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Objective To evaluate the impacts of DRGs payment reform on patients, medical insurance fund and hospitals, then to steadily promote the payment reform. Methods The reimbursement data of inpatients covered by NCMS yet beyond the single-disease payment were collected from two DRGs pilot hospitals from January 2016 to June 2018. Such means as descriptive statistics, t test and method of interrupted time series analysis were used to compare the changes found in the average out-of-pocket payment, actual reimbursement rate, average per-hospitalization compensation, average length of stay, and average hospitalization expense before and after the DRGs payment reform. Results After the reform, the average out-of-pocket payment and average length of stay began to fall slightly instead of the increasing trend (β3 were -72.79,-0.11, respectively, and P<0.01), the upward trend of average hospitalization expense slowed down ( β3 was -113. 55, and P<0.01), actual reimbursement rate and the average per-hospitalization compensation stayed the original growth trend (β3 were 0.10,-31.15, respectively, and P values were 0.08, 0.09, respectively). Conclusions DRGs encourages the hospitals to curb the average hospitalization expenses, with the growth trend kept at a slower pace. The payment reform does not increase the financial burden of patients, and tends to ease such pressure on funds, but the long-term effect remains to be seen.
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Pilot areas have achieved initial success in capitation reform. On the other hand, challenges remain unsolved in terms of practical pathways, change of national medical insurance management system, related measures, incentives and allocative mechanism for implement of the reform. With the concerning on progress, practice, effects and challenges of typical areas, this article established an institutional framework. On such basis, we propose to design and refine a scheme in terms of 5 aspects, namely strengthening the basic medical care packages′financing, setting contents and standard of the basic medical care packages rationally, establishing effective evaluation system and formulating supporting measures.
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Objective To analyze the main practices of capitation payment system reform in the case areas and put forward enlightenments and suggestions in this regard. Methods The implementation practices of the case areas were summarized, and descriptive statistical analysis was carried out on the implementation effects. Results By analyzing the effectiveness of the case areas′reform, it was found that the case areas are curbing the excessive growth of medical expenses (for example, outpatient fees per visit of Dingyuan county-level hospitals decreased from 245.11 yuan in 2015 to 218.40 yuan in 2017), increasing the actual compensation ratio of residents ( for example, the actual compensation ratio of Funan increased from 59.80% in 2015 to 63.28% in 2017), forming a medical treatment pattern within the county (for example, out-of-county compensation ratio in Dingyuan decreased from 37.38% in 2015 to 31.13% in 2017), achieving double-way referrals (for example, the number of referrals to superior hospitals of Jimo increased from 98 in 2015 to 328 in 2017), improving the subsidence of quality services, and controlling the risks of medical insurance funds. Conclusions At present, the reform of the case areas has been implemented steadily and achieved results. It is recommended to further improve such aspects as reform coordination, insurance standard setting, incentive mechanism establishment, and leadership to ensure the reform progress.
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Objective To analyze the operation of the diagnosis-related groups ( DRGs) pilots for inpatients in the new rural cooperative medical system in Yulin city of Shaanxi province. Methods The medical records of 33306 inpatients discharged from the 3 pilot hospitals between January and July in 2017 were analyzed, aided by expert discussions, on-site assessment and medical records examinations. Results By the end of July 2017, the DRGs grouping tool had been running stably. The DRGs enrollment rates of discharged inpatients were all up to 99% in the 3 pilot hospitals. The coefficient of variation ( CV) was higher than 1 only in a few DRGs. The average length of stay and the average hospitalization expenses growth rate were both found declined. However, there also exist problems in the pilots, namely incomplete regulations for DRGs, low clinical path coverage rate, hysteretic supervision and assessment, uneven quality of medical records management and so on. Conclusions The pilots operated smoothly as evidenced in their initial success. Yet the following recommendations were raised for the improvements: To strengthen the organization and leadership to improve the DRGs related supporting system in pilot hospitals; To strengthen the promotion and application of clinical paths for standardization of the medical service process;To improve the DRGs assessment program and establish DRGs operation monitoring and tracking analysis system; To strengthen the training of medical record coding staff to improve continuously the quality of medical records.
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Objective To analyze the operation of the diagnosis-related groups ( DRGs) pilots for inpatients in the new rural cooperative medical system in Yulin city of Shaanxi province. Methods The medical records of 33306 inpatients discharged from the 3 pilot hospitals between January and July in 2017 were analyzed, aided by expert discussions, on-site assessment and medical records examinations. Results By the end of July 2017, the DRGs grouping tool had been running stably. The DRGs enrollment rates of discharged inpatients were all up to 99% in the 3 pilot hospitals. The coefficient of variation ( CV) was higher than 1 only in a few DRGs. The average length of stay and the average hospitalization expenses growth rate were both found declined. However, there also exist problems in the pilots, namely incomplete regulations for DRGs, low clinical path coverage rate, hysteretic supervision and assessment, uneven quality of medical records management and so on. Conclusions The pilots operated smoothly as evidenced in their initial success. Yet the following recommendations were raised for the improvements: To strengthen the organization and leadership to improve the DRGs related supporting system in pilot hospitals; To strengthen the promotion and application of clinical paths for standardization of the medical service process;To improve the DRGs assessment program and establish DRGs operation monitoring and tracking analysis system; To strengthen the training of medical record coding staff to improve continuously the quality of medical records.
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Objective To learn the behaviorist changes of county and township hospitals in their care of the diseases categorized in the hierarchical system before and after the system was in place. Methods Descriptive statistics and correlation analysis were used to analyze the changes of the diseases categorized in the hierarchical system which were cared at both county and township levels. Results The inpatients coverage of such diseases in county W in the western region at county and township hospitals was 44. 97%and 59. 28% respectively. These data were higher than that in county F in the eastern region, which were 18. 32% and 15. 58% respectively. As discovered in the Spearmen rank correlation analysis, the inpatients growth of diseases under the hierarchical system of counties F and W in 2015 was positively correlated to the difference between the pricing for the disease in question and the average hospitalization fee for the same disease in 2014 (r=0. 462, P<0. 001;r=0. 304, P=0. 018 ). In county W where the quota payment of specific diseases was in place, the increase of the average cost per hospitalization in 2015 was positively correlated to the above mentioned difference in 2014 and 2015(r=0. 447, P<0. 001). Conclusions The coverage of such diseases should be expanded. Changes in the pricing for such diseases will influence inpatients flow, while quota payment per disease can curb the increase of costs per hospitalization.
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The hierarchical medical system is to match and balance the medical service demand and supply. This article probed into main problems encountered in introducing such a system, discussed the mechanism of action for the system which was based on diseases, and proposed the driver model for a disease-based hierarchical medical system.
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Objective To understand the influence of the disease-based hierarchical medical system on inpatients flow covered by the new rural cooperative medical system ( NRCMS) , and that on the funding diversion and medical costs so incurred. Methods One county was selected from the eastern, central and western regions of China respectively, where the disease-based hierarchical medical system has been in place. Policy documents of the three counties were reviewed to analyze such changes as NRCMS inpatients flow, inpatients subsidy diversion, NRCMS fund surplus rate of the current year and medical costs per hospitalization before and after the system was in place. Results A comparison with 2014 found a 1. 26%drop of the out-of-county inpatients of county W of the western region, a 2. 00% increase of township hospitals inpatients of county D in the middle region, and the same ratio of out-of-county and in-county inpatients in county F of the eastern region in 2015. Compared with 2014, the fund surplus rate of county W increased 10. 46%, and the inpatient subsidy ratio of county D decreased 2. 51% for those in out-of-county medical institutions in 2015. Thanks for the quota payment of specific diseases under global budget in county W, the inpatient medical costs per hospitalization dropped at both county and township medical institutions. Conclusions The disease-based hierarchical medical system could optimize the NRCMS inpatients distribution among various medical institutions, conducive for establishment and operation of such a system.
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Objective To investigate the awareness and utilization of community family doctor services of residents in Beijing and analyze its influential factors.Methods Multistage random sampling was adopted to enroll residents in Beijing from eight community health centers in Haidian District, Xicheng District and Daxing District,to investigate the awareness and utilization of community family doctor services.Customized questionnaires were recovered for descriptive statistics and influential factor analysis.Results All the 3 008 effective questionnaires were recovered.The results found that 92.2% of the residents used community family doctor services.Higher utilization rates of community family doctor services was found among those residents of chronic diseases,those with their family′s annual average outpatient expenses in the medium level,those with their first choice of medical visits in the community health centers,and those who are aware of family doctor service.Services of the most frequent use in the recent year were physical examination and follow-up phone call(87.3% and 73.4% respectively);those of lower frequency were door-to-door service,health assessment,preventive health care,physical examination,health education and consulting,and rehabilitation service.Factors of statistical significance on utilization of community health services were health condition,financial condition and awareness of community family doctor service(P<0.05).Conclusions Residents in Beijing have a high awareness and utilization of community family doctor services,yet some items of services are seldom used.Health condition,financial condition and awareness of community family doctor service are major influential factors for utilization of community health services.
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Objective To learn the awareness,attitude and behavior changes of medical workers to the family doctor service and the influential factors on their utilization of such service since the service is in place.The purpose is to provide theoretical basis to establish the family doctor service model and the incentive mechanism in line with the development of community health service in Beijing.Methods Eight community health centers were sampled randomly from three representative areas of Haidian,Xicheng and Daxing districts,which were grouped randomly as one intervention group and one control group.All the medical workers surveyed were subj ect to the research.The control group was managed as to the existing management mode,and the intervention group was classified and managed according to the new family doctor service model.A questionnaire survey was made to collect data from the baseline and final stages.Comparisons were made among the districts,institutions,and before-after intervention of the institutions themselves to evaluate the effects of the service model and incentive mechanism.Results The survey found a higher awareness by medical workers to such service,higher recognition and satisfaction, and lower rate of services provided by medical workers.The logistic regression analysis found the influential factors for willingness of medical workers to work as family doctors,include group difference, workload changes after signoff as family doctors,residents′acceptance of the community first visit system,recognition or not for whether a family should have a community service team,residents′acceptance,and the general comments on family doctor service (P< 0.05 ).Conclusions Higher incentives of community doctors to embrace family doctor service,calls for the medical workers to change their perception,better incentive mechanism and greater promotion efforts for family doctors′services.
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Boundaries definition plays a key role in defining the scope of essential medical coverage of the country and the governmental role positioning in medical service offerings.It is also a precondition of furthering the ongoing healthcare reform.This paper analyzed the data of health service demand,supply and financing using the priority setting and the integrated balance methods.It suggested that the definition of the essential medical services should embody Chinese characteristics and be consistent with the Party′s governing philosophy and social core values.It also should be fully considered that the administration system,the governing philosophy,the medical insurance system and the government duty in the healthcare system of China.This paper proposed a multiple-criteria defining of the essential medical services,which should focus on main healthcare issues in China,and be adapted to the current healthcare reform process.Three dimensions need to be considered in the defining,which are the demand,supply and financing of the healthcare services,along with the impact of the housing,equipment,personnel, technology,supplies,drugs and other medical service elements.This paper presented the overall framework of essential medical services in four levels,which is composed of the basic package,the core package,the priority package and the expansion package.
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Objective To determine the main contents and key points of the essential medical services by means of priority setting of diseases with high incidence and serious damage based on the demand of residential medical services.Methods The priority setting method is applied in this study,and the incidence,prevalence,hospitalization rates and the ratio of different types of inpatient are used as indicators to reflect medical demand and utilization.The integrated balance method is also used,and the priority diseases list is made based on the analysis from the view of disease onset,considering the service delivery,social equity and the health financing.Results Based on the data analysis made,this paper proposed that the priority diseases cover 29,66 and 103 types for primary hospitals,secondary hospitals and tertiary hospitals respectively.The main diseases so determined include hypertension,diabetes, maternal and child health,severe mental illness,infectious diseases,emergency treatment,etc.Conclusions The method and result of setting priority disease and main disease can be the basis of setting for main diseases in essential medical services.
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Objective To divide the medical services currently offered by various medical institutions into priority,extended and non-essential items.Methods The items were divided according to their actual usage at these hospitals,and such services were screened based on hospital positioning and clinical pathway of diseases.Results The selected priority services at the primary,secondary and tertiary hospitals were 255, 378 and 820 respectively.Their proportions in total medical services of these hospitals were 92.9%,95.9% and 97.4% respectively,and the proportion of their costs in total medical service costs were 57.9%,76.8% and 84.5% respectively.Conclusions The selected priority items had covered most of the services and costs,which deserve promotions at all the hospitals as it embodied the principle of benefiting the majority of the population.
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To achieve the goal of universal healthcare coverage,and the objective of the ongoing healthcare reform to establish an essential healthcare system,the study proposed a financial framework for building the essential medical service package,covering medical services offered by primary medical institutions,treatment of major diseases,and essential medical services offered by secondary and tertiary hospitals.With data over the years of the total medical expense and medical service usage as the basis,and in the principles of affordability and cost-effectiveness,the total financing quota of essential medical services is expected to reach 1 940.846-2 1 62.41 7 billion,accounting for 30.66%-34.1 6% of the total healthcare expenditure.75% of the financing load should be carried by the government and society, focusing on financing medical services offered by primary institutions and lowering out-of-pocket burden of residents.
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The improvement of women and children health,along with the growth in health needs,brings forth new challenges to maternal and children health care institutions.The dual demands of quantity and quality in maternal and children health services compel the institutions to improve capabilities under the current conditions,and more importantly,to further clarify the functional orientation which is the key issue for its development.This article is based on the analysis of the historical development and current situation of the maternal and children health care institutions,which sets up the functional orientation according with the rules and characteristics of maternal and children health services.The paper proposed a series of suggestions on its development,such as the health service admission system,appropriate staffing standards and the institution-construction standards.
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The three-level prevention theory is called into play as guided by the contemporary medical model and combination of prevention and treatment,to classify the services into three levels.Services by maternal and child health care institutions are designed as Level-1,early discovery,early diagnosis and early treatment prevention as Level-2,while clinical prevention as Level-3.The paper also clarified misunderstandings and proposed the general healthcare concept for such institutions.
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Introduction to the theories on improving coordination level of the new rural cooperative medical system,including the risk theory,great number rule,fair theory,demand theory and supply theory which are cornerstones of enhancing the NRCMS improving the pooling level.The paper also probed into the practices of improving the pooling level of the NRCMS,including the models of high level,middle level and low level pooling.These theories and practices can help the localities better design and manage the pooling level of the NRCMS.
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Objective To detect the expression of p-STAT3 and survivin in primary gallbladder carcinoma (PGC) and explore its significance for the genesis and development of PGC.Methods The expression of p-STAT3 and survivin were determined with immunohistochemistry in samples from 45 PGC tissues and 20 chronic cholecystitis.The relationship between the expression of these proteins and various clinicopathological factors was evaluated.Results The expression rate of p-STAT3 and survivin in 45 PGC tissues was 55.6％ ( 25/45 ) and 64.4％ ( 25/45 ),respectively,which was significantly higher than those in 20chronic cholecystitis tissues 5.0％ ( 1/20),10％ ( 2/20 ) ( P ＜ 0.01 ).pSTAT3 expression was correlated with survivin ( r =0.830,P ＜0.01 ).p-STAT3 and survivin protein expression were significantly associated with histopathological grading,lymph node metastatis,nevin staging and 3-year survival rate.Conclusions p-STAT3 and survivin might play a vital role in the development of PGC.The expression of p-STAT3 or survivin was an independent prognostic factor in PGC.
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The paper presented the principles and references for identifying services of the primary health care at townships and villages in Beijing, and proposed the screening criteria for primary health care package in rural Beijing. Studies made have identified the screening results for the package applicable to both townships and villages in Beijing, along with analysis for the rationale, applicability and operability of the package. Moreover, it probed into the assurance conditions for offering primary health care as a reference for other regions in the country.