Research On Out-patient Global Budget Of New Rural Coorperative Medical Scheme

【Backgrround】Since 2003, New Rural Cooperative Medical Scheme (NCMS) has made tre-mendous contributions for Chinese rural health care. At the beginning NCMS mainly aim is "Pooling Funds for Serious Illnesses", with the increase of funding level, the hospital has reached a higher compensation level, most regions already have the ability to pool of out-patient service.In order to expand the benefit package, NCMS in some areas set up the family account model with the development of NCMS, family account model's drawbacks began to appear, the advantages of pooling of out-patient service is gradually emerg-ing. In 2008, the State Council held a national NCMS work conference, put forword policy guidance, basically denied the family accounts, implemente of outpatient co-ordination. At the end of 2009, the area of outpatient co-ordination has reached one-third in China.Dependented on the Health Statistics Yearbook data of the Ministry of Health, China's total health expenditure in 2009 compared 2003 with gains of up to 145% in 2003, who received treatment in 2008 compared with 2000 per capita health care costs increased by nearly 71%, the rapid growth of medical costs has become a big challenges for medical insurance system, NCMS is also the same. With increasing of medical expenses and compensation level, some regions have arisen risk of fund cost overruns of out-patient. Although there were small per capita fees of outpa-tient, lower compensation, but it has large quantities. Therefore, from the point of view the NCMS fund balance is also needed a systemic research on the total pre-paid system of out-patient system.In the current method of payment, the best pament system of controlling expense is global budget, which many regions have begun to apply., but it is has no systematic theoretical research.Ministry of Health, "health care reform in 2010 on the implementation of the tasks of rural health services" put forward "in the proposed areas of co-ordination in carrying outout-patient, carrie out payment reform such as global budegets of out-patient". From the perspective of cost control and policy research to study the global budget of outpatient has great practical significance. This study combines the actual survey results of the current funding levels, how to launch global budget of out-patient of NCMS, providing reference for NCMS.【Objectives and Contents】(a) ObjectivesStudy the payment of out-patient through analysis current situation, combinated withthe theoretical analysis and practical experience in advance, study and explore the estimation of global budget of out-patient, conditions and regulatory mechanism in primary health care institutions in rural medical institutions, improve the out-patient payment system of NCMS and provide the basis for sustainable development.(b) Contents1. Analysis the implementation of NCMS in the sample regions, summarize payment systems and problems of out-patient.2. Analysis the estimation of global budget, conditions and regulatory mechanism of out-patient of NCMS.Proposed measurement methods and mechanisms which is adapt to the status of Chines NCMS.3. Through typical case analysis in Nanling County, Anhui Province, predict its out-patient costs in 2010, and compare the differences between estimates and actual results, summarize existing problems and shortcomings in the practical application.4. According to the results and typical case studies and analysis, put forward suggestions of estimation method and conditions for out-patient of NCMS.【Methodology】(a) Date sources1. Choice of sample area cityThe level of economic development and geographical distribution were considerd as selection criteria of samples. The sample ares are implement out-patient more than 1 years (especially has implement golobal budget of out-patient).10 samples areas selected:Zhangjiagang and Jurong City in Jiangsu Province, Nanling and Feixi County in Anhui Province, Lintong District and Xunyi country in Shanxi Province, Xundian and Chengjiang County in Yunnan Province, Nanhui District in Shanghai and Qianjiang District in Chongqing.2. Data collection methodsSite surveys were in june 2009 in 10 sample areas and march 2011 inNanling County, Anhui Province. Specific data collection methods are questionnaires, secondary data collection, key informant interviews.(b) Analysis MethodsAnalysis methods used in this study are the literature of induction, medical insurance expense premiums method, PETS feasibility analysis, Aanalysis of typical cases.Aanalysis tools are Excel2007 and SPSS11.5.【Results】(a) Conclusion1. Main conclusions of outpatient of samples1) Problems of NCMS of sample areas10 sample areas NCMS are at a good stage of development, it is mainly reflect in the following five aspects. First, the participation rate increased every year; Second, the level of funding rate is about 25% annual growth, personal finance accounted in the majority of the sample area per capita net income for the year 0.01%-0.02%; third, NCMS fund balance is stable; Fourth, coverage of hospital and the level of benefit gradually expanded each year; Fifth, at the end of 2008, the family accounts have all been transformed into out-patient co-ordination, co-participation'benifit was extended.There are also many deficiencies in the operation of NCMS. First, the hospital costs of NCMS grow faster, bring a great risk of NCMS funds; Second, patient co-ordinate fund balances between overruns and large, scientific calculations, cost control and patient supervision of out-patient co-ordinate fund are difficult; third, overall samples are at the start of outpatient co-ordination, the current actual compensation patient are at a low proportion, the attraction on the participation of farmers is not powerful; Fourth, research in individual areas reflect the actual out-patient reimbursement procedures are complex and increase many rural doctors workload.2) The situation and problem of global budget of out-patient inthe sample areasAt the end of 2009, the 10 sample areas have all been outpatient co-ordination,5 samples regions have global budget of out-patient. Proportion of fund in outpatient co-ordination areas is between 20% -40%, and Nanhui District, Shanghai is at a higher proportion for 43.4% of the total financing of the Fund; Outpatient calculation methods are diversity, but considerations simple in general;The year-end balance sheet flexibility follow the "cost overruns do not fill the balance owned by yourself" principle; addition to the Shanghai Nanhui District covers three-tier health network, the other areas covered by township and village levels;The effect of reducing out-patient medical costs is obvious Nanhui District of Shanghai and Chongqing Qianjiang District.Problems of global budget of outpatient are as follows:First, outpatient fund is imbalances; Second, the budget estimate methods are simple and lack of scientific basis; Third, year-end balance sheet flexibility are simple; Fourth, information systems in central and western regions is not perfect, bring great difficulties to the out-patient budget estimates, supervision and evaluation.2 Payment of global budget of out-patientThe design of global budget of outpatient should follow the four principles: feasibility, living within our means to protect the principle of proportionality, protecting the benefit of the supplier, relative stability and change in timely.Proposing the fund of out-patient co-ordinating accounts for annual NCMS fund are between 20%-30%.The current calculation method are divided into the total cost estimation method, counting method, according to the actual calculation method, calculation method according to the volume of services and calculating method according to the head. The last three measurement methods'basic is still the estimates of health insurance law, just in the estimation of the baseline estimate are in different ways. The estimation of global budget of outpatient of Chinese NCMS summarized are:county-level medical institutions can use the actual calculation method, the township and village-level medical institutions measured by the volume of services. Specific calculation formula is:Proposed year-end to implement flexible billing to compensate the lack of estimates, Compensation the cost overruns of 60% -75% of to the medical institutions when reasonable overruns as the make up of their health care costs; Balance of 25% -40% will be awarded to medical institutions as a encouragement of its out-patient cost savings. It should be punished for the unreasonable cost overruns and balances. Supervision and evaluation should be established. The two basic conditions of outpatient global budget are health network covering the construction of information systems and implementation of rural integrated management.3. The typical case of Nanling County, Anhui ProvinceNanling County, Anhui Province meets the basic conditions. According to the calculation of this formula, based on 2009 data, estimates its budget of outpatient of 2010 are 5,383,800 yuan, and increase of coefficient of 1.087, so the total budget adjusted in Nanling County of Anhui Province in 2010 are 5,797,800 yuan.2010 actual expenditure of funds for the outpatient are 5.4697 million yuan, the total budget are more 6.52% than the actual out-fund, which shows that the calculation method is more realistic fund expenditures and have practical significance. The comparison between 2009 and 2010 out-patient data showed that the global budget of out-patient is good at control medical cost, while ensuring the patient fund balance and promoting the use of out-patient services. (B) Discussion1. Basis of flexible year-end settlementFlexible year-end settlement of the labor cost calculated is only the income structure of rural doctors a rough analysis, lack of township and county level analysis of the cost structure of medical institutions.2. Discuss the estimate method of global budget of out-patient It is should be adjusted on the basis of the actual. It could be servel different grade level standards for outpatient expenses when there are great gaps among medical insititutions.The average actual compensation are better in the fairness theory when there are small gaps in the actual.3. Relationship between essential drug system and global budget of out-patientIn typical case study, Nanling County of Anhui Province in 2010 implement the global budget of outpatient and the essential drug zero system. From the theoretical analysis, both essential drug zero system and global budget of outpatient can reduce total outpatient costs prepaid, so the effect of control fees of global budget of out-patient need long-term observation.(C) Recommendation1. Based on reality is the premise of gobal budget of out-patient in NCMS Implement global budget of out-patient has based on a high level of hospital compensation.A high-quality leadership and a management team, strengthen policy guidance and communication with the medical institutions are also needed.2. Information systems is the basis of gobal budget of out-patient in NCMSPatient information system play an important role in collecting the outpatient costs, statistics, real-time monitoring. It includes computer, network and software facilities, more importantly, the computer operator. Main inputs sourse is finance while social capital is encouraged.3. Scientific estimates is the key of gobal budget of out-patient in NCMSAn estimate of gobal budget of out-patient is a forward-looking calculation, it has many factors, so it is likely to emerge the difference between actual and estimation. The bases of scientific estimates are data collection and reality.4. Flexible settlement is adjusting of gobal budget of out-patient in NCMSFlexible settlement can make up the defect in estimate. It is also can give economic incentives to medical institutions and punish poor medical practices.5. Supervision and evaluation are indemnification of gobal budget of out-patient in NCMSEstablish a supervision system and teams, supervise medical institutions regularly is the smooth implementation of gobal budget of out-patient in NCMS.