Changes Of Hospitalization Expenses Under The Fixed Quotas Settlement And Its Influence Factors

BackgroundCurrently,the settlement of the hospitalization expenses in most planned areas of our country is mainly the Fixed Quotas Settlement.Fixed Quotas Settlement is also called payment on the basis of average expense or service unit,i.e.,based on the historical data,the medical insurance sector signs agreement with the fixed hospitals on the payment standard,and then settles the account on the basis of actual average expense of the hospital and the payment standard in a fixed period of time.If the actual average expense is lower than the standard,settlement will be made based on the actual expense;if higher,first based on the fixed quotas,and the extra part will be settled both by the hospital and the insurance sector with a certain proposition.The advantage of this means of settlement lies in the easy operation and a low demand of management.It can actively stint the supply side,effectively control the costs,and would not affect the treatment quality by a rational standard.Its disadvantage is that some necessary services might be cut down,especially under a less rational standard, to reduce the settlement risks.The payment means of medical service would influence the medical treatment of the medical service supplier,and distinctly steer and condition the cost control,resource collocation,medical quality as well as the efficiency and equality in medical service.Research on changes of hospitalization expenses under the Fixed Quotas Settlement and its influence factors is the common concern of both medical insurance sector and medical institution.MethodsThis research is base on the case study of 13895 patients with medical insurance who were out of a 3-level comprehensive hospital from 2003 to 2006.Analysis is made on the changes of the patients' medical costs and constitutes of payment.According to ICD-9,the first 10 systematic diseases of the hospitalized patients are chosen as the cases,including:tumor,circulatory diseases,digestive diseases,nervous and sense organ diseases,urogenital diseases,respiratory diseases, endocrine,nutritional and metabolic diseases and immunity illness,trauma and toxicosis,muscle,bones and connective tissue diseases as well as some undefined symptom(diseases with unknown reasons),altogether 10900 cases,covering 78.4% of the recovered patients with medical insurance in the whole year.Statistic analysis would also be made on payment distribution of the first 10 systematic diseases and its influence factors,as well as research on means of costs settlement,hoping to offer evidence for establishing rational pattern of cost settlement.ResearchⅠ:Changes of Hospital's Medical Payment under the Fixed Quotas SettlementResult:①Comparison of the hospitalization expenses of patients with medical insurance in different years suggests that from 2003 to 2005,the average expenses of those patients has increased year after year.In 2006,the increase got control and the average expenses decreased,lower than 1226 yuan in 2005.The statistic analysis result of each year suggests that all the group differences have great statistic significance(p＜0.001) except that between 2004 and 2005(p＞0.05).②Comparison of medical insurance patients' average hospitalization expense and its constituents with different means of payment in different years suggests that the expenses has gradually increased from 2003 to 2005 and it decreased 341 yuan from 2005 to 2006, similar with medical insurance payment.The statistic analysis result of each year suggests that compared with 2005(p＜0.001),there is a clear difference of the patient's payment and medical insurance payment in 2006(p＜0.005).The main reason of patient's payment decrease in 2006 is the decrease of payment on self-payment items,i.e.,the payment on one's own decreased 567 yuan than that of the previous year,accounting for 3.0%of the decrease of hospitalization expenses. The scope of medical insurance items that patients used increased,i.e.,self-payment increased 216 yuan and the patient's subsection payment increased 10 yuan.③Hospitalization expenses distribution of medical insurance patients in different years suggests that the average medicine and treatment costs in 2006 is lower than that in 2005 and 2004,the increasing trend getting control.Compared with 2005,the average hospitalization expenses in 2006 decreased 1227 yuan,including medicine cost 815 yuan(66.4%) and diagnosis cost 412 yuan(33.6%)..ResearchⅡ:Distribution of Medical Payment on the First 10 Systematic Diseases of the Hospitalized PatientsResult:①Result of statistic basic analysis suggests that the first 10 systematic diseases are altogether 10900 cases,including 1640 cases in 2003(15.0%),2680 case in 2004(24.6%),3099 cases in 2005(28.4%) and 3481 cases in 2006(32.0%).The male-patient cases cover 51.3%while female 48.7%.The average age of the patients is 58.6±32.8.②The distribution of overall hospitalization expenses of the first l0 systematic diseases suggests that the expenses of each systematic diseases change in a wide scope(p＜0.001),showing the probability distribution of the medical payment side of normal.Square chart of overall hospitalization expenses of the first 10 systematic diseases shows that the probability distribution of the medical payment side of normal.③Box chart of medical payment of the first 10 systematic diseases shows that strange and extreme values exist in the payment on each systematic disease.According to statistic data,the percentage of high-cost patients' payment covering 5%of each system differs among the hospitalization expenses of the whole system,with the highest 29.9%the lowest 21.5%,the average 25.2%.ResearchⅢ:Influence Factors of the Medical Payment on the First 10 Systematic Diseases of the Hospitalized PatientsResult:①.Result of statistic basic analysis suggests that the first 10 systematic diseases are altogether 13472 cases,including 1962 cases in 2003(14.6%),3250 case in 2004(24.1%),3836 cases in 2005(28.5%) and 4424 cases in 2006(32.8%).The male-patient cases cover 52.3%while female 47.7%.The average age of the patients is 58.6±32.8.②.Result of multivariate regression analysis of the first 10 systematic diseases suggests that the factors influencing the payment include not only the patient's clinical manifestation,such as operation,degree of seriousness, complication,etc,but also his sociological features,such as age.In clinical factors, degree of seriousness,means of treatment,complication and emergency treatment are the main points influencing the hospitalization expense.Analysis result of each systematic disease suggests that the expense of the operation patient is higher than that of non-operation ones and those with complication higher than that without complication;analysis result of partly systematic disease shows that the expense of seriously hospitalized patients is higher than that of normal ones and those with emergency treatments higher than that without such treatments.In sociological features,age is the main point;the expense of an older patient is higher than that of a younger one.Conclusion1.Fixed Quotas Settlement influences the hospitalization expense.Statistic data shows that adopting the first one can make the increase of hospitalization expense on average medical-insurance patient under control,the medicine and treatment cost decrease,easing the patient's burden.2.The distributions of disease medical expenses have their specific.Our data demonstrated that the hospitalized medical payment was the side of normal.The box chart of medical payment of the first 10 systematic diseases presented that strange and extreme values existed in the payment on each systematic disease.According to statistic data,the percentage of high-cost patients' payment covering 5%of each system differs among the hospitalization expenses of the whole system,with the highest 29.9%the lowest 21.5%,the average 25.2%.3.Hospitalization expense is influenced by many factors at the same time.The influence factors of hospitalization expense can be divided into controllable and uncontrollable factors.Controllable factors often refer to those which can be controlled by necessary methods in the medical service system itself,including check, treatment,means of payment,number of hospitalized days.The control of irrational increase of medical payment should start with the controllable factors.By regulating process of diagnosis and treatment,unnecessary medical services can be eliminated, thus cost can be under control.Uncontrollable factors refer to those influence factors on medical expense level outside of the medical service system,including age of patient,diagnosis,seriousness of disease,complication,etc.It is hard to adopt necessary methods to control them in the medical service system itself.They are the objective index of the patient's seriousness level and the important criterion of the necessary intensity of medical service.They can also prompt that the old patients and serious patients are more likely to face the death or the loss of physiological functions, needing more forceful medical intervention and more medical resources.Payment compensation upon the fixed hospitals which treat patients with serious illness reflected in settlement mechanism would impose important realistic significance on establishing equal and efficient compensation mechanism of medical payment.So we have some suggestionsThe first,the standard of medical fixed quotas payment should be based on the distribution character of medical payment on disease.The research data shows that the hospitalization medical expense is in abnormal distribution.Because of high extreme values and standard values,the data changes in a wide scope,causing many strange values,which exerts some influences on the expense of each patient.(The medical sector has eliminated the patients under the basic payment line in settlement). To some degree,the strange value reflects the character of the disease's rise and development as well as the medical institution's usage intensity on medical resources.The second,many influence factors on payment should be taken into consideration when medical sector establishes the fixed quotas standard and compensation scope of medical expenses.The American DRGs can be implied as the reference,the basic line of average case expense should be based on the average number of case in that area during the past 3 years and the expense rate should be established in light of the hospital's condition,allowing 5%"outline cases".The medical insurance sector or a third part can organize experts to check out those "outline cases" and then decide the payment standard and the sum.As the basis of compensation payment of out-of-hospital cases,DRGs has become the only case group scheme on medical insurance payment in America during the past 20 years.In view of its outstanding effect in continuous improvement of medical quality and control of cost,many countries are making research on it and carrying it into practice.The last,the practice of the medical fixed quotas payment mode should be the combining endeavour both the hospital and medical insurance.Based on the scientific and reasonable standard of fixed quotas payment,the hospital decrease the medical expenses and improve the efficiency by strengthening of management,shortening duration of hospitalization,and establishing of average hospitalization expenses for medical insurance patients.As some as the medical insurance department should set up the corresponding policy,such as to work out the service platform of community public health,and to develop the family practice,so those old patients,chronic diseases and late stage tumor cases may shorten the duration of hospitalization, control the medical expenses and have enough medical care as well.