| SignificancesThe New Rural Cooperative Medical Scheme (NRCMS) was established to share medical economic risk and alleviate poverty due to illness on the basis of payments balance. The Research Object (the area A) in east China, carried out this Medical Scheme in2003, and had reduced the farmers’ economic burden of disease to some extent. However, the result of intention survey for the local in2008showed that56.4%of respondents thought the poverty due to illness was serious, and21%of poor families were due to illness among rural residents. In recent years, the local government improved the level of financing and adjusted the hospital compensation scheme year by year. How much economic risk and the poverty due to illness would be reduced, and whether can it realize the balance of payments after adjusting the hospital compensation scheme? To answer these questions, it is needed to evaluate the target realization degree of the NRCMS in The area A objectively and scientifically.In order to deal with the problem that the excessive growth of medical treatment charge hindered the sustainable development of the NRCMS, The new medical and health system reform had required a payment reform in the NRCMS field in2009. The ministry of health, ministry of finance, national development and reform commission, had jointly issued work guidance about payment reform of the NRCMS in2012. The province, where the area A is, strived to carry out payment reform of the NRCMS in more than90%of the NRCMS implementation areas in two or three years.Therefore, the area A needs to adjust the hospital compensation scheme to fulfill the policy requirements, on the basis of evaluating the target realization degree of the NRCMS in the area A objectively and scientifically under the policy environment This is also the aim of this study.Materials and MethodsData for this study was offered by the NRCMS management organization in the area A, including statistical data of participation and financing of the NRCMS from2007to2012, policy documents and socioeconomic status material from2010to2012, outpatient compensation database from2010to2011, inpatient compensation database from2010to the first three quarters in2012, the inpatient detail database and so on. The research would mainly use the following methods:(1) Referencing the simple "before and after" comparison analysis from the policy science theories, the research would evaluate the target realization degree of the NRCMS in the area A by comparing each evaluation index before and after the inpatient compensation of the NRCMS.(2) The study would compare the real target realization degree of the NRCMS in the area A with the ideal goal of "balance of payments, risk-sharing, eliminating poverty due to illness" by using Gap Analysis, to find out the shortage of the compensation scheme.(3) The study would confirm the indicators for evaluating implementation effect of the NRCMCS in the area A and calculation method of the per-diem payment standard of hospitalization, through consulting related information.(4) Cluster analysis, variance analysis and regression analysis were used to help for calculate the pay standard according to bed day.Results1. The implementation effect of the NRCMS in the area A(1) The general implementation effect of the NRCMS in the area AThe participation rate of the NRCMS is100%. Per capita funding level had reached from110RMB in2007to400RMB in2012, and the average annual growth rate was29.46%which exceeded the national average of it. The inpatient benefit rate was8.52%, while the actual compensation proportion was46.16%. The compensation proportion reduced as the levels of medical institutions rose. In addition, the inpatient total cost of the NRCMS increased8.38%annually between2010and2012, the average cost at a time in2011was lower than2010, which sharp rose in2012and exceeded the level of it in2012.(2) The target realization degree of the NRCMS in the area A in2011I The NRCMS funds use basically achieved the balance of paymentsThe balance rate of the NRCMS funds was-1.44%in2011, and basically achieved the balance of payments.II The NRCMS reduced the farmers’ medical economic risk to some extent, but hadn’t focus on people at high riskThe average medical economic relative risk (RR) of the crowd had reduced from11.84to 11.84, and the decreasing amplitude was43.75%. Wherein, the RR of inpatients had reduced46.16%. However, the max RR was still up to207.86after the compensation while113.40of it before the compensation. And the RR decreasing amplitude of inpatients whose medical charge exceeding their greatest ability to pay hadn’t been higher than that of other cost level. The result showed the compensation scheme in the area A hadn’t focus on people at high riskⅢ The poverty due to illness had been alleviated to some extent but not enoughThe rate of poverty due to illness had reduced58.07%by the NRCMS, which was0.83before the compensation while0.35after in2011in the area A. And the total gap of poverty due to illness was60.83million before the compensation while15.79million after, which had reduced74.04%. It showed that the NRCMS in the area A had alleviated poverty due to illness to some extent, but there was still a large gap between the real effect and the goal of eliminating it2. The per-diem payment standard of hospitalization and assessment suggestions for the area ATo establish a suitable payment standard is the key points for the per-diem payment of hospitalization. The study divided the patients into critically ill patients, surgery patients, pediatric patients and ordinary patients in view of the severity of disease, treatment, and patient age were closely related to medical expenses. Because the medical costs are significantly different in different period and at different nursing level when in hospital, we have to section the cause of disease. For example, the cause of disease was divided into the special care, senior care, secondary care and tertiary care according to nursing levels for critically ill patients, the preoperative, intraoperative and postoperative period for surgery patients, and different days for pediatric patients and ordinary patients. Furthermore, the medical expenses different levels of medical institutions were quite different, so we divided the medical institutions into Township, district, municipal hospitals. And then we would get the actual average daily cost for each level of medical institutions, each type of patients and each disease stage in2011in the area A.On the basis of the above steps, we calculated the cost standard for per-diem in2011in the area A considering the proportion of unreasonable medical expenses and the price index of medical products. In order to reduce shocks caused by the policy adjustment, we established payment standard for per-diem in2013by using the compensation ratio similar to the original ratio. Finally, we put forward some suggestions for the NRCMS management institutions to supervise assess the medical institutions according to the defects of per-diem payment system.3. The secondary compensation scheme for the area AThe per-diem payment system just compensates inpatients at a time, and couldn’t focus on the economic burden caused by the annual accumulative out-of-pocket medical expenses, and it was need to make a secondary compensation scheme for the area A. Firstly, we make sure how much funds was needed to eliminate the poverty due to illness on the basis of measuring the medical and economic risk distribution and the poverty due to illness after the per-diem payment system compensation, and judge that the funds for the secondary compensation were enough to reach the goal in the area A. Secondly, the secondary compensation was determined as the risk type according to its focus points.In order to control the growth of unreasonable demand, the secondary compensation needs shared characteristics, such as the deductible, the top line, the cost segment and the compensation ratio. Theoretically, all the expenses upon the greatest ability to pay should be compensated at the highest ratio because of the plan’s primary goal to eliminate the poverty due to illness, but we adopted the multilayer decreasing compensation mode to avoid the negative impact on the development of the NRCMS made by the direct effect of income on health consumption.4. The pre-assessment of the adjusted hospitalization compensation scheme in the area ACombining the per-diem payment scheme and the secondary compensation scheme, we pre-assessed the effects of the adjusted hospitalization compensation.(1) The balance rate of the NRCMS funds would be-0.29%.(2) The average medical economic relative risk (RR) would reduce53.10%, and the max RR would be63.95after the compensation while228.83of it before the compensation. The RR decreasing amplitude of inpatients whose medical charge exceeding their greatest ability to pay would be obviously higher than that of other cost level, and the max of it would be up to72.05%. The result showed the compensation scheme in the area A hadn’t focus on people at high risk.(3) The rate of poverty due to illness would reduce87.50%, while97.97%of the gap of poverty due to illness, which showed the poverty due to illness would be eliminated basically.Explorations1. This research has a certain guiding value. Because it had shown the overall process of adjusting and evaluating the NRCMS’compensation scheme from the perspective of theory and practice, and resolved the key problem existing in the NRCMS definitely.2. The study explored the idea to adjust the NRCMS’compensation scheme that can control the excessive growth of medical expenses and achieve the system’s goals at the same time. |
PDF Full Text Request