The Impact Of Outpatient Pooling With Chronic Diseases On The Expenditure Of Medical Insurance Fund Of Basic Medical Insurance For Urban Employees

The incidence of chronic non-communicable diseases in China has increased rapidly,becoming the number one health threat to the residents of our country.The expenditure of medical expenses for chronic diseases has been rising continuously,accounting for more than 70% of the total expenditure of medical expenses in China,and the cost of routine outpatient treatment has become an important factor in poverty caused by illness in China.Although China has established a high-quality universal medical security system,the security mechanism specifically designed to disperse the economic risks caused by chronic diseases is not perfect.In particular,the basic medical insurance for urban employees implements a unified accounting model and uses outpatient treatment for a large number of chronic diseases.Under the circumstances,the individual account with the nature of savings does not play a good role in mutual assistance.Under the concept of value medical care,how to improve the efficiency and value of the medical insurance fund in the prevention and treatment of chronic diseases,to achieve the purpose of prevention and treatment of chronic diseases,improve or maintain the health status of patients with chronic diseases,and to control the expenditure of medical insurance funds,undoubtedly have very great theoretical value and practical significance.Many studies have proposed that individual accounts should be reformed to implement outpatient coordination,enhance the mutual assistance of basic medical insurance,and improve the protection of patients with chronic diseases;some studies have pointed out that the establishment of individual accounts is conducive to avoiding moral hazard,and outpatient pooling is bound to distorted patient behavior,and lead to over-medical treatment.Should the costs of outpatient for chronic diseases for urban employees be covered by the pooling fund? This is the first question raised in this article.If the outpatient pooling policy with chronic diseases for urban employee is implemented,which means reducing the outpatient price paid by patients,three phenomena may occur: Firstly,due to cross-price elasticity,patients who originally chose inpatient treatment may turn to outpatient treatment,and outpatient services may replace inpatient services.It is equivalent to replacing the large funds in hospitals with small fund expenditures in outpatient clinics.It points out that the total expenditure of the current medical insurance fund is reduced.Secondly,due to its own price elasticity,patients with chronic diseases who have delayed treatment due to economic constraints choose to seek medical treatment in time,releasing normal outpatient clinics The demand for medical treatment,the release of this demand can lead to changes in the patient’s health outcomes,that is,reduce the incidence of later complications and reduce the large fund expenditures brought about by future complications,which is equivalent to replacing the future large funds with small fund expenditures Expenditure reduces the total medical insurance fund expenditures in the time dimension.The third phenomenon is that due to the reduction of outpatient out-of-pocket prices,resulting in distorted patient behavior,outpatient services are overused,and unnecessary medical insurance fund expenditures increase.So,will the implementation of outpatient pooling policy with chronic diseases for urban employee improve the efficiency of the use of medical insurance funds and save fund expenditures;or will it cause excessive use of outpatient services,increase moral hazards,and increase medical insurance fund expenditures? This is the second question raised in this article.If the outpatient pooling policy with chronic diseases for urban employees will have an impact on the expenditure of the medical insurance fund,is this effect achieved through the above-mentioned changes in the behaviors of patients in the use of medical service to reduce the incidence of complications? That is,what is the mechanism of this effect? This is the third question raised in this article.In order to answer the above questions,this paper analyzes outpatient pooling policy for chronic diseases of urban employees,examines its effect on the total expenditure and expenditure structure of the medical insurance fund,and analyzes the short-term and long-term effect of the outpatient pooling policy for chronic diseases on the medical insurance fund expenditure.That is,the overall effect and structural effect on the expenditure of medical insurance funds by changing the utilization of patients’ medical services and reducing the incidence of chronic disease complications.Specifically,this paper first constructs a theoretical analysis framework for the effect and mechanism of chronic disease outpatient pooling on the medical insurance fund,proposes the theoretical basis for chronic disease outpatient medical expenses to be paid by the pool fund,and proposes that outpatient pooling for chronic disease may replace inpatient services through outpatient services,which is named short-term effect,and reduce the incidence of chronic disease complications,which is named long-term effect,thereby reducing the hospitalization fund expenditure and the total expenditure of the medical insurance fund.Using the 2013～2017 "Basic Medical Insurance Participants Medical Service Utilization Survey" and the corresponding regional chronic disease outpatient pooling policy relevant data,empirically verify the above-mentioned effects and mechanisms,and comprehensively analyzes the overall effect,structural effect and internal mechanism of the outpatient pooling for chronic diseases on medical insurance fund expenditures.In response to the first question,on the basis of clarifying related concepts,starting from the coverage of China’s basic medical insurance,this paper analyzes medical insurance should be “insured big disease”,should not be "insured minor illness" from the perspectives of insurance and transaction costs and patient moral hazard.Secondly,this paper analyzes the chronic disease trajectory framework and the characteristics of patients’ medical behaviors,and concludes that chronic diseases are “big diseases” in outpatient clinics.Combined with the analysis of the coverage of basic medical insurance,the theoretical basis for chronic disease medical expenses to be included in the pooling fund payment is provided.In response to the second question,on the basis of the existing literature and the current status of China’s current outpatient pooling policies for chronic disease,this paper proposes that outpatient pooling policy for chronic disease of urban employees will reduce medical fund expenditures through two ways.On the one hand,through the substitution of outpatient services for inpatient services and small outpatient expenditures substitute large hospitalizations,the policy will reduce the fund expenditures.On the other hand,by guiding patients with early chronic diseases to use outpatient services for treatment to reduce the incidence of later complications,small expenditures in the current period can replace large expenditures in the future,thereby changing the structure of fund expenditures and reducing fund expenditures.This paper describes the general situation of urban employee basic medical insurance fund expenditure,and analyzes the difference of fund expenditure under different chronic disease outpatient co-ordination policies.With the help of econometric tools,this paper empirically analyzes whether the outpatient pooling policy for chronic disease of urban employees is implemented,the number of diseases included and the implementation time on the current fund balance rate and inpatient fund expenditure of the urban employees medical insurance fund,and tests the robustness of the regression results by using instrumental variable and replacement explanatory variable,and analyzes the differences in the impact of the chronic disease outpatient pooling policies on fund expenditures in different regions and different pooling unit types.In response to the third question,from the perspective of demand price elasticity theory and value-based healthcare,this paper analyzes the rationality of the outpatient pooling policy for chronic disease of urban employee affects the utilization of patient medical services,improves the patient health,and reduces the incidence of complications.Using econometric models,this paper empirically tests the two possible influence paths proposed by the theory,namely short-term effect and long-term effect,to test the mechanism of the impact of outpatient pooling for chronic disease on fund expenditures.Through theoretical and empirical analysis,the following main conclusions are obtained in this paper:First,from the perspective of insurance and transaction costs and patient moral hazard,based on the chronic disease trajectory framework theory and the characteristics of patients’ medical behavior,outpatient expenses for chronic disease should be included in the pooling fund payment.Second,the implementation of outpatient pooling policy for chronic disease can significantly increase the current fund balance rate and reduce the expenditures of inpatient fund,and control the excessive growth of fund expenditures in total.Specifically,the implementation of the outpatient pooling policy for chronic disease will significantly reduce the expenditure of inpatient fund by 23.3%,and the fund balance rate will increase by 2.8%.Third,there are obvious difference of regional and pooling unit types in the effect of outpatient pooling for chronic disease on the total expenditure and structure of medical insurance funds.The effect in western regions is greater than that in the eastern regions;and which in provincial medical insurance is greater than non-provincial medical insurance.Fourth,the outpatient pooling policy for chronic disease of urban employees is heterogeneity in the effect of controlling the expenditure of medical insurance funds for different diseases.In terms of disease types,the inclusion of malignant tumor radiotherapy and chemotherapy,blood/renal dialysis and hypertension in the policy will have a better effect on the control of inpatient fund expenditure.Fifth,the outpatient pooling for chronic disease policy can affect the total expenditure and structure of medical insurance funds through short-term and long-term effects.Firstly,to change the utilization of patient medical services,significantly reduce the number of inpatient visits,increase the number of outpatient visits and the total number of medical services,and achieve outpatient services substitution for inpatient services.Secondly,to guide patients with potentially critical chronic diseases to seek medical treatment as soon as possible to reduce the occurrence of chronic disease complications.The longer the policy is implemented and the longer the inclusion period,the lower the incidence of hypertension and diabetes complications.Sixth,the effect mechanism of outpatient pooling for chronic disease on the expenditure of medical insurance funds is different for different types of chronic diseases.For chronic critical diseases,it mainly affects fund expenditures by changing the utilization of medical services;for potential chronic critical diseases,it focuses more on guiding patients who have delayed treatment due to economic constraints to early treatment,reducing the incidence of chronic diseases,thereby saving medical costs and funds expenditure.Based on the above research conclusions,this paper puts forward four policy recommendations: first,weaken individual accounts,establish and improve the outpatient pooling protection mechanism of chronic disease;second,accurately evaluate the inclusion of chronic disease,and give priority to chronic critical diseases and potential chronic critical diseases;third,pay attention to the health management of chronic diseases,and realize value-based healthcare;and fourthly,improve the quality of outpatient medical services for chronic disease,reform the payment method of the outpatient chronic disease pooling fund,and guide patients with chronic diseases to seek medical treatment at the grassroots level.Through the above research,the novelty of this article is mainly reflected in the following:First,classify chronic diseases from the two-dimensional perspective of medicine and medical insurance.Based on the research results of medicine and nursing,this paper takes chronic diseases as a dynamic development process,tries to classify chronic diseases,and links their development and transfer with public health projects and basic medical insurance projects.Second,introduce the concept of value-based healthcare to analyze the impact mechanism of outpatient pooling for chronic disease on the expenditure of medical insurance funds.The concept of value-based health in this paper is embodied in two aspects: first,it proposes the subsitition of outpatient services on inpatient services,which not only reduces the waste of medical insurance funds,but also reduces the burden of care for patients and their families due to hospitalization;second,it puts forward that timely treatment of chronic diseases can reduce complications,reduce the probability of future emergency and inpatient,improve the health of patients,and reduce the expenditures of future fund.Third,the long-term effect of outpatient pooling for chronic disease on the medical insurance fund expenditure is proposed.This paper finds that patients with chronic diseases have the characteristics of delayed treatment,and proposes that the implementation of the outpatient pooling policy for chronic disease relaxes the economic constraints of patients,improves the compliance and initiative of patients with chronic diseases,thereby reducing the incidence of chronic disease complications,and reducing the frequency of future emergency and inpatient visits.And probability,and enrich the results of the research on the mechanism of the effect of outpatient pooling for chronic disease on the expenditure of medical insurance funds.