Outpatient co-ordination: an important step for payer to promote medical service reform

With the official launch of the reform of outpatient co-ordination and accounting, there will be significant changes in the medical services and drug markets.
reform will strengthen the existing market pattern on the medical service side, expand the size of the in-hospital market on the pharmaceutical side and narrow the size of the drug retail market.
if it is implemented with DRG, medical expenses will continue to be transferred from inpatient to outpatient, it is clear that the account can not bear the scale of this transfer, outpatient co-ordination is also the main tool to solve this problem.
, although the size of the clinic will continue to expand over the next 10 years.
but that doesn't mean the spring of primary clinics, the biggest gainer in this market is still level three hospitals.
-patient co-ordination and individual account reforms involve two different markets, medical services and medicines, which are closely linked but have their own characteristics.
, from the point of view of the medical service market, there will be more than 200 billion yuan after the reform of the accounts, which as a reserve for outpatient reform, can effectively ensure the implementation of the policy.
same time, as the amount of individual accounts shrinks, groups that used to buy drugs in pharmacies will see more people in medical facilities to obtain medicines, which will boost the expansion of the outpatient market and be good for all medical institutions.
but this is only a general view, if in terms of financing and service capacity, the gap between different regions and different types of medical institutions is very large.
first, in terms of financing, only Beijing, Shanghai and Guangdong provinces now account for nearly 50% of the overall balance, if you include other provinces in the developed eastern regions, the balance is higher.
income is directly linked to wages, with higher average wages in the developed eastern regions, especially among high-income earners, and higher overall incomes.
if the existing account unit contributions into the co-ordination, the eastern developed provinces of the co-ordination fund growth is more.
in the Midwest and other economically less developed regions are themselves low, and their co-ordination funds are actually relatively limited.
the paradox of funding is that health insurance funds in less developed areas are out of funding, and limited co-ordination means that outpatient reimbursements in those areas will be more limited.
the eastern region because of the relatively generous funds, outpatient co-ordination reimbursement amount can be relatively high.
central financial transfer payments are still needed if reimbursements are to be increased in the Midwest.
, from the point of view of medical service capacity, the proportion of outpatient visits in level III hospitals is increasing year by year and will be further strengthened under the out-patient co-ordination policy.
number of outpatient visits to third-tier hospitals rose from 1.5 billion in 2015 to 2 billion in 2019, and the growth rate rose from 8.67 percent in 2016 to 11.35 percent in 2019.
same time, the proportion of total visits rose from 19.51 per cent in 2015 to 23.62 per cent in 2019.
while the proportion of outpatient visits at the grass-roots level is still the highest, rising from 4.34 billion in 2015 to 4.53 billion in 2019, the growth rate has been very low, from 0.69 percent in 2016 to 2.72 percent in 2019, and from 56.44 percent in 2015 to 51.95 percent.
Although the number of outpatient visits at the grass-roots level is more than double that of the level III hospitals, the size of the outpatient market at the grass-roots level is in fact much lower than that of the level III hospitals, as the average cost at the grass-roots level is 1/3-1/5 in the primary level hospitals.
as patients are affected by the out-patient co-ordination policy, especially under the shrinking of the single account, the proportion of outpatients and the size of the market in the third-tier hospitals will be further boosted.
Second, from the point of view of the pharmaceutical market, because the implementation of outpatient co-ordination and individual account reform is synchronized, the reduction of individual account funds will promote individuals to reduce the consumption of credit cards in pharmacies, directly to primary medical institutions or hospitals.
will drive the expansion of the retail market for out-of-hospital drugs and the expansion of the in-hospital drug market.
this trend will continue to increase if the overlay of drug collection is fully pushed aside, especially after some OTC drugs are included in the collection, there will be a long-term upside-down between hospitals and pharmacies.
account point of view, according to the 2019 statistical bulletin issued by the State Health Insurance Administration, the cost of individual employee health insurance accounts in pharmacies is 202.9 billion yuan.
2019, employee health insurance personal account income of 584 billion yuan, an increase of 10.3% over the previous year.
once revenue is halved, the cost of what users are willing to leave to pharmacies will be significantly reduced.
As the amount of money available for individual health insurance accounts shrinks, individuals may change their habits and reduce the need to go to pharmacies to buy medicines, because the cost of going to pharmacies needs to be paid entirely from individual accounts, but at least 50 percent of the medical insurance fund can be reimbursed if it is an outpatient co-ordination.
, on the other hand, in and out of the hospital drug prices upside down also affect the will of consumers.
Since the implementation of the hospital drug price difference in 2015, retail pharmacies are facing increasing challenges, with the development of drug collection, especially the medical insurance payment price in the future finally landed, pharmacies to the hospital's original drug price advantage has been lost, in the field of pharmaceutical e-commerce is the same.
without price advantage, the outside channel attraction will be weaker and weaker, which is one of the reasons why the number of hospital outpatients has increased year by year.
Finally, from the implementation of DRG, in order to meet the requirements of packaged payment, the hospital has the need to transfer inpatient expenses to outpatients, if not the implementation of outpatient co-ordination, patients can only use a limited amount of funds, the amount of out-of-charge will be greatly increased, not conducive to the reduction of the burden of patients.
the implementation of DRG, the hospital's primary means of operation is to divest non-surgical items from hospital due to the packaged payment of individual cases.
whether it is the introduction of integrated medical care in Germany (the integration of outpatient and inpatient care) or the increased development of outpatient clinics in Taiwan, it is to make it easier to move divestable inpatient projects into outpatient clinics.
, all hospitals are stepping up outpatient development in order not to allow the income to be accessed by other medical institutions.
The same trend is true when combined with the U.S. market, where hospitals expand the size of their primary clinics once payer regulation of hospitalizations increases, ensuring that their total revenue does not decline.
, from the point of view of DRG implementation, outpatient co-ordination is a reform initiative that must be introduced.
other countries and regions of the health insurance itself does not have a bill, there is no accounting out-patient policy led to patients eventually have to pay out of their own money.
, however, due to China's weak grass-roots inpatient strength, large hospitals in the field of inpatient advantages, from inpatient to outpatient cost transfer will also be mainly large hospitals, which will promote large hospital outpatients to the next level.
the proportion of hospital admissions to level 3 hospitals increased from 32.44 per cent in 2015 to 39.42 per cent in 2019, making it the largest sector in the hospital sector.
2017, hospitalization revenue in tier 3 hospitals was close to 1.1 trillion yuan, with an average annual growth rate of 15% from 2013 to 2017.
, the scale of inpatient income of secondary hospitals and first-class hospitals was only 464.3 billion yuan and 53.8 billion yuan, respectively.
, the largest sector to undertake inpatient fee transfers will also be outpatient clinics in level III hospitals, which also means that the cost of outpatient co-ordination will mainly flow into this area.
In short, the reform of outpatient co-ordination and individual accounts is related to the overall reform of the health care system, not only the gain or loss of individual or pharmaceutical benefits, but also the key step in promoting the overall transformation of the medical services and drug market from the perspective of the payer.