| BackgroundMedical insurance out-patient financing is the effective policy to enlarge and satisfy the essential medical demands of employees,to make full use of medical resources effectively,to improve the efficiency of medical service and to save the health insurance fund.With the implementation of the policy,out-patient planning gradually expand to out-patient ordinary diseases,chronic diseases,and catastrophic disease.Meanwhile,its coverage,benefits,and the degree of benefit are increasing.But with the development of medical science and technology,the implementation of medical insurance,the improvement and release of consumer demand and other factors.More and more in-patients should not have been hospitalized also stay in hospital,that could have been in the out-patient treatment to deal with the disease,because the insurance factors,also to promote the medical insurance demand and the supplier side shall stay in hospital with the game of interests.Therefore,it greatly wastes the medical resources,reduces the operation efficiency of medical service,and wastes the medical insurance fund,so that the limited insurance fund can not maximize its mutual assistance.How to consider and analyze the influencing factors of various aspects is a new problem for employee essential medical insurance.to attract the patients who should not be hospitalized through the adjustment of out-patient policy to the clinic and to change both the doctors diagnosis and treatment and patients hospitalizing behaviors,expand the spectrum of out-patient diseases.On this account we can effectively improve out-patient coordination,improve the utilization rate of medicare funds,improve the efficiency of medical service,and make full use of medical resources.ObjectivesBased on the analysis of the basic conditions of the out-patient co-ordination policies of the essential medical insurance in the sample counties,to analyze the out-patient service capabilities of the sample medical institutions and the common disease epidemiological spectrum.And then determine the scientific and rational general out-patient disease spectrum through expert discussion.The scientific division of out-patient and in-patient funds is determined based on the common out-patient disease spectrum,and analyze the influence mechanism and influencing factors of out-patient co-ordination policies from the perspective of different stakeholders,such as supply and requisitioning parties,which can provide policy recommendations for the sustainable development of out-patient co-ordination policy.MethodsDescriptive methods were adopted to analyze the overall operation and implementation effect of the basic medical insurance fund for employees in the sample county.Pearson correlation analysis was used to analyze the relationship between out-patient service benefited range,out-patient service benefited range and capital utilization rate.The expert group discussion method is adopted to determine the out-patient co-ordination disease spectrum,and analyze the scientific division of funds between out-patient and hospitalization through economics of health insurance.Multivariate linear regression was used to find the main important factors of out-patient co-ordination disease expense.Results1.The out-patient compensation fund increases year by year,and the compensation effect enhances significantlyAfter the implementation of the out-patient policy,the sample county out-patient compensation fund of employees’ basic medical insurance fund increases year by year,Out-patient compensation visits,total out-patient expenses and outpatient reimbursement also increases year by year,the out-patient benefited range expansion,the out-patient benefited degree increase,the capital utilization rate also increases.Pearson correlation analysis showed that there was positive correlation between out-patient service benefited range,out-patient service benefited range and capital utilization rate,and the correlation coefficients were 0.881 and 0.941 respectively.2.Sample medical institutions’ out-patient service capacity is relatively strong,which is suitable for more diseases to be treated in the out-patient department.The samples medical institutions meet the requirements of service ability of common disease,polymorphic,chronic diseases and catastrophic disease in the human,financial,physical aspects.Medical institutions can not only treat the existing out-patient disease spectrum of pulpitis,hypertension Ⅱtype,chronic gastritis and other diseases,but also suitable for more diseases to be treated in clinic.3.A more complete out-patient disease spectrum is establishedBased on the determination of 50 species of disease spectrum in an existing clinic by expert discussion,use the average hospitalization day and the average hospitalization expense as the standard.From the hospital disease Spectrum,there are 36 kinds of common diseases,such as internal hemorrhoids,climacteric syndrome,acute gastroenteritis has been confirmed,that can be treated in out-patient clinics.4.A scientific and reasonable compensation plan for out-patient department is established.After the adjustment of out-patient disease spectrum,the proportion of out-patient and hospitalization compensation fund is 3.2:6.2,and the out-patient compensation ratio is 44%which is relatively reasonable.5.The determination of out-patient disease spectrum requires the cooperation of different stakeholders and then determine the influencing factors of out-patient co-ordination diseasecosts.The influence mechanism of out-patient disease spectrum was analyzed from manager,supplier,demand and supervisor.And the multivariate linear regression found that the main influencing factors of out-patient disease cost from high to low in the order were drug-accounted ratio,surgery,age and sex.Recommendations1.To improve the out-patient service capacity of medical institutions in order to adapt to the reform of out-patient co-ordination disease spectrum2.To perfect out-patient co-ordination disease spectrum,determine reasonable compensation scope3.To control the out-patient co-ordination disease expense,prevent aggravating the patients’ medical expense burden4.To improve the ratio of out-patient compensation and promote the reasonable diversion of out-patient and inpatient5.To control the risk of the fund and coordinate the division of funds between out-patient and hospitalization... |
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