ABSTRACT
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.
ABSTRACT
Objective To study the impact of capitation payment on obstetric indicators for the maternity insurance of urban workers in Yinchuan city.Methods Collection of indicators on lying-in women hospitalized at the obstetrics departments of designated hospitals in Yinchuan,in the period of 2011 to 2012 when the capitation payment was put in place.Such indicators include the percentage of uterine-incision delivery,diagnostics and therapeutic expenses,drug expenses,and average days of stay,along with mortality of pregnant and lying-in women and that of newborns,which are used as indicators to measure quality of care.Results The capitation payment policy has witnessed drops in the percentage of uterine-incision delivery,cost per inpatient,drug expenses per inpatient and average days of stay among urban workers covered by the insurance.The drops amount to 10％ for cost per inpatient and 45％ for drug expenses per inpatient.The differences found in pregnant and lying-in women are not statistically significant.Conclusion Capitation payment is conducive to dropping the percentage of uterine-incision delivery and medical expenses,and saving medical insurance payment,for the sake of optimal use of healthcare resources.
ABSTRACT
OBJETIVO: analizar la evolución de la unidad de pago por capitación (UPC), los métodos y las variables existentes para su definición dentro del Sistema General de Seguridad Social en Salud colombiano, luego de su implementación entre 1995 y el 2011. METODOLOGIA: estudio de tipo observacional descriptivo de corte longitudinal. La población de referencia la constituyeron todos los documentos consultados, entre libros, artículos de revista, bases de datos y presentaciones oficiales, que contuvieran los términos claves. Todos los documentos analizados se clasificaron tomando como referencia una escala de tipo Likert con cinco niveles. RESULTADOS: se encontró que la UPC se valora como elemento indispensable para mantener el equilibrio financiero del sistema. Desde 1995 hasta el 2011, los métodos para definirla fueron variados, pasando por una definición basada solo en el equilibrio financiero y la disponibilidad de recursos hasta configurar un estudio técnico con herramientas estadísticas que la ajustara anualmente. CONCLUSIONES: el origen de la UPC puede atribuirse a la orientación del sistema hacia un esquema de mercado y a la confluencia de tres teorías básicas. Las variaciones de la UPC siempre han referido un valor similar año tras año; por ello, aunque cambie la metodología para su definición, esta seguirá en proporciones iguales si se compara con años anteriores.
OBJECTIVE: to analyze the evolution of the Capitation Payment (UPC for its Spanish name "unidad de pago por capitación") as well as the methodologies and variables for defining it that have existed in the Colombian Social Security System in Health since its implementation between 1995 and 2011. METHODOLOGY: An observational, longitudinal descriptive study. The reference population was made up of all the papers reviewed, including books, journal articles, databases, and official presentations containing the key concepts. RESULTS: It was found that the Capitation Payment (UPC) is valued as an essential element to maintain the financial balance of the health system. From 1995 to 2011 there were a number of methodologies for defining this payment. They ranged from a definition based only on the financial balance and the availability of resources, to a technical study using statistical tools to annually adjust the value of the UPC. CONCLUSIONS: The origin of the UPC can be attributed to the systems orientation toward a market scheme and to the convergence of three basic theories. The variations in the value of the UPC have always resulted in a similar value year after year; this is why even if the methodology for defining it changed, the proportions will be the same when compared to previous years.