evaluation of the new rural cooperative medical scheme outpatient capitation payment reform in...

Evaluation of the New Rural Cooperative Medical Scheme

Outpatient Capitation Payment Reform in Qianjiang District of

Chongqing, ChinaQu, Qian (1); Sun, Jing (2); Kang, Jun (3); Zhang, Weibin (1);

Tan, Yongqian (4); Xiang, Wenxian (4)

1: Chongqing Health Bureau, P.R. China; 2: National Institute of Hospital Administration, MOH, P.R. China;

Corresponding author: e-mail: [email protected]: Chongqing Medical University, P.R. China;

4: Qianjiang District Health Bureau, Chongqing, P.R. China

16 Nov. 2011 Antalya, Turkey

13c-Economics: Health Insurance Coverage for Medicines in LMIC

http://www.inrud.org/ICIUM/Conference-Overview.cfm

Background

• There has been an increasing cost containment pressure for the New Rural Cooperative Medical Scheme in China

• The fee-for-service payment and other factors create perverse incentives, which drive the irrational provider behaviours




Setting

• Capitation payment reform is piloted in Qianjiang where there are 30 township/community health centres and 169 village clinics




Study Aims

• This study evaluates if the capitation payment reform in Qianjiang:

- Contained the cost- Rationalized the providers’ behaviour- Caused income losing of the health

workers and facilities




Methods-1

• The effect of the policy is measured with the changes of the following indicators before and after the reform in Qianjiang :

- cost per visit;- quality of care;- income of facilities and health workers




Methods-2

● The effect of the policy is also showed by comparing the cost and hospitalization data of Qianjiang with that of Southeast Chongqing where has similar social and economical development situations with Qianjiang




Methods-3

• Quality of care is evaluated with:

- Prescription indicators to show medicines use status;

- Referral rate, proportions of appropriate referrals and hospitalization rate show if patients are selected and shifted from outpatient to inpatient




Methods-4

• Cost is measured with:

- Annual average cost of all facilities of Qianjiang and compared with Southeast Chongqing during 2006-9;

- Annual median cost of all and sample

facilities in Qianjiang during 2007-9;

- Both costs are compared with the prescription caps




Methods-5

• Quality of care and income data of Qianjiang are collected from sample facilities

• Interviews provide complementary information




Results-1• The average cost per visit of all THC/CHCs

and village clinics in Qianjiang is at the same level of Southeast Chongqing in 2006, getting much lower in 2009



2006 2007 2008 2009 Cost N

(facilities) Cost

N (facilities)

Cost N(facilities) Cost N(facilities)

Qianjiang

Township /community

health centers (THC/CHC)

16.35 32 15.4 32 16.85 30 19.73 30

village clinics 11.56 137 11.35 158 12.34 158 11.97 169

Southeast Chongqing

Township /community


17.49 201 22.69 213 25.9 199 24.54 200

village clinics 11.06 1,284 16.39 1,243 20.98 1,288 18.43 1,431

Prescription caps in

Qianjiang

Township /community


/ 15 / 18 / 20 /

village clinics / 10 / 12 / 15 /


Results-2• The median cost per visit of all THC/CHC and

sample THC/CHC in Qianjiang both are with an increasing trend during 2007-9. Both increases are statistically significant (Ⅹ²= 851.7614, P<0.0001 and Ⅹ² =1078.8001, P<0.0001)



All township/community health centers (THC/CHC)

Sample township/community health centers (THC/CHC)

2007 2008 2009 2007 2008 2009

N (prescriptions) 402,420 484,328 599,450 69,805 89,332 110,055

Means 17.9904 19.5742 20.132737 17.4528 19.6795 19.749782

25th Percentile 7.9900 8.5300 9.034600 7.3600 8.0000 8.678600

Median 13.2800 14.9400 15.248000 12.3100 13.9500 15.231400

75th Percentile 22.6000 25.5400 25.439500 22.4600 27.3700 25.830000


Results-3

• Both average and median cost of Qianjiang keep within the prescription caps during 2007-9, when costs of Southeast Chongqing far exceed




Results-4• There are no significant changes of referral

and prescription data in Qianjiang during 2007-9 ( ² test, P>0.05)Ⅹ



2007 2008 2009 Ⅹ² P

Referral rate in township/community health centers (%)

37.16 36.45 36.240.018 0.8928

Appropriate referral rate in township/community health centers (%)

92 95 950.7952 0.3725

% of essential medicinestownship/community

health centers 95 100100 7.6017 0.0058

village clinics 98 100 100 3.0101 0.0827% of prescriptions with steroids in township/community health centers 3.58 3.19 2.59

0.1616 0.6877% of prescriptions with antibiotics in township/community health centers 24.11 19.93 16.57

1.7573 0.185% of prescriptions with infusions in township/community health centers 13.69 12.92 11.90

0.1427 0.7056

Results-5

• The qualitative interviews and group discussions show that, doctors are more likely to adopt less costly alternative treatments, and are more willing to provide outreach services for preventive care



Results-6• There are no significant differences between

the average hospitalization rates of sample township/community health centers of Qianjiang and Southeast Chongqing in 2006 and 2009 ( ² test, P>0.05)Ⅹ



2006 2007 2008 2009 2 P

Qianjiang 4.06 4.73 2.87 4.57 0.0151 0.902

Southeast Chongqing

4.1 4.75 7.08 3.72 0.0014 0.97

Results-7

• The monthly income of the health workers and the outpatient revenue of facilities in Qianjiang keep growing during 2007-9

• There are no overruns in all the sample facilities in Qianjiang



Summary-1

• The cost containment objective is achieved

• Provider behaviours are partially improved but with limited affect on prescriptions



Summary-2

• The reform does not bring financial loss to both the facilities and the individuals, but creates incentive for less costly alternative treatments and more attention to prevention



Policy Implications and Conclusions

• Capitation payment dose raise the cost awareness of providers

• Comprehensive performance assessment system and other supporting policies could help address the unexpected side effects of the capitation payment

• Changing prescription behaviors needs more comprehensive interventions



evaluation of the new rural cooperative medical scheme outpatient capitation payment reform in...

Documents

health insurance coverage

health workers

lmic slide

turkey slide

chongqing health bureau

facilities of qianjiang

income data of qianjiang

sample facilities interviews