2004～2006 Medical Costs Analysis Of Urban Workers Basic Medical Insurance Outpatient Special Disease In Fujian Province

For adapting to the demand of socialist market economic system, protecting the Urban Workers Basic Medical Insurance (BMI) needs, our government began to gradually establish BMI system referring to individual Medisave in Singapore. This is a fund operation mode that combines medical insurance Personal Account with Social Pooling Account. Personal Account is mainly used for the medical insurance cost of drugstore and outpatient, Social Pooling Account is mainly used for the medical insurance cost of inpatient.With the further development of the system reform, it has gradually exposed the intrinsic flaw in the actual operation: the contradiction between high outpatient personnel medical costs with the Personal Account fund is insufficient payment. It has protruded gradually the problem that increase the outpatient medical costs burden of the sick.Therefore, most areas which have carried out the policy of BMI, took part of the outpatient treatment costs or related project costs integrate to Social Pooling Account fund payment scopes, which formed the special policy in the BMI system according to actual needs. As a"New emerging thing", the special disease costs disbursement increased the Fund's operating risk. It has some characteristics as follows: the largest proportion of Social Pooling Account fund payment expenditure and the high elasticity of demand. Therefore, it is the necessary to make the research in outpatient medical costs and its influencing factors. Therefore we have to seek the effective management mechanism to guarantee the safe operation of the Fund and the balance of revenues and expenditures.This research selects all outpatient medical costs records of the special disease as the object of study, which were insured under the provincial unit from 2004 to 2006 years in the Fujian Province. This study mainly analyzes the constitution, the distribution, the flow and the major effecting factors, and the effecting factors extent of outpatient special disease medical expense. We can provide the data support to the health insurance management department in order to control expense payment, and for other regions who carried out special disease policy to provide some kind of reference and put forward some feasible policy proposal, at the same time, explore how to strengthen the hospital outpatient special disease management to take the initiative to comply with the BMI system reform requirements.The research uses qualitative and quantitative research methods to collect and analyze the data. The major method is the quantitative analysis by SPSS13.0which includes the basic statistics description, the single factor analysis method, the multiple linear stepwise regression method.Main founding of this study include: 1) Outpatients amount,visiting times and total medical costs of men are significantly higher than that of women. 2) The state-owned units and institutions occupy more than 80% of the total visiting times, over the age of 60 accounted for 60.53 % of the number of visiting times. Compared to the number of the Incumbency, outpatients amount,visiting times and total medical costs of the retirees accounted for a higher proportion. 3) The Hypertension,Diabetes Mellitus and Radio-Chemotherapy for Malignant Tumor occupy total outpatient visiting times 87.40%, total medical costs 80%. In specific disease, average annual costs growth of the Aplastic Anemia is the fastest, reaches 145.32%; average annual visiting frequency rise of the Schizophrenia is the quickest. The total medical costs and visiting times of the Pulmonary Tuberculosis is the negative growth tendency. The highest and lowest average annual costs of visiting times are the Organ Transplantation Anti-Rejection therapy and the Hypertension. The fastest average annual per visiting costs is the Aplastic Anemia. The highest average annual per person costs is Organ Transplantation Anti-Rejection therapy. The fastest growth of annual average per person costs is the Aplastic Anemia, reaches as high as 73.47%. 4)The influencing factors of the outpatient special disease service expenses have mainly sex,age,type of insured units,the base payment standards of wages,different visiting years,the in-service status,the enjoyment of the official medical service subsidy,the hospital rank,visiting times and the drugs proportion of the total costs. In the different year, visiting times,the drugs proportion of the total costs,age and sex are the common influencing factors for outpatient special disease total medical costs. In the different the hospital rank, the high rank hospital accounts for high proportion of the total medical costs, the average annual per person costs and the average annual per visiting costs are the higtest. Annual visiting times and annual visiting numbers are the highest. Visiting times and the drugs proportion of the total costs are the common influencing factors for outpatient special disease total medical costs.5) In this research, the costs of major expenditure payment way is the risk-pooling fund disbursement primarily, next for the individual cash disbursement and the individual account disbursement.6) In this research, the drugs costs (western medicine, traditional Chinese medicine) occupy the vast majority of the outpatient special disease total costs. The first three costs constitutions of the different diseases medical costs constitutes are different, but the drugs is a common factor.7) The special disease costs flow: as a whole, the special disease,outpatients numbers,visiting times and costs have the central tendency which flow to tertiary hospital and first-level hospital. In special disease, the Organ Transplantation Anti-Rejection therapy completely flows to tertiary hospital in 2006. The outpatient medical costs and outpatient numbers of Aplastic Anemia has declining trend in the first-level hospital and centrally flows to the tertiary hospital.Conclusions: The Urban Workers Basic Medical Insurance outpatient special disease policy is constituted and promulgated, which reduced most of insured personnel's outpatient disease economic burdens that have serious diseases and chronic illness, and enhanced the outpatient basic medical service degree of protection. The special disease costs disbursement is an important influencing factor that affects the funds safe operation, it should be emphasized to the research and formulated effectively policy of expenditure control to protect the fund effective and safe operation.Policy implications include: 1) To strengthen the outpatient special management and adopt the single-type disease norm payment method. 2)To pay attention to primary hospital construction, regulate Two-way Referral System. 3)"Rational drug use, Total Amount Control"principle should be applied for the outpatient special disease medical drugs costs control. 4) The health management concept should be advocated. 5) To strengthen community-based 3 level comprehensive prevention and treatment policy. 6) The medical institutions should strengthen the self-building to take initiative to adapt the medical insurance reform requirements.