An Empirical Analysis And Process Evaluation On The Serious Illness Insurance Of Urban And Rural Residents In Qinzhou,Guangxi

ObjectiveThis study analyze the operational effects and existing problems of Qinzhou Serious Illness Insurance (SII) system based on the theory of structure-process-outcome framework with three level of indices (the third level with 11 indices), through analysis of historical evolution and construction of Qinzhou SII system, empirical research of its current development situation together with the situation of Qinzhou medical service and drawing lessons from domestic and foreign advanced experience of SII, aimed to explore and improve the mechanism in line with Qinzhou SII, thus provide experience for broader implantation of the SII in Guangxi.MethodsIn this paper, literature review was applied by searching the studies associated with SII from database in Chinese and English before empirical study. We summarized and classified the qualified studies to get an initial understanding of the status quo of research and evaluation on SII at home and abroad. Secondly, case study method was used with questionnaires handing out to Qinzhou urban and rural residents who claimed for SII in 2014, using multi-stage random sampling investigation. In this stage, the basic situation of surveyed objects and their awareness and satisfaction of Qinzhou SII system was analyzed. Their advice and suggestions were collected. The results were statistically analyzed. In addition, focus group interview was carried out among the selected staff from social security, New Rural Cooperative Medical Insurance System (NRCMIS) offices, and the underwriters in order to know the existing problems in SII system and collect their advices and suggestions. Finally, qualitative and quantitative analysis were implemented and the prediction was made based on the principles of statistics, in order to offer basis for formulation and improvement of SII policy.ResultsAs a pilot, Qinzhou SII started since January 2013, a total number of 10.73 million people were enrolled accumulatively by December 31,2015, with an accumulative SII premium of 302.2407 million yuan. The beneficiaries were 35628 person times, with accumulative compensation of 207.84 million yuan, and mean of 5833.58 yuan. The reimbursement of medical expenses increased by 16.03%, higher than the national average, which effectively reduced the economic burden of the patients with serious illness and partly solved the problems of poverty caused by illness, obtaining good social effect. There was statistical difference in total compensation, mean compensation, medical fees, mean medical fees, basic medical insurance reimbursement ratio, global reimbursement ratio, reimbursement ratio increased between the Urban Resident Basic Medical Insurance (URBMIS) and NRCMIS and among different counties and districts (P< 0.05). There was statistical difference in satisfaction of NRCMIS, reimbursement ratio of SII and healthcare quality in the counties against the satisfaction of SII system among the beneficiaries of SII, with lowest satisfaction in SII system(P<0.05). Out of the 150 surveyed patients,84% of them believed SII was helpful in reducing family burden from serious illness, of which,24% thought it was very helpful.ConclusionI. To establish a stable and long-term dynamic financing mechanism is helpful to improve the ability of resistance to risk of the SII funds and expand enrollment, which is convenient to the free flow of urban and rural population and flexible employment. This will be helpful to raise unified fund levels and ensure stable and sustainable development of SII system for urban and rural residents, offering basis for integration of URBMIS and NRCMIS.II. To establish and improve a SII information platform shared by all parties is helpful to monitor real-time medical fees and control unreasonable medical expense behavior. It can also accumulate data on medical cost of serious illness, and accurately account and set financing levels and reimbursement ratios accordingly. The instant reimbursement while discharge can be realized, reducing the non-reimbursement rates and costs of transportation. At the same time, it also facilitates the government to urge underwriters to fulfill the contracts and implement inspection.III. The sustainable development of a SII system requires a better hierarchical medical system with rational allocation of health resources. Currently, the compensation cases of a serious illness mainly occur in county level hospitals and tertiary hospitals, which produces high medical costs and causes waste of resources in SII system. The governments and health authorities should increase support for grassroots healthcare institutions and guide the patients select medical treatment reasonably so as to reduce the risk of SII funds.IV. Better coordination should be formed among the government, social security and insurance regulatory commission, by formulating or perfecting related policies, transforming government function, separating management and operation, clarifying responsibility and obligation of relevant authorities in different loops in order to ensure healthy development of a SII with laws strictly enforced.V. The precision poverty alleviation mechanism should be established in SII system, improving medical assistance, implementing the policy of poor residents enjoying priority of SII according to Chinese central government decision on poverty alleviation. Thus the civil affairs departments may buy basic medical insurance or commercial health insurance for the poor people if the local finance can afford it, which will improve healthcare protection for the poor people and avoid poverty due to illness.