A Study On The Implementation Effects And Problems Of Outpatient Planning Policy Of Basic Medical Insurance For Urban And Rural Residents In Chengdu Based On The Perspective Of Insured

In the report of the 19 th CPC National Congress,General Secretary Xi Jinping proposed that it is necessary to improve a unified basic medical insurance system and serious illness insurance system for urban and rural residents,and establish a medical security system with Chinese characteristics in an all-round way.In order to implement the spirit of General Secretary Xi’s report,on February 25,2020,the CPC Central Committee and the State Council issued the opinions on deepening the Reform of the Medical Security system(hereinafter referred to as the opinions),which pointed out that it is necessary to improve the basic medical insurance system.It is also emphasized that outpatient medical expenses should be gradually included in the scope of payment of the basic medical insurance fund,and the security mechanism of out-patient assistance should be established and improved.Outpatient security is once again emphasized in the central document,in the process of in-depth implementation of the decision-making and deployment of the 19 th CPC National Congress on the comprehensive establishment of a medical security system with Chinese characteristics,it is of strong theoretical and practical significance to study the implementation effect of the overall policy of medical insurance outpatient service for urban and rural residents.In this paper,through the field investigation of many grass-roots medical institutions in Wenjiang District of Chengdu,combined with the evolution characteristics of the overall policy of urban and rural residential insurance clinics in Chengdu,referring to the data of questionnaires and in-depth interviews,based on the perspective of the insured,this paper makes a comprehensive analysis on the implementation effect,existing problems and influencing factors of the policy in Wenjiang District in recent years,and attempts to put forward suggestions to optimize the implementation effect of the policy.The research object of this paper is the out-patient overall planning policy of basic medical insurance for urban and rural residents,the research focus is the implementation effect and problems of the out-patient overall planning policy,the research perspective is the perspective of the insured,and the main research method is the field investigation method.The research order of this paper is as follows: first,it analyzes the theoretical basis of outpatient co-ordination,and points out the theoretical and practical significance of outpatient co-ordination policy for the insured;secondly,a set of index system for evaluating the implementation effect of outpatient co-ordination policy is constructed from the perspective of participants.Then,according to the evaluation index system,combined with the data and materials obtained from the field investigation,the paper actually evaluates the implementation effect of the overall policy of outpatient service in Wenjiang District of Chengdu,and finds out the problems existing in the process of policy implementation and the main factors that affect the policy effect.Then,according to the problems and influencing factors found by the evaluation,draw lessons from the advanced experience in the implementation process of the out-patient overall planning policy in typical domestic cities,and extract the excellent practices of several typical cities;finally,in view of the problems and influencing factors found,draw lessons from the excellent experience of typical cities,and make suggestions and suggestions for optimizing the implementation effect of the out-patient overall planning policy in Chengdu.Based on the above research ideas,the research contents and viewpoints of this paper are summarized as follows:The first chapter is the introduction.First of all,starting from the background of the country’s call for the establishment and improvement of the basic medical insurance system for urban and rural residents and the increasing outpatient medical needs of the insured,the background and significance of the topic are drawn;then,the literature on outpatient medical security at home and abroad is reviewed and briefly reviewed;finally,the research ideas,research methods,possible innovation and lack of research are described.The second chapter is the concept definition and theoretical basis of outpatient co-ordination.First of all,this paper makes a brief analysis of the three ways of outpatient co-ordination: outpatient co-ordination of serious diseases,outpatient small subsidies and general outpatient expenses,and defines that the outpatient coordination studied in this paper refers to the co-ordination of general outpatient expenses.Then,it analyzes the three ways and characteristics of patients’ selfpayment,fund accumulation system,individual medical insurance account and outpatient planning to solve the outpatient economic burden,and points out that the advantage of outpatient planning lies in fairness and mutual assistance.It has a significant redistributive function.Finally,through the law of large numbers and the principle of risk diversification,the theory of disease prevention and health management,and the theory of information asymmetry and moral hazard,this paper expounds the enlightenment of the three theories for the analysis of outpatient overall planning.The third chapter is the outpatient overall planning policy and its evaluation of the effectiveness of the implementation of the insured.First of all,it expounds the policy objectives and design points of outpatient co-ordination,which are expounded from four angles: participants,medical institutions,medical insurance agencies and the system itself.the main points of the design include the standard of head quota,the proportion of reimbursement and the top line,the determination of designated medical institutions,the scope of reimbursement and the mode of cost settlement,and then analyzes the historical evolution characteristics of the policy of outpatient co-ordination in Chengdu.Then,based on the perspective of the insured,from the following four aspects: whether the out-patient overall planning policy reduces the outpatient financial burden of the insured,whether it improves the health status of the insured,whether it increases the medical convenience of the insured,and whether it improves the medical habits of the insured,make clear the various dimensional indicators to evaluate the effectiveness of the policy implementation;finally,it expounds the significance of each dimension index and determines the evaluation index system for the evaluation content.The fourth chapter is the investigation and evaluation of the effect of the outpatient co-ordination policy in Wenjiang District of Chengdu based on the perspective of the insured.First of all,it expounds the sample selection of field investigation on the effect of out-patient overall planning policy.Then,according to the evaluation index system determined in the previous chapter,this paper evaluates and analyzes the implementation effect of Chengdu outpatient overall planning policy,when evaluating the impact of outpatient overall planning policy on the economic burden of insured outpatients,five indicators are taken into account: the sub-average outpatient expenses,the head quota standard,the actual reimbursement proportion of the insured outpatient expenses,the annual reimbursement limit and the insured outpatient financing standard.When evaluating the impact of the outpatient overall planning policy on the health status of the insured,the changes of the number of outpatient visits and hospitalization rate and the health level of the insured were taken into account.When evaluating the impact of the out-patient overall planning policy on increasing the medical convenience of the insured,two indicators are taken into account: the insured’s satisfaction with the reimbursement efficiency and the satisfaction with the medical service.When evaluating the influence of the out-patient overall planning policy on the improvement of the insured’s medical habits,three indexes were taken into account: the choice of the hospital,the awareness of the out-patient overall planning policy and the insured’s response to medical treatment.Then,after evaluation,the article found that the main problems in the implementation of the policy are: the family policy can’t effectively reduce the economic burden of the insured outpatient service,and the utilization rate of the insured outpatient service is not significant.there is even a downward trend,and the convenience of the insured has been improved,but there is still room for improvement in details and the insured are still weak in their medical habits such as hospital choice and responsiveness.Finally,for the problems found above,this paper believes that the main influencing factors are that the unreasonable distribution of outpatient co-ordination funds leads to the undetermined scientific reimbursement proportion and annual reimbursement limit,the non-inclusion of private hospitals in the policy scope affects the formation of diversified competition pattern,and the poor service capacity of grass-roots medical institutions leads to the lack of medical stickiness of the insured and the lack of effective connection with public health,family doctors and graded diagnosis and treatment system.The fifth chapter is the implementation of out-patient planning in typical areas and experience for reference.This chapter draws lessons from the excellent experience of four cities and intends to provide suggestions for optimizing the implementation effect of the overall policy of outpatient service in Chengdu.First of all,it draws lessons from the excellent practices of Zhuhai City,which can be used for reference: first,to implement a differentiated annual settlement quota per capita for participants of different ages and suffering from different degrees of diseases;second,second-and third-tier medical institutions are also included in the scope of outpatient co-ordination policy,so that participants have more options.Then,the article believes that Yancheng can be used for reference: first,it is a general trend to bring private hospitals into the scope of outpatient fund reimbursement,which can create a diversified competition pattern;second,bring private hospitals into the scope of outpatient co-ordination policy and provide a platform for the cooperation of public and private hospitals,so that public and private hospitals can promote symbiosis and better benefit the insured population.Then,Shanghai is giving full play to the core role of community general practitioners,opening the last kilometer of graded diagnosis and treatment,and cooperating with experts from Pudong Hospital to improve the service level of general practitioners in an all-round way.it is worth learning from two aspects: providing more high-quality and convenient outpatient services for the insured.Finally,the excellent experience of Qingdao is: first,the family doctor system provides real medical benefits for contracted people,significantly reducing the economic burden of contracted participants;second,the number of contracts is directly linked to the amount of medical insurance funds of various medical institutions to increase the enthusiasm of medical institutions to sign contracts.The sixth chapter is the suggestions to optimize the overall policy of medical insurance outpatient service for urban and rural residents to improve the implementation effect.On the basis of the problems and influencing factors found in the previous article,and by drawing lessons from the excellent practices of four typical cities,this chapter thinks that the differentiation strategy can meet the outpatient medical needs of different categories of insureds.therefore,it is proposed that the outpatient overall planning fund can be allocated scientifically,and the differential reimbursement ratio and per capita annual reimbursement limit can be set to meet the outpatient medical needs of different categories of participants and reduce the burden of outpatient expenses.The article finds that the lack of grassroots service capacity is the main reason why the insured do not form the path dependence of medical treatment,so it is suggested to improve the service ability of grass-roots medical institutions,cultivate the grass-roots stickiness of the insured,and improve the utilization rate of outpatient service.improve the health status of the insured.The formation of diversified competition pattern can enable public medical institutions to take the initiative to improve the quality of medical services.therefore,the article suggests to expand the scope of medical choice of participants,and bring second-and third-level hospitals and private hospitals into the scope of application of outpatient overall planning policy.create a diversified competitive atmosphere,improve the service quality of medical institutions,and increase the convenience of outpatient care for the insured.Finally,this paper believes that we should take the community(township)general practitioner as the core,combined with public health services,family doctors and graded diagnosis and treatment system,provide quality health security services for the insured,strengthen the health awareness of the insured,and improve their medical habits.The possible innovations of this paper are as follows: first,from the perspective of research methods,this paper constructs a set of evaluation index system for the implementation effect of the overall policy of basic medical insurance outpatient service for urban and rural residents from the perspective of insureds.it provides a tool reference for medical insurance agencies to evaluate the implementation effect of the policy.Second,unlike the academic circles,which mostly explain and analyze the effect of outpatient overall planning policy through theoretical or macro data,this paper goes deep into a number of grass-roots medical institutions in Chengdu to conduct on-the-spot investigations and informal interviews,which can more truly reflect the problems and deficiencies in the implementation of outpatient overall planning policy.Third,from the research perspective,based on the perspective of the insured to examine the implementation effect of the outpatient co-ordination policy,the perspective is relatively new,which can better reflect the original intention of the establishment of the health insurance system.