Study On The Mechanism Of The Combination Of Capitation And Family Doctor Contract Service

Objectives:Based on the experience of the combination of capitation payment in typical countries and the investigation of the policy design and implementation of capitation payment at primary outpatient clinics in typical pilot areas in China,the core mechanism of the combination of capitation payment at primary outpatient clinics and family doctor contracted service was extracted.Propose supportive conditions and policy recommendations for an effective link between the family physician contract system and the Medicare payment system and provide strategic support for improving family physician contract services.Contents:Based on the experience of the combination of capitation payment in typical countries and the investigation of the policy design and implementation of capitation payment at primary outpatient clinics in typical pilot areas in China,the core mechanism of the combination of capitation payment at primary outpatient clinics and family doctor contracted service was extracted.Propose supportive conditions and policy recommendations for an effective link between the family physician contract system and the Medicare payment system and provide strategic support for improving family physician contract services.Methods:The literature review was conducted to review the international experience of the combination of ambulatory and general practitioner/family physician systems,as well as the policy status of the combination of outpatient ambulatory and family physician contract services in China.Through case studies,fieldwork was conducted in Shengzhou,Jinhua,Tianjin,Guangzhou and other typical areas for field research,semi-structured interview and personal in-depth interview were used to collect data on family physician contract services,capsize payments,and the combination of outpatient capsize payments and family physician contract services.Thematic framework analysis was used to analyze the design,practice and implementation of the system and to summarize key policies and initiatives of the system in conjunction with the contract services of family physicians.Based on principal-agent theory and synergistic theory,we construct a core mechanism for combining outpatient fee-for-service and family physician contract services in China through comparative analysis.Results:1.International experience in the integration of ambulatory care with general practice/family practice systemsThree typical countries in Britain,the United States and Thailand grant family doctors the right to manage the medical insurance fund and residents to sign free contracts.The number of signers determines the total amount of the head fee,and the head fee is directly used for the salary incentive of doctors.On the basis of implementing the strict first-treatment system at the grass roots level,capitation is adopted as the payment method for family doctors/general practitioners,which makes the allocation of health resources reasonable.The quality and efficiency of grass roots medical services have been ensured.2.The policy status of outpatient capitation combined with family doctor contract service in ChinaFrom 2016 to 2022,there were 159 documents related to the combination of primary outpatient capitation and family doctor contracted service in China,of which 10 were issued by the state and 149 by local governments.The state had not issued a special policy document on the combination of primary outpatient capitation and family doctor contracted service.A total of 27 local cities(counties)have clarified the special policy of outpatient capitation payment,and 6 cities(counties)have clarified the relevant rules of"combination with family doctor contract service".Zhejiang,Tianjin and other localities have pushed forward the pilot work of outpatient capitation payment and improved the relevant technical specifications.The key measures of the pilot in different regions mainly included issuing special policy documents;The outpatient fund package quota was allocated by distinguishing between "contracted" and "non-contracted" members of the insured and family doctors;To link such elements as capsize standard,risk adjustment,capsize division,total budget,year-end final accounts,and assessment with family doctor contract indicators;Efforts should be made to establish an incentive and constraint mechanism oriented by health management results,by strengthening the cooperation between vital health and medical insurance departments and the family doctor contract system,and finally trying to establish a health management resultoriented incentive and constraint mechanism.At present,there are still some problems to be further explored,such as rough risk adjustment and blind area in the allocation of surplus retention.3.The combination of outpatient capitation payment and family doctor contract service in typical areas of ChinaThe design of capitation payment policies in Shengzhou,Jinhua,Tianjin and Guangzhou vary greatly.The capitation payments in Tianjin and Guangzhou are not in the true sense and have not been integrated with the contracted services of family doctors.The city has essentially realized the combination of capper payment and family doctor contract service by means of the following measures:higher capper quota standard for contracted family doctors,different budget and settlement schemes for contracted and non-contracted family doctors,linkage assessment between capper payment and family doctor contract service,and coordinated promotion by medical and health departments.By means of differential "capper payment" under the total budget,the capper quota standard and the total budget are linked to the contracted service indicators,and the settlement is paid by contracted institutions,while APG payment by non-contracted institutions,Jinhua has essentially realized the combination of primary outpatient capper payment and family doctor contracted services.4.Constructing a core mechanism for the combination of outpatient services and contract services for family doctors in ChinaThe core mechanism of the combination of outpatient capitation and family doctor contract service in China should be built around three aspects:integrating family doctor service and capitation contract management,establishing a surplus retention and distribution mechanism to achieve incentive consistency,and improving the supervision and assessment mechanism to reduce the risk of "agent problem".In this way,the synergy between health care and health insurance can be achieved,and incentives and constraints can be established that are directed by the outcomes of health management.Conclusions:In the world,the community first visit system is commonly used,with GPs/family physicians being paid based on capitation payments.National policy documents in related fields have clarified the reform direction of combining primary outpatient capitation payments with contract services from family doctors,and all localities are in the pilot exploratory phase.There are great differences in the design of the trial capitation system in Shengzhou,Jinhua,Tianjin and Guangzhou,among which Tianjin and Guangzhou have not implemented the "capitation" system in the real sense,and have not yet realized the real combination with family doctor contract service.The cities of Shengzhou and Jinhua have essentially implemented the combination of outpatient capitation payment and contract services from family doctors.It is suggested to build a combination mechanism of outpatient capitation payment and family doctor contract service in China from three aspects:integrating family doctor service and capitation contract management,calculating the total capsize according to the number of contracted patients to achieve incentive compatibility of medical institutions,establishing a surplus retention and distribution mechanism to achieve incentive consistency,and improving the supervision and assessment mechanism to reduce the risk of "agent problem",so as to achieve synergy between medical insurance and medical services.Establish incentives and constraints based on health management outcomes.To help family doctors assume the dual "gatekeeper" duties of residents’ health and medical insurance costs.