Health insurance data: How does the level of outpatient co-ordination affect hospitalization rate?

Text . . Zhu Fengmei The Center for Public Policy Research of the Chinese Academy of Social Sciences on October 16th pushed an article on the impact of the overall reform of the medical insurance outpatient clinic for workers: "Analysis of health insurance data" How does the overall reform of medical insurance outpatient care affect patients' access to medical care? 》。
paper used the 2017 sample data of China Medical Insurance Research Association to carry out relevant analysis and research, and found that the overall reform of outpatient care improved the utilization rate of outpatient services, while reducing the hospitalization rate.
in view of the different affordability of funds and the different ways in which outpatient co-ordination is chosen, we continue to consider the question: How can differences in the level of out-patient co-ordination further affect patient care? Has the effect of outpatient co-ordination in some reform areas been magnified? We first used the 2017 sample data of the China Medical Insurance Research Association to count 66 regions (of which 26 were outpatient co-ordination reform areas), all outpatient and inpatient information for each patient in a year;
reform options: the three outpatient co-ordination models are divided into three models based on the 2017 outpatient co-ordination policy documents and outpatient co-ordination reforms in 26 reform areas: the first is the "general model".
the largest number of regions to choose this model, with a total of 13.
Outpatient co-ordination is characterized by the general out-patient reimbursement starting line (tens to 2000 yuan) and capping line (from a few hundred yuan to several thousand yuan), but also for different levels of medical institutions, or different groups (retired workers and current employees) set different reimbursement ratios, in this mode, the level of outpatient care is generally not high.
the second type is No starting line mode.
choose this model from Guangzhou, Shenzhen and other economically developed regions, but also Yinchuan, Guyuan and other economically underdeveloped areas.
in this mode, in addition to no starting line, the cap line and reimbursement ratio settings are similar to the "general mode", so the level of outpatient protection is slightly higher.
this paper regards Jinhua outpatient co-ordination model as no starting line.
the third type is "No cap line or high cap line mode".
this model has been chosen by Beijing, Shanghai, Dongguan, Xiamen and Hangzhou economically developed areas, the common characteristics of these areas are a large number of foreign population, workers' health insurance funds are relatively abundant, medical resources are relatively rich.
, Dongguan, Xiamen and Hangzhou outpatient co-ordination model, can also be regarded as neither the starting line nor the cap line.
can be seen that this outpatient co-ordination model, the highest degree of outpatient protection for insured patients.
1:26 Reformed Regional Outpatient Co-ordination Model Selection Note: The authors thank Ye Wei, Liu Yang and Bloomberg of the Institute of Medical Information of the Chinese Academy of Medical Sciences for their support in the collation of policy documents.
effect: the higher the level of outpatient protection, the more obvious the relationship between outpatient inpatient substitution and found that the reform effect of different outpatient co-ordination models in the reform areas is different compared to the unrefinished areas.
First, from the proportion of medical service choices for employees' health insurance patients, 11 out of every 100 patients in unrefinished areas have been hospitaled, 79 out of every 100 patients have been to outpatient clinics, and nearly 10 out of every 100 patients have visited both clinics and hospitals throughout the year.
With this reference, although outpatient co-ordination has been achieved in the reformed areas, when the level of outpatient care is outpatient co-ordination (general model), there is no significant difference between patient visits and unrefinished areas, and even the proportion of outpatient visits in a year (71.7 per cent) is lower than that of the latter (79.2 per cent), and the proportion of patients who have both been in hospital and visited clinics (18.6 per cent) is higher than that of the latter (9.8 per cent).
At the same time, although outpatient co-ordination (no starting line) has reduced the proportion of patients admitted to hospital (only 2 out of 100) and increased the proportion of outpatient visits (85 out of every 100), the proportion of people who have been admitted to both hospitals and outpatient clinics during the year is not low (12.4 per cent), and is higher than the 9.8 per cent in the unrepaired areas.
Only under outpatient co-ordination (no capping line or high capping line), there has been a significant change in patient behavior, with only 2 people per 100 patients in hospital, 88 people who have been to the clinic, and 9 people who have been to the clinic.
Figure 1: The proportion of outpatient co-ordination mode and the number of medical service choices for employees' medical insurance patients Note: 1. The proportion of patients who have been in hospital in that year is calculated according to the proportion of patients who have been in hospital in that year and the proportion of patients in the insured areas;
In terms of the proportion of hospitalizations in each reformed region, the proportion of hospitalizations for health insurance for employees under outpatient co-ordination (no cap line or high cap line) is generally lower than the national average (18.3% in 2018).
same time, other outpatient co-ordination model of Guangzhou, Shenzhen, Fuzhou, Tianjin, Changzhou, Nantong and other places the proportion of hospitalization is not high.
if the proportion of hospitalizations is used as an alternative variable for hospitalization rates, Shenzhen, Xiamen and Beijing have hospitalization rates of only 7.7%, 9.2% and 10.7%, respectively.
Figure 2: Proportion of the number of patients hospitalized for medical insurance for workers in the outpatient co-ordination area Note: 1. Because of the sample size problem, the data of Jinan, Zibo and Weifang were excluded from the figure, but it did not affect the analysis results under the large sample data of this paper.
2. The proportion of hospitalizations is calculated according to the proportion of patients admitted to hospital in that year as a proportion of the total number of patients.
Second, from the composition of the annual utilization of medical services for employees' medical insurance patients, in the unrefinished areas, the total number of patients' annual use of medical services accounted for 86.2% and the number of hospitalizations accounted for 13.8%, which means that patients may be hospitalized once every six outpatient visits.
as a reference, there is no significant difference between patients seeking medical treatment and unrefinished areas under outpatient co-ordination (general model).
But under outpatient co-ordination (no starting line), patients are admitted only once every 20 outpatient visits, and under outpatient coverage level (no cap line or high cap line), patients are admitted only once every 34 outpatient visits.
means that the reform of outpatient co-ordination will help reduce the likely for patients to go straight to hospital, and the higher the level of outpatient coverage, the more obvious the policy effect, and the stronger the "alternative relationship" between outpatient and inpatient services.
Figure 3: Outpatient co-ordination model and the number of annual medical service utilization of employees' medical insurance patients constitute note: We have counted the number of outpatient services and the number of inpatient services per employee's medical insurance patients in each region in the sample.
1. The proportion of inpatient service utilization is calculated according to the proportion of patients' annual inpatient service as a proportion of the number of annual inpatient services and the number of annual outpatient services, and 2. The proportion of outpatient service utilization is calculated according to the proportion of patients' annual outpatient service as a proportion of the number of annual inpatient services and the number of annual outpatient services.
of patients' outpatient services is more price sensitive than inpatient services.
that is, by reducing the actual price paid by patients, outpatient co-ordination will significantly increase the probability of insured patients attending outpatient clinics and prescription drugs, and promote more outpatient services for insured patients.
is also the main reason why we found that the reform of outpatient co-ordination will improve the utilization rate of outpatient services for insured patients.
but will these out-patient services be further translated into inpatient care, i.e. will they replace inpatient services or reduce the use of inpatient services? The above analysis shows that this may depend on the level of protection of outpatient co-ordination.
For reform areas with a high level of outpatient care, such as outpatient co-ordination without a cap line or a high cap line, insured patients can obtain most of the required medical services at the clinic, and the conversion rate of outpatient hospitalization is low.
In the case of relatively low level of outpatient protection, such as higher starting line, lower cap line, there is also a reimbursement ratio, this outpatient co-ordination system design, in improving the accessability and affordability of outpatients, may be due to inadequate outpatient protection, will not reduce the probability of hospitalization, but improve the likelihood of hospitalization.
of course, this is not to say that the overall reform of out-patient clinics in the co-ordination areas should move towards high protection, and the choice of out-patient co-ordination model depends not only on the situation of the local medical insurance fund, but also on the characteristics of the supply side of medical services.
Therefore, adjusting the personal account account of medical insurance for employees, moving towards outpatient co-payment protection, how to find a balance between outpatient security and inpatient protection, not only to optimize the allocation of medical resources, will not increase the burden on patients, but also to explore the characteristics of outpatient medical services payment methods and payment systems, reasonable design of patient cost-sharing methods.