Health Care Data Analysis . . How does the overall reform of medical insurance outpatient care affect patients' access to medical care?

For a long time, the personal account system of workers' medical insurance has been widely criticized for its lack of risk-free co-payment, the low efficiency of capital utilization and the difficulty of exerting the effect of income redistribution.
In response to this, on August 26, 2020, the State Administration of Medical Security issued the Guidance on establishing and improving the mechanism for the protection of outpatient assistance for basic medical insurance for workers (draft for comments) to the public for comments, with the aim of improving the social security function of individual accounts and moving towards out-patient assistance protection.
, what are the expected effects of outpatient co-ordination reform, and whether it can achieve the goal of orderly outpatient hospitalization and improve the efficiency of the use of medical insurance funds? In fact, since the new medical reform in 2009, conditional areas have begun to explore ways to adjust the use of personal accounts, and some areas have established outpatient co-ordination.
this provides us with a sample for study.
Based on this, this paper first used the 2017 sample survey data of the China Medical Insurance Research Association to sort out 66 survey areas, and then collected and collated the outpatient reimbursement policy documents of the 66 survey areas through the network, dividing 66 regions according to the existing public policy documents. For the "implementation of the staff medical insurance outpatient co-ordination reform area" (referred to as "reform area") and "the implementation of the staff medical insurance outpatient co-ordination reform area" (referred to as "unrefinished area"), and finally, the outpatient co-ordination reform area and the unrefinished area of the outpatient and inpatient service utilization of a comparative analysis.
in order to give a pre-judgment on the effect of the overall reform of the medical insurance outpatient clinic for employees.
of the sample of the reform was matched by sample data and policy documents, 39.4 per cent (26 districts) of the 66 surveyed areas implemented the reform of outpatient co-ordination and 60.6 per cent (40 regions) did not implement the reform of outpatient co-ordination.
, the economic situation in the areas where outpatient co-ordination is implemented is relatively good, which may also be the main reason for the reform.
the average age of patients attending clinics, patients in areas where outpatient co-ordination is implemented are younger and on average 6 years younger than 2 years in areas where outpatient co-ordination is not implemented.
table 1: Basic situation of reformed and unrealted regions Figure 1: Sample distribution of reformed and unrealed regions Note: Xinjiang's military and the 4th Division are not shown in the map, both of which are unrefinished co-ordination areas.
Frequency of outpatient visits: Increase in outpatient utilization and decrease in inpatient utilization To compare the differences in the utilization of outpatient care services in areas with non-reform areas, we have made the following analysis: First, we measure the utilization rate of outpatient services by the proportion of patients in the sample who have had outpatient experience (both outpatient and inpatient).
results show that the annual utilization rate of outpatient services for employees' medical insurance patients is significantly higher than that of unrefined areas, with the former about 10 percentage points higher than the latter.
the number of annual outpatient visits, the average annual number of medical insurance patients in reformed areas is close to 13, which is higher than the nine times in unrefined areas.
to some extent, this shows that outpatient co-ordination brings more frequent use of outpatient services for insured people, so as to avoid patients from being treated for economic reasons, which is conducive to early diagnosis and early treatment of patients through outpatient services.
table 2: Annual outpatient utilization and annual outpatient visits Second, we measure inpatient service utilization using the proportion of patients in the sample who have experienced inpatient visits, both outpatient and inpatient.
results show that the annual hospitalization rate of employees' medical insurance patients is significantly lower than that of unrefinished areas in areas where outpatient co-ordination reform is implemented, and the former is about 7 percentage points lower than that of the latter.
the number of hospitalizations per year, the average number of hospitalizations per year for workers' health insurance patients in reformed areas was 1.82, slightly higher than the 1.56 in unrefinished areas.
To this extent, outpatient co-ordination reform can reduce the use of inpatient services, while unrefinished areas of insured patients because they can not be guaranteed in outpatient care, mostly through inpatient access to medical services, thereby increasing the rate of inpatient care.
hospitalizations are higher in the reformed areas, possibly due to the relatively serious condition of the patient.
Table 3: Annual inpatient rate and annual hospitalization cost: Outpatient for hospitalization The above analysis results show that compared with the reformed areas, the behavior of medical insurance patients in reformed areas has been reversed, i.e. the outpatient utilization rate is relatively high and the inpatient rate is relatively low.
of medical consultation will inevitably lead to a change in the allocation of medical resources (medical expenses).
From the four-year outpatient fee and annual inpatient cost, it can be seen that the total annual outpatient cost is relatively high (average 2749 yuan), which is 3.8 times the total annual outpatient cost (average 714 yuan) for patients in the reformed area because they can obtain medical services through multiple outpatient guarantees.
This also leads directly to the fact that only those with more serious conditions will choose to receive treatment through hospitalization, so the total annual hospitalization cost of patients in reformed areas (average of 20,475 yuan) is 1.5 times that of the total annual hospitalization cost in unrefinished areas (average of 13,521 yuan).
Table 4: Annual Outpatient Expenses and Annual Inpatient Expenses For further analysis of cost differences, we divide the annual hospitalization expenses of employees' health insurance patients into five groups by cost: low-cost group (0-05,000 yuan), The low- and medium-cost group is 0.5-10,000 yuan, the middle-cost group is 1-30,000 yuan, the middle-high-cost group is 3-50,000 yuan, and the high-cost group is more than 50,000 yuan.
The annual outpatient expenses and total annual outpatient expenses (including outpatient expenses and inpatient expenses) of employees' health insurance patients are divided into the following five groups according to the cost: the low- and medium-cost group (0-0.1 million yuan) and the low- and medium-low-cost groups. 1-0.3 million yuan, the middle-cost group (0.3-0.5 million yuan), the medium-high-cost group (0.5-10,000 yuan), the high-cost group (more than 10,000 yuan).
Figure 2 shows that: (1) In terms of annual hospitalization costs, the proportion of patients in the low-cost segment of the reformed area (under 0.5 million yuan) is relatively low compared with that in the unrefined areas, but the proportion of patients in the medium-cost segment and above (more than 10,000 yuan) is close to 50%, compared with less than 35% in the unrefined areas.
(2) In terms of annual outpatient costs, the proportion of patients in the low-cost segment of the reformed area (under 0.1 million yuan) is also lower, at just over 50 per cent, compared with more than 80 per cent in the unrefinished areas.
(3) In terms of the total annual cost of medical visits, the proportion of patients in the low-cost segment of the reformed areas (under $0.1 million) is also lower than in the unrefinished areas, with an overall increase of no more than 50 per cent, compared with more than 65 per cent in the unrealed areas.
note that the proportion of patients in the low-cost segment (0.1-03,000 yuan) in the reformed areas was 21.5%, higher than the 12% in the reformed areas.
It can be seen that the reform areas as a whole show two high characteristics of "higher annual outpatient costs and higher annual hospitalization costs", while the unreformed areas show two low characteristics "lower annual outpatient costs and lower annual hospitalization costs".
for the latter, we have reason to suspect that the high rate of hospitalization is the result of a large number of patients with minor illnesses accessing medical services through hospitalization.
Figure 2: The proportion of different cost groups in reformed areas and unrefined areas Is reduced, we give the following basic judgments: Outpatient co-ordination reform has improved the use of outpatient services, which in turn has led to an increase in annual outpatient costs, and because outpatient clinics can solve the majority of patients' minor problems, avoid patients flocking to large hospitals, so that large hospitals can use more medical resources to solve serious illnesses, major diseases, difficult diseases and other patients' treatment, help improve the efficiency of medical insurance funds.
On the contrary, the cost of outpatient care for other major and minor diseases can only be compensated through inpatient care, which also lowers the average cost of inpatients, in addition to the provision that outpatient costs for diseases can be compensated.
this by the relatively high proportion of patients in the low-cost segment of hospitalization costs in unrefined areas.
next step, we will analyze the possible resource allocation effect of outpatient co-ordination reform from the perspective of the pressure of health care fund expenditure and the flow of health insurance fund expenditure.