Study On Schizophrenic Outpatients Service Utilization And Reimbursement Model Of Special Disease Outpatient Pooling Funds

Objective:Based on the understanding of schizophrenic outpatients service utilization, burden ofmedical expenses, reimbursement policy of medical insurance, the essay tries to analyzeproblems existing in the outpatients service utilization and the effect of reimbursementmodel on medical expenses, care-seeking behavior, and operation of fund, estimate thenecessity of integrating schizophrenia into special disease outpatient pooling funds and therationality of reimbursement model, and then put forwards more targeted policy suggestionon reimbursement model.Methods:Medical expenses, special disease outpatient pooling funds implementation effect, andother related data or materials were collected through retrospective data survey, typicalquestionnaire survey, insider interview. The normative analysis, statistical analysis, expertevaluations were applied to analyze the above-mentioned data and materials.Results:1. In the study, the average number of schizophrenic outpatient attendances per personper year was7.4in Wuhan, and21.9in Hangzhou respectively. Over80%of theoutpatients received treatment in the2nd-level medical organization and3rd-level medicalorganization. The proportion of outpatients visiting1st-level medical organization in Hangzhou was higher than that in Wuhan. The average expenditures per visit were227.6Yuan and268.9Yuan in Wuhan and Hangzhou respectively. The annual medical expensesper patient were2043.2Yuan and5893.3Yuan in Wuhan and Hangzhou respectively,which accounted for9.8%and19.6%of per-capita disposable income in Wuhan andHangzhou respectively. The proportion of drug cost, which accounted for95.9%of totalschizophrenic outpatient costs in Hangzhou, was higher than that in the total costs ofgeneral outpatient (50.9%).2. Annual medical expenditure per outpatient of urban employees’ basic medicalinsurance (2062.8Yuan) was higher than the annual medical expenditure per outpatient ofurban residents’ basic medical insurance (1847.7Yuan) in Wuhan, and the actualcompensating proportion of urban employees’ basic medical insurance (76.7%) was higherthan the actual compensating proportion of urban residents’ basic medical insurance(44.2%). Annual medical expenditure per outpatient of urban employees’ basic medicalinsurance (5905.8Yuan) was higher than the annual medical expenditure per outpatient ofurban residents’ basic medical insurance (4939.9Yuan) in Hangzhou, and the actualcompensating proportion of urban employees’ basic medical insurance (84.1%) was higherthan the actual compensating proportion of urban residents’ basic medical insurance(60.3%). The cost included in the scope of urbanemployees’basic medical insurance socialpooling fund accounted for78.7%of the total cost, and the cost included in the scope ofurban residents’basic medical insurance socialpooling fund account for47.8%of the totalcost in Wuhan. The main influencing factors of outpatient out-of-pocket medical expenseswere age, type of medical insurance, visiting times, and the medical organization rank.3. Annual out-of-pocket medical expenditure per schizophrenic inpatient of urbanemployees’basic medical insurance were3475.1Yuan,8781.1Yuan,2796Yuan, and5183Yuan in Wuhan, Hangzhou, Changsha and Wuxi respectively. Meanwhile, annualout-of-pocket medical expenditure per schizophrenic inpatient of urban residents’ basicmedical insurance were4875.1Yuan,10809Yuan,13760.4Yuan and5726.2Yuan in thefour above-mentioned city respectively. The results showed that inpatients insured byspecial disease outpatient pooling funds spend less money on inpatient service.4. In2010, the number of schizophrenic receiving both outpatient and inpatient care was375in Wuhan, accounted for7.1%of all patients. This kind of patients’ annualmedical expenditure per person was13160.8Yuan, and annual out-of-pocket medicalexpenditure per person was4245.1Yuan in Wuhan. The number of schizophrenic receivingboth outpatient and inpatient care was344in Hangzhou, accounted for9.4%of all patients.This kind of patients’ annual medical expenditure per person was32760.6Yuan, andannual out-of-pocket medical expenditure per person was7656.1Yuan in Hangzhou.5. To estimate the out-of-pocket medical expenditure of schizophrenic outpatientensured by general outpatient pooling funds in Hangzhou. It turns out that annualout-of-pocket medical expenditure per outpatient of urban employees’ basic medicalinsurance was1686.8Yuan, which accounted for39.6%of annual net income per person ofschizophrenic, and annual out-of-pocket medical expenditure per outpatient of urbanresidents’ basic medical insurance was2155.9Yuan, which accounted for50.5%of annualnet income per person of schizophrenic.Conclusion1. The general outpatient pooling funds could not eliminate the cost risk ofschizophrenic effectively because of its limited security capability. The out-of-pocketmedical expenditure of schizophrenic outpatient is prohibitive. The study suggests thatschizophrenia should be preferential integrated into special disease outpatient poolingfunds.2. Special disease outpatient pooling funds can resolve high cost risks, reduce theinpatient care utilization, and improve efficiency of funds operation. However, there areproblems which need much more attention and q uick reformation. For instance, outpatientservice utilization insufficiency, hidden danger of drug utilization, lack of mental healthservice providing in grassroots medical organization, irrationality of reimbursement model,unfairness between urban employees’ basic medical insurance and urban residents’ basicmedical insurance, etc.3. For reimbursement, this essay holds the opinion that the deductible should beabolished, the compensating proportion should be set rationally to guide suitable utilizationof health care while taking fully mental health resources distribution and the characteristics of schizophrenic into consideration, and the sole ceiling should cover outpatient andinpatient expenses together. For payment to medical organization, this essay holds theopinion that adopting the global budget to control costs. Considering the present situationin which grassroots medical organization lacks mental health services, the fixed medicalorganization policy should be loosen, the atypical antipsychotic should be included innational essential medicine list and the rehabilitation program should be integrated intoscope of medical insurance reimbursement. In addition, the government needs to makehealth medical aid policy aiming at giving assistance to schizophrenic being insured byspecial disease outpatient pooling funds.