Effect Of NCMS Outpatient Capitation Payment Reform On Prescribing Behavior Of Villagedoctors

BackgroundNew rural cooperative medical scheme (NCMS) has been implemented for ten years and achieved remarkable results. Empirical studies have shown that the establishment and improvement of NCMS has a positive impact on improving the accessibility and fairness of rural health services and providing risk protection. However, with the rapid development of NCMS, the medical costs of rural areas have been rising quickly, which would seriously restrict the sustainable development of NCMS. Currently, the physician payment system of NCMS rewards physicians for the volume of services they provide, which is so called Fee-for-Service (FFS) and may increase overuse of services. FFS has been criticized because it does not ensure quality care, control costs, or promote appropriate service use. Therefore, the need to physician payment reform as a means of control medical costs has become increasingly imperative. In2011, MoH passed a legislation which proposed to accelerate the payment reform of NCMS and aimed to create incentives for providers to seek improved quality, lower costs, provide more efficient care, and maintain or improve access to care for consumers. Whether these goals can be attained depends on how physicians respond to payment incentives. How the payment reform would change the behavior of health care providers is a critical variable. Prescribing behavior is the most important medical practices which not only reflect the quality of health service, but also closely related to changes in medical costs. Therefore, study on the effects of NCMS capitation payment reform on village doctors prescribing behavior under the new health care reform background has important practical significance.The aim and objectives The aim of this study is to evaluate the effect of NCMS capitation payment combine with quality assessment on village doctors prescribing behavior through an empirical trial in the framework of NCMS and finally to provide political evidence for improving outpatient payment system of NCMS and promoting the sustainable development of the NCMS. The specific objectives include:to learn about the status and existing problems of payment reform of NCMS; to evaluate the effect of NCMS capitation payment combine with quality assessment on village doctors prescribing behavior through an empirical trial; and to provide policy implications for the improvement of the NCMS payment system through summarizing the lessons of our empirical analysis.Study Data and MethodsData source:We used data from the project "Health equity and financial protection in Asia" funded by European Union, which implemented capitation payment reform of NCMS outpatient system in Junan County and Liangshan County, Shandong Province. Data were collected before (2011) and after (2012) the payment reform was implemented for both the "treatment" group (that is, village doctors in Junan and Liangshan County) and the comparison group (that is, village doctors in Pingyin County that did not implement payment reform), mainly included agency information, health personnel information and prescription data and other policy documents.Methods:In assessing how the capitation payment reform has affected the prescribing behavior of village doctors in these counties, we compared the change in prescribing behavior before and after the payment reform was implemented for both the "treatment" group and the comparison group. To do this, we used a difference-in-differences framework, wherein the change for the comparison group (before and after implementation of the project) is subtracted from the change for the treatment group, to control for other changes over time beyond payment reform. That is, the comparison group provides an estimate of what would have happened to village doctors in Junan and Liangshan County in the absence of the payment reform.Defining evaluation indicators:For much of the analysis, we focused on the qualified prescription writing rate, the proportion of prescribing more than5kinds of drugs, jointly using antimicrobial drugs, prescribing hormones and intravenous, which were used to measure prescribing behavior.Data analysis methods:Descriptive statistics was used to analyze the economic status of target counties (Population, administrative villages, GDP, etc.). Chi-square test and analysis of variance was used to analyze the basic information of participants (age, sex, marital status, educational level, etc.) while logistic regression was employed to analyze the change in prescribing behavior before and after the payment reform. The statistical analysis was applied by Microsoft Access2010, Excel2010, SPSS17.0and STATA10.0.Results· After the payment reform, knowledge and skills test scores of village doctors in Junan County increased from baseline52.02points to67.46while in Liangshan County increased from baseline at49.76points up to64.58points.· Focusing first on our core model, we find that the payment reform increased the qualified prescription writing rate by1.16times in Junan,3.87times in Liangshan, and1.22times overall.· Estimates from the difference-in-differences models show that the payment reform reduced the proportion of prescribing more than5kinds of drugs by83%in Junan,68%in Liangshan, and68%overall.· Estimates from the difference-in-differences models show that the payment reform reduced the proportion of jointly using antimicrobial drugs by66%in Junan,37%in Liangshan, and57%overall.· We find that the payment reform reduced the hormone prescription ratio by39%in Junan and41%overall. Estimates from our models do not show a significant reduction in Liangshan.· Estimates from our models show that the proportion of prescribing intravenous dropped by5%in Junan,27%in Liangshan and26%overall.ConclusionsAfter a period of intervention, most township hospitals in the experimental groups strengthen the supervision of village clinics and the overall penalty score gradually decreased, indicating that the pressure of quality assessment makes the township hospitals pay more attention to the quality of health services; knowledge and skills test scores of village doctor in the experimental groups had improved slightly, indicating that the village doctors has a low level of specialized knowledge and ability; prescribing behavior indicators of village doctor in the experimental groups had significantly improved, indicating that capitation payment combine with quality assessment in NCMS outpatient payment may create incentives for providers to seek improved quality, provide more efficient care.Policy Implications· Intensify efforts to implement the NCMS payment reform and perfect rural grassroots health institutions incentive mechanism.· Strengthen village prescription management system and establish management and regulatory mechanisms of village doctors’rational drug use behavior.· Improve related supporting policies to perfect the payment system.