSS 13.0. The Disease-case classification was conducted by the Case Management System Software (BSCCS-V2.0).Resultsâ… . Fairness analyzes of insurance payment.1st, insurance mutual assistance payment coverage is narrow.In the payment aspect, The mutual assistance funds mainly are used to pay for hospitalization and special outpatient services in the case of certain chronic diseases, and personal accounts are mainly used to pay for general outpatient services, so-called " combining socially pooled funds with personal contributions" the settlement way possibly causes the insurants to change tendency treatment disease by inpatient. There were 405,700 attendances using outpatient service specific project, but there were actual 48530 persons, accounts for 2.17% which the insurants count, the average per person use number of times is 8.36 times.The medical insurance inpatient service is 139,200 attendances, actual by 95499 persons of uses, the average per person in hospital number of times is 1.46 times, accounts for 4.27% which the insurants counts. The medical insurance the outpatient service specific project and inpatient service actual by 109310 human of uses, accounts for 4.88% which the insurants counts. According to the medical service use investigation result from the Ministry of Health, the big city two weeks seeing a doctors rate was 119.7‰in 2003, in which urban employers basic medical insurance was 149.3‰, was lower than who enjoy free medical care is 195.0‰and the cooperative medical treatment was 213.6‰, was higher than who does not have any medical system indemnitor was 70.9‰. According to the medical service use investigation computation, The insurants every two week seeing a doctor population were 334,200 people in Guangzhou during July 1 2005 to June 30 2006. The proportion of insurants who had profited from medical insurance is low very much..Second, the medical insurance fund massive precipitations and individual payment proportion excessively is high, during July 1 2005 to June 30 2006. Individual payment proportion is 46.0% for insurants in Guangzhou, and Economic burden to be overweight for insurants. However, the medical insurance fund massive precipitations, according to the report of 2009 "two meetings", medical insurance fund precipitation coefficient of whole nation was surpass 30%.Mutual assistance function of medical insurance was not to be able to manifest fully. If medical insurance fund giving full play efficiency, medical care insurance fund must pay rationality.â…¡. Multi-factor analysis to inpatient expenditure of insurantsBy multi-factor regression analysising, affects factor according to influence size arrangement is in turn: number of days in hospital, average norm in hospital, whether the ultra 4 time of fixed quantities, the hospital rank, the age group, the gender, situation of occupancy, outcome of treatment, Coefficient of determination R² is 0.495. Classifying to the influence factor, number of days in hospital, whether the ultra 4 time of fixed quantities, the hospital rank, the age group, the gender, situation of occupancy, outcome of treatment and so on 7 factors were objective factors, but the average norm was subjective (artificial) factor. The identical kind of disease in different fixed quantity hospital diagnosing and treating, the medical expenditure which produces possible different, insurants and hospital which obtains from medical insurance fund payment are possibly dissimilar.â…¢. Analysis average norm in hospitalAt present, the pattern of average norm was adopted in all country medical insurance system, according to service unit settlement is the fundamental mode which the medical insurance settles accounts. We discovered in hospital average norm which affected one of in hospital expenditure primary factors is only inferior to number of days in hospital..Statistics have indicated, payment from medical insurance fund by fixed quantity payment in hospital was above 90%.Besides of hospital rank, fixed quantity was greatly related to formerly collected fees, but not a determination in hospital fixed quantity quantification standard, the identical disease in the different rank hospital or the same rank different hospital diagnosis, the medicine guaranteed the overall plan fund and individual payment expenditure is all dissimilar. Because the fixed quantity standard is directly affecting the fixed-point hospital medical expenditure compensation horizontal and the income, thus the influence medical establishment guarantees the patient to the medicine the diagnosing and treating behavior. The medical establishment in guarantees the control section with the medicine (government) to gamble in the process, possibly through decomposes the diagnosing and treating number of times to gain the profit, or the mean breakthrough fixed quantity standard, will prepare for the next year fixed quantity adjustment.2005 society guarantees in the year in hospital patient to have 5615 people (to account for ordinary in hospital people 4.2%) to be only hospitalized 1 day, cannot remove the hospital for to obtain by illegal purchase the fixed quantity to handle the vacation in hospital the suspicion. But regarding the average per person basic medical expenditure had not achieved the fixed quantity standard the medical establishment, possibly adopts provides excessively the medical behavior, enables the average in hospital expenditure to achieve or the close fixed quantity standard, in order to avoid the next year has the situation which the fixed quantity drops. Therefore, reasonable, the fair in hospital average norm standard making appears especially importantly.â…£. About DRGsDRGs was quite advanced and science payment way ,but it was affected by development level of economy and public health, so it was difficulty to settlment using DRGs,and we must do it greatly diligently.On one hand it could have medical insurance payment hasten reasonably, on the other hand, it could establish foundation of DRGs theory research and practice. At present,single disease payment way was used to insurants in special hospitals or general hospital's faculty ward in Guangzhou. For example, tumor, cardiovascular, orthopedics pexia, organ transplanting and so on,which was adjustment and consummation for general in hospital fixed quantity settlement way. But there was still unreasonable factor, which it adopted different fixed quantity to tumor ward of different hospital, and adopted identical fixed quantity to all tumor disease in a hospital, was obviously unreasonable. DRGs had provided mentality and practice foundation to reasonable payment. By analysising the cost of single disease, it was demonstrated that there was significant different from expenditure of difference diseases, surgery and non-surgery. Research indicated main factors which affects hospitalized expenditure were main diagnosis,age, surgery, treatment result and disease serious degree and so on, which was consistent to DRGs-PPT So we should establish DRGs region research center as soon as possible.â…¤. About aging of population.At present, the ratio of insurants of in-service staff with retirement was approximately three to one, the ratio of inpatient in-service staff with was approximately one to three, the ratio of expenditure from medical insurance in-service staff with retirement was also close one to three, in other words, retired personnel used approximately 3/4 medical insurance fund. .Along with the population aging unceasing aggravating, insurants structure also to be able to have change sweeping, as a result, the retired personnel does not need individual payment insurance cost, but medical service used probability is 9 times than in-service staffs, therefore, medical insurance fund is also facing massive risk. Suggested establishes old-age medical insurance which is similar to Medicare in US.â…¥.. Method of medical expenditure standardizationAverage expenditure of inpatient was common index to weighing expenditure of medical service. The primary data was direct used to comparison at present, but it was affected by constitute of disease, degree of serious as well as method of treatment. Simply average expenditure was used unobjectively to reflect the level of medical service. This procedure neglected influence of important factors in the constitution difference. Such as number of hospital bed distribution difference, disease constitution difference, condition degree difference, and so on, when comparison different hospital. Its consequences cause the wrong analysis conclusion possibly. Therefore, important influence factor must remove when we analysis inpatient expeniture, and one of means is to standard by transforming to identical constitution, namely so-called standardized method. Method of count material standardized was recognized, but rarely had mentioned. In this research method of measurement material standardized was carried on medical expenditure.The inpatients' expenditure of hospital in 2007 is researched,and the regression analysis demonstrated 9 factors have the remarkable influence to inpatient expenditure, it were in turn by intensity treatment days of main disease, surgery, disease-case classification, age, times of blood transfusion, outcome of main disease treatment, charge-type, gender, times of rescue. Coefficient of determination R² is 0.457. Surgery and disease-case classification was primary factor according to level of influence to hospital expenditure, and expenditure was standardized with primary factor. In other condition consistent situation, average hospital expenditure of AB cases were lower than CD (t=72.354, P< 0.0001); average hospital expenditure of surgery patient were higher than non-surgery patient (t=61.92, P< 0.000 l).Because of different proportion of A, B, C, D case, of surgery and non-surgery case, standardization processing or lamination analysis were used according to surgery and disease-case classification when hospital expenditure of different charge-type were compared.â…¦Comparison of inpatient expenditure between insurants and non-insurants,or different local insurantsDue to medical insurance policy exist regional characteristic, we must consider over promiscuous factor of regional disparity when coparison of hospital expenditure of different local medical insurance and own patient. In this research,hospital expenditure was compared own and medical insuranc patient who came from the identical local. Average expenditure in a hospital were significant regional disparity to Guangzhou city medical insurance, Yi city medical insurance and Bin city medical insurance. Rregardless of AB or CD cases,average hospital expenditure were compared, medical insurance of Bin city >own expenditure of Bin city > medical insurance of Yi city > own expenditure of Yi city > medical insurance of Guangzhou > own expenditure of Guangzhou (P< 0.0001). Therefore it was obtained average expenditure of medical insurance of Guangzhou city, Yi city, Bin city to be higher than corresponding own expenditure patient in the hospital..In usual situation,hospital expenditure was mainly related to disease and degree of serious. According to this research, influence included of patient condition, social characteristic, but also patient's payment ability or payment way. The medical insurance management of Guangzhou had stricter controlled in hospital fixed quantity payment system, in certain degree controlled hospital expenditure growth. Yi city and Bin city carried out more loose verification policy, so it causes average hospital expenditure of Yi city and Bin city medical insurance to be higher than Guangzhou medical insurance expenditure.â…§Disease economic burden researchAt present, disease economic burden research of domestic and foreign mainly concentrated to infectious disease, chronic illness, congenitalness, vulnerability disease et. Point of view from research ,it concentrated to disease economic burden studies on individual, family, society's . This research disease economic burden was analysised from medical insurance, we could realize clearly medical insurance system could reduce disease direct economic burden of patient individual or family. But in the process of disease treatment, it was possible that medical resources had been used excessively or wasted, thus increased society's economic burden.Computation of disease economic burden, usually carried on by a city, the expenditure may include other cities personnel's, and accuracy was inferior to medical insurance information system. Some authors calculate a disease economic burden through sample investigation, it possibly has sampling error. But all insurants's hospital expenditure information was recorded in medical insurance information system., the datum were complete. In 2006 Guangzhou medical insurance average patient's direct economic burden was 1796.79 Yuan, among, hospital patient average economic burden was 6402.18 Yuan. In 2006 staff of Guangzhou's average wages were 36321 Yuan, average goverable income was 19851 Yuan in city family. Average disease direct economic burden occupied 9.05% of average goverable income.direct economic burden of inpatients occupied 32.25% average goverable income. Disease economic burden of apoplexy in Guangzhou medical insurance community were 211.449 million Yuan, economic burden of diabetes is 74.703 million Yuan.90.65% diabetics chose outpatient service in Guangzhou medical insurance, and only 9.35% patient's conditions developped to need be hospitalized, years of life lost of diabetes are 286 years, years of lost complete productive forces are 187.5 years. Because 95.20% apoplexy patients chose in hospital service, years of life lost apoplexy are 2082 years, years of lost complete productive forces are 1406.45 years. It showed apoplexy is serious disease,we could draw a conclusion tahat direct economic burden of apoplexy was higher than diabetes. Moreover apoplexy patient's direct non-medical expenditure, as fee for company, wage loss, nutrition spends was obvious more than diabetic patient. Therefore, we suggested manage expenditure of apoplexy patient according to single-disease norms.â…¨..Forecasting amount of medical insurance fund paymentThere were many kinds of forecasting methods in medical service domain,such as regression analysis, gray dynamic model, neural network, Markov model, exponential smoothing , atoregression model, ARIMA model. Medical insurance fund disbursement of 2004-2008 was analysised in this research, it had apparent characteristic of period sequence and long trend ,and was fitted by the exponential smoothing and ARIMA model. Finally exponential smoothing's parameter was: Conventional parameterα=0.20, tendency parameterγ=0.90, seansonal parameterδ=0.00. Primary data was fitted with exponential smoothing,and compared to fitting value and the corresponding actual value, average relative error is 3.90%. With the ARIMA(0,1,1)(1,0,1)₁₂ model forecast medical insurance fund disbursement of 2008, and with the actual value as well as the exponential smoothing forecast value compares, ARIMA model forecast value and the actual value average relative error is 5.57%. The exponential smoothing forecast value and the actual value average relative error is 5.66%. Average error of exponential smoothing could surpass ARIMA(0,1,1)(1,0,1)₁₂ model as a whole;But average error of ARIMA(0,1,1)(1,0,1)₁₂ model surpasses exponential smoothing slightly on the near future forecast. Forecast value sequence chart demonstrated forecast value could carry on very good track. Medical insurance fund of Guangzhou payment is 2.686 billion Yuan, in 2009.Conclusionsâ‘ Needs further to promote medical insurance for fairness. On one hand, we must expand the overall plan payment scope, if also gives certain proportion payment to the general outpatient. On another hand,we must enhance the payment proportion.â‘¡A major factor which impact medical insurance hospitalization costs were the number of days hospitalized, the average fixed cost. Such as hospitalization, the average fixed-cost management more subjective (human) factors. Single disease cost analysis showed that patients with diseases of the patients treated in different hospitals with a fixed cost,hospital management, the average fixed obvious defects, the proposed establishment of a regional system of DRGs-PPS.â‘¢Comparison on mdical insurance and non-medical insurance, expenditure of inpatients were significantly different among different regions or charge-type in a hospital., suggesting that different parts of medical insurance payment policies have a greater impact on medical expenditure. It was necessary that regorious medical insurance policy conducive to control the growth unreasonable medical expenses.â‘£Surgery and disease-case classification affects inpatient costs as a major factor. It is recommended that Medical cost is paid difference by operation and different types of disease-case classification,before establishment of DRGs-PPS.â‘¥Quantitative data (hospital costs) standardization. Impact on hospital costs through standardization of the main factors to explore the comparison of quantitative data. Economic burden of disease study shows that medical insurance system can effectively reduce financial burden on patients, but the heavier the financial burden of diseases, medical insurance policy to pay and concerns should be tilted.⑦ARIMA models and exponential smoothing method can be better fiting to co-ordinate fund expenditure of medical insurance in Guangzhou. By comparison, ARIMA model was more suitable for short-term forecasts.