Positive Economic Analysis And Process Evaluation On The New Rural Cooperation Medical System

Positive Economic Analysis and Process Evaluation on the New Rural Cooperation Medical System[BACKGROUD]Seventy-nine percent rural residents had no medical insurance in China in 2003. At the same time, the growth rate of medical expenses were risen faster than that of the earnings of rural residents. In 1999, medical expenses per discharge in China almost exceeded the one-year earning of a rural resident. Excessive medical expenses have become a heavy burden for rural residents. Thus, it is even for some rural families to fall into poverty due to catastrophic illnesses. In the World Health Report 2000, China ranked the last fourth place comparing fairness in health financing among 191 member states. In 2003, Chinese government launched a voluntary health insurance program for rural residents named new rural cooperation medical system (NRCMS) which aimed to alleviate the economic burden for rural residents and to improve the equity in health financing in China.On a voluntary and family basis, in the beginning of the year of 2003, the central government, local governments and individuals contributed 10 Yuan (RMB), respectively, at least for per enrollee in the pilot counties, where were in the middle and west of China focusing primarily on alleviating the poverty due to catastrophic illnesses. In 2006, the contribution from the central government and local government raised to 20 Yuan (RMB) per capita, respectively. However, the contribution from individuals still pays 10 RMB per capita remains. Therefore, in 2006 NRCMS contribution of each insured was more than 50 Yuan (RMB). It was required that the subsidies from governments should be used to release the economic burden of catastrophic illness. Up to 2006, the central government and the local government had contributed 5.492 billion RMB and 16. billion (excluded the specific transfers and overhead costs) in NRCMS, respectively. It is imperative to assess the operation of the NRCMS for 5 years and its sustainability by using the structure- process-outcome framework and propose policy recommendations for NRCMS betterment on the basis of the findings from the assessment. [OBJECTIVES]China is a large country with a lot of rural residents and with great variance in regions, economic development, culture and peasants' willingness to be covered by the NRCMS. In China, there has several models of NRCMS. The aim of the study is to assess the process of short-term (about 5 year) operation of the NRCMS, such as status quo of the NRCMS, outpatient reimbursement models, reimbursement levels, equity in reimbursement, health check-up, managerial models of the NRCMS. Finally, the author will put forward some policy recommendations for NRCMS manager.The specific objectives of the study are listed as follows:1. To describe the effectof the NRCMS;2. To compare main reimbursement models of the NRCMS;3. To compare NRCMS outpatient reimbursement model: pooling funds (PFs) and family medical savings accounts(FMSAs);4. To evaluate the effect of the NRCMS on alleviating medical economic burden of rural residents;5. To evaluate inequality on the medical resource utilization and the NCMS funding reimbursement allocation in the rural people with different level of earning;6. To compare the effect of physical examination system of the NCMS system;7. To compare managerial models of the NCMS.[METHODS]1. MaterialsSeven pilot counties from four national pilot provinces were selected in 2003. Jiangsu province presented the rich area in the east region of China, Hubei and Jilin provinces presented the moderate rich areas in the middle of China, and Yunnan province presented the poor area in the west China. There were two models of ambulatory service reimbursement, which were pooling funds (PFs) and family medical savings accounts (FMSAs) in every selected province. Since there were no family savings accounts model in Jiangsu province, so that our study only selected one representative piloted county in Jiangsu province. Of all selected counties, four pilot counties were outpatient pooling models. such as Mo Jiang county in Yunnan ce, Wu Xue county in Hubei, Zhen Lai county in Jilinand Gan Yu county in Jiangsu. On the other hand, three pilot FMSAs counties were Xundian county in Yunnan, Gong An county in Hubei, Jiao He county in Jilin.Supplemental field surveys were conducted in Zhongxiang, Chibi Cities and other 8 pilot counties in Hubei province as well as Other four pilot counties in Jiangsu province, second- hand materials such as data of pilot counties in Hubei Province from 2005 through 2006 were added.2. Research MethodsDocuments and data were collected from interviews with managerial staff of the NRCMS in 7 pilot counties and cities, qualitative and quantitative methods were used to analyze the operation of the pilot counties. Key informant interviews, focus group discussion were conducted at provincial, county and township levels to compare the effect of two models of ambulatory service reimbursement.About 250 households in each sample county, totally, 1841 households, 6783 farmers and depends were Conducted via field survey in utilization rate of health service, reimbursement from the NRCMS, income and expenses of households, attitude of heads of households toward the NRCMS. Based on the household survey, analysis was conducted to knowthe ratio of poverty due to catastrophic illness, to compare the utilization of health services and reimbursement from the NRCMS by income. Benefit incidence analysis will be done to understand the equity of the NRCMS.3. Statistical Analysis3.1 The poisson test was used to analyze the rate of ambulatory visits and the admission rate;3.2 X~2 test was used to analyze attitudes of rural citizens towards and knowledge rate of two ambulatory models;3.3 The wilcoxon Z test was used to analyze the medical expense per capita, including inpatient and outpatient expenses.4. Econometric Analysis4.1 Concentration curve and concentration index were used to evaluate inequality in health utilization and the total number of reimbursement of the NRCMS; 4.2 The Pen Cohort analysis was used to rate the poverty before and after catastrophic diseases and the extent which the NRCMS to alleviate the poverty.4.3 The Six-Part model and liner regression model were used to identify, to some extent, factors such as income, gender and age which will influence the health utilization and the reimbursement of NRCMS.4.4 The SWOT analysis was used to compare the managerial models.[RESULTS]By the end of 2006, there were 1451 piloted counties of the NRCMS conducting in China. The NRCMS has coveraged 58.5ï¼…rural population, and 4.1 hundred million rural residents (47.2ï¼…of total rural population) have been covered by NRCMS. Enrollment rate was 80.7 percent, and the contributions per capita on average was 52 Yuan (RMB). The benefit rate of outpatient visits was 47 percent, and the benefit rate of inpatient was 3.9 percent. The beneficiaries of free physical examination I was 14.1 percent, the total benefit rate was 65 percent. The rate of inpatient reimbursement to total expenses amounted to 69ï¼…to 79ï¼…between 2004 and 2006, which showed that the expenses reimbursed was primarily used in catastrophic illnesses and the reimbursement rate showed an upward tendency.There are mainly four NRCMS models, the first is only reimbursing the inpatient expenses, the second model is reimbursing the inpatient and catastrophic outpatient expenses, the third one is to reimburse the inpatient cost and pooling outpatient financing expenses, the forth oneis to reimburse the inpatient cost but and outpatient expenses paid by family savings accounts. Comparing four NRCMS models, it is found that the reimbursement ratio of the inpatient and catastrophic outpatient cases is not as high as it was expected. It is found that it is too difficult to keep the rural residents to invest in NRCMS if most of them receive nothing in reimbursement. So the last two models may be more feasible in the future.There are some characteristics in FMSAs if compared with PFs. Generally speaking, the counties conducted FMSAs have poor economic status, lower income per capita and higher poverty head count. FMSAs have neither significantly increasing the coverage rate of CMS, nor increasing the utilization of ambulatory services. The reluctant to use clinic visits will lead to miss the basic health services. The FMSAs model results in a lot of fund deposition. The inequality occurred in the FMSAs model reimbursement, and the PFs model may result in inequality in the NRCMS reimbursement.It was found by the six-part model that income level, especially in the poor regions, may affect health service utilization in rural population. The poor utilized the health services less than the non-poor and were reimbursed the medical expenditure less than the non-poor in the NRCMS. Of 7 sample counties, Mo Jiang county in Yun nan province was the most poverishment. It was found that there were obvious inequality on medicine utilization and NRCMS reimbursement by income quintiles among the population in Mo Jiang county.The NRCMS funding level as well as its reimbursement level, is low. The reimbursement rate in NRCMS is about one quarter of total medical expenses. There was about 3.35 percent people fell into poverty due to catastrophic illnesses. After the NRCMS reimbursement, only 1 percent people were avoided and become the poor. It showed that NRCMS can not completely help people out of poverty.It was also found that the funding for physical medical examination had low efficiency, most enrollees recognized the free medical check-up is totally useless.There are three NRCMS management models in China at this moment in terms of managerial sectors. The first model of managerial sector belongs to the Bureau of Health, the second model is the Bureau of labor and social security, the third one is managed by commercial insurance companies. Most of the pilot counties belong to the first management model and this model works well in controlling the cost of medical expenses.[CONCLUSIONS AND RECOMMENDATIONS]1. The enrollment rate of NCMS should be further expanded It is suggested to be legislation for rural people in compulsory enrolling NRCMS by 2010.2. The medical expenses should be controlled. The NRCMS reimbursement system can be framed that the reimbursement inthe township hospital may get higher rate than that of county hospital, and the same for the city or provincial hospital. It is suggested that the good reimbursement system can lead inpatient choose the appropriate hospital, and reduce the medical expenses. Besides the costs can be reduced by moving from fee-for-service to a prospective payment system, such as diagnostic-related groups(DRGs) in which hospitals receive a fixed payment per patient depending upon patient's diagnosis. Finally, in order to attracted more people, the township center should strength staff training to improve clinical skills and technologies.3. NRCMS should cooperate with civil affairs sectors to ensure the poor utilize healthcare and services, and increase the reimbursement rate of the NRCMS.4. FMSAs should be replaced by the PFs in order to increase the efficiency of outpatient funds gradually.5. The efficiency of physical medical examination funds should be increased. It's suggested to select some vulnerable and. high-risk group instead of to do all people free of charge.6. In the past five years, health authority which managed the NRCMS had accumulated some invaluable experiences. And this managerial model has its advantage. The managerial expertise of the NRCMS managers should be improved.7. Insurance awareness of the rural people should be advanced and cultivated to abide by the NRCMS. NRCMS should be considered as a medical security system for rural people in the future.