完善新型农村合作医疗筹资与支付制度的实证研究
摘要
一、研究背景
我国的农村合作医疗制度在20世纪六、七十年代有过辉煌的历史,覆盖了约90%的农村人口。但随着农村经济体制改革的深入,合作医疗在全国范围内急剧萎缩,到2003我国农村有79.1%的居民没有任何医疗保险。许多农村居民出无力承担医疗费用而不能获得基本医疗服务,因病致贫、因病返贫现象严重。
为解决我国农村居民的医疗保障问题,中央政府提出要建立以大病统筹为主的新型农村合作医疗制度。新型农村合作医疗制度建立的目的,是切实减轻农民因疾病带来的经济负担,重点解决农民因病致贫、因病返贫问题,提高农民的健康水平。自2003年起,我国新型农村合作医疗制度开始试点。到2004年底,全国共有8040.01万农民参加了合作医疗,參合率为75.20%。随着试点工作的铺开,新型农村合作医疗制度实施中的问题也逐渐显现。在筹资与支付制度方面的问题主要表现为:部分农民参合意愿不强,特殊和困难群体参合缴费困难,筹资过程成本高,报销比例设置不合理,农民受益而窄,获得的实际补偿比低等。合理的筹资与支付制度是新型农村合作医疗制度持续发展的保证。由于我国新型农村合作医疗制度尚处于试点阶段,筹资与支付制度还不完善。如何促进和改善新型农村合作医疗筹资与支付制度、保证新型农村合作医疗在农村得以可持续发展,是新型合作医疗制度发展过程中所面临的重大挑战。
已有关于新型农村合作医疗的筹资与支付制度的研究,较少对合理的筹资标准和支付标准进行科学地测算,对调整和完善新型农村合作医疗筹资与支付制度开展的实证研究也比较少见。因此,为探索科学合理的新型农村合作医疗筹资与支付制度,本研究选取我国已开展新型农村合作医疗试点的县(巾)作为研究对象,在对新型农村合作医疗实施情况进行分析的基础上,设计新型农村合作医疗筹资与支付制度的改进方案,并根据方案实际调整和实施的情况,评价改进方案所带来的效果,为进一步发展和完善新型农村合作医疗筹资与支付制度提供参考依据,促进新型农村合作医疗制度的可持续发展。
二、研究目的
本研究的目的是通过对完善新型农村合作医疗筹资与支付制度的实证研究,探索新型农村合作医疗合理的筹资与支付制度,为完善新型农村合作医疗制度、促进新型农村合作医疗制度的可持续发展提供依据。
具体研究目标为:
1、了解样本县(市)新型农村合作医疗制度实施过程中筹资与支付制度上存在的问题。
2、找出影响和制约新型农村合作医疗筹资与支付制度发展的因素。
3、针对样本县(市)存在的问题提出筹资与支付制度上可行的改进措施。
4、评价样本县(市)实施新型农村合作医疗筹资与支付制度改进方案后的效果。
5、提出完善新型农村合作医疗筹资与支付制度的政策建议。
三、研究方法
(一)资料来源
1、样本县(市)选择
本研究采取分层抽样的方式选择样本县(市)。先根据中国各省(区)的地理位置和经济发展状况选择山东省和宁夏回族自治区作为研究对象。然后,在两个省(区)内按照经济发展水平高、中、低各抽取一个县(市)。在山东省,依照经济发展水平高、中、低选取了章丘市、昌乐县和东阿县;在宁夏回族自治区依次选取了青铜峡市、永宁县和中宁县。
2、调查方法及资料收集
本研究于2006年和2008年进行两次大规模现场调查,调查方法和资料收集情况如下:
(1)机构调查。机构调查的对象之一是六县(市)新型农村合作医疗管理办公室。通过设计并发放新型农村合作医疗实施情况调查表,了解2005-2008年新型农村合作医疗的总体运行情况、县(市)的人口、经济及健康和卫生资源状况。同时获取2005-2008年新型农村合作医疗住院报销数据库,了解参合农民获得住院补偿的情况。机构调查的对象之二是六县(市)所有县(市)级医疗机构、各县(市)三个抽样乡镇卫生院及九个抽样村卫生室。通过设计并发放医疗机构调查表,了解相关医疗机构2005-2008年的业务收支情况及从新农合获得的补偿情况。
(2)二手资料收集。系统收集国内外关于新型农村合作医疗的研究文献、中央政府自2002年以来出台的有关新型农村合作医疗制度的政策文件、2005-2008年六县(市)新型农村合作医疗制度的政策和实施方案,以了解国内外研究进展及中央政府和样本县(市)关于新型农村合作医疗的政策情况。
(3)定性访淡。通过关键知情人访淡和焦点组访淡,了解各县(市)新型农村合作医疗实施的情况、存在的问题及他们对新型农村合作医疗的意见看法。
(4)家庭入户调查。入户调查主要通过调查问卷了解该户全体家庭成员的基本情况、卫生服务需求及利用、从新农合获得的补偿情况以及对新农合的看法和意见。2006和2008年分别调查农村家庭6147户和3288户。
本研究的分析主要基于新型农村合作医疗管理机构及相关医疗机构的凋查资料和政策文献资料,以访淡资料和家庭入户调查资料为补充.
(二)分析方法
本研究所用分析方法如下:
1、文献归纳法。对收集的文献及政策文件等二手资料进行归纳和总结。
2、卫生系统诊断树分析法。通过卫生系统诊断树分析,由“果”溯“因”,找出导致新型农村合作医疗筹资与支付制度中问题产生的原因。
3、医疗保险费的粗估法。通过医疗保险费的粗估法,测算不同支付方案下新型农村合作医疗制度所需要筹集的保险费,为调整六县(市)新型农村合作医疗筹资与支付制度提供参考依据。
4、PETS可行性分析法。利用PETS可行性分析法,分析本研究所设计的新型农村合作医疗筹资与支付制度的调整方案在政治、经济、技术以及社会文化方面的可行性。
5、“结构—过程—结果”的评价框架。利用美国学者Avedis Donabedian提出的“结构—过程—结果”的评价框架,评价六县(市)实施新型农村合作医疗筹资与支付调整方案的效果。
6、灾难性卫生支出测量方法。通过计算参合住院者因年住院费用导致灾难性支出发生的频率以及严重程度,了解新型农村合作医疗对减轻参合住院者疾病经济负担的作用。
7、连锁替代法。运用连锁替代法分析新型农村合作医疗筹资的影响因素及贡献率大小。
8、分析工具。新型农村合作医疗管理机构和医疗机构调查资料出研究者录入Exce12003并进行统计分析。新型农村合作医疗住院补偿数据库导入SPSS11.5进行统计分析。对定性访谈资料在取得首访人知情同意后录音,由研究者录入Maxqda2并进行分析。家庭入户调查资料由研究者重复录入Epi Data 2.1,并用SPSS11.5进行统计分析。
四、研究结果
本研究的主要结果如下.
(一)2005年样本县(市)新型农村合作医疗实施情况
对2005年六样本县(市)新型农村合作医疗实施情况的调查发现,六县(市)新型农村合作医疗试点实施较为平稳。六县(市)新型农村合作医疗年人均筹资额为20-30元,参合率在山东和宁夏分别达到了91.08%和63.44%。六县(市)的新型农村合作医疗补偿模式以“保大病”为主,由住院统筹基金对参合农民的住院费用给予补偿。四县(市)参合农民的门诊费用补偿主要由家庭账户支付,两县(市)由门诊统筹基金支付。2005年六县。(市)参合农民住院补偿的受益率为1.83—5.07%,受益农民的实际住院补偿比为13.11-26.63%。2005年除章丘外的五县(市)新型农村合作医疗基金都有结余,结余率为30.38-58.09%:章丘市由于门诊基金超支而导致总基金当年出现赤字。2005年六县(市)新型农村合作医疗制度的住院补偿对减轻参合农民的疾病经济负担有一定作用,能使0.43%的参合住院者免于发生灾难性卫生支出,使参合住院者发生灾难性卫生支出的严重程度减少1.49—6.65个百分点。另外,78.30%的参合农民表示对新型农村合作医疗制度感到满意。
(二)2005年样本县(市)新型农村合作医疗制度实施中的问题及原因分析
同时,六样本县(市)新型农村合作医疗的筹资与支付制度也存在着以下问题:第一,筹资水平低,与经济发展水平不相适应。第二,各县(市)参合率差异较大,部分县(市)参合率不高。第三,政府财政补助不能及时到位。第四,新农合补偿水平较低,参合农民疾病经济负担沉重。第五,基金结余较多或出现赤字,影响制度的可持续性。
通过卫生系统诊断树进行原因分析,导致上述问题的原因主要为以下几方面:第一,新型农村合作医疗管理办公室工作人员缺乏医疗保险的专业能力导致人均筹资额和补偿方案的设计不合理。第二,政府的政治性考虑导致人均筹资额较少。第三,县(市)级政府的财政能力不足和“逐级配套”的筹资机制导致政府财政补助不能及时到位。第四,农民经济拮据、健康风险意识薄弱、对新农合政策不理解、以及新农合的宣传和筹资方式问题导致有些地区参合率不高。第五,报销手续复杂导致部分参合农民得不到补偿。第六,医疗费用高、增长快影响新型农村合作医疗减轻农民疾病经济负担的效果。
(三)样本县(市)新型农村合作医疗筹资与支付制度的调整方案设计
针对上述问题和原因,研究者提出以下调整和完善六县(市)新型农村合作医疗筹资与支付制度的建议:第一,提高筹资水平:第二,逐步推广自愿式筹资方式;第三,提高补偿水平:第四,简化报销手续:第五,控制医疗费用的不合理增长。同时,研究者以永宁县和昌乐县为例,用医疗保险费粗估法测算了两县在不同支付方案下所需筹集的保险费情况,并提供六县(市)可参考的筹资与支付调整标准:建议六县(市)2007、2007年将农民个人筹资额提高到15-20元,各级政府对参合农民的补助额提高到30-50元:建议山东三县(市)设守起付线,减少分段报销的组段,并提高名义补偿比,最高支付限额设定为年人均收入的4倍。建议宁夏三县(市)制定相对统一的补偿方案,将起付线设定为乡镇卫生院100元,县级医院200-250元,县外医院500元,取消分段报销,设置统一的名义补偿比,乡镇级、县级和县外医疗机构的名义补偿比分别为50%、45%和15%,每人每年最高报销限额调整为10000元。
(四)样本县(市)新型农村合作医疗筹资与支付制度的调整方案实施情况评价
本研究提出的调整建议和设计在六县(市)基本得到了采纳和实施。调整方案实施2年后,研究者对六县(市)2007-2008年实施新型农村合作医疗筹资与支付调整方案的效果进行评价。六县(市)新农合调整方案的实施取得了积极的效果,主要概括如下:
第一,筹资水平不断提高。2008年六县(巾)新农合人均筹资额达到70—100元,约为2005年人均筹资水平的3倍。其中,各级政府对新型农村合作医疗的补助不断增多,成为新农合保险费增加的主要来源。六县(市)中有四个县(市)农民个人筹资水平也得到提高。
第二,参合率不断增加。2005—2008年六样本县(高)新型农村合作医疗的参合率不断提高,宁夏三县(市)参合率的增长尤为迅速。2008年山东和宁夏样本县(市)的新型农村合作医疗参合率分別达到96.84%和94.56%。个人缴纳参合费用提高没有影响到农民的参合积极性。
第三,参合农民的卫生服务利用趋于合理。2008年除永宁县以外的其它五县(市)79-97%的参合住院者在乡镇卫生院和县级医院住院,70-93%的新农合住院补偿基金流向了乡镇卫生院和县级医院,即大部分参合农民的卫生服务需求在本县就可以得到满足。
第四,受益面不断扩大,受益水平不断提高。2007、2008年各县(市)参合农民的门诊人次和住院人次增加,受益面扩大。各县(市)2008年每百人受益人次数比2005年增加了4—184人次:住院补偿受益率比2005年提高了3—7个百分点。同时,参合者的实际补偿水平比不断提高。实际住院补偿比由2005年的五县(市)均在15%以下,增长为2008年的五县(市)均在27%以上,最高达37%。门诊补偿方面在实施了门诊统筹的县,2008年门诊实际补偿比达到15—25%.
第五,单病种限额支付对医疗费用控制效果较好。3年来东阿县单病种限额支付制度的实践证明,单病种限额支付是控制医疗费用的有效支付方式,对医疗费用的有效控制也有利于减轻参合农民的疾病经济负担。
第六,降低疾病经济风险的作用加强。通过分析新农合制度减少参合住院者灾难性卫生支出发生的作用可知,2008年六县(市)的新农合住院补偿能使1.23%的参合住院者免于发生灾难性支出、使参合住院者发生灾难性支出的严重程度减少6.89-9.83个百分点,均高于2005年的相应比例。表明2008年调整后的新农合制度对于降低参合住院者疾病经济风险的作用比2005年增强了.
第七,满意度提高。家庭入户调查显示,对新农合表示非常满意或满意的农民居民所占比例由2006年的78.3%上升到2008年的84.5%。同时,表示对新农合不满意或极不满意的农民所占比例由13.9%下降到3.2%。
在总结新型农村合作医疗制度取得成绩的同时,也应看到六县(市)新型农村合作医疗制度仍存在着不容忽视的问题,主要表现为:第一,筹资与支付标准的确定尚不科学;第二,政府补助资金到位率有待提高;第三,个人保费水平仍然偏低;第四,基金运行不平稳,风险基金的提取不规范,存在超支风险:第五,家庭账户对门诊补偿作用有限;第六,医疗费用增长使部分县(市)参合农民疾病经济负担加重;第七,医疗费用控制缺乏内在动力。
(五)影响新型农村合作医疗筹资与支付制度的关键因素分析
本研究还分析了影响新型农村合作医疗筹资与支付制度的关键因素。对于新农合筹资而言,人均筹资额是最关键因素,其贡献率为61-97%;第二主要影响因素为参合率,第三为基金到位率。对于新农合支付而言,在筹资增加的情况下,提高名义补偿比、减少费用分段、降低起付线都能有效提高实际补偿比,应优先考虑从这三方而提高支付水平,且这些支付水平的提高在县(市)级医疗机构最有效率。提高最高补偿限额对于提高实际补偿比效率是不高的。起付线的设置会在一定程度上影响实际补偿比,由于其对限制过度利用医疗服务所起到的“门槛”作用,还是应该合理设置起付线。
五、政策建议
第一,保持新农合制度的稳定性。目前新农合制度扩大覆盖面工作已经取得了较好的成果,制度发展的重点可以逐渐由扩大覆盖面转为提高受益程度,进一步发展新型农村合作医疗制度需要注意政策的稳定性,避免过于频繁地调整新农合制度方案。
第二,逐步增加各级政府投入,保证基金及时到位.各级政府应切实承担起对新农合的补助责仟,尤其是省级财政和中央财政应及时、足额地给予各县(市)财政支持,以保障新农合基金的持续性.
第三,科学调整筹资与支付制度,提高受益程度。应经过科学的测算确定筹资与支付标准。在调整筹资标准时,可以提高个人筹资额度;调整支付标准时,可以考虑优先提高县(市)级医疗机构的补偿水平。
第四,提高新农合制度的统筹层面。一些样本县(市)采取的机构互认、全市或全区采取比较统一的新农合制度等实践已经为新农合实施市级统筹打下了好的基础,可以在有条件的县(市)首先尝试市级际统筹,提高新农合的抗风险能力。
第五,取消家庭账户,实施门诊统筹。本研究发现新农合制度中家庭账户的作用十分有限,在新农合制度中采取门诊统筹是可行的,能够提高参合者的受益面和门诊受益水平。在家庭账户向门诊统筹转变的过程中,需要处理好两种支付方式的衔接问题。
第六,推广和完善单病种限额支付制度。本研究证明了在新农合制度中实施单病种限额支付对于医疗费用控制的效果较好。建议其它县(市)可以在科学地确定病种、合理地制定不同级别医疗机构单病种支付标准的前提下,实施单病种限额支付制度。
第七,加强医疗费用控制。在新型农村合作医疗制度的实施过程中,应严格控制医疗费用的不合理增长,使新农合制度切实发挥降低参合者疾病经济风险的作用,使参合农民真正获得实惠。
第八,加强新农合管理机构自身能力建设。各级卫牛部门应增加对新农合管理机构的投入,将合管办的办公经费列入财政预算,配备必要的设备和网络,增加人员编制,以保证新农合日常工作的顺利进行。同时,合管办工作人员应该加强医疗保险知识的学习,提高自身专业能力.
第九,推进农村医疗卫生体制的各项改革,促进新农合制度的可持续发展。应大力推进我国农村医疗卫生体制改革,加快农村医疗机构的发展,从根本上解决医疗费用不合理增长、卫生资源利用不合理等问题,促进新型农村合作医疗制度的可持续发展。
[Background]
During 1960s to 1970s, Cooperative Medical Scheme in China has covered more than 90% of rural residents. However, as economic reform deepened in rural areas, Cooperative Medical Scheme has collapsed. In 2003, 79.1% of rural residents were not covered by any form of health insurance. Many of them had no access to health care services because of economic reason and impoverished due to disease.
In order to solve this problem, the central government determined to build up a New Cooperative Medical Scheme (NCMS). The aim is to effectively relieve rural residents' burden of disease, solve the problem of impoverishment due to disease and improve health. Since 2003, NCMS has been implemented in pilot counties. By the end of 2004, NCMS had covered 80 million rural residents, with coverage rate of 75.20%. As NCMS in pilot counties developed, some problems emerged. For example, some rural residents were unwilling to participate, vulnerable population had difficulties in paying premium, premium collection was costly, benefit package was not well designed, the reimbursement rate was low and so on. The sustainable development of NCMS depends on reasonable financing and payment system. As the development of NCMS in China is still in pilot period, financing and payment system is not perfect. How to improve financing and payment system in NCMS to ensure sustainable development is a great challenge.
Previous studies on NCMS financing and payment were less concerning the criteria of financing and payment and the overall evaluation of NCMS. The research related to improve financing and payment system in NCMS was less reported. Therefore, in order to explore a reasonable financing and payment system in NCMS, this study chooses NCMS piloted counties as objects, tries to design revised financing and payment scheme and implement them, then evaluates the effect of revised scheme, which may provide an evidence for improve financing and payment in NCMS and promote the development of NCMS.
[Objectives]
The aim of this study is to explore a reasonable financing and payment system in NCMS, which may provide an evidence for improve financing and payment in NCMS and promote the development of NCMS.
Detailed objectives are as follows.
1. Finding out problems in NCMS financing and payment.
2. Exploring determinants and influencing factors of NCMS financing and payment.
3. Designing a revised financing and payment scheme.
4. Evaluating outcomes of revised scheme implementation in piloted counties.
5. Providing political suggestion for NCMS improvement.
[Methodology]
Data sources
1. Study sites. According to geographic and economic situation, two provinces Shandong and Ningxia were chosen. Then, three counties were selected from each province in accordance with economic situation. As a result, Zhangqiu. Changle and Dong'e were chosen in Shandong, Qingtongx, Yongning and Zhongning were chosen in Ningxia.
2. Data collection. Two large-scaled field investigations were conducted in 2006 and 2008. Data were collected in four ways as follows.
2.1 Institution investigation. Firstly, NCMS administration. A questionnaire was designed by researchers and filled out by NCMS officials in NCMS administration to know about the implementation of NCMS. Meanwhile, database related to inpatient reimbursement were provided either. Secondly, healthcare providers. A questionnaire was designed by researchers and filled out by healthcare providers to know about their revenue and expenditure and subsidies from NCMS.
2.2 Second-hand materials collection. Academic references, policy documents about NCMS in the central government and sampled counties were collect in order to understand research frontiers and policies concerning NCMS.
2.3 Interview. To know about the implementation, problems in NCMS and stakeholders' attitudes, key-informant interviews and focus-group interviews were conducted.
2.4 Household Survey. To know about health demand and utilization, NCMS reimbursement and attitude towards NCMS among rural residents, household surveys were conducted in 2006 and 2008, with sample size as 6147 and 3288 households respectively.
Analysis in this dissertation is mainly based on data from the first two sources.
Analysis Methods
1. References reviews. Summarizing second hand materials collected.
2. Diagnosis tree. Finding out problems in NCMS financing and payment and their causes by using diagnosis tree in health sector.
3. Premium calculation. To calculation NCMS premium in different benefit packages.
4. PETS. Analyzing feasibility of a scheme from political, economical, technical and social perspectives.
5. Evaluation framework of 'structure-process-outcome'. Evaluating NCMS from three perspectives of structure, process and outcome.
6. Catastrophic health expenditure measurement. To know about the effect of NCMS on reducing burden of disease by measuring the frequency and severity of Catastrophic health expenditure.
7. Chain replacement analysis. To analyze influencing factors and their contributions to financing by chain replacement analysis.
8. Analysis tool. Data from institutions were input and analyzed by Excel 2003. NCMS inpatient reimbursement database were analyzed through SPSS 11.5. Interviews were recorded with informant consent and analyzed by Maxqda2. Data concerning household survey were double input to Epi Data 2.1 and analyzed by SPSS 11.5.
[Results]
Results of this study are as follows.
1. The status quo of NCMS implementation in 2005
According to the investigation results, in 2005 NCMS implemented smoothly in six sampled counties. The premium was 20 to 30 Chinese yuan (CNY) and the participation rate in Shandong and Ningxia was 91.08% and 63.44% respectively. NCMS reimbursement was mainly on inpatient service in six counties. The unified fund was set to reimburse inpatient expenditure, medical saving account in four counties and unified fund in two counties was set to reimburse outpatient expenditure. In 2005, 1.83-5.07% of enrollees obtained NCMS reimbursement on hospitalization expenditure and the effective reimbursement rate was 13.11-26.63%. In five counties except Zhangqiu, the surplus rate of NCMS fund was 30.38-58.09%. However, in Zhangqiu, NCMS fund has deficit in unified fund concerning outpatient reimbursement. NCMS in six counties had some effect in reduce enrollees' burden of disease. It could protect 0.43% of enrollees off the occurrence of catastrophic health expenditure and reduce the severity of catastrophic health expenditure off 1.49-6.65 percentages. Moreover, 78.30% of enrollees satisfied with NCMS.
2. Problems in NCMS implementation and causation analysis
Meanwhile, there were some problems in NCMS financing and payment system. Firstly, the premium was low, not in accordance with economic situation. Secondly, coverage rate varied among counties, with lower coverage in some counties. Thirdly, financial subsidies from government could not be allocated adequately and in time. Fourthly, the effective reimbursement rate was low and enrollees still had heavy burden of disease. Fifthly, NCMS fund in six counties either had excessive surplus or deficit, which might undermine the sustainability of NCMS.
Trough diagnosis tree, causes for previous problems could be summarized as follows. Firstly, NCMS office lacked knowledge on health insurance so that could not design rational premium and payment scheme. Secondly, political consideration constrained premium increase. Thirdly, limited financial capacity of the government at county level and the bottom-up mechanism of allocating match fund by government at all levels caused inadequate subsidies. Fourthly, enrollees' economic difficulty, low concept of health risk, misunderstanding of NCMS and problems in premium collection procedure resulted in low coverage rate in some counties. Fifthly, complicated procedures to obtain reimbursement caused some enrollees could not acquire reimbursement. Sixthly, health cost escalation undermined the effect of NCMS.
3. Improvement design on financing and payment system in NCMS
The author proposed some suggestions to improve financing and payment in sampled counties. The premium should be increased, and the way of premium collection should gradually be changed from door-to-door collection to voluntarily pay. The reimbursement rate should be raised and the procedure to get reimbursed should be simplified. More effort should also be made to control irrational growth of health expenditure. Meanwhile, the author calculated NCMS premiums in different benefit packages taking Yongning and Changle as examples and proposed suggestion to adjust financing and payment scheme in six counties as follows. Individual premium could be raised to 15-20 CNY and subsidies from government at all levels could be raised to 30-50 CNY. It is suggested that three counties in Shandong should set deductible, reduce health expenditure segment in reimbursement, elevate reimbursement rat and set ceiling as four times of annual income. For Ningxia, it is suggested that counties employ the similar payment scheme, set deductible and reimbursement rate in township hospital as 100 CNY and 50%. in county level hospital as 200-250 CNY and 45%, in hospital above county level as 500 CNY and 15%, cancel health expenditure segment in reimbursement, set ceiling as 10000 CNY.
4. Evaluation on the implementation of improved financing and payment system in NCMS
These proposals to adjust financing and payment scheme in NCMS have almost been accepted and implemented in six counties. This study has evaluated the effect of adjusted financing and payment scheme in NCMS after implementing for 2 years. In general, adjusted scheme has had positive effects.
Firstly, the premium has been raised, up to 70-100 CNY per capita in 2008, almost 3 times of that in 2005. The increase of government subsidies became the main source of premium increase. In four counties, individual premium also rose.
Secondly, NCMS coverage expanded. In 2008, NCMS coverage rate in Shandong and Ningxia was 96.84% and 94.56% respectively. Individual premium increase had no effect on coverage.
Thirdly, enrollees used healthcare services more rationally than before. Enrollees' most healthcare demand could be met within county.
Fourthly, reimbursement level has been raised. The percentage of enrollees that obtained NCMS reimbursement in 2008 was more than that in 2008. Meanwhile, the effective reimbursement rate also increased in 2008.
Fifthly, case-based payment had good effect on cost containment, which may also help to reduce enrollees' burden of disease.
Sixthly, the effect of reducing financial risk was strengthened.
Seventhly, satisfaction rate increased from 78.3% in 2005 to 84.5% in 2008.
Although gained achievement, NCMS in six sampled counties was also confronted with challenges. The premium and payment was not rationally determined. Government subsidies were still not allocated adequately and in time. Individual premium was low. The NCMS fund was not stable and faced risk. Medical saving account had limited effect on reimbursement to outpatient expenditure. Health cost escalation aggravated enrollees' burden of disease in some counties. Health cost containment lacked of internal motivation.
5. Analysis on the key influencing factors of financing and payment system in NCMS
Moreover, this study also analyzed the key influencing factors of financing and payment system in NCMS. As for financing, premium was the most important factors with contribution rate as 61-79%. The following factors were coverage rate and actually financing rate. As for payment, raising reimbursement rate, reducing health expenditure segment, lowering deductible could effectively elevate effective reimbursement rate. These three factors should be given priority when adjusting payment scheme.
[Conclusion and political recommendation]
1. Keeping the stability of NCMS. At present stage, NCMS has achieved a broad coverage. To further develop NCMS, it is suggested to keep certain stability in policy, avoiding adjusting policy frequently.
2. Government at all levels should further support the development of NCMS. Government especially the central and provincial government should take the responsibility and subsidize NCMS in time and in full amount.
3. Rationally adjusting the financing and payment scheme to improve enrollees' benefits. When adjusting financing scheme, it is suggested that individual contribution to premium should be raised. When adjusting payment scheme, it is supposed to give priority to reimbursement policy in county level hospitals.
4. Setting a unified fund at a higher level. Some piloted counties have employed similar schemes with other counties. It provides a good basis for setting a unified fund at a prefectual level which can strengthen NCMS capacity of risk protection.
5. Canceling medical saving account, employing unified fund in outpatient reimbursement. The effect of medical saving account has been proved to be limited. Employing unified fund in outpatient reimbursement has been demonstrated to be effective, which can increase enrollees' benefits. More attention should be given to solve the problems in transition period.
6. Developing and improving case-based payment system. In this study, case-based payment has been proved to be effective in cost containment. It is suggested to developing case-based payment system in other counties under the precondition of rationally choosing diseases and setting payment criteria.
7. Strengthening cost containment. It is proposed to strictly control the irrational growth of health expenditure in order to effectively reduce enrollees' burden of disease.
8. Intensifying the capacity building in NCMS administration. Health bureau should take overhead expenditure of NCMS office into consideration, add equipment, network and position in NCMS office to ensure routine work. Meanwhile. NCMS administration officials should have more knowledge on health insurance to be more professional in daily work.
9. Promoting reforms in health sector to ensure sustainable development of NCMS. Reforms in health sector should be deepened and the development of healthcare providers in rural areas should be sped up so as to solve the problems such as irrational growth of health expenditure, unreasonable use of health resources from the root to promote the development of NCMS.
我国的农村合作医疗制度在20世纪六、七十年代有过辉煌的历史,覆盖了约90%的农村人口。但随着农村经济体制改革的深入,合作医疗在全国范围内急剧萎缩,到2003我国农村有79.1%的居民没有任何医疗保险。许多农村居民出无力承担医疗费用而不能获得基本医疗服务,因病致贫、因病返贫现象严重。
为解决我国农村居民的医疗保障问题,中央政府提出要建立以大病统筹为主的新型农村合作医疗制度。新型农村合作医疗制度建立的目的,是切实减轻农民因疾病带来的经济负担,重点解决农民因病致贫、因病返贫问题,提高农民的健康水平。自2003年起,我国新型农村合作医疗制度开始试点。到2004年底,全国共有8040.01万农民参加了合作医疗,參合率为75.20%。随着试点工作的铺开,新型农村合作医疗制度实施中的问题也逐渐显现。在筹资与支付制度方面的问题主要表现为:部分农民参合意愿不强,特殊和困难群体参合缴费困难,筹资过程成本高,报销比例设置不合理,农民受益而窄,获得的实际补偿比低等。合理的筹资与支付制度是新型农村合作医疗制度持续发展的保证。由于我国新型农村合作医疗制度尚处于试点阶段,筹资与支付制度还不完善。如何促进和改善新型农村合作医疗筹资与支付制度、保证新型农村合作医疗在农村得以可持续发展,是新型合作医疗制度发展过程中所面临的重大挑战。
已有关于新型农村合作医疗的筹资与支付制度的研究,较少对合理的筹资标准和支付标准进行科学地测算,对调整和完善新型农村合作医疗筹资与支付制度开展的实证研究也比较少见。因此,为探索科学合理的新型农村合作医疗筹资与支付制度,本研究选取我国已开展新型农村合作医疗试点的县(巾)作为研究对象,在对新型农村合作医疗实施情况进行分析的基础上,设计新型农村合作医疗筹资与支付制度的改进方案,并根据方案实际调整和实施的情况,评价改进方案所带来的效果,为进一步发展和完善新型农村合作医疗筹资与支付制度提供参考依据,促进新型农村合作医疗制度的可持续发展。
二、研究目的
本研究的目的是通过对完善新型农村合作医疗筹资与支付制度的实证研究,探索新型农村合作医疗合理的筹资与支付制度,为完善新型农村合作医疗制度、促进新型农村合作医疗制度的可持续发展提供依据。
具体研究目标为:
1、了解样本县(市)新型农村合作医疗制度实施过程中筹资与支付制度上存在的问题。
2、找出影响和制约新型农村合作医疗筹资与支付制度发展的因素。
3、针对样本县(市)存在的问题提出筹资与支付制度上可行的改进措施。
4、评价样本县(市)实施新型农村合作医疗筹资与支付制度改进方案后的效果。
5、提出完善新型农村合作医疗筹资与支付制度的政策建议。
三、研究方法
(一)资料来源
1、样本县(市)选择
本研究采取分层抽样的方式选择样本县(市)。先根据中国各省(区)的地理位置和经济发展状况选择山东省和宁夏回族自治区作为研究对象。然后,在两个省(区)内按照经济发展水平高、中、低各抽取一个县(市)。在山东省,依照经济发展水平高、中、低选取了章丘市、昌乐县和东阿县;在宁夏回族自治区依次选取了青铜峡市、永宁县和中宁县。
2、调查方法及资料收集
本研究于2006年和2008年进行两次大规模现场调查,调查方法和资料收集情况如下:
(1)机构调查。机构调查的对象之一是六县(市)新型农村合作医疗管理办公室。通过设计并发放新型农村合作医疗实施情况调查表,了解2005-2008年新型农村合作医疗的总体运行情况、县(市)的人口、经济及健康和卫生资源状况。同时获取2005-2008年新型农村合作医疗住院报销数据库,了解参合农民获得住院补偿的情况。机构调查的对象之二是六县(市)所有县(市)级医疗机构、各县(市)三个抽样乡镇卫生院及九个抽样村卫生室。通过设计并发放医疗机构调查表,了解相关医疗机构2005-2008年的业务收支情况及从新农合获得的补偿情况。
(2)二手资料收集。系统收集国内外关于新型农村合作医疗的研究文献、中央政府自2002年以来出台的有关新型农村合作医疗制度的政策文件、2005-2008年六县(市)新型农村合作医疗制度的政策和实施方案,以了解国内外研究进展及中央政府和样本县(市)关于新型农村合作医疗的政策情况。
(3)定性访淡。通过关键知情人访淡和焦点组访淡,了解各县(市)新型农村合作医疗实施的情况、存在的问题及他们对新型农村合作医疗的意见看法。
(4)家庭入户调查。入户调查主要通过调查问卷了解该户全体家庭成员的基本情况、卫生服务需求及利用、从新农合获得的补偿情况以及对新农合的看法和意见。2006和2008年分别调查农村家庭6147户和3288户。
本研究的分析主要基于新型农村合作医疗管理机构及相关医疗机构的凋查资料和政策文献资料,以访淡资料和家庭入户调查资料为补充.
(二)分析方法
本研究所用分析方法如下:
1、文献归纳法。对收集的文献及政策文件等二手资料进行归纳和总结。
2、卫生系统诊断树分析法。通过卫生系统诊断树分析,由“果”溯“因”,找出导致新型农村合作医疗筹资与支付制度中问题产生的原因。
3、医疗保险费的粗估法。通过医疗保险费的粗估法,测算不同支付方案下新型农村合作医疗制度所需要筹集的保险费,为调整六县(市)新型农村合作医疗筹资与支付制度提供参考依据。
4、PETS可行性分析法。利用PETS可行性分析法,分析本研究所设计的新型农村合作医疗筹资与支付制度的调整方案在政治、经济、技术以及社会文化方面的可行性。
5、“结构—过程—结果”的评价框架。利用美国学者Avedis Donabedian提出的“结构—过程—结果”的评价框架,评价六县(市)实施新型农村合作医疗筹资与支付调整方案的效果。
6、灾难性卫生支出测量方法。通过计算参合住院者因年住院费用导致灾难性支出发生的频率以及严重程度,了解新型农村合作医疗对减轻参合住院者疾病经济负担的作用。
7、连锁替代法。运用连锁替代法分析新型农村合作医疗筹资的影响因素及贡献率大小。
8、分析工具。新型农村合作医疗管理机构和医疗机构调查资料出研究者录入Exce12003并进行统计分析。新型农村合作医疗住院补偿数据库导入SPSS11.5进行统计分析。对定性访谈资料在取得首访人知情同意后录音,由研究者录入Maxqda2并进行分析。家庭入户调查资料由研究者重复录入Epi Data 2.1,并用SPSS11.5进行统计分析。
四、研究结果
本研究的主要结果如下.
(一)2005年样本县(市)新型农村合作医疗实施情况
对2005年六样本县(市)新型农村合作医疗实施情况的调查发现,六县(市)新型农村合作医疗试点实施较为平稳。六县(市)新型农村合作医疗年人均筹资额为20-30元,参合率在山东和宁夏分别达到了91.08%和63.44%。六县(市)的新型农村合作医疗补偿模式以“保大病”为主,由住院统筹基金对参合农民的住院费用给予补偿。四县(市)参合农民的门诊费用补偿主要由家庭账户支付,两县(市)由门诊统筹基金支付。2005年六县。(市)参合农民住院补偿的受益率为1.83—5.07%,受益农民的实际住院补偿比为13.11-26.63%。2005年除章丘外的五县(市)新型农村合作医疗基金都有结余,结余率为30.38-58.09%:章丘市由于门诊基金超支而导致总基金当年出现赤字。2005年六县(市)新型农村合作医疗制度的住院补偿对减轻参合农民的疾病经济负担有一定作用,能使0.43%的参合住院者免于发生灾难性卫生支出,使参合住院者发生灾难性卫生支出的严重程度减少1.49—6.65个百分点。另外,78.30%的参合农民表示对新型农村合作医疗制度感到满意。
(二)2005年样本县(市)新型农村合作医疗制度实施中的问题及原因分析
同时,六样本县(市)新型农村合作医疗的筹资与支付制度也存在着以下问题:第一,筹资水平低,与经济发展水平不相适应。第二,各县(市)参合率差异较大,部分县(市)参合率不高。第三,政府财政补助不能及时到位。第四,新农合补偿水平较低,参合农民疾病经济负担沉重。第五,基金结余较多或出现赤字,影响制度的可持续性。
通过卫生系统诊断树进行原因分析,导致上述问题的原因主要为以下几方面:第一,新型农村合作医疗管理办公室工作人员缺乏医疗保险的专业能力导致人均筹资额和补偿方案的设计不合理。第二,政府的政治性考虑导致人均筹资额较少。第三,县(市)级政府的财政能力不足和“逐级配套”的筹资机制导致政府财政补助不能及时到位。第四,农民经济拮据、健康风险意识薄弱、对新农合政策不理解、以及新农合的宣传和筹资方式问题导致有些地区参合率不高。第五,报销手续复杂导致部分参合农民得不到补偿。第六,医疗费用高、增长快影响新型农村合作医疗减轻农民疾病经济负担的效果。
(三)样本县(市)新型农村合作医疗筹资与支付制度的调整方案设计
针对上述问题和原因,研究者提出以下调整和完善六县(市)新型农村合作医疗筹资与支付制度的建议:第一,提高筹资水平:第二,逐步推广自愿式筹资方式;第三,提高补偿水平:第四,简化报销手续:第五,控制医疗费用的不合理增长。同时,研究者以永宁县和昌乐县为例,用医疗保险费粗估法测算了两县在不同支付方案下所需筹集的保险费情况,并提供六县(市)可参考的筹资与支付调整标准:建议六县(市)2007、2007年将农民个人筹资额提高到15-20元,各级政府对参合农民的补助额提高到30-50元:建议山东三县(市)设守起付线,减少分段报销的组段,并提高名义补偿比,最高支付限额设定为年人均收入的4倍。建议宁夏三县(市)制定相对统一的补偿方案,将起付线设定为乡镇卫生院100元,县级医院200-250元,县外医院500元,取消分段报销,设置统一的名义补偿比,乡镇级、县级和县外医疗机构的名义补偿比分别为50%、45%和15%,每人每年最高报销限额调整为10000元。
(四)样本县(市)新型农村合作医疗筹资与支付制度的调整方案实施情况评价
本研究提出的调整建议和设计在六县(市)基本得到了采纳和实施。调整方案实施2年后,研究者对六县(市)2007-2008年实施新型农村合作医疗筹资与支付调整方案的效果进行评价。六县(市)新农合调整方案的实施取得了积极的效果,主要概括如下:
第一,筹资水平不断提高。2008年六县(巾)新农合人均筹资额达到70—100元,约为2005年人均筹资水平的3倍。其中,各级政府对新型农村合作医疗的补助不断增多,成为新农合保险费增加的主要来源。六县(市)中有四个县(市)农民个人筹资水平也得到提高。
第二,参合率不断增加。2005—2008年六样本县(高)新型农村合作医疗的参合率不断提高,宁夏三县(市)参合率的增长尤为迅速。2008年山东和宁夏样本县(市)的新型农村合作医疗参合率分別达到96.84%和94.56%。个人缴纳参合费用提高没有影响到农民的参合积极性。
第三,参合农民的卫生服务利用趋于合理。2008年除永宁县以外的其它五县(市)79-97%的参合住院者在乡镇卫生院和县级医院住院,70-93%的新农合住院补偿基金流向了乡镇卫生院和县级医院,即大部分参合农民的卫生服务需求在本县就可以得到满足。
第四,受益面不断扩大,受益水平不断提高。2007、2008年各县(市)参合农民的门诊人次和住院人次增加,受益面扩大。各县(市)2008年每百人受益人次数比2005年增加了4—184人次:住院补偿受益率比2005年提高了3—7个百分点。同时,参合者的实际补偿水平比不断提高。实际住院补偿比由2005年的五县(市)均在15%以下,增长为2008年的五县(市)均在27%以上,最高达37%。门诊补偿方面在实施了门诊统筹的县,2008年门诊实际补偿比达到15—25%.
第五,单病种限额支付对医疗费用控制效果较好。3年来东阿县单病种限额支付制度的实践证明,单病种限额支付是控制医疗费用的有效支付方式,对医疗费用的有效控制也有利于减轻参合农民的疾病经济负担。
第六,降低疾病经济风险的作用加强。通过分析新农合制度减少参合住院者灾难性卫生支出发生的作用可知,2008年六县(市)的新农合住院补偿能使1.23%的参合住院者免于发生灾难性支出、使参合住院者发生灾难性支出的严重程度减少6.89-9.83个百分点,均高于2005年的相应比例。表明2008年调整后的新农合制度对于降低参合住院者疾病经济风险的作用比2005年增强了.
第七,满意度提高。家庭入户调查显示,对新农合表示非常满意或满意的农民居民所占比例由2006年的78.3%上升到2008年的84.5%。同时,表示对新农合不满意或极不满意的农民所占比例由13.9%下降到3.2%。
在总结新型农村合作医疗制度取得成绩的同时,也应看到六县(市)新型农村合作医疗制度仍存在着不容忽视的问题,主要表现为:第一,筹资与支付标准的确定尚不科学;第二,政府补助资金到位率有待提高;第三,个人保费水平仍然偏低;第四,基金运行不平稳,风险基金的提取不规范,存在超支风险:第五,家庭账户对门诊补偿作用有限;第六,医疗费用增长使部分县(市)参合农民疾病经济负担加重;第七,医疗费用控制缺乏内在动力。
(五)影响新型农村合作医疗筹资与支付制度的关键因素分析
本研究还分析了影响新型农村合作医疗筹资与支付制度的关键因素。对于新农合筹资而言,人均筹资额是最关键因素,其贡献率为61-97%;第二主要影响因素为参合率,第三为基金到位率。对于新农合支付而言,在筹资增加的情况下,提高名义补偿比、减少费用分段、降低起付线都能有效提高实际补偿比,应优先考虑从这三方而提高支付水平,且这些支付水平的提高在县(市)级医疗机构最有效率。提高最高补偿限额对于提高实际补偿比效率是不高的。起付线的设置会在一定程度上影响实际补偿比,由于其对限制过度利用医疗服务所起到的“门槛”作用,还是应该合理设置起付线。
五、政策建议
第一,保持新农合制度的稳定性。目前新农合制度扩大覆盖面工作已经取得了较好的成果,制度发展的重点可以逐渐由扩大覆盖面转为提高受益程度,进一步发展新型农村合作医疗制度需要注意政策的稳定性,避免过于频繁地调整新农合制度方案。
第二,逐步增加各级政府投入,保证基金及时到位.各级政府应切实承担起对新农合的补助责仟,尤其是省级财政和中央财政应及时、足额地给予各县(市)财政支持,以保障新农合基金的持续性.
第三,科学调整筹资与支付制度,提高受益程度。应经过科学的测算确定筹资与支付标准。在调整筹资标准时,可以提高个人筹资额度;调整支付标准时,可以考虑优先提高县(市)级医疗机构的补偿水平。
第四,提高新农合制度的统筹层面。一些样本县(市)采取的机构互认、全市或全区采取比较统一的新农合制度等实践已经为新农合实施市级统筹打下了好的基础,可以在有条件的县(市)首先尝试市级际统筹,提高新农合的抗风险能力。
第五,取消家庭账户,实施门诊统筹。本研究发现新农合制度中家庭账户的作用十分有限,在新农合制度中采取门诊统筹是可行的,能够提高参合者的受益面和门诊受益水平。在家庭账户向门诊统筹转变的过程中,需要处理好两种支付方式的衔接问题。
第六,推广和完善单病种限额支付制度。本研究证明了在新农合制度中实施单病种限额支付对于医疗费用控制的效果较好。建议其它县(市)可以在科学地确定病种、合理地制定不同级别医疗机构单病种支付标准的前提下,实施单病种限额支付制度。
第七,加强医疗费用控制。在新型农村合作医疗制度的实施过程中,应严格控制医疗费用的不合理增长,使新农合制度切实发挥降低参合者疾病经济风险的作用,使参合农民真正获得实惠。
第八,加强新农合管理机构自身能力建设。各级卫牛部门应增加对新农合管理机构的投入,将合管办的办公经费列入财政预算,配备必要的设备和网络,增加人员编制,以保证新农合日常工作的顺利进行。同时,合管办工作人员应该加强医疗保险知识的学习,提高自身专业能力.
第九,推进农村医疗卫生体制的各项改革,促进新农合制度的可持续发展。应大力推进我国农村医疗卫生体制改革,加快农村医疗机构的发展,从根本上解决医疗费用不合理增长、卫生资源利用不合理等问题,促进新型农村合作医疗制度的可持续发展。
[Background]
During 1960s to 1970s, Cooperative Medical Scheme in China has covered more than 90% of rural residents. However, as economic reform deepened in rural areas, Cooperative Medical Scheme has collapsed. In 2003, 79.1% of rural residents were not covered by any form of health insurance. Many of them had no access to health care services because of economic reason and impoverished due to disease.
In order to solve this problem, the central government determined to build up a New Cooperative Medical Scheme (NCMS). The aim is to effectively relieve rural residents' burden of disease, solve the problem of impoverishment due to disease and improve health. Since 2003, NCMS has been implemented in pilot counties. By the end of 2004, NCMS had covered 80 million rural residents, with coverage rate of 75.20%. As NCMS in pilot counties developed, some problems emerged. For example, some rural residents were unwilling to participate, vulnerable population had difficulties in paying premium, premium collection was costly, benefit package was not well designed, the reimbursement rate was low and so on. The sustainable development of NCMS depends on reasonable financing and payment system. As the development of NCMS in China is still in pilot period, financing and payment system is not perfect. How to improve financing and payment system in NCMS to ensure sustainable development is a great challenge.
Previous studies on NCMS financing and payment were less concerning the criteria of financing and payment and the overall evaluation of NCMS. The research related to improve financing and payment system in NCMS was less reported. Therefore, in order to explore a reasonable financing and payment system in NCMS, this study chooses NCMS piloted counties as objects, tries to design revised financing and payment scheme and implement them, then evaluates the effect of revised scheme, which may provide an evidence for improve financing and payment in NCMS and promote the development of NCMS.
[Objectives]
The aim of this study is to explore a reasonable financing and payment system in NCMS, which may provide an evidence for improve financing and payment in NCMS and promote the development of NCMS.
Detailed objectives are as follows.
1. Finding out problems in NCMS financing and payment.
2. Exploring determinants and influencing factors of NCMS financing and payment.
3. Designing a revised financing and payment scheme.
4. Evaluating outcomes of revised scheme implementation in piloted counties.
5. Providing political suggestion for NCMS improvement.
[Methodology]
Data sources
1. Study sites. According to geographic and economic situation, two provinces Shandong and Ningxia were chosen. Then, three counties were selected from each province in accordance with economic situation. As a result, Zhangqiu. Changle and Dong'e were chosen in Shandong, Qingtongx, Yongning and Zhongning were chosen in Ningxia.
2. Data collection. Two large-scaled field investigations were conducted in 2006 and 2008. Data were collected in four ways as follows.
2.1 Institution investigation. Firstly, NCMS administration. A questionnaire was designed by researchers and filled out by NCMS officials in NCMS administration to know about the implementation of NCMS. Meanwhile, database related to inpatient reimbursement were provided either. Secondly, healthcare providers. A questionnaire was designed by researchers and filled out by healthcare providers to know about their revenue and expenditure and subsidies from NCMS.
2.2 Second-hand materials collection. Academic references, policy documents about NCMS in the central government and sampled counties were collect in order to understand research frontiers and policies concerning NCMS.
2.3 Interview. To know about the implementation, problems in NCMS and stakeholders' attitudes, key-informant interviews and focus-group interviews were conducted.
2.4 Household Survey. To know about health demand and utilization, NCMS reimbursement and attitude towards NCMS among rural residents, household surveys were conducted in 2006 and 2008, with sample size as 6147 and 3288 households respectively.
Analysis in this dissertation is mainly based on data from the first two sources.
Analysis Methods
1. References reviews. Summarizing second hand materials collected.
2. Diagnosis tree. Finding out problems in NCMS financing and payment and their causes by using diagnosis tree in health sector.
3. Premium calculation. To calculation NCMS premium in different benefit packages.
4. PETS. Analyzing feasibility of a scheme from political, economical, technical and social perspectives.
5. Evaluation framework of 'structure-process-outcome'. Evaluating NCMS from three perspectives of structure, process and outcome.
6. Catastrophic health expenditure measurement. To know about the effect of NCMS on reducing burden of disease by measuring the frequency and severity of Catastrophic health expenditure.
7. Chain replacement analysis. To analyze influencing factors and their contributions to financing by chain replacement analysis.
8. Analysis tool. Data from institutions were input and analyzed by Excel 2003. NCMS inpatient reimbursement database were analyzed through SPSS 11.5. Interviews were recorded with informant consent and analyzed by Maxqda2. Data concerning household survey were double input to Epi Data 2.1 and analyzed by SPSS 11.5.
[Results]
Results of this study are as follows.
1. The status quo of NCMS implementation in 2005
According to the investigation results, in 2005 NCMS implemented smoothly in six sampled counties. The premium was 20 to 30 Chinese yuan (CNY) and the participation rate in Shandong and Ningxia was 91.08% and 63.44% respectively. NCMS reimbursement was mainly on inpatient service in six counties. The unified fund was set to reimburse inpatient expenditure, medical saving account in four counties and unified fund in two counties was set to reimburse outpatient expenditure. In 2005, 1.83-5.07% of enrollees obtained NCMS reimbursement on hospitalization expenditure and the effective reimbursement rate was 13.11-26.63%. In five counties except Zhangqiu, the surplus rate of NCMS fund was 30.38-58.09%. However, in Zhangqiu, NCMS fund has deficit in unified fund concerning outpatient reimbursement. NCMS in six counties had some effect in reduce enrollees' burden of disease. It could protect 0.43% of enrollees off the occurrence of catastrophic health expenditure and reduce the severity of catastrophic health expenditure off 1.49-6.65 percentages. Moreover, 78.30% of enrollees satisfied with NCMS.
2. Problems in NCMS implementation and causation analysis
Meanwhile, there were some problems in NCMS financing and payment system. Firstly, the premium was low, not in accordance with economic situation. Secondly, coverage rate varied among counties, with lower coverage in some counties. Thirdly, financial subsidies from government could not be allocated adequately and in time. Fourthly, the effective reimbursement rate was low and enrollees still had heavy burden of disease. Fifthly, NCMS fund in six counties either had excessive surplus or deficit, which might undermine the sustainability of NCMS.
Trough diagnosis tree, causes for previous problems could be summarized as follows. Firstly, NCMS office lacked knowledge on health insurance so that could not design rational premium and payment scheme. Secondly, political consideration constrained premium increase. Thirdly, limited financial capacity of the government at county level and the bottom-up mechanism of allocating match fund by government at all levels caused inadequate subsidies. Fourthly, enrollees' economic difficulty, low concept of health risk, misunderstanding of NCMS and problems in premium collection procedure resulted in low coverage rate in some counties. Fifthly, complicated procedures to obtain reimbursement caused some enrollees could not acquire reimbursement. Sixthly, health cost escalation undermined the effect of NCMS.
3. Improvement design on financing and payment system in NCMS
The author proposed some suggestions to improve financing and payment in sampled counties. The premium should be increased, and the way of premium collection should gradually be changed from door-to-door collection to voluntarily pay. The reimbursement rate should be raised and the procedure to get reimbursed should be simplified. More effort should also be made to control irrational growth of health expenditure. Meanwhile, the author calculated NCMS premiums in different benefit packages taking Yongning and Changle as examples and proposed suggestion to adjust financing and payment scheme in six counties as follows. Individual premium could be raised to 15-20 CNY and subsidies from government at all levels could be raised to 30-50 CNY. It is suggested that three counties in Shandong should set deductible, reduce health expenditure segment in reimbursement, elevate reimbursement rat and set ceiling as four times of annual income. For Ningxia, it is suggested that counties employ the similar payment scheme, set deductible and reimbursement rate in township hospital as 100 CNY and 50%. in county level hospital as 200-250 CNY and 45%, in hospital above county level as 500 CNY and 15%, cancel health expenditure segment in reimbursement, set ceiling as 10000 CNY.
4. Evaluation on the implementation of improved financing and payment system in NCMS
These proposals to adjust financing and payment scheme in NCMS have almost been accepted and implemented in six counties. This study has evaluated the effect of adjusted financing and payment scheme in NCMS after implementing for 2 years. In general, adjusted scheme has had positive effects.
Firstly, the premium has been raised, up to 70-100 CNY per capita in 2008, almost 3 times of that in 2005. The increase of government subsidies became the main source of premium increase. In four counties, individual premium also rose.
Secondly, NCMS coverage expanded. In 2008, NCMS coverage rate in Shandong and Ningxia was 96.84% and 94.56% respectively. Individual premium increase had no effect on coverage.
Thirdly, enrollees used healthcare services more rationally than before. Enrollees' most healthcare demand could be met within county.
Fourthly, reimbursement level has been raised. The percentage of enrollees that obtained NCMS reimbursement in 2008 was more than that in 2008. Meanwhile, the effective reimbursement rate also increased in 2008.
Fifthly, case-based payment had good effect on cost containment, which may also help to reduce enrollees' burden of disease.
Sixthly, the effect of reducing financial risk was strengthened.
Seventhly, satisfaction rate increased from 78.3% in 2005 to 84.5% in 2008.
Although gained achievement, NCMS in six sampled counties was also confronted with challenges. The premium and payment was not rationally determined. Government subsidies were still not allocated adequately and in time. Individual premium was low. The NCMS fund was not stable and faced risk. Medical saving account had limited effect on reimbursement to outpatient expenditure. Health cost escalation aggravated enrollees' burden of disease in some counties. Health cost containment lacked of internal motivation.
5. Analysis on the key influencing factors of financing and payment system in NCMS
Moreover, this study also analyzed the key influencing factors of financing and payment system in NCMS. As for financing, premium was the most important factors with contribution rate as 61-79%. The following factors were coverage rate and actually financing rate. As for payment, raising reimbursement rate, reducing health expenditure segment, lowering deductible could effectively elevate effective reimbursement rate. These three factors should be given priority when adjusting payment scheme.
[Conclusion and political recommendation]
1. Keeping the stability of NCMS. At present stage, NCMS has achieved a broad coverage. To further develop NCMS, it is suggested to keep certain stability in policy, avoiding adjusting policy frequently.
2. Government at all levels should further support the development of NCMS. Government especially the central and provincial government should take the responsibility and subsidize NCMS in time and in full amount.
3. Rationally adjusting the financing and payment scheme to improve enrollees' benefits. When adjusting financing scheme, it is suggested that individual contribution to premium should be raised. When adjusting payment scheme, it is supposed to give priority to reimbursement policy in county level hospitals.
4. Setting a unified fund at a higher level. Some piloted counties have employed similar schemes with other counties. It provides a good basis for setting a unified fund at a prefectual level which can strengthen NCMS capacity of risk protection.
5. Canceling medical saving account, employing unified fund in outpatient reimbursement. The effect of medical saving account has been proved to be limited. Employing unified fund in outpatient reimbursement has been demonstrated to be effective, which can increase enrollees' benefits. More attention should be given to solve the problems in transition period.
6. Developing and improving case-based payment system. In this study, case-based payment has been proved to be effective in cost containment. It is suggested to developing case-based payment system in other counties under the precondition of rationally choosing diseases and setting payment criteria.
7. Strengthening cost containment. It is proposed to strictly control the irrational growth of health expenditure in order to effectively reduce enrollees' burden of disease.
8. Intensifying the capacity building in NCMS administration. Health bureau should take overhead expenditure of NCMS office into consideration, add equipment, network and position in NCMS office to ensure routine work. Meanwhile. NCMS administration officials should have more knowledge on health insurance to be more professional in daily work.
9. Promoting reforms in health sector to ensure sustainable development of NCMS. Reforms in health sector should be deepened and the development of healthcare providers in rural areas should be sped up so as to solve the problems such as irrational growth of health expenditure, unreasonable use of health resources from the root to promote the development of NCMS.
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