Study On Risk-adjusted Capitation Model Of Outpatient Pooling Fund In Basic Medical Insurance

[Objective] On the basis of deep understanding of Shenzhen's Social Medical Insurance policies and capitation payment scheme,this study tried to analyse the insured's enrollment,visit conditions and the factors which could influence them,then find out the risk adjustors,and develop the payment standards to compensate health providers.[Methods] A combination of qualitative and quantitative research methods were used for this study:literature review was conducted to realise the risk adjustment theory and method,in-depth interview was conducted to realise Shenzhen's Social Medical Insurance policies and capitation payment scheme,descriptive statistical analysis was conducted to analyse the insured's enrollment and visit conditions,and two-part model was conducted to develop the payment standards.[Results](1)Factors that influence the health services utilization including age,sex,level and community health service center which the insured choose. The maximum value of utilization probability is 0.862,the minimum value is 0.012 and the mean value is 0.177;(2) Factors that influence the health services expenditure including age,sex,level,community health service center which the insured choose and have chronic disease or not. The predict value of total expenditure per person per month is 6.17 yuan;(3) Age,sex,level and have chronic disease or not are choosen as risk adjustors. The whole insured are divided into 52 groups by this four factors, and payment standards for each group are calculated.[ Conclusions] For different age,sex,level and have chronic disease or not people,the health expenditures are different,It's necessary to conduct the risk adjusted capitation.