Health insurance system has been proved to be an effective way to promote the quality of health service in many countries. However, how to control health expenditure under health insurance system remains a problem to be resolved. Some developed countries like UK, Canada and Sweden linked their health technology assessment results with decision making and health insurance management, and made prominent achievements in both expenditure control and quality improvement. China is carrying out its health system reform and running a new health insurance project. Using the experiences of other countries is undoubtedly of great importance in developing and managing our health insurance system.
Objective To explore the impact of diagnosis-related group (DRG) payment method reform under total amount control on neurology and neurosurgery departments. Methods The DRG grouping data of the Department of Neurology and the Department of Neurosurgery of Panzhihua Central Hospital from January 2018 to December 2020 were collected, and the mature DRG evaluation indexes in China were selected. Using the interrupt time series analysis method, the DRG-related indexes of the two departments before and after the introduction of the performance appraisal plan in July 2019 were compared, to evaluate the intervention effects on the two departments. Results Both neurology and neurosurgery departments showed a slow downward trend in the overall medical service capacity under the DRG payment. The efficiency of medical services showed a slow upward trend and the consumption of medical expenses showed a slow downward trend in the Department of Neurology, while the efficiency of medical services showed a slow downward trend and the consumption of medical expenses showed a slow upward trend in the Department of Neurosurgery. According to the results of interrupt time series analysis, in the Department of Neurosurgery, the total weight showed a significant downward trend before intervention (β1=−5.526, P=0.003), and the downward trend became sluggish after intervention, with a statistically significant slope difference before and after intervention (β3=4.546, P=0.047); the case-mix index showed a downward trend before intervention (β1=−0.050, P<0.001), and no obvious trend after intervention, with a statistically significant slope difference before and after intervention (β3=0.052, P=0.001); the cost consumption index showed no obvious downward trend before intervention (β1=−0.006, P=0.258), and an upward trend after intervention, with a statistically significant slope difference before and after intervention (β3=0.027, P=0.032). The impact of this assessment plan on the Department of Neurology was not statistically significant (P>0.05), needing further observation. Conclusions The reform of DRG payment method under total amount control has different effects on the evaluation indicators of clinical departments of different natures. It is recommended to implement classified management and assessment for clinical departments of different natures.
Objective To systematically review the effects of cost sharing in health insurance schemes, so as to provide evidence for better designing cost sharing ratio in health insurance scheme. Methods The search terms were discussed, tested and then chosen by subject matter experts and search coordinators. The total 20 databases including comprehensive scope, health, economics, sociology, and grey literatures were searched to retrieve all the description or evaluation studies on the effects of cost sharing, such as health services utilization, financial burden or moral hazard. The information from the included studies was extracted into a pre-designed data extraction form, and then it was analyzed and summarized. Results A total of 73 studies were included, covering 17 countries like Australia, Canada, and China, etc. The results of statistical analyses showed that, a) Cost sharing methods were applied to every kind of health insurance scheme. The target population included general population, the elder, the poor, those with chronic disease and children, etc. The services covered clinic, hospitalization, mental health, prevention and drug; and b) The effects brought from cost sharing included: From full fee to cost sharing scheme, the enrollee in developing countries increased their health care utilization, and decreased their financial burden. From full coverage to cost sharing, the utilization of health services decreased in developed countries, but the cost of health insurance could not be reduced, and some undesirable effects were brought due to the decrease of both essential health service utilization and essential drugs compliance.
Objective To explore the impact of Diagnosis-Intervention Packet (DIP) reform on the operation of pilot county-level hospital, analyze the challenges that hospitals may face in DIP reform, and propose strategies to adapt to the reform. Methods The settlement list data of inpatients insured by medical insurance for 2022 from a county-level tertiary public hospital in Jiuquan City, Gansu Province were collected, where DIP was planned to operate. The DIP payment was simulated, and the operational status of the hospital and departments after implementing DIP reform was analyzed based on enrollment status, cost deviation, length of stay, hospitalization expenses, and DIP payment as relevant indicators. Results Under the implementation of DIP payment, the overall enrollment rate of the hospital was 98.1%, including 85.4% in the core group, 7.0% in the comprehensive group, and 7.6% in the grassroots group. Normal costs accounted for 88.9%, deviation costs accounted for 11.1%, with high magnification cases accounting for 1.9% and low magnification cases accounting for 9.2%. The payment standard for all cases included in the hospital according to DIP was 15.464 million yuan, the total amount paid by the pooling fund was 19.986 million yuan, and the difference between DIP payment and payment by project was –4.522 million yuan. Conclusion There is a significant difference in the medical insurance payments received by county-level hospitals after implementing DIP payment, and there is an urgent need to adapt to the DIP payment reform as soon as possible.
ObjectivesTo analyze the economic burden caused by delay in the diagnosis and treatment of diabetes.MethodsThe employee/non-employee health insurance and medical examination data from Japan Medical Data Center (JMDC) and Milliman Inc. were used to analyze the health economic burden of the situation in case the diabetic population receives timelydiagnosis and treatment with real world data.ResultsThe overall population delaying the diabetes diagnosis and treatment in Japan was estimated to be 916 000, and the average time of delay was 39.6 months. The increase in time of delay was related with the increase in monthly medical costs after diabetes diagnosis. If the whole delayed population could receive timely diagnosis and treatment, it can totally save about 38.24 billion yuan (1.5% of the annual Japanese national medical expenditure.ConclusionsThe current study suggests a huge potential health economic burden that can be improved by promoting the diagnosis and treatment of diabetes, which provides reference for the economic evaluation of similar health policies and also the application of real world data in China in future.
Objective To explore the medical insurance quota payment of dialysis treatment for outpatients with end-stage renal disease in Chengdu from following aspects, evaluation indexes and reasonable amount, so as to provide scientific basis for the payment of single disease. Methods A questionnaire survey was conducted to collect the cost information of patients, and to formulate the assignment of evaluation indexes according to the therapeutic principles and statistical results; Delphi method was adopted to determine the assignment and the standard of quota payment. Results A total of 17 dialysis organizations approved by Chengdu municipal medical insurance were involved in this study. Of 700 questionnaires distributed, 686 were retrieved. After excluding 26 questionnaires for incomplete filling and incorrect treatment information, a total of 660 questionnaires were included actually, accounted for 94.28% of all informants. The results of survey showed that, the hemodialysis treatment rate accounted for 84% (555/660) of all informants, while the peritoneal dialysis treatment rate accounted for 16% (105/660). By assessing the project assignment of outpatient dialysis treatment, the minimum annual payment of hemodialysis was RMB 118 242.75 yuan, while that of peritoneal dialysis was RMB 96 498.00 yuan. Conclusion The quota payment of outpatient dialysis shows b evidence after adopting the treatment project assignment. The grading quota payment of outpatient dialysis enables the medical insurance fund to be more reasonably used.
ObjectiveTo explore effective evaluation tools as well as systems of medical service capability related to total payment control of medical insurance. MethodsCombining references and using the Delphi method, the evaluation indicators of total payment control of medical insurance were screened and identified. Then, based on analytic hierarchy process, a weight questionnaire was designed and weighted coefficients of all-level indicators were also calculated. ResultsWe proposed a mathematical model to evaluate medical service capability related to total payment control of medical insurance using three types of primary evaluation indicators and seventeen types of secondary evaluation indicators with their weighted coefficients. ConclusionThe establishment of the evaluation systems of medical service capability in medical institutions could objectively reflect medical service capability to some extent, and provide references on total payment control of medical insurance for medical insurance agencies.
Judging from the latest policies related to the medical insurance payment reform of the state and Sichuan province, the reform of medical insurance diagnosis-related group (DRG)/diagnosis-intervention packet (DIP) payment methods is imperative. The impact of DRG/DIP payment method reform on public hospitals is mainly analyzed from the aspects of hospital cost accounting and control, quality of filling in the first page of medical cases, coding accuracy, standard of medical practice, development of diagnosis and treatment technology innovation business, multi-departmental linkage mechanism, competition between hospitals, performance appraisal mechanism, and negotiation and communication mechanism. We should put forward hospital improvement strategies from the top-level design of the whole hospital and from the aspects of improving the quality of the first page of the cases and the quality of the coding, strengthening the cost accounting and control of the disease, carrying out in-hospital and out-of-hospital training, establishing a liaison model, finding gaps with benchmark hospitals, enhancing the core competitiveness of innovative technologies, and improving internal performance appraisal, etc., to promote the high-quality development of hospitals.
Value-based healthcare (VBHC) is an important guideline for current and future healthcare services. In practice, VBHC should be the best goal of public welfare of healthcare service. Meanwhile, VBHC and cost-effectiveness analysis together provide scientific evidence for healthcare decision-making. Pay by value is inevitable in the next stage of the reform of the payment system of medical insurance, and the health service system should be reconstructed based on VBHC. Finally, the challenges of VBHC implementation are discussed.
ObjectiveTo investigate the factors that influence Chinese residents, self-rated health and the effects of the multilevel health insurance system and neighborhood social capital on self-rated health. MethodsBased on the 2018 China labor-force dynamics survey data, and Stata 15.0 software was used to conduct χ2 test, univariate analysis and multiple logistic regression model were used to analyze the influencing factors of self-rated health of Chinese residents. An interaction model was used to analyze the interactive effects of the multilevel health insurance system and the social capital of the neighborhood on self-rated health. ResultsA total of 10 201 people were investigated in this study, and 39.20% of them were self-rated unhealthy. After adjusting for confounders, the results of the multivariate logistic regression model showed that having social health insurance (OR=0.8, 95%CI 0.7 to 1.0) and having neighborhood social capital (OR=0.7, 95%CI 0.6 to 0.8) were more inclined to self-rated health. In addition, the results showed that being male, having a college degree or higher, having a job, and drinking alcohol increased the risk of self-rated unhealthy (P<0.05); whereas being 45-59 years of age, 60 years of age or older, in the central and western regions, exercising regularly, and having a disease or injury within two weeks decreased the risk of self-rated unhealthy (P<0.05). There was a positive multiplicative interaction effect between health insurance and neighborhood social capital on residents’ self-rated health (univariate: OR=1.5, 95%CI 1.1 to 3.7, P<0.05; multivariate: OR=1.7, 95%CI 1.2 to 2.4, P<0.05), and negative additive interactions (RERI=−0.8, 95%CI −1.4 to −0.1; AP=−0.3, 95%CI −0.6 to −0.1; SI=0.6, 95%CI 0.5 to 0.8). ConclusionAttention should be paid to the self-rated health status of key populations through means such as health promotion and education, and healthy behavior lifestyles should be promoted. The health insurance system should be further improved, and attention should be paid to the role of social capital in the neighborhood, encouraging residents to actively build a good social neighborhood, and realizing the coordinated development of the multilevel health insurance system and the social capital in the neighborhood.