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As the major means of outpatient payment for basic medical insurance (the insurance for short) relies on fee-for-service, it tends to encourage unreasonable growth of medical expenses. Based on the principal-agent theory, this paper analyzed the principal-agent relationship between the insurance handling agencies and the hospitals designated by the insurance, and constructed a benefit game model of outpatient payment methods and the supporting supervision game model. This practice aims to explore the optimal and balanced benefit of the insurance payment methods and supporting supervision mechanism, and provide decision support for promoting the reform of medical insurance outpatient payment in China. The analysis results of the benefit game model of payment methods showed that a system mixing the post-payment and pre-payment could optimize and maximize the total benefits and interests of all the stakeholders within the system. Specifically, the practice recommended was a mixed payment integrating ambulatory-payment-classification, fee-for-service and global-budget-payment. The analysis of the supporting regulatory game model found that the factors that must be considered to ensure the expected utility of the above mixed payment mode as follows: the gap between the unreasonable income obtained by the hospital by out-of-control charging and the reward obtained by under-control charging, the size of the penalty after the unreasonable income of the hospital was discovered, the size of the regulatory cost and the loss of benefits of the government and the insured group. It is suggested to adopt the mixed payment method mainly based on the ambulatory-payment-classification supported by fee-for-service and global-budget. At the same time, medical insurance agencies can improve their supervision mechanism from such aspects as perfecting penalties, reducing supervision costs, leveraging government administrative power and advocating public supervision.
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Objective To analyze the composition and influencing factors of the hospitalization expenses of patients with cardiovascular and cerebrovascular diseases who has participated in basic medical insurance, and to provide evidence for controlling excessive increase in the hospitalization expenses and reducing the financial burden of patients. Methods The hospitalization information of 14,271 insured patients with cardiovascular and cerebrovascular diseases from January 1, 2019 to December 31, 2019 in Xianning City, Hubei Province was retrospectively collected. The basic information of the patients and the composition of their hospitalization expenses were descriptively analyzed, and the influencing factors of hospitalization expenses of the patients were analyzed by univariate analysis and logistic regression analysis. Results Among the patients included in the study, coronary heart disease, cerebral infarction, cerebral hemorrhage and essential hypertension were the four main types of cardiovascular and cerebrovascular diseases with the largest proportion of hospitalization expenses, accounting for 26.18%, 20.29%, 11.82% and 9.94%, respectively. The largest proportion of hospitalization expenses was treatment expenses and drug expenses, accounting for 44.09% and 32.52%, respectively. Logistic regression analysis showed that age, length of stay, type of insurance, type of cardiovascular and cerebrovascular diseases, whether there were other comorbidities or complications, and whether they visited tertiary medical institutions were the influencing factors of hospitalization expenses for patients with cardiovascular and cerebrovascular diseases. Conclusion It is necessary to strengthen the disease prevention and control for the elderly and patients with cardiovascular and cerebrovascular diseases such as coronary heart disease, cerebral infarction, cerebral hemorrhage and essential hypertension, accelerate the integration of the basic medical insurance system, scientifically and reasonably shorten the length of hospital stay, and strengthen the promotion of the hierarchical medical system.
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Objective:To investigate the current status and influencing factors of outpatient institution choice for hypertensive patients with basic medical insurance in Beijing, for reference to promote the implementation of the hierarchical medical system and guiding hypertensive patients to seek healthcare in primary care.Methods:Based on data of hypertensive outpatients from the basic medical insurance database of Beijing from April 2019 to January 2020, we analyzed major demographic characteristics of hypertensive patients, the selection of outpatient institutions and its influencing factors. The chi square test was used for comparison between groups, and the multivariate logistic regression model was used to analyze influencing factors.Results:2.842 1 million outpatients with hypertension were enrolled. 39.03% of them chose primary healthcare institutions, 5.16% chose secondary healthcare institutions, and 17.34% chose tertiary healthcare institutions, while the rest 38.47% chose two or more types of healthcare institutions. Gender, age, type of medical insurance, place of residence, utilization of Chinese herbal drugs, utilization of Chinese patent drugs, polypharmacy, needs of outpatient tests and examinations were the influencing factors for their selection of primary healthcare institutions for hypertensive outpatients under Beijing basic medical insurance.Conclusions:At present, the primary institutions have become the first choice for the majority of hypertensive patients with medical insurance in Beijing, but there are still many influencing factors on their choice of institutions. In the future, we should optimize the allocation of medical resources, promote the reform of medical insurance payment methods, strengthen the construction of primary medical institutions, expand the coverage of contracted services of family doctors, and reasonably guide the patients to seek healthcare in primary healthcare institutions.
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As a powerful attempt by government to promote the construction of the multi-level healthcare security system and social and commercial integration in China, " City-customized Medical Insurance" still has many problems to be solved at the beginning of its development, such as unclear boundary between government and enterprises, limited coverage and strength of security. On the basis of clarifying the current situation of " City-customized Medical Insurance", and combing the management experience of social and commercial integration in Medicare Part C plan of the United States, the authors put forward that China should make full use of the advantages of the combination of promising government and efficient market, guide differentiated product design, and establish market access and evaluation mechanism, so as to promote the effective connection between China′s commercial health insurance and basic healthcare insurance, and further reduce the people′s medical burden.
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Objective:To analyze the filing mechanism for cross provincial immediate reimbursement of medical insurance in China, so as to provide reference for optimizing the filing mechanism and improving the filing accessibility of insured personnel.Methods:Taking the filing policy of cross provincial immediate reimbursement of medical insurance in 2019 as the research object, on the basis of a comprehensive understanding of the national filing policy background, 90 coordinating regions in Zhejiang Province, Hubei Province and Ningxia Hui Autonomous Region were taken as survey samples to evaluate the relevant policies and extract key parameters, including filing identification methods, filing-related settlement benefits and filing ways. The parameters were compared and analyzed by using descriptive statistical methods.Results:The results of the survey showed that in terms of identity recognition methods, the provision of various supporting materials(residence permit, work certificate, etc.)was still the main way to carry out identity recognition for medical insured persons in different places.Filing-related reimbursement benefits were mainly adjusted by limiting the area of medical insurance treatment and adjusting the benefits parameters(reimbursement ratio). In terms of filing channels, 51(56.7%)sample co-ordination areas had realized at least one remote filing mode.Conclusions:The inclusiveness of filing identity verification mechanism for the floating population needs to be further improved, the filing-related treatment policies need to be further improved, and the convenience and standardization of filing channels need to be strengthened.
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OBJECTIVES@#To verify the applicability and extensibility of the satisfaction index of basic medical insurance for rural and urban residents, and to explore the mechanism responsible for the satisfaction index in Kunming and Changsha City, and provide references for effective management and policy making.@*METHODS@#A stratified cluster sampling method was conducted. A total of 560 familial decision makers were randomly selected in 24 classes of 14 schools of Kunming and Changsha City. Model reliability was tested by SPSS18.0. In addition, Smart PLS 3.0 was applied to conduct model validity test, calculate the satisfaction index, and to compare the model path coefficients of Kunming and Changsha by multi-group analysis.@*RESULTS@#In the application of the satisfaction index of basic medical insurance for rural and urban residents in Kunming, Cronbach's α of the model was 0.93, split-half reliability coefficient was 0.90, and the latent variable composite reliability coefficient values were more than 0.86; the latent variable average variance extraction (AVE) values were greater than 0.66, and the square root of the AVE of each latent variable (all greater than 0.66) was larger than the correlation coefficient with other latent variables. The factor loading values were greater than 0.70, with statistical significance. The basic health insurance satisfaction index of Kunming and Changsha was 60.40 and 52.05, respectively. The difference between the path coefficient of Kunming and Changsha was not statistically significant except the path from public satisfaction to public loyalty. Perceived value had the largest direct and total effect on public satisfaction latent variable in Kunming City. While the perceived value had the largest direct effect on public satisfaction, and the perceived quality had the largest total effect on public satisfaction in Changsha City.@*CONCLUSIONS@#The satisfaction index model reflects the satisfaction of pupils' basic medical insurance for urban and rural residents, and it also shows good reliability and validity in Changsha and Kunming. What's more the model can be extended to the national level to evaluate the satisfaction of basic medical insurance for urban and rural residents for primary school students. The basic health insurance satisfaction index of familial decision makers in Kunming is higher than that of Changsha. There are differences between Kunming and Changsha in the influential mechanism of the satisfaction index of for Chinese pupils with basic medical insurance for rural and urban residents, and the measures taken by the government and relevant departments to improve the satisfaction of basic medical insurance should be based on local conditions.
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Humans , China , Decision Making , Personal Satisfaction , Reproducibility of Results , Rural Population , Urban PopulationABSTRACT
OBJECTIVE：To provi de reference for classification ，selection and management of antibacterial drugs in medical institutions. METHODS ：The adjustment of antibacterial drug list in 2019 edition of National Basic Medical Insurance ，Work Injury Insurance and Maternity Insurance （called“New List ”for short ）was introduced. The politic reference of selection and adjustment of antibacterial drugs and the principle of classification selection in medical institutions were sort out. The challenges which may bring to pharmaceutical administration and clinical use in medical institutions were investigated. RESULTS & CONCLUSIONS： Three new varieties of the antibacterial drugs in the New List have been added ，including Doxycycline injection，Faropenem granules and Metronidazole oral regular-release preparations. Nine product specifications were excluded ，such as Tetracycline oral regular-release preparations ，Dirithromycin oral regular-release preparations ，etc. The limitation of indications and/or indications of 19 regulations was modified ，and some antibacterial requirements were limited to patients with clear evidence of drug sensitivity test or severe infection. When classifying and selecting antibacterial drugs ，medical institutions should take the existing policy documents as the basis ，strictly implement the relevant provisions of antibacterial drug management ，give priority to meeting various national prescription sets and drug list varieties ，select drugs with sufficient evidence-based treatment basis ，drug quality and safety ，and take into account the convenience and economy of drug use ，supply guarantee service capacity of drug production and circulation enterprises and local situation of pathogenic bacteria resistance. The adjustment of New List also brings challenges to use and management of antibacterial drugs in medical institutions. For example ，New List emphasizes“limited drug sensitivity evidence ”for many antibacterial specifications. But if the clinicians choose drugs mechanically according to the drug sensitivity results and ignores the experience treatment in anti-infection treatment ，another type of “abuse”may be abused ；in addition，the indications of myxomycetin B and colistin （sulfate myxomycetin ）are completely different ，which also deserves further study.
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Objective To explore the utilization of the basic medical insurance and the influence of age factors on the medical expenses of the retirees. Methods Descriptive statistics and variance analysis were used to analysis the 265 426 medical service use records of the retirees in Y city in 2016. Results Increase of age pushes up the utilization rate of retirees for hospitalization services and reduces the service utilization of chronic disease outpatient clinics. In total, the medical expenses are concentrated in the age of 60-70, and the total medical cost of the population decreases with age. The per-capita medical expenses of different age groups were different, the greater the age the higher the average.Conclusions The change of the disease spectrum such as higher incidence of chronic diseases poses a new challenge to the medical service system. Aging will continue to pressurize the medical security system. It is urgent to establish a healthcare system centering on the elderly and a sound medical insurance system.
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This paper defined the main stakeholders of basic medical insurance mobile payment using the stakeholder theory, namely the government ( medical insurance bureaus, human resources and social insurance authorities, and healthcare regulators ), medical insurance agencies, pilot hospitals, medical workers, patients, and third-party social resources ( third-party payment entities, commercial insurers, web-based medical enterprises, and state-own financial institutions). SWOT analysis is used in analysis of stakeholders, to uncover the strength, weakness, opportunity and threats in advancing basic medical insurance mobile payment, thereby proposing how to guarantee the healthy and sustainable development of such mobile payment.
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Objective To find out research progress for remote medical treatment of basic medical insurance in China,in order to provide evidences for further research and policy-making.Methods Doing literature research.Results Research progress is summarized from five aspects,such as concepts and theoretical basis,causes of remote medical treatment and different social problems caused by it,the observation of domestic and foreign experiences,shift and continuity of basic medical insurance for rural residents,as well as instant reimbursement.Conclusion The enlightenment from the existing research is put forward,that is to solve the related problems of remote medical treatment.The most important thing is to classify the people who need remote medical treatment,and then to give solutions acording to different categories.
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Objective: To compare the differences and caused of patients' utilization of Traditional Chinese Medicine service under three basic medical insurance systems.Methods: Using self-developed questionnaire,random sample survey was conducted among the basic medical insurance outpatients in five hospitals in Nanjing and Lanzhou.The survey content included the basic information of the patients,the utilization of Traditional Chinese Medicine outpatient clinics,the utilization of Traditional Chinese Medicine service items,and the suggestions for the Traditional Chinese Medicine service.Results:①The utilization rate of the Traditional Chinese Medicine out-patient clinics in new rural cooperative medical system patients was much lower than that in urban basic medical in-surance patients.②The utilization rate of Traditional Chinese Medicine service projects in patients under basic medical insurance for urban employees was higher than those under medical insurance for urban residents and new rural cooperative medical system patients.In all Traditional Chinese Medicine service projects,the utilization rate of cupping project was the highest(48.3％).③ The gap between urban and rural areas made the utilization rate of Traditional Chinese Medicine service projects different among patients participating in basic medical insurances.④ The most expected suggestion of patients was the improvement of the efficacy of Traditional Chinese Medicine(68.5％),followed by the improvement of medical insurance-related reimbursement ratio(65.2％)and the in-crease of reimbursement items(64.3％).Conclusion: The government should increase the financial input in new rural cooperative medical system and improve the basic medical insurance system.Traditional Chinese Medicine medical institutions should improve the quality of services in order to achieve the fairness in the provision of health services.
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OBJECTIVE:To provide reference for improving related policy and list about medical insurance medicines in China. METHODS:The descriptive analysis method was used to compare 2017 and 2009 edition of Medicine List for National Basic Medical Insurance,Employment Injury Insurance and Maternity Insurance in respects of item,medicine classification (including classification code,grading and name),medicine types(including new type,removed type),dosage(including new dosage classification,adjusted dosage form),the limit of payment and use.The trend of its development and the existing problems were discussed. RESULTS:Compared with 2009 edition,2017 edition of medicine list added the item of"drug classification code"and removed the item of"English name". The grading of drug classification code was reduced from six grades to four grades. The code and name of four grades classification were in accordance with the first four grades classification rules of the anatomical-therapeutic-chemistry(ATC). A total of 2 535 types were included in 2017 edition,increasing by 362 types compared to 2009 edition(151 chemical medicines,211 Chinese patent medicines). 15 types of chemical medicines were removed,and 4 types were transferred to Chinese patent medicine list;11 types of Chinese patent medicines were removed,and one type was transferred to chemical medicine list. 2017 edition was actually 20 more dosage forms than 2009 edition,involving 31 types;dosage forms of 231 types were adjusted(143 chemical medicines,88 Chinese patent medicines). Chemical medicines of usage and payment restriction increased from 239 to 302,and Chinese patent medicines increased from 72 to 115,respectively. CONCLUSIONS:2017 edition of list increases the number of medicine,expands the scope of clinical medication and improves the classification structure of the list.The number of medical insurance cost control type shows a growing trend.
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Objective:To calculate the government and society financing limit under different compensation schemes in Inner Mongolia Autonomous Region,forecast the funding level for the next 5 years;to analyze the financing ability of government and society under different compensation schemes in the process of integration of basic medical insurance for urban and rural residents in Inner Mongolia Autonomous Region.Methods:Based on the Even Difference Grey model,it simulated and forecasted the government and social future financing levels for the next 5 years.Based on the Synthetic Degree of Incidence model,it analyzed the feasibility of government and society under different compensation schemes.Results:No matter under which type of compensation schemes,the funding body of government and society occupied a dominant position,and the amount of financing has increased rapidly.From 2011 to 2015,the growth rate was above doubled.In the next 5 years,the growth rate has reached to tripled.According to the calculation of 3 types of compensation schemes(30％ of outpatients and 60％ of hospitalized patients,30％ of outpatients and 70％ of hospitalized patients,40％of outpatients and 70％ of hospitalized),the government and society financing was more feasible under these three types of compensation schemes.Conclusion:The amount of government and social financing raising continues to increase,it faced enormous challenges.In terms of feasibility,there were 3 types of compensation programs which were more reasonable.
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Objective:To evaluate the efficiency of basic medical insurance operated by commercial insurance in Anhui and provide evidence for medical insurance management system reform.Methods:Using the ultra-efficient DEA model to evaluate the efficiency of basic medical insurance operated by commercial insurance in 2016.Results:The pilot areas with comprehensive effective efficiency accounted 40％ of the evaluated pilot areas,increasing returns to scale occurs in 30％ pilot areas and decreasing returns to scale occurs in 40％ pilot areas.Conclusion:It needed to improve the management level of commercial insurance companies and services capabilities of operators.
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Objective:To evaluate the impact of the establishing universal basic medical insurance system(UMIS) on pharmaceutical industry in China.Methods:Based on the accumulated main business income data of China's pharmaceutical industry from 2002 to 2014,the influence change of UMIS on China's pharmaceutical industry before and after 2008 was analyzed by the segmented regression model.Results:Segmented regression model showed that the slope rate of development trend of main business income of China's pharmaceutical industry was 1.03×107 thousand yuan per quarter(P=0.000) before the implementation of UMIS in 2008.After the implementation of UMIS in 2008,the slope rate of development trend of main business income of China's pharmaceutical industry was 2.75× 107 thousand yuan per quarter (P=0.000) and trend increased 1.72× 107 thousand yuan per quarter(P=0.000).Conclusion:The UMIS had impact on the structure,sales volume of pharmaceutical products and sale costs of China's pharmaceutical industry.UMIS had a significant effect on the increase of China's pharmaceutical industry.
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Objective:To study the effect of individual and system characteristics on migrant workers' participation in basic medical insurance for urban employers.Methods:The data of "2014 National Floating Population Dynamic Monitoring Survey" and official documents from 28 provincial capital cities and municipalities directly under the central government were used to analyze the influencing factors of 50 679 migrant workers' participation in medical insurance.Results:The characteristics of human capital,economic characteristics,mobility and access to basic public health services of migrant workers all had significant impacts on their participation in medical insurance;local governments' support for trans-provincial transfer medical insurance,the years of payment could be accumulated while one to one conversion and personal account could be roll-in roll-out were important factors to promote migrant workers to participate in medical insurance,and also helped to attract interprovincial migrant workers.Conclusion:In the system design,the overall level of medical insurance should be improved,and the obstacle to identification of the years of payment and the transfer of personal medical insurance account should be cancelled.
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Objective:It examined the impact of Urban Resident Basic Medical Insurance(URBMI) program launched in 2007 on labor supply.Methods:Using ordinary least square and instrumental variable estimation,the regression analysis was conducted on URBMI household survey data.Results:Although the URBMI increased the accessibility to medical services and decreased residents' financial burdens,the unemployment rate for residents with URBMI were increased by 13％.Conclusion:In respect to the problems of aging and labor force reduction in China,the policy-maker should not ignore the potential negative labor market outcomes while expanding public health insurance coverage.
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Objective:To calculate the individual financing amount of residents under different compensation schemes in Inner Mongolia Autonomous Region,and to analyze the feasibility of financing individual residents in the process of integration of basic medical insurance for urban and rural residents in Inner Mongolia Autonomous Region.Methods:Based on the absolute correlation model,the relative correlation model and the comprehensive correlation degree,it calculated the individual financing quota of different compensation schemes in Inner Mongolia Autonomous Region from 2011 to 2015,and analyzed the feasibility of its financing.Results:The increase in the amount of funds required for the residents in 5 years was more than 2 times,and the average annual growth rate was more than 25％.These three types of compensation programs(30％ outpatients + 70％ hospitalized).The correlation degree of the compensation scheme (40％ outpatient service + 70％ hospitalization) was between 0.60 and 0.85.The correlation degree of the compensation scheme was relatively high,which reached to 0.920.The correlation degree of these five compensation schemes was relatively low,which reached to 0.508.Conclusion:The amount of funding required for individual residents in Inner Mongolia Autonomous Region increased by years.The three types of compensation programs(30％ outpatient service + 70％ hospitalization) were more feasible than the four types of compensation programs(40％ outpatient service + 70％ hospitalization).
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Objective:To calculate the medical compensation fee,management fee and risk reserve in the medical insurance fund of Inner Mongolia,calculate the total financing amount of the medical insurance fund under the different compensation scheme in 2011-2015 and the amount of fund-raising fund of the per capita health insurance fund,and study the financing feasibility of urban and rural areas in Inner Mongolia in the integration process of Basic Medical Insurance for urban and rural residents.Methods:The medical insurance fund under different compensation schemes in Inner Mongolia was calculated by using the residual qualified model,the correlation degree qualified model,the variance ratio qualified model and the small error probability qualified model.Results:The average health insurance fund under the five compensation schemes in 2011-2015 was between 521.43 yuan and 2012.27 yuan.The five compensation schemes were to be raised between 128.85 yuan and 49.73 billion yuan respectively.Based on different kinds of compensation program,the financing amount of basic medical insurance fund for urban and rural residents in Inner Mongolia increased by years.The average annual growth rate was 20％,the average annual growth rate of per capita health insurance fund financing was 10％.Conclusion:The amount of fund raising increased quickly by years with high financing pressure.This was a difficult task for the advancement of the integration of basic medical insurance for urban and rural residents in Inner Mongolia.Meanwhile,it provided a scientific and effective financing plan of insurance fund for promoting the integration of basic medical insurance in Inner Mongolia.
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Objective:To estimate the medical compensation fees in medical insurance fund under different compensation schemes in Inner Mongolia,and to study the feasibility of financing in the integration process of basic medical insurance for urban and rural residents in Inner Mongolia Autonomous Region.Methods:Based on the method of ratio method,original difference GM (1,1) model,Delphi method and moving average,the medical compensation fees under different compensation schemes in Inner Mongolia in 2015 was calculated.Results:Ignoring the factors such as pay line and cap line,the total compensation for medical expenses under the five medical compensation schemes were 18.778 billion yuan,25.355 billion yuan,30.351 billion yuan,32.346 billion yuan and 46.04 billion yuan.Conclusion:Based on the measurement of medical compensation under different compensation schemes,it calculated the financing amount of the integration of medical insurance,analyzed the feasibility of the basic medical insurance financing in Inner Mongolia.In the treatment of growth factors,insurance factors and other indicators,the innovative use of a variety of methods combined approach,scientific and effective calculation of the growth factor and insurance factor,revised a part of the annual growth factor which had large growth,the insurance factor value was too high and other problem,in order to accurately assess the medical compensation.