Study On Pre-payment System Of Rural Cooperative Medical Care In Community Health Centers In Shanghai Suburbs

[OBJECTIVES AND BACKGROUND]The key issue in the new rural cooperative medical care is the balance between financing and payment. The fund balance guarantees the sustainable development of the rural cooperative medical care. The rationality of the payment system is very important to ensure the fund balance in the premise that the financing of rural cooperative medical care is relatively stable.1.67 million people participated in the new rural cooperative medical care in Shanghai suburbs in 2009. The per capita funding was￥560. The rapid rise in medical costs of the participating farmers brought great pressure to the cooperative medical fund in recent years. The total cost of outpatient was 1.074 billion RMB in 2009. It increased 80.06%(487 million RMB) compared with the year of 2006, whereas the increase in total funding was only 228 million RMB. The widely used Post-pay system in the cooperative medical care can not contain the rapid rise in medical costs effectively.The community health centers are the primary units of the rural health service network, the main carriers of the cooperative medical system and the important participators of the CMS management. According to the statistics, the medical service utilization in the community health centers and village clinics (community health service stations) account for 80% of the total outpatient service in rural cooperative medical care in Shanghai. The pre-payment system has been promoted in medical insurance in 2006, while the post-pay system was still implemented in the rural cooperative medical care. The management problems and unfairness will be produced by the coexistence of two different payment systems in the rural community health centers. The objective of this study is to explore the appropriate cooperative medical pre-payment system of the community health centers in order to promote the rational use of the cooperative medical fund and contain the rapid rise of medical costs.[CONTENTS AND METHODS]This study analyzed the status of the rural cooperative medical system in Shanghai suburbs and the trial effect of the pre-payment system in community health centers in Nanhui district.The core methods of materials are as following:1st:Collect the Statistics Yearbook, reports and other relevant information at home and abroad in recent years. 2nd:Investigate the satisfaction and effect assessment of the pre-payment system trial by the staff in the cooperative medical office and the community health centers in Nanhui district with questionnaires.3rd:Find out the effect, difficulty and problems in the implement of the pre-payment system through qualitative interviews with key insider. The interview objects include the director of the cooperative medical office and community health centers.[RESULTS]1. Cooperative medical system was improved continuously in ShanghaiThe cooperation medical coverage increased from 89.14% in 2006 to 96.29% in 2009. While the per capita premium increased, the proportion of individual payments decreased year after year. The financial investment from district government became the main source of funding. The service utilization structure of Cooperative medical care was reasonable. The outpatient services was centralized in the Village-level health facilities as the inpatient services was concentrated in the community health centers. On the other hand, the increases of outpatient visiting rate and average hospitalization expenses led to the fast-rising total medical expenditure so that the cooperative medical fund faced the risk of cost overrun.2. Medical costs increases has been controlled by pre-payment systemThe average outpatient expenses in Nanhui district was obviously higher than the average level of other areas and showed the upward trend in the opposite in 2007 and 2008. Through the trial of pre-payment system in the community health centers in 2009, the sharp decrease of the average outpatient expenses in Nanhui district showed that the pre-payment system can control the health care costs effectively.3. Trial of pre-payment system was approbated by all partiesThe survey results show that the cost-control effect of pre-payment system was approbated by all parties. The staff in community health facilities and cooperative medical offices satisfied with the effect of the pre-payment trial. They were also positive to promote the pre-payment system. Among them the directors of community health facilities and the staff of cooperative medical offices were relatively more positive than the medical staff.4. The funding should be allocated according to the capitation or service unit under the total prepaid amountCurrently, the cooperative medical system was still prepaid for the outpatient expenditure in the health facilities. The funding should be allocated according to the capitation or service unit under the total prepaid amount of all community health centers. In addition, the year-end flexible settlement, supervision, propaganda and supporting measures should be improved continuously.[RECOMMENDATIONS]1. Recommendations of outpatient pre-payment model in rural community health centers1.1 Calculation of total prepaid amountAccording to the principle of being supported by income, the outpatient prepaid amount should be determined by the year funding and the expenditure structure in recent years.Expendable outpatient fund of cooperative medical system =Year funding×(1-10%)×(1-5%)×Outpatient costs/Total costs last yearsTotal prepaid amount in community health centers =Expendable outpatient fund of cooperative medical system×Outpatient costs/Total costs by town- and village-level in recent years Among them the grant fund of serious illness account for 5%, as the medical risk fund of new rural cooperative medical care account for 10%.1.2 Calculation of the fund of each community health centerAfter the determination of the total prepaid amount in community health centers, the amount can be allocated to each community health center according to the capitation or the number of visits.1.2.1 Calculation by capitationGenerally speaking, the visiting place of participating people was relatively stable. Therefore, the total prepaid amount can be allocated to each community health center by the capitation due to the simplicity of services and controllability of costs.Amount in each town=Total prepaid amount/Number of total participating people X Number of participating people in each town1.2.2 Calculation by number of visitsAccording to the recent data on the utilization and expenditure of cooperative medical system in Shanghai, the increases of total outpatient expenditure was due to the fast-rising outpatient person times. Fee for service unit should be used for allocating the total prepaid amount objectively.Amount in each town=Total prepaid amount/Total outpatient visits×Outpatient visits in each townTotal outpatient visits=∑Number of participating people in each town×Outpatient visit rate in each town1.3 Establishment of elastic settlement indicators1.3.1 Elastic settlement indicators of Calculation by capitationAfter the calculation of total prepaid amount by capitation, elastic settlement should be carried out referring to the indicators of the per capita outpatient cost. The benchmark was the average per capita cost, than the upper and lower limits were determined proportionally.1.3.2 Elastic settlement indicators of Calculation by number of visitsThe settlement indicators of average visits were calculated on the basis of the growth estimate of average visits. The benchmark was the average outpatient cost, than the upper and lower limits were determined proportionally.1.4 Assessment and paymentExcept the establishment of elastic settlement indicators, the supervision and assessment also should be applied to give consideration to the cost control and utilization of the medical resource. The payment of health facilities and the rewards of the staff should be associated with the results of the assessment.2. Suggestions to improvet and promote the cooperative medical pre-payment system2.1 Enhance the funding level and rationalize the funding structure2.2 Update ideas among the management department and improve the management ability2.3 Strengthen the propaganda to medical staff and participating people; reduce the resistance of implementing the pre-payment system2.4 Establish the stage targets according to the actual situation and adjust the pre-payment method by phases2.5 Increase supporting measures...