The Study On Compensation Plan Of New Rural Cooperative Medical System

BACKGROUNDBy June 2008, 31 provinces have implemented New Rural Cooperative Medical System, and so a rural primary health insurance system that is in consonant with the situation of China and in Chinese national style, has already taken shape initially. The practice has proved that the macroscopic policy environment and the financial support were the essential foundation of Cooperative Medical System building and developing, and once the policy and fund were available, its safeguard function's key lied in the compensation. Especially under the situation of limited funding, the scientific, reasonable and operable compensation plan may ensure safeguard function effective, and also guarantee fund operating safely, which promote the system to develop sustainablely. In 2008, the funding level of New Rural Cooperative Medical System has been raised significantly, and in this context, the study on compensation plan's design and adjustment, to use the additional fund well and make the farmers enjoy more the benefit that is brought by the increasing subsidy of the government, appears particularly important.The compensation plan is very important to achieve the system's goals, the main problems in the existing studies are the following: lacking a set of systematic compensation plan design theory; not comprehensively comparing four kinds of compensation patterns in present, not synthesizing deductible, coinsurance and ceiling to compare; not using more precise actuary methods such as Model Method and Loss Distribution Approach to calculate the compensation plan; still occupying the qualitative appraisal stage regarding the compensation plan, and lacking quantification comparison; not systematically and precisely studying how the compensation plan adjusts. AIMSThis study's overall goal is to totally and systematically discuss the compensation plan from two aspects of theory and demonstration and from two levels of macroscopy and microscopy, in order to provide reference for NRCMS's consummation and sustainable development. The concrete study aims include: establishing systematical compensation plan design theory of NRCM; discussing the optimized pattern of NRCM's compensation plan; establishing a quantifiable and operable evaluation index system of NRCM's compensation plan; studying the ajustment and consummation procedure of NRCM's compensation plan.METHODOLOGYThe data chiefly comes from literature review, expert consultancy, self-administered questionnaire and field survey. The self-administered questionnaire is mainly used to gain the pooling information of the national sample counties implementing NRCMS to analyze at present the ideal compensation plan pattern, and according to the difference of geographic region and economic development level, we altogether extract 150 sample counties. The field survey is mainly used to gain the data on plan design and adjustment, and according to the principle of typical sampling, we choose Zhangqiu and Pingyin County as the samples, where we altogether extract 2160 families of countryside residents, and 7607 persons. The expert consultancy is mainly used to determine the evaluation index and its weight coefficient of NRCM's compensation plan, and we have altogether consulted 20 experts. The data analysis methods mainly include descriptive statistical analysis, single factor statistical inference, Generalized Linear Regression, Panel Data Model, Multi-factor Logistic Regression, Multiple Linear Regression, Structural Equation Model, Loss Distribution Model, Synthetical Index Method, Principal Components Analysis, Cluster Analysis and so on, and the analysis softwares include SPSS13.0, SAS8.1 and EVIEWS5.0.MAIN RESULTS AND FINDINGS1. Theoretical study on compensation plan design of NRCMS: The compensation plan's design should follow the principles such as feasibility, deciding expenditure on the basis of income and moderately safeguarding, key prominent, guiding the patient to disperse reasonably, relative stabilization and at the right moment changing reasonably. Hospitalized compensation plan mainly should pay attention to deductible, coinsurance, ceiling and Directory of Drugs and Directory of Diagnosis and Treatment Items. The compensation plan's design should be discussed on the foundation of mixed insurance theory, which is the insurance having deductible, the coinsurance and the ceiling, and mainly consider how the consumer profits, but not solely strive for the fund to break even.2. The effect of NRCMS's compensation plan to hospitalization rates, expense and benefit: (1) The effect of NRCMS's compensation plan to hospitalization rates and expense: The hospitalization rates of farmers attending NRCM are lower in the area where outpatient compensation fund is family account, and ones are higher where inpatient compensation plan is that deductible is rising and coinsurance at county level is the highest. The major influencing factors of hospitalization rates include rural per capita net income, compensation pattern and hospitalized compensation plan type. County and township medical institutions are the main ones where the farmers attending NRCM are hospitalized. The propotion of hospitalizing in the county is higher in the area where outpatient compensation fund is unified planning or family account. The propotion of hospitalizing is highest at township level and is lowest outside the county, and the gap between them is biggest when rising deductible and degressive coinsurance are set simultaneously. The average expense per time is highest (average 4377 Yuan) where the fund is only used to compensate hospitalization, while it is lowest (average 2987 Yuan) where outpatient compensation fund is unified planning; the average expense per time is highest (average 3185 Yuan) when equal deductible and equal coinsurance are set simultaneously, while it is lowest (average 1948 Yuan) when rising deductible and degressive coinsurance are set simultaneously; the major influencing factors of the average expense per time include the proportion of farmers, rural per capita net income, compensation pattern and hospitalized compensation plan type. (2) The effect of NRCMS's compensation plan to benefit of farmers attending NRCM: the propotion of farmers in hospital compensated is highest (average 87%) where outpatient compensation fund is unified planning, while it is lowest (average 70%) where the fund is only used to compensate hospitalization; the propotion of farmers in hospital compensated is highest (average 86%) when equal deductible and equal coinsurance are set simultaneously; the major influencing factors of the propotion of farmers in hospital compensated include rural per capita net income, per capita amount of funds raised, compensation pattern and hospitalized compensation plan type. The actual compensated propotion is highest (average 29%) where outpatient compensation fund is family account, while it is lowest (average 25%) where the fund is only used to compensate hospitalization; the actual compensated propotion is highest when rising deductible and degressive coinsurance are set simultaneously; the major influencing factors of the actual compensated propotion include rural per capita net income, per capita amount of funds raised, compensation pattern and hospitalized compensation plan type. The average expense payed by himself per time is highest (average 3292 Yuan) where the fund is only used to compensate hospitalization, while it is lowest (average 2165 Yuan) where outpatient compensation fund is unified planning; The average expense payed by himself per time is highest (average 2858 Yuan) when equal deductible and equal coinsurance are set simultaneously, while it is lowest (average 1617 Yuan) when rising deductible and degressive coinsurance are set simultaneously. (3) The direction of project optimization is that inpatient and outpatient compensation fund both are unified planning, and rising deductible and degressive coinsurance are set simultaneously in the hospitalized compensation plan.3. Loss Distribution study on NRCMS: (1) The risk factor analysis of hospitalization rates and expense: the economic factor is the most important one influencing hospitalization rates, and health condition and age are also the important influencing factors. The influencing factors of hospital expense include the basic feature of the farmer, the disease characteristic, the feature of medical institution and the treatment process in hospital, among which the treatment process and the treatment way in hospital are keys affecting the medical expense finally. (2) Loss Distribution fitting: from the fitting result of the number of admission distribution, the fitting effect of Negative Binomial Distribution is best, Poisson-Poisson Distribution is next, and Poisson Distribution is worst. From the fitting result of the average expense distribution, the fitting effect of Burr Distribution is best, Pareto Distribution is next, and Logormal Distribution and Weibull Distribution are worse. (3) Forecasting Loss Distribution: the actual distribution curve and the forecast distribution curve of 2007 are nearly overlapping, and K-S examination obtains P>0.05, so combining the increasing coefficient of the expense, we can forecast Loss Distribution of the latter year by using actual Loss Distribution of the preceding year.4. Evaluation on compensation plan of NRCMS: In the evaluatation indicator system, 12 indicators choosed finally are in the range of expert consultancy, and all come from the regular work, and the feasibility is good. The indicators and their weighting are determined by expert consultancy, and the enthusiasm of experts is high (expert Positive Coefficient in two rounds respectively is 95% and 100%), the authoritative degree of experts is high (Authoritative Coefficient is above 0.85), and the coordination of opinions is good (Coordinated Coefficient in the second round is between 0.4455-0.7803), so the indicator system is reasonable. Through the assessment, the indicator system has good reliability and validity, and has basic condition to make it be utilized in the practice.5. Adjustment on compensation plan of NRCMS: According to farmer's choice, Zhangqiu and Pingyin's facts and the development trend of NRCMS, the patterns of two countys' both are adjusted to one that inpatient and outpatient compensation fund is unified planning. According to the loss distribution model of 2008, the deductible at township level, county level and outside the county in Zhangqiu is decided as 50,200, 600 Yuan in turn, and in Pingyin is decided as 150, 200, 500 Yuan in turn, which can guarantee that about 98% farmers who are in hospital at any level will obtain the compensation. The ceiling of Zhangqiu and Pingyin in 2008 is separately 36000 and 31000 Yuan. According to the optimized pattern and the loss distribution model, in 2008 the hospitalized compensation proportions of two counties both are set according to two-section and increasing type on expense and decreasing type on medical institution grade.RECOMMENDATIONS(1) Each region should play down the family account gradually, and transfer to the pattern that the outpatient compensation fund is unified planning, and guarantee that the proportion of outpatient compensation fund is not lower than 20%; (2) Every region should carry out the plan that according to the medical institution grade the increasing deductible and decreasing coinsurance are implemented and according to the expense the two-section and increasing coinsurance is implemented; (3) The region should establish and perfect the management information system of NRCMS, and through the informationization management the precious empirical data can be accumulated; (4) A series of quantification indicators are used to standardize the hospital and doctor's behavior, or the pattern of settling accounts of expense with the hospital is used to control expense, even the course of patient's treatment is involved directly, and the perfect and reasonable payment pattern is the breakthrough point and key point to control the medical expense risk in NRCMS; (5) The region should comprehensively consider the provincial economic increment rate, the price expense index, the farmers' per capita income, the increasing coefficient of medical expense and so on to unceasingly enhance the amount of fund raised of the government and the farmer and establish the reasonable growing mechanism about fund raised.INNOVATION AND INADEQUACYThe innovation includes that: (1) The innovation of research thought: In view of the characteristic and content of NRCM's compensation plan, the author combines theory with demonstration, macroscopy with microscopic view, and grasping from the whole with partial discussion, to construct a complete logical thinking frame, which is from the theory discussion of the project design, the comparison of different compensation plans, the study of the loss distribution, the evaluation of the compensation plan to the adjustment and optimization of the compensation plan. (2) The innovation of research view: For the first time four kinds of patterns and the different compensation plans are compared synthetically, and the ideal compensation plan is discovered, and the field of vision is more comprehensive. (3) The innovation of methodology: Panel Data Model is first used to analyze the effect of NRCMS compensation plan to hospitalization rates, expense and benefit; Structural Equation Model is first used to analyze the risk factor of hospitalized expense; Loss Distribution Approach is first used to design and adjust the compensation plan of NRCM.The inadequacy includes that: Because of the limited data and key, Insurace Factor is not considered in the plan design; NRCMS started to make experiment only from 2003, and the measures of the policy and management were gradually perfected, which all had affected the forecast precision.