| BackgroundNon-communicable diseases are the major issues of public health that affects national economic and social development and peoples’ health.During the reform process of Urban Employees Basic Medical Insurance and Urban and Rural Residents Basic Medical Insurance(URRBMI)in China,the medical costs of outpatient chronic diseases have been included in the payment scope of the medical insurance through the Outpatient Special Chronic Disease System(OSCDS),so as to ease the burden of chronic diseases,enhance the efficiency of medical insurance funds,and promote the sustainable development of Chinese medical insurance system.At present,the URRBMI is the social basic health insurance that has the biggest coverage in China.However,the OSCDS of URRBMI in China has several issues,such as the source of financing is limited,the design of payment methods is sloppy,and the effectiveness of payment methods needs to be improved.As one of the four core system elements of the medical insurance system,the payment method can directly influence the provider’s healthcare behavior,and then affect the implementation effect of the medical insurance policy.Regulating provider’s healthcare behavior is an important prerequisite to achieve the reform goal of payment method.However,at present,there are few relatively empirical researches about the impact of OSCDS payment methods of URRBMI on provider’s healthcare behaviors.It is urgent to carry out systematic research on the policy design of OSCDS payment methods of URRBMI in China,the impact of OSCDS payment methods on provider’s healthcare behaviors,and the influence pathways of OSCDS payment methods on provider’s healthcare behaviors,which are in order to optimize the design of the OSCDS payment methods and to provide scientific evidence for improving the implementation effect of OSCDS system.Objectives and ValuesBased on the systematic analysis of the design characteristics and the major problems of the OSCDS payment methods of URRBMI in China,this study takes the OSCDS payment methods of URRBMI in Shandong Province as an example,investigates the differences in healthcare-provision features of medical institution and doctors’ healthcare behaviors as well as influencing factors under the different OSCDS payment methods of URRBMI,and explores the influence pathways of the OSCDS payment methods on doctors’ healthcare behaviors,aiming to provide the basis for optimizing and perfecting the OSCDS payment methods of URRBMI.Design and MethodsUsing incomplete contract theory,principal-agent theory etc,as the theoretical basis,this study adopts a research design that combines cross-sectional and retrospective survey research,and uses qualitative and quantitative research methods to conduct the study according to the specific objectives of each research phase.Based on the main type of OSCDS payment methods of URRBMI in China,this study uses the judgement sampling method to select three cities in Shandong Province that implement global budget,capitation and mixed payment methods of OSCDS of URRBMI as the case cities for the study.The main collects and analyses methods of research data follow:(1)Policy combing method and policy text analysis.The policy combing method and policy text analysis were used to systematically comb the policies on OSCDS payment methods of URRBMI of different provinces in China and each city in Shandong Province,and to analysis the design features and major problems of the OSCDS payment methods and elements of URRBMI in China.(2)Key person interviews and focus group interviews.In each case city,key person interviews and focus group interviews were conducted with 25 relevant persons in charge of health insurance management departments,designated medical institutions at all levels 41 clinicians of 9 groups etc,to analysis the characteristics and basis of the design of different OSCDS payment methods,the existing problems,the impacts and influencing factors of the OSCDS payment methods on healthcare provision of medical institution through thematic framework approach.(3)OSCDS medical claim data of URRBMI.The local medical insurance claim data of OSCSD from 2016 to 2021 were collected,and the descriptive statistics was used to analyze the difference features of healthcare provision of medical institution under different OSCDS payment methods.(4)Questionnaire survey on for health insurance specialists and doctors.Through a questionnaire survey of 25 healthcare insurance experts,the impacts of the OSCDS payment methods on the healthcare provision were analyzed using decision laboratory analysis and explanatory structural modeling which are the research methods belong to the system science and system engineering.The key influencing factors of the healthcare provision of medical institution were systematically revealed,and the doctor survey questionnaire was developed based on the results.The survey questionnaire was distributed to 1055 doctors from various levels of designated medical institutions in different case cities,and the chi-square test were used to analyzed under different payment methods:doctors’ knowledge of the OSCDS payment policies,doctors’ knowledge of internal supervision and assessment policy in the OSCDS designated medical institution,risk factors for exceeding the OSCDS health insurance fund,and differences in the doctors’ healthcare behaviors of the OSCDS.While using a binary logit regression model to analysis the impact of different payment methods on the doctors’ healthcare behavior and influencing factors of doctors’healthcare behaviors.The Mediating Effect Model was used to explore the influence pathways of the OSCDS payment methods on doctors’ specific healthcare behaviors,and Structural Equation Modeling was used to explore the influence pathways of the OSCDS payment methods on doctors’multiple healthcare behaviors.Results(1)The design of OSCDS payment methods of URRBMI in China faces several issues,including the relatively limited payment methods,vague payment coverage,simplistic payment standards calculation,and unsound adjustment factors of risk.(2)There is a significant difference in the healthcare provision of medical institution of different OSCDS payment methods of URRBMI.Compared with the mixed payment methods,the lower level of OSCDS care provision and the higher growth rate of OSCDS medical costs are important features of the healthcare provision of global budget and capitation payment.During the period from 2016 to 2021,the average annual utilization per capita of OSCDS services under the global budget,capitation and mixed payment methods was 4.11,4.53 and 9.07,respectively;and the average annual growth rates of OSCDS medical-costs were 22.62%,28.50%and 19.40%,respectively.In addition,the expenditures proportion of OSCDS medical insurance fund under the capitation payment has the highest growth rate,averaging 0.88 percentage points per year.(3)The systematic impact pathway of healthcare provision of medical institution shows that the level of medical institutions,the actual cost of OSCDS services,the number and the accessibility basis of diseases are the key factors affecting the healthcare provision of medical institution.Among the many key influencing factors,the level of medical institutions and the actual cost of OSCDS services are the most important influencing factors,which have the greatest impact on the healthcare provision of medical institution and can affect healthcare provision of medical institution in the long term.Moreover,the level difference of medical institution may lead the difference healthcare provision of designated medical institution at all level.The number and accessibility basis of OSCDS diseases,as the effective underlying factors affecting the healthcare provision of medical institution,have an important moderating effect on the healthcare provision of medical institution.(4)There are different degrees of differences in doctors’ healthcare behaviors of medication service under different OSCDS payment methods of URRBMI.Controlling the proportion of medication costs in the total medical costs of OSCDS is the main doctors’healthcare behavior of medication service under different OSCDS payment methods;The frequency of doctors engaging in this behavior is highest under the per capita payment method,accounting for 62.50%(P<0.05).In terms of induced-demand and shirking behavior,it is recommended that doctors under different payment methods mainly induce patients with special chronic diseases to purchase drugs outside the hospital.The frequency of doctors engaging in this behavior is highest under the global budget,accounting for 48.22%(P<0.05).(5)The different OSCDS payment methods of URRBMI can significantly impact doctors’healthcare behavior.Compared with the doctors under the capita payment and mixed payment,the global budget can significantly increase the doctors’ ratio of controlling the number of reimburse examination of OSCDS(P<0.05).Moreover,compared to the tertiary and primary designated medical institution,the effect of OSCDS payment method on multiple doctors’healthcare behaviors in secondary designated medical institutions are more significant.Compared with the doctors of secondary medical institution under global budget,the capita payment and mixed payment can significantly decrease the ration of doctors’ controlling the proportion of medication costs in the total medical costs of the OSCDS and transferring the OSCDS patients purchasing medicines outside the hospital,respectively(P<0.05).In addition,elderly patients during the process of OSCDS care,doctors’ knowledge of OSCDS payment method policy,and hospital internal supervision and evaluation policy also have a significant effect on doctors’ healthcare behavior.(6)The OSCDS payment methods of URRBMI not only can directly doctors’ specific healthcare behavior,but also can indirectly influence doctors’specific healthcare behavior through doctors’ knowledge of the payment method policy and the knowledge of the hospital internal supervision and evaluation policy elements(P<0.05).The effects of OSCDS payment methods on multiple healthcare behavior of doctors,however,consisted of two pathways of action.First,the OSCDS payment method can have a direct effect on doctors’ induced-demand and shirking behavior;compared with global budget,capitation or mixed payment methods can significantly reduce the incidence of doctors’ induced-demand and shirking behavior(P<0.001).Secondly,the payment method has a unidirectional pathway of action on doctors’ medicine and examination of healthcare behavior;the OSCDS payment method directly affects doctors’knowledge of the payment method policy,which then sequentially affects doctors’ knowledge of the hospital internal supervision and assessment policy,the overspending risk on the health insurance fund,and ultimately,the overspending risk on the health insurance fund affects the doctors’ medicine and examination of healthcare behavior(P<0.05).In addition,doctors also mitigate the overspending risk of OSCDS health insurance fund by induced-demand and shirking behavior(P<0.05).Conclusions and ImplicationsConclusions:This study found that compared with global budget and capitation of OSCDS of URRBMI,the case cities that uses the mixed payment method has a relatively higher level of OSCDS service provision,a lower rate of growth in medical costs,a relatively more efficient expenditure of health insurance funds,and relatively more normative healthcare behaviors of doctors.The most important factors affecting healthcare provision of medical institution are the level of designated medical institutions and the actual service cost of OSCDS services.The designated medical institutions at all levels which lead the differences in the service capacity of and the actual service costs of OSCDS services have led to significant differences in the doctors’ healthcare behavior of designated medical institutions at all levels under the same OSCDS payment method.Beside the payment method,doctors’ healthcare behavior is also directly or indirectly affected by a variety of factors,such as the hospital internal distribution mechanism of the health insurance fund and the internal supervision and management mechanism of the OSCDS designated medical institutions,as well as the individual differences of the service recipients.In the absence of a scientific design for payment elements and an inadequate risk adjustment mechanism,policymakers have not yet been able to effectively regulate doctors’ healthcare behavior by merely changing the OSCDS payment method.Implications:(1)Promoting the reform of the mixed payment method OSCDS of URRBMI,to fully release the functional advantages of different payment methods,to fit the complexity of OSCDS care and promote the payment efficiency of health insurance fund;(2)Establishing a scientific and dynamic risk adjustment mechanism for the OSCDS payment standard of URRBMI,to compensate the actual cost of services of the designated healthcare institutions at all levels.Some economically developed regions may try to explore the separate payment mechanism for medicines-treatment of OSCDS,so as to alleviate the cost-control pressure of medical insurance medical institutions and ensure the healthcare provision of medical institution;(3)Based on the influence pathways of the OSCDS payment of URRBMI on the doctors’ healthcare behaviors,systematically optimizing the payment method supporting incentive and supervisory mechanisms,incentivizing medical institutions to carry out the refinement management of the medical insurance fund,and scientifically monitoring doctors’healthcare behaviors and evaluating the quality of services,so as to regulate the doctors’healthcare behaviors,and comprehensively ensure the implementation effect of the OSCDS payment of URRBMI.Innovations and LimitationsInnovations:(1)In response to the significant needs of the national medical insurance system reform,based on the complete view of the payment impacts on the providers’ healthcare provider,implement the relative research on the design of payment and payment elements of OSCDS of URRBMI,healthcare provision of medical institution and influence pathways of doctors’ healthcare behavior from macro,meso,and micro levels.It can provide reference bases for the establishment of outpatient expense co-ordination and payment mechanism of OSCDS,exploring the systematic evaluation framework of OSCDS payment methods;(2)Deeply explore the systematic pathways of the healthcare provision of medical institution,and the impact pathways of the payment methods’ effects on the doctors’ healthcare behaviors,which systematically reveal the key influence factors of healthcare provision of medical institution of OSCDS and doctors’ healthcare behavior.It can provide reform target for the policymaker systematically optimize the design of the OSCDS payment methods,and provide the empirical support for the further development of relevant research;(3)Drawing on the research methods of system science and system engineering,analyze the systematic impact pathways of the healthcare provision of medical institution.To some extent,this approach overcomes the limitations of quantifying payment methods and policy elements,enriching the application of relevant methodologies.Limitations:The results of this study need further validation and generalization on a larger scale.Given the ongoing reforms in national payment methods and the complex diversity of factors influencing doctors’ healthcare behavior,long-term tracking studies are needed to explore the net effects of influence pathways of payment methods and influence factors on the doctors’ healthcare behavior. |
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