Objective To compare the national essential medicines list (EML) and national essential insurance medicine list (EIML) of China with that of the WHO, so as to provide reasonable evidence for the adjustment of new EML and EIML of China. Methods The similarities and differences in the selection, updating, categories, subcategories and the amounts of medicines in the EML and EIML of China and the WHO EML were compared and analyzed. Results There are some differences among the three lists in selecting principles, updating of medicines .The latest version of WHO EML (version in 2007) has 27 categories, including 340 medicines; China EML (version in 2004) has 23 categories and 773 western medicines, containing 23 categories and 225 (66.17%) similar medicines of WHO EML, which accounts for 29.11% of EML of China. China EIML (version in 2005) has 23 categories and 1 031 western medicines, containing 22 categories and 227 (66.76%) of WHO EML, which accounts for 22.02% of EIML of China. China EIML was developed based on China EML. There is little difference in selecting, updating, categories of medicines. Conclusion The difference was obviously found in medicine selection, updating and categories between China EML, EIML and WHO EML. We suggested that our national EML and EIML should be more reasonably selected and updated base on the principals of WHO EML.
Objective To identify the chief factors influencing the hospitalization expenses in fracture patients with health insurance so as to provide information for the control of irrational increase in medical expenses and reform in the mode of medical insurance payment. Methods A total of 113 fracture patients with medical insurance in a hospital of a certain city from September 2006 to April 2007 were included and statistical analysis was performed by using multinomial linear regression analysis. Results The major factors influencing the hospitalization expenses in fracture patients with health insurance included the proportion of material fees and drug fees, length of stay, performance of operations and blood transfusion and etc. Conclusion Lowering the proportion of material fees and drug fees reasonably, reducing the length of hospital stay and avoiding operations and blood transfusion were the key to the control of hospitalization expenses for fracture. It is imperative to speed up and deepen the reform in medical insurance system, formulate scientific diagnostic and treatment routines and clinical pathways as well as expense standards, and try out the payment on certain single disease such as fracture.
Objective To explore the impact of Diagnosis-Intervention Packet (DIP) reform on the operation of pilot county-level hospital, analyze the challenges that hospitals may face in DIP reform, and propose strategies to adapt to the reform. Methods The settlement list data of inpatients insured by medical insurance for 2022 from a county-level tertiary public hospital in Jiuquan City, Gansu Province were collected, where DIP was planned to operate. The DIP payment was simulated, and the operational status of the hospital and departments after implementing DIP reform was analyzed based on enrollment status, cost deviation, length of stay, hospitalization expenses, and DIP payment as relevant indicators. Results Under the implementation of DIP payment, the overall enrollment rate of the hospital was 98.1%, including 85.4% in the core group, 7.0% in the comprehensive group, and 7.6% in the grassroots group. Normal costs accounted for 88.9%, deviation costs accounted for 11.1%, with high magnification cases accounting for 1.9% and low magnification cases accounting for 9.2%. The payment standard for all cases included in the hospital according to DIP was 15.464 million yuan, the total amount paid by the pooling fund was 19.986 million yuan, and the difference between DIP payment and payment by project was –4.522 million yuan. Conclusion There is a significant difference in the medical insurance payments received by county-level hospitals after implementing DIP payment, and there is an urgent need to adapt to the DIP payment reform as soon as possible.
ObjectiveTo investigate the factors that influence Chinese residents, self-rated health and the effects of the multilevel health insurance system and neighborhood social capital on self-rated health. MethodsBased on the 2018 China labor-force dynamics survey data, and Stata 15.0 software was used to conduct χ2 test, univariate analysis and multiple logistic regression model were used to analyze the influencing factors of self-rated health of Chinese residents. An interaction model was used to analyze the interactive effects of the multilevel health insurance system and the social capital of the neighborhood on self-rated health. ResultsA total of 10 201 people were investigated in this study, and 39.20% of them were self-rated unhealthy. After adjusting for confounders, the results of the multivariate logistic regression model showed that having social health insurance (OR=0.8, 95%CI 0.7 to 1.0) and having neighborhood social capital (OR=0.7, 95%CI 0.6 to 0.8) were more inclined to self-rated health. In addition, the results showed that being male, having a college degree or higher, having a job, and drinking alcohol increased the risk of self-rated unhealthy (P<0.05); whereas being 45-59 years of age, 60 years of age or older, in the central and western regions, exercising regularly, and having a disease or injury within two weeks decreased the risk of self-rated unhealthy (P<0.05). There was a positive multiplicative interaction effect between health insurance and neighborhood social capital on residents’ self-rated health (univariate: OR=1.5, 95%CI 1.1 to 3.7, P<0.05; multivariate: OR=1.7, 95%CI 1.2 to 2.4, P<0.05), and negative additive interactions (RERI=−0.8, 95%CI −1.4 to −0.1; AP=−0.3, 95%CI −0.6 to −0.1; SI=0.6, 95%CI 0.5 to 0.8). ConclusionAttention should be paid to the self-rated health status of key populations through means such as health promotion and education, and healthy behavior lifestyles should be promoted. The health insurance system should be further improved, and attention should be paid to the role of social capital in the neighborhood, encouraging residents to actively build a good social neighborhood, and realizing the coordinated development of the multilevel health insurance system and the social capital in the neighborhood.
Objective To investigate the variation of total hospitalization cost for single-diagnosed disease of different types of acute appendicitis in a three-A hospital, so as to provide evidence for the reimbursement amount of social medical insurance. Methods All patients with acute appendicitis who had surgery treatment during January-April 2011 (before implementing the fee system for single-diagnosed disease) and January-April 2012 (after implementing the fee system for single-diagnosed disease) were collected in this study for analysis. According to the types of acute appendicitis, the patients were stratified into the low risk group (simple, suppurative and gangrenous) and the high risk group (perforative, abscess-formed and pregnancy-combined). The correlation between total hospitalization cost and types of acute appendicitis, as well as the changes of total hospitalization cost after implementing the fee system for single-diagnosed disease were analyzed. Results A total of 90 eligible patients were included. The disease types were positively correlated with hospital stays and total hospitalization cost. All three types in the low risk group could control the average total hospitalization cost within RMB 10 000 yuan. The results of sensitivity analysis showed that, before implementing the fee system for single-diagnosed disease, the total hospitalization cost up to RMB 6 000 yuan could be positively correlated with the above risk stratification (r=0.442, P=0.003). After implementing the fee system for single-diagnosed disease from January to April 2012, the constituent ratio of hospital stays, compared with that in the same period of 2011, had no significant difference (P=0.108) between the two groups; but the ratio of hospital stays (less than 5 days) increased from 45% to 64%, and the ratio of hospital stays (greater than or equal to 10 days) decreased from 17% to 4%, indicating a tendency of shortening hospital stays. Also, the constituent ratio of total hospitalization cost had no significant difference (P=0.114) between the two groups; but the ratio of total hospitalization cost (greater than or equal to RMB 9 000 yuan) decreased from 32% to 13%, indicating a tendency of lowering total hospitalization cost. Conclusion The low risk group of acute appendicitis, RMB 6 000 yuan should be rated as the rational reimbursement amount of social medical insurance. The total hospitalization cost for the high risk group is quite various, so the further studies are needed to investigate the feasibility of the fee system for single-diagnosed disease as well as the rating amount of total hospitalization cost. The implementation of the fee system for single-diagnosed disease is helpful to shorten hospital stays and reduce total hospitalization cost.
ObjectiveTo explore effective evaluation tools as well as systems of medical service capability related to total payment control of medical insurance. MethodsCombining references and using the Delphi method, the evaluation indicators of total payment control of medical insurance were screened and identified. Then, based on analytic hierarchy process, a weight questionnaire was designed and weighted coefficients of all-level indicators were also calculated. ResultsWe proposed a mathematical model to evaluate medical service capability related to total payment control of medical insurance using three types of primary evaluation indicators and seventeen types of secondary evaluation indicators with their weighted coefficients. ConclusionThe establishment of the evaluation systems of medical service capability in medical institutions could objectively reflect medical service capability to some extent, and provide references on total payment control of medical insurance for medical insurance agencies.
Objective To assess the effectiveness of outreach strategies for expanding insurance coverage of children who are eligible for health insurance schemes. Methods We searched The Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 2), PubMed (1951 to 2010), EMBASE (1966 to 2009), PsycINFO (1967 to 2009) and other relevant databases and websites. In addition, we searched the reference lists of included studies and relevant reviews, and carried out a citation search for included studies to find more potentially relevant studies. Randomized controlled trials, controlled clinical trials, controlled before-after studies and interrupted time series which evaluated the effects of outreach strategies on increasing health insurance coverage for children. The included strategies were increasing awareness of schemes, modifying enrolment, improving management and organization of insurance schemes, and mixed strategies. Two review authors independently screened literatures, extracted data and assessed the risk of bias. We narratively summarized the data. Results We included two studies, both from the United States. One randomized controlled trial study with a low risk of bias showed that community-based case managers who provided health insurance information, application support were effective in enrolling Latino American children into health insurance schemes (RR=1.68, 95%CI 1.44 to 1.96, n=257). The second quasi-randomized controlled trial, with an unclear risk of bias, indicated that handing out insurance application materials in hospital emergency departments can increase enrolment of children into health insurance (RR=1.50, 95% CI 1.03 to 2.18, n=223). Conclusion The two studies included in this review provide evidence that providing health insurance information and application assistance and handing out application materials in hospital emergency departments can probably both improve insurance coverage of children. But the application of the interventions to other countries beyond the US still depends on contextual factors of health medical systems. Further studies evaluating the effectiveness of different outreach strategies for expanding health insurance coverage of children in different countries are needed, with careful attention given to study design.
Objective To systematically review the effects of cost sharing in health insurance schemes, so as to provide evidence for better designing cost sharing ratio in health insurance scheme. Methods The search terms were discussed, tested and then chosen by subject matter experts and search coordinators. The total 20 databases including comprehensive scope, health, economics, sociology, and grey literatures were searched to retrieve all the description or evaluation studies on the effects of cost sharing, such as health services utilization, financial burden or moral hazard. The information from the included studies was extracted into a pre-designed data extraction form, and then it was analyzed and summarized. Results A total of 73 studies were included, covering 17 countries like Australia, Canada, and China, etc. The results of statistical analyses showed that, a) Cost sharing methods were applied to every kind of health insurance scheme. The target population included general population, the elder, the poor, those with chronic disease and children, etc. The services covered clinic, hospitalization, mental health, prevention and drug; and b) The effects brought from cost sharing included: From full fee to cost sharing scheme, the enrollee in developing countries increased their health care utilization, and decreased their financial burden. From full coverage to cost sharing, the utilization of health services decreased in developed countries, but the cost of health insurance could not be reduced, and some undesirable effects were brought due to the decrease of both essential health service utilization and essential drugs compliance.
Objective To perform data-driven, assisted prediction of health insurance reimbursement ratios for the major thoracic surgery group in CHS-DRG, in addition to providing an optional solution for health insurance providers and medical institutions to accurately and effectively predict the references of health insurance payments for the patient group. Methods Using the information on major thoracic surgery cases from a large tertiary hospital in Sichuan province in 2020 as a sample, 70% of the total dataset was used as a training dataset and 30% as a test dataset. This data was used to predict health insurance spending through a multiple linear regression model and an improved machine learning method that is based on feature selection. Results When the number of filtered features was the same via three machine learning methods including random forest, logistic regression, and support vector machine, there was no significant difference in the prediction effectiveness. The model with the best prediction effect had an accuracy of 78.96%, sensitivity of 83.93%, specificity of 71.27%, precision of 0.818 8, AUC value of 0.841 4, and a Kappa value of 0.610 8. Conclusion The basic characteristics such as the number of disease diagnoses and surgical operations, as well as the age of patients affect the reimbursement ratio. The cost of materials, drugs, and treatments has a greater impact on the reimbursement ratio. The combined method of feature selection and machine learning outperforms traditional statistical linear models. When dealing with a larger dataset that has many features, selecting the right number can enhance the prediction ability and efficiency of the model.