Study On Path To Case-based Payment System Under The New Rural Cooperative Medical Insurance

At present, the New Rural Cooperative Medical Scheme (NRCMS) is facing the challenge to raise benefits with lower funding. International experience shows that the core technology in designing a case-based payment system is case grouping and pricing, and that the case-based payment can play a positive role in controlling unreasonable medical expenses, improving efficiency and the quality of medical services and so on. Case-based payment reforms have been conducted in many regions in rural China since the New Rural Cooperative Medical Scheme was initiated in2003. Targets and the paths of case-based payment reform differed significantly among different regions. Moreover, there are still many theoretical and practical problems and obstacles. A few of studies have carried out comparative analysis and evaluations of these models but few of them have promoted the path to smoothly implement the case-based payment reform in rural China. In this sense, our study has important theoretical and practical significance.[Purpose] To explore the path to case-based payment under the New Rural Cooperative Medical Scheme based on China’s basic national conditions, and to ensure that the medical insurance funds are utilized scientifically, rationally and efficiently.[Methods] This study combines macro and micro, qualitative and quantitative, inductive and deductive methods. Data collection methods:a. Literature review methods. Collect domestic and foreign literature, policy documents and reports of pilot reforms related to case-based payment through database and relevant department websites, b. Site investigation. Understand the health service system and the New Rural Cooperative Medical Scheme as well as the designing and development of case-based payment reform in Zhen’an County in Shaanxi Province and Qianjiang District in Chongqing City, c. Individual in-depth interviews and panel interviews. Understand the obstacles, operation rules, profit distribution and key influencing factors in the process of implementing case-based payment. What is more, to discuss the dimensions and index of the monitoring and evaluation system in view of case-based payment. Data analysis methods:a. Case study. Research on the structure of case-based payment system under the New Rural Cooperative Medical Scheme in Zhen’an County in Shaanxi Province and Qianjiang District in Chongqing. Taking the Guangxi Zhuang Autonomous Region as an example to explore the path to case-based payment system in rural China. b. Systematic Approach. Explain the relationship between multiple subjects in the Entrust-agent Theory, including the medical insurance management agency, medical service providers, rural patients and the government. c. Focus group. Understand the barriers, key problems and possible solutions in the process of formulating and implementing case-based payment system under the New Rural Cooperative Medical Scheme. d. Statistical Analysis. Calculate statistical variables using Excel or SPSS software, such as hospital volume, average hospitalization costs and reimbursement ratio to provide the base for impact evaluation and system design.[Results] Strategic paths to case-based payment system in rural China:a. Strategy to cover whole diseases by way of quotas, ceilings, and exceptions0b. Strategy to cover all health care institutions by case pricing considering different levels of health institutions and improve competition of medical service market. c. Strategy of rational case pricing through scientific approach, giving full consideration to rising prices, medical technology updating, the adjustment of the New Rural Cooperative Medical Scheme and on the basis of consultation with health institutions. d. Strategy of cost risk-sharing between health service providers and purchaser by way of different mechanism of payment, such as quotas, ceilings, and exceptions. e. Establish the monitoring and evaluation system for case-based payment based on the incomplete system theory and limitations. f. Strategy to develop case-based payment system sustainably:case grouping and pricing should be coordinated and supported by resources and technology, the balance of the New Rural Cooperative Medical Scheme funds and to improve hospital management level and autonomy. [Conclusions] The structure of case-based payment system including system design, system implementation and required external environmental conditions. The core of system design is case grouping and pricing. Standardized management and strengthened supervision are primary in the process of institutional implementation. Technological process of case-based payment system:a. Divide the New Rural Cooperative Medical Scheme funds reasonably to coordinate various system and policies considering outpatient service, charge for diagnosis and treatment, essential drugs, critical illness, etc. b. Negotiate with medical institutions and specialists about the disease grouping and pricing, c. Define prerequisites, determine the implementation plan and establish management system. d. Monitor the implementation and the effects of case-based payment to continuously improve the system. The required external conditions to implement a case-based payment system:a. Government decision-making is primary for the implementation of case-based payment system, b. Improving the level of hospital service is crucial and the following aspects really concerns, such as reforming health service system, strengthening the construction of county hospitals especially the township health institutions, implementing the director responsibility system in health institutions, improving the financial management system and promoting institutional cost accounting, c. Giving full play to the initiative of medical insurance institutions is also important, for example, to establish negotiation mechanisms between health care providers and the purchaser, to strengthen the regulation of case-based payment system, to establish a system of rewards and punishment and to improve the management level of medical insurance institutions. Subsequent research:to perfect the health information system, implement clinical pathways and improve the autonomy of health providers.[Innovations] Build a structural model of case-based payment system under the New Rural Cooperative Medical Scheme, which provide guidance and reference for designing and completing the local case-based payment system. Summarize the strategic paths to case-based payment system under the New Rural Cooperative Medical Scheme. The core in designing a case-based payment system is case grouping and pricing. This research has explored the ways to cover all the diseases and hospitals within the county by way of quotas, ceilings and exceptions according to the clinical rules and cost distribution. In order to guide reasonable behavior of health care providers as well as doctors, normative management systems and monitoring mechanisms have been innovated and improved. Monitoring mechanisms and monitoring index systems have been set up.[Limitations] Limitation of theoretical research. The data of theory research was mainly from literature, which may have been restricted by information accessibility, especially in low-income countries. Limitation of the empirical part. This study did not implement the path of case-based payment system for feasibility test because of some external reasons and the Guangxi Zhuang Autonomous Region did not practice the case-based payment reform scheme. The path is remains only in theory or at the policy level, which is to say whether it is feasible and how well it works are to be practical. Limitation of the study time period. Rural areas in China are experiencing a deeper reform of medical and health care system and these reforms directly or indirectly affect the formulation or the environment of case-based payment, which needs further research. Limitation of the study methods. Because of the influence of confounding factors, it is difficult to distinguish the single factor of case-based payment influencing medical costs, hospital volume and medical service quality.