Study On Urban Community Public Health Service And Medicaid For The Poor

BackgroundAt present, as the issue of poverty of urban area has aroused extensive attentions from all circles, governments at different levels have invested a great deal of fund to solve the poverty-related problems in the urban area. While the focus of poverty assistance is to solve the poverty and improve the livelihood of the poor, strengthen of providing fund for medical security is still limited. So far, no policy on medical security for poor population in urban area people has been formulated, so no Medicaid plan has been practiced under the guidance of unified policy by now. Because of the steady increase of medical expenditure of poor population in urban area, governments of all levels have conducted a lot of sound explorations in providing medical assistance for them. However, these Medicaid practices have showed many problems, for example, the irrational funding and reimbursement system and the unclear definition on the content and scale of assistance are of most prominence. Meanwhile, the coordination and cooperation among different governmental sectors related to poverty development need to be improved. Therefore, at the time that providing medical assistance for the poor population has become a new focus of the demographic development in the 21 st century, it is necessary and pressing to establish an appropriate Medicaid system for poor population in urban area in accordance with our national conditions.Under this background, Urban Health and Poverty Project (UHPP) has been carried out in 2001 with the cooperation of Chinese government and U.K. government. One of main objectives of this project is to establish a effective and sustainable community health services system (CHSs), from which the poor and vulnerable population in urban area can get basic health care. In addition, the objective of the project is to improve the health level of the poor population in urban area by improving the accessibilities of CHS. The reason why UHPP choose CHS as the base of Medicaid system is that the CHS is cost-effective. The CHS is a all-around health services, including medical service, preventive service, health care service, family planninginstruction and health education. Many researches have indicated that CHS is the best way for the residents to get basic health services. At the same time, the CHS plays very important roles in ensuring the equity and accessibilities of health services for the poor population in the urban area and controlling the health expenses. Given the level of economic development is low and the ability to supply health resource to poor population is limited, it is essential and vital to establish a Medicaid system based on the CHS for the poor population.ObjectivesThe development of CHS is a important action that can disposing the health resources rationally, reduce medical expenses and improve the accessibility of health services, and it is one of the effective ways to solve the basic medical demand of the poor population in urban area. At present, because of the lack of effective reimbursement mechanisms, many public health services that provided by CHS facilities can not get reasonable reimbursement for a long time, which has had the serious impact on the healthy operation and sustainable development of the CHS facilities. For the sake of establishing a sustainable development CHS system and set up a Medicaid system for the poor population in urban area nationwide on this basis, it is necessary to classify community health service items, and specify the responsibility and obligation that the government should undertake. In addition, in order to solve the health care problems of the poor population in urban area under the real economic development level, one of the key questions is: how much money should we supply for the Medicaid? How to raise the fund?Based on the above-mentioned problems, the main purposes of this research are:1. To define and classify the urban community public health service2. To calculate the cost of urban community public health service and the reimbursement amount that government should undertake3. Probe the reimbursement mechanism of urban community public health service4. Calculate the Medicaid cost of the poor population in urban area5. Probe the fund-raising and reimbursement mechanism of Medicaid thatappropriate for the real economic conditionsMethodsQualitative and quantitative methods, for instance, literature review, expertconsultation, focus group discussion, health statistics method, health economic analysis, cost estimation and health policy study are applied together to collect the data in this study. This study try to solve questions about classification and reimbursement mechanism of urban community public health, fund-raising and reimbursement mechanism of Medicaid for the poor population in urban area. The detailed information are as following:1. The community health service item having been provided in 16 cities nationwidehas been defined and classified by using the public product theory, and then make it prefect by using the focus group discussion2. The health statistics methods and health economic methods have been used to analyze the health care demand and utilization of the poor population in urban area. In addition, the demographic characteristics, economic, community health service status have been analyzed by use the health economic and policy analysis and problems-solving suggestions have been provided.3. The Medicaid plans of poor population in 4 cities have been analyzed using thecomparative analytical method, and the reimbursement amount of the Medicaid have been calculated at the same time.4. The cost of community health service items have been calculated using costestimation method. Based on the analysis result, the reimbursement amount of community public health services that the government should undertake, the cost of community health services for the poor population in urban area also have been calculated at the same time.Main results1. Classification of the urban community public health service itemsTotal 103 community health service items that provided in 16 cities have been classified into three groups: 38 items have been grouped into public health service, 27 items have been grouped into quasi-public health service and 38 items have been grouped into private health service. Among public and quasi-public service items, about 47 items are the basic health services. And these items are mainly about preventive health care services, its social benefit is significant. As the result, these 47 items should be the priority to implement, regardless of economic situation of different area.2. The cost of urban community public health service items and the reimbursementamount that government should undertakeAccording to the result of classification of the items of community health service, four cities (Shenyang , Chengdu , Xi'ning and Yinchuan ) investigated in this research have provided 22 items of public health service, 13 quasi-public health service items and 37 private health service items, respectively.The per capita cost of public and quasi-public health service items that provided in Shenyang, Chengdu, Xi'ning and Yinchuan in 2003 are 2.58 yuan, 4.09 yuan , 1.75 yuan and 2.72 yuan respectively. If calculate with the permanent population in the urban area, the total cost of the public and quasi-public health service that provided in Xi'ning and Yinchuan in 2003 are account for 0.09% to city's fiscal expenditure, Shenyang and Chengdu are 0.08% and 0.12% respectively, the average level of 4 city is 0.10%. If calculated with the population of the whole city in year of 2003, the proportion of 4 cities was 0.19 % on average.The study set up a linear regression model that regards average monthly income of the doctor in community health service organization of four cities as the independent variable, regards job cost of every minute of each person as the dependent variable. The Pearson correlation coefficient of the two indexes is 0.744, P <0.001. The decision coefficient of the model is 0.55, which reflect the salary of the doctor in community health service organization exerts a great influence on unit's service item cost, the model as follows:Y = 0.025 + 0.02\X (F =24.79, PO.001)According to the regulation " the standard of urban community health service center " that issued by ministry of health , the community health service center generally sets up according to the range of sub-district , about 30- 50 thousand of people in this range can accept the health service from each center. Suppose there are average 40,000 people accepted the health care from each CHS center, the reimbursement amount of public health and quasi-public health that the government should pay for each CHS center in four cities is about 70- 160 thousand Yuan appropriately every year.3. The cost of Medicaid and the reimbursement amount of government in four citiesAccording to the Medicaid scheme of the four cities, the reimbursement amount of the Medicaid in Shenyang, Chengdu , Xi'ning and Yinchuan is 23.56 million Yuan , 26.28million Yuan , 31.13 million Yuan and 35.91 million Yuan respectively, account for 0.15% ,0.17% ,0.30% and 0.18% of each cities' fiscal expenditure respectively, 4 city is 0.20% on average.According to base-line survey data and Medicaid scheme of the four cities (Shenyang representatives with the Heping district scheme, Chengdu representatives with the Wuhou district scheme), the proportion of medical expenses that the project should undertakes as follows: The Heping district scheme in Shenyang is 25.15%, the Wuhou district scheme in Chengdu is 38.40%, the scheme of Xi'ning is 25.15%, the scheme of Yinchuan is 12.39%, 4 city is 25.27% on average.4. The reimbursement amount of community health services for the poor population inurban areaShenyang , Chengdu , Xi'ning and Yinchuan have 27 , 32 , 36 and 22 community health service items listed in community health service package, respectively, These items mainly involve preventive health care, health education and medical care, among them many items belong to the public health service and quasi-public health service. The reimbursement of the public and quasi-public health service paid by government is obviously insufficient in every city at present, and community health facilities usually reduced or remitted clinic registration fee and diagnosis fee for poor population in urban area in the course of offering medical rescue. As the result, government should offer reasonable compensation to these service items. On the basis of cost estimation, the cost of CHS items for the poor population in urban area mainly depended on two indexes: the scale of the CHS and the number of the Minimum Living Standard beneficiaries at present in four cities. The result shows that the proportion of cost of community health service for the poor population in urban area to each city's Medicaid amount is: Shenyang 5.63%, Yinchuan 4.68%, Chengdu 2.02%, Xi'ning 1.79%, respectively.5. The existing problems of the Medicaid for the poor population in urban areaThe main problems are as follows: the Medicaid system is inefficient, lack clear Medicaid standard, low Medicaid reimbursement, the low coverage of the Medicaid, imbalance between supply and demand of health care.Conclusion1. Community public health service of urban area have remarkable function ofimproving the accessibilities of CHS for the resident as well as reducing community public health risk. During the course of reimbursement, the government should follow such principles: cost-effective and cost-benefit principle, the principle in conformity with economic development level and fair principle. For the area that the economic development level is relatively backward, the state finance should offer support, so as to ensure the residents of these areas can get the basic public health service equally. According to the result drawn from this study, if government pay for the community public health service and quasi-public health service on the basis of CHSs scale of each city, the reimbursement amount should account for about 0.1 %- 0.29-6 of every city's annually fiscal expenditure. Considering the social benefit and economic benefits of the public and quasi-public health services, government should invest certain proportion of expenditure on community public health service annually, so as to guarantee the continuity and stability of the fund of community public health service.2. Although he urban community health service has already begun to take shape, its fund-raising and reimbursement mechanism still lack of vigor. To guarantee the sustainable development of the urban community health service, the fund-raising channel of community health service should be widened actively, and its reimbursement mechanism should be improved step by step. Meanwhile, quite a lot of community health service organizations of every city lack of basic medical treatment equipments and information management equipments, which are obstacles to the smooth development of community health service. As result, the disposition of the basic equipment of community health service organization should be strengthened so as to ensure its function that there should be.3. The Medicaid schemes of the cities have been investigated still have some shortages: the function of Medicaid is quite low at present. Most cities regard minimum living standard beneficiaries as medical rescue target. And clinic and medical rescue only include part of minimum living standard beneficiaries. At the same time, the payment proportion of the poor in the Medicaid scheme is a little higher at present, which limited the normal use of the relief fund. So, the Medicaid program is very difficult to improve the state of seeking medical advice for the poor population in urban area. The proposition of the study is: to improve the proportion of actual reimbursement of Medicaid; clinic medical rescue should cover all minimum living standard beneficiaries so as to prevent them from serious disease as much as...