Identification Of Out-of-County Hospitalizations And Its Influencing Factors In The New Cooperative Medical Scheme

Objective:Throughout the duration of the New Cooperative Medical Scheme(NCMS)(2008-2016),it was found that an increasing number of rural patients were seeking out-of-county medical treatment,especially the phenomenon of out-of-county hospitalization is widespread,which increased the operational risk of the NCMS fund.Our study was conducted to understand the prevalence of out-of-county hospitalizations and its related factors to obtain a scientific basis for follow-up health insurance policies.Methods:The National Health Commission Statistical Information Center(NHCSIC)of China provided all of the data,which had been collected and reported by local health departments.A total of 215 sample counties in the central and Western regions of China from 2008 to 2016 were collected.The Chimerge-?~2 method was adopted to discretize the possible related factors,including region,rural population,per-capita per-year net income,per capita GDP,per capita funding amount of NCMS,compensation ratio of out-of-county hospitalization cost,per-time average in-county hospitalization cost,and per-time average out-of-county hospitalization cost.Firstly,univariate analysis was performed to describe the distribution of variables related to out-of-county hospitalization rate,then stepwise logistic regression analysis was carried out to identify node variables in the Bayesian Network(BN).Variables with statistical significance in Logistic analysis were included to construct a Bayesian network model combining Max-Min Hill-Climbing algorithm(MMHC)with prior knowledge.The interrelationship and interdependence strength between out-of-county hospitalization rate and its related factors were quantitatively analyzed.Results:(1)During the implementation of NCMS,the structure of hospitalization in the central and western research areas of China is unreasonable,and the inpatients,hospitalization expenses and hospitalization compensation funds tend to flow out of the county year by year.The Out-of-county hospitalization rate increased from 12.37%in2008 to 19.21%in 2016 with an average annual growth rate of 5.66%(the central region is higher than the western region).The marginal probability of out-of-county hospitalization rate is as high as 81.7%.The proportion of out-of-county hospitalization compensation in total fund expenditure increased by 3.46%,which brought great pressure on the stability of medical insurance funds.(2)Based on the stepwise logistic regression results,eight factors,namely,region,rural population,per-capita per-year net income,per capita GDP,per capita funding amount of NCMS,compensation ratio of out-of-county hospitalization cost,per-time average in-countyhospitalization cost,andper-time averageout-of-county hospitalization cost,were incorporated into the Bayesian network model.The network structure consists of 9 nodes and 15 directed edges.The accuracy and AUC area of the model are 88.06%and 81.70%respectively.The Bayesian network model constructed has good prediction accuracy and discrimination.(3)According to the BN model constructed in this study,the out-of-county hospitalization rate was closely related to per-time average out-of-county hospitalization cost,rural per capita net income,per capita GDP and compensation ratio of out-of-county hospitalization cost,and indirectly related to the out-of-county hospitalization rate in region,rural population,per capita funding amount of NCMS and per-time average in-county hospitalization cost.Based on the hospitalization expenses factors(per-time average in-county hospitalization cost and per-time average out-of-county hospitalization cost),economic factors(per capita GDP and rural per capita net income),regional characteristics factors(region and rural population),and NCMS policy factors(per capita funding amount of NCMS and compensation ratio of out-of-county hospitalization cost),it is obtained that if per-time average in-county hospitalization cost and per-time average out-of-county hospitalization cost belong to the higher level,the probability of out-of-county hospitalization is 95.7%;if the per capita net income and per capita GDP of a county belong to the higher level,the probability of out-of-county hospitalization rate is 91.1%;when the rural population of a county is small and belongs to the central region,the probability of out-of-county hospitalization rate increases to 93.0%;if the per capita funding amount of NCMS and compensation ratio of out-of-county hospitalization cost of a county belongs to the higher level,the probability of out-of-county hospitalization rate is 88.8%.Conclusions:The increase of out-of-county hospitalization rate brought burden to the operation of the medical insurance fund.It is suggested that reasonable supervision should be taken to control the increase of out-of-county hospitalization rate,and the factors influencing the increase of out-of-county hospitalization rate should be taken into account when formulating and adjusting follow-up policies.While strengthening the service capacity building of rural primary medical institutions and improving the management system at the grass-roots level,comprehensive regulation and control should be carried out according to the local economic and regional differences,continue to improve the construction of Hierarchical medical system,improve the compensation ratio of NCMS in the county,increase the reimbursement compensation ratio of different medical institutions,improve the referral system,and reasonably guide and control the direction of rural patients'medical treatment and the medical insurance fund flow,so as to promote the long-term sustainable development of rural medical system.