Study On The Outpatient Co-ordination System Of The Urban Employees’ Basic Medical Insurance In Hubei Province

Purpose: Firstly,the study analyzed the practice model and reform framework of the Outpatient Co-ordination System(OCS)of the Urban Employees’ Basic Medical Insurance(UEBMI)in Hubei Province.Secondly,effects of the OCS and its impact on the utilization and expenses of outpatient and inpatient services were evaluated.Thirdly,the study tried to estimate and calculate the fund demands of the OCS under the different mix of policies,and explore the best policy combinations matched up with ability to pay of UEBMI.Finally,we condensed the obstacles and problems faced in present reform of OCS,and provided some path references for its continued reform.Methods: This study summarized the relevant concepts and reform models of OCS through literature and policy analysis;and applied typical investigations to interview key informants and collect related policy text and data for the evaluation and estimation of implementation effect and fund demands of the OCS.Data information: The insurance reimbursement data of overall patients in the sample areas from 2015 to 2019,mainly including serial number of the insured,disease diagnosis,medical expenses,etc.Results:1.The employees’ OCS in Hubei province can be divided into two forms: the expenses-based OCS and diseases-based OCS,with the latter still occupied the main status.The funds of OCSs were mainly from the UEBMI’s fund pools,but the financing scale and management methods are very different,and the insurance scope and benefit level also were diverse.2.Taking Xianning city as an example to analyze the implementation effect of employees’ OCS in Hubei:(1)expenditures of OCS increased rapidly,its was 81 million in 2019,increased nearly 89% by 2015.(2)The expenditure for the diseases-based OCS was dominant,from 2015 to 2019,the number of outpatients attended diseases-based OCS increased from 145,900 to 209,300 with an annual increasing rate of 9%;its costs paid by UEBMI’s fund increased from 42.78 million to79.09 million yuan,and in 2019 the costs of diseases-based OCS accounted for97.52% in whole OCS insurance expenditures.(3)The utilization of inpatient and outpatient services increased simultaneously.(4)More hospitalized patients and expenses flow to the tertiary hospitals.3.Taking Ezhou city as an example to calculate and estimate the funds demands of the employees’ OCS:(1)According to the frequency of the diseases to determine the diseases category for calculating,the bronchial asthma,chronic obstructive pulmonary disease,epilepsy,chronic heart failure and chronic renal failure should be incorporated in OCS.(2)Based on the original treatment,the five new diseases insurance costs were between 0.3 million and 0.5 million yuan;whereas based on the average treatment level of the diseases-based OCS in Hubei,the 28 illnesses in the target list needs 28.0 million～32.7 million yuan,and based on the highest treatment level,the fund need was between 35.9 million and 36.5 million yuan.(3)The local available insurance fund of the employees’ OCS is at least 16.7% of the total fund on UEBMI,about 130 million yuan in 2019.It suggested to adjust in three years,the available fund for first year was 40 million yuan.(4)The management rates of some diseases in the OCS were not as expected,a considerable sum of fund can be saved if more patients selected outpatient services than hospitalization.Conclusion:1.Problems and obstacles faced in the reform of the employees’ OCS in Hubei province:(1)Lack of top-level design;(2)The coverage of OCS was restricted within narrow limits;(3)Insufficient capacity of primary medical institutions was in contradiction with the OCS reform,and the Essential Medicine System(BMC)caused some resistances;(4)The basic situation of UEBMI and the financing space for the OCS were different.2.The reform path of the employees’ OCS in Hubei:(1)The main source of funds is from the unit capture in UEBMI’s personal accounts,and the actual differences should be fully considered.When the condition is mature,additional financing may be more powerful supporters for OCS.(2)At the beginning of the reform,the focus should be on the integration and unification of existing policies.Take the diseases-based OCS as example,including cerebrovascular disease,coronary heart disease,myasthenia gravis,ankylosing spondylitis and other,20 diseases appeared frequently in local catalogs,it suggested to gradually increase the above diseases within the fund’s ability to pay.In addition,day surgery,family hospital beds,special medicines,etc.can also be considered as special items to join the OCS.(3)Implementing Disease classification management,payment methods should be formulated according to the characteristics of the diseases.(4)Promote payment by diseases group and capitation methods,explore “APG points” payment in outpatient services.(5)Develop contract-based management,make full use of primary medical resources,promote healthy competition among medical institutions,and explore the contract model in designated pharmacies.(6)Policy cohesion,including adjustments to medical personal accounts,hospitalization insurance,supplementary medical insurance,public health.