better financial protection in qingdao_china_ihea
TRANSCRIPT
Tatyana Makarova, Jian Wang, Baorong Yu, Bart Smet
EU-China Social Security Reform Co-Operation Project
EPOS Health Management
July 13, 20097 Health Congress, iHEA, Beijing 1
Presentation outlinePresentation outlineo Brief overview of Qingdao
o Objectives and policy context of the pilot
o Pilot scope and main dimensions
o Pilot progress and first results
o Challenges and next steps
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About QingdaoAbout Qingdaoo Coastal City in Shandong
Provinceo City with special status
(special economic zone)o 7,579,900 population
(2007)o Developed diversified
economy o Mixed urban and rural
population - 7 districts and 5 counties
o Well developed health service network and sufficient health workforce
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Health service delivery capacityHealth service delivery capacity
139 8
93
10
6
20
13
1621
889
hospital
sanitarium
health center
maternal and children healthfaciliti
special disease prevention andtreatment institution
center for disease preventionand control
health monitoring andsupervision organization
clinic
community health station
Total 2,834 health institutions in Qingdao (2006) with number of hospital beds, licensed physicians and registered nurses per 1,000 pop-n higher than average in the province and nationally
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Health insurance in Qingdao: Health insurance in Qingdao: pre-pilot overviewpre-pilot overviewo Health insurance oriented towards hospital-based
care o Primary health care (PHC) out of benefits packageo Underdeveloped primary health care
o Weak referral system: patients report directly to hospitals regardless of their conditiono Issues with timeliness of disease prevention,
detection and management o Patients tend to trust only hospital based physicians
o Recurrent underutilization of insurance fundso Fragmentation of funds - limited practice of pooling
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Innovations in Qingdao (1)Innovations in Qingdao (1)o Expanding health insurance benefits by inclusion
of cost-effective outpatient services – transition from “disease insurance” to “health insurance” o Such strategy embraces two key policies:
restructuring of health services delivery system to emphasize ambulatory primary care and community orientation and strengthening health insurance towards its universality and better financial protection
o Qingdao became one of pioneers in incorporating services of community health centers (CHCs) into public insurance benefits for urban citizens and migrant workers.
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Innovations in Qingdao (2)Innovations in Qingdao (2)o CHC is a core type of primary health care delivery
organizations in China that render outpatient and inpatient services o Provide health education, preventive and curative
care, maternal and child care, rehabilitation o Some affiliated with hospitals
o Covering CHC services by insurance is a multiple goal strategy of Qingdao that aim at:1.restructuring health services consumption among
insured towards cost-effective health care choices, 2.introducing referral system for efficient patient flows
and service utilization, and3.improving utilization of individual savings accounts
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Policy context (1) Policy context (1) o February 2006: enacted by the State Council
“Regulation on Urban Community Health Service Institution Management” and “Guiding Opinions on the Pilot Urban Resident Cooperative Medical Insurance” specified:1. “Effects of services at urban community level
should be fully availed; 2. Functions and scope of services at urban
community level should be incorporated, enhanced and broadened;
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Policy context (2) Policy context (2) 3. Health services of community level should be
utilized efficiently; 4. Qualified health service facilities of community
level should be included in insurance contracting system;
5. Cost recovery for community service providers from health insurance funds should be reasonably increased”.
Qingdao promptly followed up with the adoptionQingdao promptly followed up with the adoptionof these policy directions and piloting their of these policy directions and piloting their implementation strategy implementation strategy
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MainMain milestones in pilot evolution milestones in pilot evolution 1. January 2006: a pilot to cover costly outpatient
services of community health centers (CHC) by insurance for urban employed
2. May 2006: a pilot to cover home care for elderly and “inpatient home-based care” of CHC by insurance
3. January 2007: a pilot to establish community-based family physician model with gate-keeping function and new referral system
4. October 2007: pilot to enroll elderly and disabled through better pooling of funds
5. January 2009, a pilot to establish outpatient pooling fund in 4 urban districts
Categories of insured coveredCategories of insured coveredo Beneficiaries include such groups among insured
as:o Urban employees, including retiredo Urban residents
o Elderlyo Disabledo Childreno Students
o Migrant workerso Thus, over time all enrolled into basic medical
insurance and urban insurance schemes became eligible, and in addition migrants covered by new cooperative medical scheme
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Gradual expansion of scope of CHC services for insured:
o The Pilot started with coverage of:1. Outpatient services for costly diseases
(diseases that formerly were typically treated in hospitals) - a list of 18 chronic diseases
o Later added:2. Post hospitalization home-based care3. Ordinary (common) outpatient care 4. Elderly & family medical care
Innovations in benefitsInnovations in benefits package (1)package (1)
Innovations in benefitsInnovations in benefits package (2)package (2)Gradual expansion of benefits (continued):
5. Introduction of health examination (check) for contracted households and establishment of family health record
6. Health education for insured7. Medical intervention mechanism for prevention,
detection and management of chronic diseases like diabetes, hypertension, etc.
o Counseling to change unhealthy behaviors and lifestyle
o Follow up for patient with chronic diseases and complications
8. Rehabilitation
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New contracting New contracting Introduction of contracting with CHCs:
1. Contracts between CHC and Insurance Center: Designated Community Health Centers should contract with Municipal Center for Health Insurance (MCHI) for provision of specified services to the insured
o CHC fills out application form for every qualified patient, and applies to the MCHI for approval
2. Contracts between PHC physician and insured: patients select one CHC and a physician within it
o Annual contracts with renewal or change of choice
Patient’s choice and gate-keeping Patient’s choice and gate-keeping o Insured choose a primary care provider –
family doctor for the whole familyo CHCs lists qualified physicians for selection o Maximum of contracted insured per FD ≤ 2,000,
among which retired, elderly and disabled ≤ 500. o By late 2008 80,308 insured signed contracts
with FDs within 132 CHCs, among them: o 59,648 employees,o 20,660 urban non working residents (among them
elderly and disabled - 18,408)o FDs are first points of service with gate-
keeping and care coordination functionso Lack of qualified FDs presents a challenge
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New referral system New referral system o Old referral system between hospitals of three
levels replaced by a new system:o Between ambulatory care in CHC and inpatient
care in referral hospitalso All referrals for enrolled patients should be
administered by FDs
o New is a two way system:o Referrals from CHC to referral hospitalso Referrals from hospitals to CHC for continuation
of care (ambulatory observations, routine disease management, rehabilitation and home-based care)
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Incentives for patients to obey Incentives for patients to obey enrollment with CHCs/FDs and referralsenrollment with CHCs/FDs and referralsoNo coverage for services in other than chosen
CHC
oCoverage of referrals for inpatient care:o For the elderly, severely disabled, and non-employed: o no FD’s referral - no insurance reimbursement
o For insured urban employees: no FD’s referral – covered, but favorable reimbursement policy does not apply
o For emergencies, referral process should be finalized by FD within 7 days since the hospitalization, otherwise – no reimbursement
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New financial mechanism: New financial mechanism: individual savings accounts (ISA)individual savings accounts (ISA)o Contributions to ISA from two sources:
o from employees - direct contribution to ISA o from employers - part goes into ISA depending
(vary by age and status of insured: 2.3% - 3.5% of annual payroll and 5% of pension for retired)
o ISA – a bank account; funds can be consumed for only designated benefits, such as pharmaceuticals, inpatient copayments, now used for CHCs services
o Historically ISA funds were underutilized, now they are partially pooled for financing CHC services o Do to pooling expansion of benefits did not require
any increase in insurance premiums
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New financial mechanism: New financial mechanism: funds pooling funds pooling o Funds pooling for outpatient care for insured:
o For retired: pooling of 10 RMB from ISA, other 20 RMB collected from the social pooling fund (SPF) per member
o For per currently employed - 8 RMB from ISA and 10 RMB from Social Pooling Fund (SPF)
o For urban residents, 10 RMB from SPF for the elderly, disabled and non-employed (no ISA exist for them)
o Family pooling of ISA:
o Once contracts with FD signed for the whole family, ISA can be shared among family members
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Incentives for patients Incentives for patients to consume CHC services to consume CHC services o While coverage deepens, patients receive
financial incentives to comply with gate keeping & referral rules: o Direct user charges replaced by insurance
reimbursemento Lower deductibles: discounted or zero deductibles
o E.g. deductibles for inpatient care are half size for patients referred from contracted CHCs
o Lower co-payment rate: discounted or zero co-paymentso Co-payment rate is reduced if medical expenses are
above deductible, but less than 20,000RMB o Higher patient reimbursement rates for comparable
services in CHCs than in hospitals 21
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o “Capitation” for common outpatient care is used to set a budget ceiling, but not as a payment methodo Per capita ceilings established by type of services and insured
o Mainly FFS payments – rates competitive with hospital rates for comparable services; per diem for home based care
o Multiple deducible and co-payment schedules
o Patients have pay 100 % service fee OOP and wait for further reimbursement
o Transactions from Insurance Center to CHC, and then from CHCs to patients
Payments for CHC servicesPayments for CHC services
PricingPricing andand paymentpayment system: system: example on costly outpatient casesexample on costly outpatient cases
CHC Level I hospital
Level II hospital
Level III hospital
Deductible 300 RMB 500 RMB 670 RMB 840 RMBCopayment for expenses below 5,000 RMB
8% 12% 14% 16%
Copayment for expenses 5,000RMB to 10,000 RMB
8% 10% 12% 14%
Copayment for expenses 10,000 to 20,000 RMB
8% 10% 10% 10%
Copayment for expenses above 20,000RMB-ceiling
8% 5% 5% 5%
Reimbursement rate for expenses over the ceiling
70% 50% 50% 50%23
Pricing and payment system for outpatient care for costly (“catastrophic cost”) conditions brings incentives to make shifts towards CHCs and lower level hospitals
Drug benefits andDrug benefits and paymentpayment systemsystemo The MCHI adopts essential drug list and medical
service list for common sickness, chronic disease and frequently occurred sickness
o Co-payment rate reduced to 10% from 20% and above for some drugs (list A) for those receiving costly outpatient services and care for elderly
o Those whose with co-payment rate for some drugs of 10% (list B), no co-payment to be charged
o However, only about 120 drugs are available within CHCs as centralized supply is insufficient – hence patients are reluctant to buy them from CHCs and go to pharmacies.
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o Issues of access to care and affordability of OOP payments: o Insured patients have to pay OOP first and get
reimbursed by CHCs one year later or when medical expenses accumulate 3,000 RMB (~$440)
o Relatively high co-payment rates, e.g.:o For family medical care: 4% - for retired, 8% - for
currently employed, 30% - for others; o For care for elderly: 4% - for retired and 30% -
others; o For common outpatient services: 50% for retired
and currently employed and 30% for elder, severely disable and non-employed.
o Over engineered payment mechanism: too many payment policies, rules, methods and schedules
PricingPricing andand paymentpayment system: system: issuesissues
Pilot progress and first results
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Main developments (1)Main developments (1)o Gradual expansion of the number of CHCs
contracted for provision of services for insured:o Between January 2006 and by late 2008, the
number of contracted CHCs increased from 41 to 181, from 4 to 7 city districts.
o Growing number of CHCs staffed with FDs: o From initial 22 to 165 pluso Increasing number of FDs engaged in contacts
with health insurance through patient enrollmento More than 30% of PHC physicians are FDs
o Patients respond to new incentives: o Numbers of enrolled with CHCs and reporting to
CHC for services grow steadily
Main developments (2)Main developments (2)o Chronic disease management:
o By now CHCs have exceeded hospitals in a share of reimbursed cases of hypertension and diabetes.
o Spending on outpatient care for costly disease cases served by CHCs was increasing from 27.3 M RMB in 2006 t0 42, 6M RMB in 2008
o Shift in consultations from higher level hospitals – by the means of gate keeping mechanism
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oUp to July, 2008, per capita expenditure on management of special chronic diseases in CHCs covered by health insurance accounted for 2,652.33 RMB – it is 640.5 RMB or 24% lower than that in hospitals
oAverage co-payment accounted for 683.15 RMB in CHCs , which is 767.59 RMB or ~60+% lower than that in hospitals.
Cost saving gains and benefits Cost saving gains and benefits for insured: selected examples (1) for insured: selected examples (1)
Cost saving gains and benefits Cost saving gains and benefits for insured: selected examples (2)for insured: selected examples (2)o Between January 2006 and July 2008, at
least 236,300 visits to hospitals transferred to community level resulting in almost 61M RMB in savings
o For a patient with special chronic diseases from 4 to 500 RMB could be saved in CHCs in comparison to hospitals:o Only in the first half of 2008, 7.81M RMB of
OOP got saved by insured patients of this category.
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Case study on strengthening CHCs through the pilot processo The EU-China Social Security Reform
Cooperation Project carried out situation analysis of Qingdao pilot
o Analysis included a survey of eleven CHCs:o Public - 6; private - 4; enterprise affiliated – 1
o Expansion of insurance benefits in CHCs has been associated with several positive effects in overall development of CHCs:o Increases in serviced patients o Increases in total revenueso Expansion and renewal of inputs (e.g. personnel
and equipment)o Increases in outpatient service volume in CHCs
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Findings from 11 CHCs
0100200300400500600700
1 2 3 4 5 6 7 8 9 10 11
（万
/年）
图1- 8 保险纳入前后社区卫生服务中心收入变化
前后
Annual revenue of 11 CHCs before and after inclusion of PHC services into health insurance package
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020406080
100120140160（万）
1 2 3 4 5 6 7 8 9 10 11
1-10 图 保险纳入前后社区卫生服务中心设备变化
前后
Value of medical equipment before & after introducing PHC in health insurance package
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050
100150200250300350
/（人次 天）
1 2 3 4 5 6 7 8 9 10 11
1- 12 图 保险纳入之后社区卫生服务中心门诊量变化
前后
Change of outpatient volume before & after introducing PHC in health insurance package
Service mix of site #1 after inclusion in insurance influenced by renovation
Next steps (1)o Further expansion of population coverage by
main public insurance schemes – expansion in breath and depth
o Improved mobilization and pooling of revenues:
o Improve administration and level of revenue collection
o Sustain subsidies from budgets of all levels o Enlarge scale of pooling: plan to cover all through
establishment of outpatient care pool using up to 40-50% of ISA of employed
o Elevate level of funds po0ling by integrating cross-county pooling and cross-district into city pooling (county and districts together), particularly for urban resident insurance.
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Next steps (2)o Funds allocation and payment system:o Lower burden of up front payments for patientso Streamlining and unifying payments o Introduce capitation as a payment methodo In combination of performance oriented rewards
o Performance - based contracting with CHCso Incentives in remuneration of FDs
o Clinical practice development:o More effective competition with hospitals o Strengthened referral system o Better and broader management of chronic diseases
o Guidelines for performing with quality & appropriateness o Clinical guidelines and standardso Provider performance monitoring and assessment
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Next steps (3)o Using systems and means to attract patient to
CHCs/PHC and to build population trust:o Level of financing and input renewals and expansionso Improvement of drug procurement rules and
practices o Patient enrolment, gate-keeping and referral systemo Publishing results of CHCs performance o Integration of social and medical services at CHCso Direct communication and links with communities
o Strengthening of CHCs information system and interface with IS of Insurance Center
o Capacity building within CHCs: upgraded clinical skills and skills in effective management
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