| Since 1990s, the basic health insurance system has been primarily built up all over the country. Up to the end of 2010, the employee's basic health insurance system (EBHIS) has 237.34 million insurants, and the urban resident basic health insurance system (RBHIS) has 194.72 million insurants. Up to the end of 2009, the new cooperative medical scheme (NCMS) has 0.83 billion insurants, and the coverage rate is 94%. Calculated on the base of these data, the coverage rate of the basic health insurance systems is about 94% in China.Since the pilot of RBHIS in 2007, it has spread fast and got reception of the residents. But there were still some problems:firstly, the financing. The governmental average subsidies occupied 41% of the total premium in the pilot cities, but whether it was sustainable and whether it was affordable to the residents were in doubt. Secondly, the reimbursing rate. The average reimbursing rate of inpatient costs was 34.39%, and of outpatient costs was 23.97%, which was even lower than that of the NCMS.From the world wide perspective, there are two kinds of types of health insurance for residents:firstly, the dependents affiliated to the employees can get the coverage of health insurance automatically. They don't need to pay the premium. These countries include Germany, France, and Japan etc. secondly, establishing special health insurance system for non-income residents under the governmental subsidies, such as Korea, Thailand etc. The US also established Medicare and Medicaid to cover the elderly over 65 and poor residents. The former free medical system and labor insurance system covered the dependents in China. But since the reform of EBHIS, they were excluded from the system. So, it is necessary to establish a new health insurance for the non-income residents, who are the dependents of the employees mostly. The RBHIS was implemented in Shanhgai in January 1,2008, which covered the infants, students, handicapped people, the unemployed, and the elderly over 60 etc. It has 1.88 million insurants up to now. As a whole, the RBHIS ran very well, though there were still some problems, such as the budget unbalancing, some resident still uncovered, the too low financing level, simple reimbursing mechanism, and the gap between rural and urban etc. This research was aimed at these questions, trying to find good measures to solve them and providing a reform scheme for the health insurance administration of Shanghai.?Objectives?The paper will analyze the practice of RBHIS from 2008 to 2009 in shanghai. On the base of that, it will evaluate the policy, including estimating the effects, defining the problems in the process. Then, according to the evaluation, it will probe the situation, including the coverage of RBHIS, the utilization of health services of insurants, the cost increase and affecting factors, the premium and its sources, the reimbursing mechanism etc., and try to find the roots and mechanism of the problems. Finally, it will raise some suggestions to extend the coverage, contain the cost increase, stabilize the sources of premium, and revise the reimbursing mechanism.Detailed objectives are as follows:1. The primary evaluation of the implementing process of RBHIS in Shanghai.2. The analysis of coverage and measures to extend the coverage of RBHIS.3. Analysis of utilization of health services and affecting factors of the costs.4. Calculation and forecast of premium and the feasible financing measures.5. Modeling calculation and comparison of reimbursement mechanism.6. Policy suggestions to the further reform of RBHIS in Shanghai.?Date sources?1. The running database of RBHIS of Shanghai. We gathered the running data base of RBHIS of 2008 and 2009 from Shanghai Health Insurance Office, including the data of detailed record of inpatient, outpatient medical services of insurants in different hospitals, and the data of reimbursement by health insurance funds.2. The registration database and the financial report form of RBHIS of Shanghai. We gathered the registration database of 2008 and 2009 from Shanghai health insurance affair center, which including the identity, characters, premium types etc. we also gathered the financial report form to analyze the income and outgo of the funds.3. The statistical data of shanghai EBHIS. We gathered the statistical yearly book, yearly report, and other statistical data of EBHIS of Shanghai from the administration department.4. Literature search and public statistical data. We gathered the information of RBHIS of many cities of China, including the coverage, financing, reimbursement etc. We also gathered many statistical yearly books of Shanghai and China to apply them second times.5. Interview (or Focus group interview) information of key persons. We interviewed many insurants, and some health insurance managers, hospital directors, and leaders of health insurance administration, to know their viewpoints to RBHIS.[Methodology]1. Health policy analyzing methods.According to the macro model of health policy analysis, and the guideline of policy making procedure, the logic steps of the research includes the evaluating, the root analysis of problems, designing of feasible scheme.2. Statistical and economical methods.The first is the bio-statistics method. Using SAS 9.1?PASW statistics 18.0?EXCEL2003 and other statistic software, it counts many heath services and health insurance index between different groups, times and surroundings. The second is the method of sequencing substitution. It can analyze the degree of affecting factors of outpatient costs, inpatient costs and total costs of RBHIS. The thirdly is the time sequence forecasting method. By using the time sequence model, we can forecast the increasing rate of total costs, then to calculate the premium of RBHIS in 2011.3. Health insurance methods.The research used some special health insurance methods, such as premium calculation, which is used to calculate the premium in different insurance factors, to design and select the reimbursing scheme with index comparison etc.4. Social research methods.The first is the evaluation framework of "structure-Process-outcome" by Avedis Donabedian's. It was used to calculate the RBHIS from structure, process and outcome perspectives. Secondly, PETS analysis, which was used to analyze the feasibility of reform scheme from political, economical, technical and social perspectives.5. Experts consultation.By consulting some experts of health insurance and health services, it can get suggestions to resolve the policy problems.?Results?1. The general evaluation of RBHIS in Shanghai(1) It has a wide coverage and has unified the benefit of the urban and rural students. All the residents with Shanghai urban identity can attend RBHIS if they don't have other health insurance. All the infants and students, whether they live in rural or urban area, are covered by RBHIS, so they can get unified benefit.(2) Residents attend RBHIS actively due to the high subsidies of finance. In the total premium,30% is contributed by insurants themselves, and 70% is contributed by the governmental finance. All the insurants can get the subsidies, and poor people can get more. Furthermore, some social funds also contribute to the premium of poor people and handicapped. So, residents attend RBHIS actively.(3) The benefit is suitable which includes inpatient and outpatient reimbursement. Insurants enjoy different benefits according to their age layers. Generally,50?70% of the inpatient costs and 50?60% of the outpatient costs can be reimbursed. The benefit is higher than that of the older free medical system and labor insurance system.(4) It is convenient for the insurants to pay premium and get reimbursement. The insurants can pay the premium in school or in community which is very convenient. Insurants can get instant reimbursement by using a health insurance card when they go to see a doctor or go to the hospital.(5) Most of the insurants are satisfied with RBHIS. According to the survey in 79 pilot cities, about 68% of the insurants are satisfied with RBHIS. According to the interview in the community in Shanghai, most of the insurants are satisfied with RBHIS in Shanghai.(6) There are still some problems to resolve. It includes the budget unbalancing, some resident still uncovered, the too low financing level, simple reimbursing mechanism, etc. 2. The general coverage of RBHIS(1) The insurants show obvious characteristics. The average age is 18.3 years old in 2009, which has a right and sharp distribution. The proportion of male and female is 1:1.08. Most of the insurants are between 0 and 20. The average age of male is 16 years old, and that of female is 21 years old. Females are more than males in the insurants over 6o years old.(2) There is adverse selection in RBHIS.Because it is a kind of voluntary insurance, the RBHIS can not avoid the adverse selection, especially in the insurants between 19 and 60 years old. The hospitalization rate is 20.66% and the average yearly costs are?1561.60 Yuan for 19?60 years old insurants which are higher than that of the 60?70 years old insurants and more higher than that of the employees in the same age layer.(3) It is necessary and feasible to attend RBHIS for the immigrants'children in primary schools. From the perspective of the equalization of public services, the immigrants'children should be covered by RBHIS. It is feasible according to the practice of other provinces in China.3. The medical services utilization and the affecting factors of costs.(1) The medical services utilization is high and has a kind of tend of transferring to community hospitals. The average times of outpatient were 7.24 for insurants in 2009, which increased 31.04%. About 93.58% children between 0 and 6 years old went to see a doctor in 2009. The proportion of outpatient increased 5% in community hospitals.(2) All the index increased heavily, especially the average times of outpatient. The average outpatient costs are lower than that of the employees, but the increase rate is far higher. The total outpatient costs increase is due to various kinds of factors, but the average times of outpatient is the most important factors which contribute 55.34% to the increase.(3) The hospitalization rate is stable, and the main factor of the increase of total hospitalization costs is the average costs per time. The hospitalization rate is 8.89% in 2009, which increased only 9.35% than that of 2008. The increase of average costs per time contributed 64.08% to the total hospitalization costs.(4) The increase rate of total costs was very high, and the outpatient costs were the main reason. The total cost increased 48.06% in 2009 and the outpatient cost contributed 71.92% to the increase. So it was very important of containing the outpatients cost to decrease the increase rate of the total costs.4. The premium and financing sources of RBHIS.(1) It calculated the premium under different insurance factors. It calculated and forecasted the premium in 2011 under the different insurance factors of 0,5%,10%, 15% in 2010. the premium was?943 Yuan,?990yuan,?1038yuan,?1085 yuan respectively.(2) Brought forward four schemes of financing sources. They were:merging RBHIS and EBHIS; using the employee's personal medical saving account to pay the premium of dependents; setting premium according to the average income of residents; and resolving the imbalance by governmental subsidy. The recommended one was merging RBHIS and EBHIS.5. The design and comparison of different reimbursing mechanism.(1) Designing several reimbursing schemes. It discussed the parameters of deductible, medical saving account, co-payment, reimbursing ceiling and personal payment ceiling. Then, it designed six reimbursing schemes by the different combinations of the parameters.(2) Comparison and recommendation of the schemes. By computing the benefit rate, relative risk, and the degree of poverty because of disease etc., it compared the six schemes and recommended No.3 scheme, namely the deductible was fixed on Y300 Yuan, and the reimbursing rate was raised 5% on outpatient costs and 20% on hospitalization costs. This scheme can be adopted as the reform of RBHIS.[Conclusion and Recommendation]1. Widen the coverage by encouraging and constraint. The reimbursing rate of hospitalization should be linked to the registered years. It should be raised 1% per registered year, and the highest is 5%. The registered years of RBHIS could be transferred to that of EBHIS and the transferring proportion is 3:1. It should establish 3 month waiting period for the insurants who quit and then registered again.2. The children in primary school of the immigrants from rural areas should be allowed to attend RBHIS. Firstly, the immigrants from rural areas should attend the social insurance system of Shanghai. Secondly, when they had attended the social insurance system for more than 1 year, their children in primary school can attend RBHIS. Thirdly, when they had attended the social insurance system for more than 5 years, their children during 0-6 years old can attend RBHIS.3. Adopting the Globe Budget to contain the cost increase. According to the costs of RBHIS last year, we can get the basic budgets for each contracted hospital. We can forecast the increase rate of the costs based on the data of income etc. Then, we can compute the budget for each hospital in next year and assess their implementing effects.4. Enhancing the supervision of health services. Shanghai Health Insurance Office should strengthen the supervision to the hospitals, and increase the punishment to the illegal behavior. And, it should checkup the times and costs of inpatient and outpatient services of the insurants by computer software.5. Computing the more suitable premium and finding the right sources. According to the different insurance factors, the premium should be?943yuan,?990yuan,?1038yuan,?1085yuan in 2011. It suggested merging RBHIS and EBHIS, so the dependents of employees don't need to pay the premium anymore.6. Revising the reimbursing scheme. It suggested the deductible should be fixed on?300 Yuan, and the reimbursing rate could be raised 5% on outpatient costs and 20% on hospitalization costs. Though some low cost risk insurants would decrease their benefits, but the high cost risk insurants would get more benefits, which was better for justice.7. The health insurance should be merged gradually to realize universal coverage. EBHIS and RBHIS can be merged firstly. Then, the NCMS can be merged. After that, a universal health insurance system with unified premium, benefits and management will be established in Shanghai. |
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