Analysis And Measurement Of Hospital Expenses Of Medical Insurance Of Fourteen Critical Diseases

[Purpose] By analyzing hospital expenses of fourteen critical diseases of all insured residents in typical area in Hubei Province, to make up the calculation method and the amount of money insuring critical diseases by social basic medical insurance and supplementary commercial insurance under different compensation scope and proportion is to be measured. And by discussing the relationship between financing and system construction of critical diseases security, as well as the policy justification, the relevant suggestions was made to assist the financing, managing and system construction of critical diseases security.[Methods] Based on document analysis, essential information of all resident in City A in Hubei covered by basic medical insurance was obtained from January2009to May2011by retrospective data survey, including name, sex, disease, hospital fees, and reimbursement. Besides,2qualified hospital was investigated for hospital fees and treatment mode about part of the14diseases in the same period. Method of statistic analysis, Counter factual analysis, sensitivity analysis and Specification analysis was used on data collected.[Results]1.mode of treatment and cost characteristics:a variety modes of treatment is required for critical diseases, including surgical options, radiation treatment, chemotherapy and combined treatment. Hospital fees including surgical treatment is higher than others, but the proportion of surgical treatment patients is relatively low(<17.7%).2. Distribution and constitution of critical diseases hospital fees:(1) the hospital fees distribution could be characterized in part by skewness of the distribution, the average hospital fees is9401.09yuan, and77.5%hospital fees was under10000yuan.(3) Fees of cerebral infarction(24.9%), lung cancer(18.9%) and gastric cancer(16.5%) was top3from the whole hospital fees.(4) In the new rural cooperative medical care, the drug fees(48.0%) and treatment(19.3%) cost the most. Among that drug fees out of catalogue was22.46%. 3.Analysis of hospital fees per year:(1) The average hospital fees per year was13223.30yuan, the median was5218.10yuan.69.0%percent of patients was under10000yuan.(2) Compared with the standards of critical disease payment limits, at least25%cancer patient fees per year were above them. Because of the low proportion of surgical treatment cases, if the standard placed strict restriction to the surgical treatment mode, patients treated other ways with extremely high fees would not be reimbursed.4.Service utilization and patients flow:(1) The critical diseases average annual inpatients was4.7percent of that of the area. The number of inpatients was increased by the level of institution.68.3%inpatients went to level-3institutions. The rural inpatients went to level-3hospital the least(62.2%), while the citizen covered by medical insurance for workers went there the most(82.4%).(2)1963inpatients(21.3%) went to hospitals out of the city. Among them the rural inpatients went out the city the least(19.6%), while the citizen covered by medical insurance for workers went out the most(25.9%)5.Reinbursement for the critical diseases:(1) the actual compensation of hospital fees was lower in rural areas. The actual compensation proportion of hospital fees was52.3%. That of the new cooperative medical care was35.5%, and medical insurance for workers was70.5%.(2) Rural inpatients had a lower actual compensation proportion of hospital fees than others in higher level institutions.(3) Rural inpatients had a lower actual compensation proportion of hospital fees than others in hospitals out of the city.6.Insurance measurement of the fourteen critical diseases:(1) If the basic insurance compensated70%on the14diseases,3411.1thousand yuan was needed(4.74yuan average) per year in the rural area;2829.3thousand yuan was needed(8.08yuan average) in the city; the total was6240.4thousand yuan. Funds needed for new rural cooperative medical care was3.5%of its total funds raised in2010, and4.4%of total that years’expenditure.297.1thousand yuan was needed for the medical rescue fund(3.67yuan average).(2) According to the new rural cooperative medical care, by insuring part of the surgical treated diseases1278.1thousand yuan was needed.57.6thousand yuan was needed for the medical rescue fund.7.Financing-compensation sensitivity analysis of new rural cooperative medical care: by the increase of compensation proportion of new rural cooperative medical care, each1%would need to increase the fund by0.10-0.11%.8. The measurement of supplementary commercial medical insurance financing:to compensate out-of-pocket fees by sub-claims in both rural and urban areas without disease limits, the supplementary commercial medical insurance needed to raise a fund of9286.5thousand yuan(8.68yuan average).[Conclusions]1If the critical diseases insurance was restricted to only surgical treated patients, patients treated other ways and part patients with extremely high fees would not be reimbursed, which would lower the efficiency of fund using.2For the chosen city, it is feasible to improve the fourteen critical diseases compensation ratio to70%, covering all hospital fees. Such areas with ability of fund raising should cancle the restriction of treatment.3The service utility and compensation ratio had a different between rural and urban area. The rural residents had a lower utility of high-level institution and a lower compensation ratio, too. That means new rural cooperative medical care lack the ability sharing risk of critical diseases. The rural area was the priority in critical diseases insurance policy.4Average8.68yuan for the supplementary commercial medical insurance financing is34.7%of the instructional financing standard over province(25yuan average per year), which showed the standard was able to satisfy the fund demand.5Different areas should calculate the premiums and establish proper critical diseases insurance according to the local economy and insurance managerial capacity.