The Basic Ways of Solving the Problems of Underlying Liabilities of China＇s Endowment Insurance

The supply of basic pension is seriously lacking, the personal accounts is operated with no money. This is a problem belonging to conversion cost in essence. This paper points out that the government should undertake the responsibility to solve the problem by using the increment method and stock method to repay the latent liability; then the government can enrich the personal accounts in response to the aging population crisis and the concussion brought by the endowment insurance system＇s conversion.

Exploring the Development of Financial Inclusion in the Context of Financial Technology

The concept of inclusive finance was proposed and promoted by the United Nations in 2005 with the main purpose of providing services for those who lack good financial services while promoting the economic growth of family enterprises and eliminating social poverty as well as inequality.With the innovation of financial technology and its application in the field of financial inclusion,the new inclusive finance has shown strong vitality and great prospects in recent years.It provides certain ideas and directions for the development of inclusive finance in the banking industry.

Analysis of inpatient payments of breast cancer patients with different medical insurance coverages in China(mainland) in 2011–2015

Objective： An understanding of the levels and trends of medical cost is made for breast cancer patients with different medical insurance coverages in China（mainland）, in an attempt to offer a clue to further control the costs.Methods： The inpatient payments of 9,716,180 breast cancer patients spent in medical institutions of different types and grades during 2011–2015 were collected from the inpatient medical record home page（IMRHP） dataset.The data were then processed with SAS（Version 9.3; SAS Institute, Cary, NC, USA）. Indicators like means,increase（decrease） percentages were used to descriptively analyze the average hospitalization expense of each time（AHEET） and its trends of breast cancer patients with different medical insurance coverages treated in medical institutions of different types and grades.Results：In 2011–2015,the AHEET borne by breast cancer patients in China had been constantly increasing.Specifically,the self-pay inpatients had the largest increase,inpatients covered by Urban Employee Basic Medical Insurance（UEBMI）and Urban Resident Basic Medical Insurance（URBMI）were the next,and those covered by New Rural Cooperative Medical System（NRCMS）had the least increase.Breast cancer inpatient treated in public hospitals had quite greater increase and higher expenditure level than those in private hospitals.The AHEET borne by the inpatients in Grade 3 hospitals had greater increase and higher cost than those in Grade 2 hospitals.Conclusions：The inpatient payments of breast cancer patients will be wisely controlled by reducing the number of self-pay inpatients,taking advantage of restriction mechanism of the medical insurances,and promoting healthy competition between private hospitals and public hospitals.The economic burden imposed on the society by breast cancer can be relieved through further control of inpatient payments of UEBMI-and URBMI-covered breast cancer patients and of Grade 3 hospitals.

A Study on Locations of Death and Factors Associated with Death among Cancer Patients in South Korea

Background: Location of death has been used to examine an indicator for good death. This study aims to examine location of death among patients with three major cancers (gastric, liver, and lung) and other factors associated with location of death in South Korea. Methods: We selected the medical and pharmacy claims data for health services and location of death among the 42,596 decedents with cancer (lung 16,632, liver 15,872, gastric 10,092) from 2009 to 2013. We used logistic regressions to identify factors associated with home death. Outcome measures are locations of death (hospital, outpatient clinics or emergency room and home). Results: Only 8.9% died at home whereas 46.5% died in hospital as inpatients. Patients with more than one comorbid cancer or receivers for any supportive care were significantly more likely to die in hospital. Female and younger than 55 years old liver cancer patients were associated with home death. Patients living in metropolitan area, or paying more insurance premium, or being public aid beneficiaries, were associated with home death. Conclusions: The supportive care service use prior to death was significantly associated with increasing odds to hospital death. Being older than 75, or having multiple cancers was significant factors associated with hospital death, whereas living in metropolitan area, lower income or emergency visit were significant factors with home death. These findings are opposite to what is found, as the palliative care and hospice is predominantly hospital-centered. The findings emphasize a need to available end-of-life care in community for dying patients.

Tackling China’s Pension Fund Payment Crisis:Will the “Two-Child Policy” Be the Answer?——An example with the basic pension insurance program for urban employees

Based on the reality that 29 Chinese provinces have already implemented the policy allowing a couple to raise a second child if either parent is an only child, this paper provides an empirical study on the effect of this policy on the financial status of the social pooling fund of basic pension insurance for urban employees. Our study suggests the followings. First, under the previous unchanged family planning policy, current deficits and cumulative deficits will occur in the social pooling fund in the year 2047 and 2063 respectively. Second, if lO% to 50% of qualified couples choose to raise a second child, the financial status of the social pooling fund will improve; relative to the previous unchanged family planning policy, the contribution ratio can decrease from 20% to the range between 18.06% and 19.57% without causing any changes to the original financial status of income and expenditure. Third, if the percentage of couples choosing to raise a second child rises to 60% to 100%, the contribution ratio can even decrease to the range between 16.55% and 17. 7% without causing any changes to the financial status as under the previous unchanged family planning policy. The above conclusions have all passed the sensitivity test. Therefore, the ＂two-child policy＂ for qualified couples is favorable to alleviating the payment pressures of pension insurance but the policy effectiveness is subject to fertility desire and the intensity of government implementation.

DRG Payment System in the United States and Its Enlightenment to China

Objective To study the successful experience of implementing diagnosis related group(DRG)payment system in the United States and provide a reference for China’s reform of health insurance payment.Since the United States is the first country to develop and apply the DRG in the world,its research and practice of DRG are always at the forefront.Methods Literature research method was used to investigate DRG payment system,the specific steps of the payment,the setting method of relevant indicators,and the quality supervision measures.Results and Conclusion There are mainly three aspects from the experience of DRG payment system in the United States.Firstly,the government’s responsibility for health insurance is clarified.Secondly,the relevant indexes are set reasonably.Thirdly,the DRG weight and base rate are adjusted dynamically to ensure the fairness of DRG payment.Therefore,China should pay attention to the following three aspects:clarifying the main responsibility of the government in the reform of health insurance payment,establishing the quality control system of the first page of medical records,and improving the supervision mechanism for medical quality.

Inspiration of Foreign Innovative Drug Pricing Methods and Medical Insurance Payment Standards to China

Objective To study the innovative drug pricing methods and medical insurance payment standards in foreign countries and to provide reference for China’s government.Methods The official websites were searched for information and related literature,and literature review was used.Results and Conclusion In foreign countries,the clinical value of innovative drugs and their impact on medical insurance funds were comprehensively evaluated based on factors such as quality-adjusted life years,clinical benefit,and improvement of clinical benefit.Then,the evaluation results were taken as an important basis for whether innovative drugs were admitted to the medical insurance catalog and establishing medical insurance payment standards.By using international experience for reference,innovative drug pricing methods and medical insurance payment standards for China’s national conditions can be improved by establishing a basic database of clinical value and drug economic evaluation of innovative drugs,as well as innovative drug payment models based on decision thresholds.

Fund balance of payments equilibrium perspective study birth insurance system in China

The balance of payments is birth insurance fund raising and using the basic principle, from the Angle of the fund balance of payments to the maternity insurance system in China has very strong theory significance and practical significance. Birth insurance is an important part of social security system, has the protection of women＇s health, improve population quality, guarantee the importance of women＇s equal employment, and more attention from the whole society, but there exist many obstacles in the process of implementation and resistance. This article obtains from the national birth insurance fund balance of payments, by combining it with the ginseng of birth insurance, enjoy treatment number, per capita salary level, worker year, per capita average wage level is found hidden in the maternity insurance system in China problems and contradictions, in order to provide feasible Suggestions for maternity insurance system in China.

Effects of Preoperative Risk Stratification on Direct In-hospital Costs for Chinese Patients with Coronary Artery Bypass Graft:A Single Center Analysis

The purpose of this study was to analyze the components of inpatient costs for coronary artery bypass graft(CABG)according to preoperative risk stratification and to provide evidence for improvement of diagnosis-related groups(DRGs)payment.All patients(n=458)receiving an isolated CABG between January 2014 and December 2016 in a tertiary referral center,in southwest China,were analyzed.Hospital mortality was predicted by the EuroSCORE Ⅱ for each patient. The patients were subdivided into two groups according to the observed mortality(1.97%,9/458):a high-risk group(group H,predicted mortality≥1.97%)and a low-risk group(group L,predicted mortality<1.97%).Clinical outcomes,resource use,in-hospital direct costs,and reimbursement expenses were compared between the two groups.Significant differences existed between group L and group H in postoperative mortality(0.4% vs.3.4%;P=0.02),postoperative complications(10.6% vs.45.7%;P<0.001),postoperative length of hospital stay(17.5±4.9 days vs.18.8±6.5 days,P=0.01),in-hospital costs($20 256±3096vs.$23 334±6332;P<0.001),and reimbursement expenses($7775±2627 vs.$9639±3917;P<0.001).In general,a higher EuroSCORE Ⅱ was significantly associated with a worse clinical outcome and increased costs.The CABG cost data provide evidence for improvement of DRGs payment. Key words:coronary artery bypass graft;risk stratification;hospital costs;medical insurance

Foreign Experience and Enlightenment of Reimbursement Management of Multi-indication Drugs

Objective To provide reference for China’s medical insurance reimbursement plan of multi-indication drugs.Methods By referring to relevant foreign literature,the implementation process and conditions of different reimbursement management modes of multi-indication drugs were analyzed to provide suggestions for reimbursement of multi-indication drugs in China.Results and Conclusion It is suggested to further explore the suitable conditions and select the corresponding mode in China.Payment standards should be set according to value pricing and budget impact analysis.Besides,data collection and analysis mechanism must be improved.Lastly,reward and punishment mechanism can be adopted to improve management efficiency.

Impact of an innovative financing and payment model on tuberculosis patients'financial burden:is tuberculosis care more affordable for the poor?

Background:In response to the high financial burden of health services facing tuberculosis(TB)patients in China,the China-Gates TB project,PhaseⅡ,has implemented a new financing and payment model as an important component of the overall project in three cities in eastern,central and western China.The model focuses on increasing the reimbursement rate for TB patients and reforming provider payment methods by replacing fee-for-service with a case-based payment approach.This study investigated changes in out-of-pocket(OOP)health expenditure and the financial burden on TB patients before and after the interventions,with a focus on potential differential impacts on patients from different income groups.Methods:Three sample counties in each of the three prefectures:Zhenjiang,Yichang and Hanzhong were chosen as study sites.TB patients who started and completed treatment before,and during the intervention period,were randomly sampled and surveyed at the baseline in 2013 and final evaluation in 2015 respectively.OOP health expenditure and percentage of patients incurring catastrophic health expenditure(CHE)were calculated for different income groups.OLS regression and Iogit regression were conducted to explore the intervention's impacts on patient OOP health expenditure and financial burden after adjusting for other covariates.Key-informant interviews and focus group discussions were conducted to understand the reasons for any observed changes.Results:Data from 738(baseline)and 735(evaluation)patients were available for analysis.Patient mean OOP health expenditure increased from RMB 3576 to RMB 5791,and the percentage of patients incurring CHE also increased after intervention.The percentage increase in OOP health expenditure and the likelihood of incurring CHE were significantly lower for patients from the highest income group as compared to the lowest.Qualitative findings indicated that increased use of health services not covered by the standard package of the model was likely to have caused the increase in financial burden.Conclusions:The implementation of the new financing and payment model did not protect patients,especially those from the lowest income group,from financial difficulty,due partly to their increased use of health service.More financial resources should be mobilized to increase financial protection,particularly for poor patients,while cost containment strategies need to be developed and effectively implemented to improve the effective coverage of essential healthcare in China.

From“selective two-child policy”to universal two-child policy:Will the payment crisis of China’s pension system be solved?

With the rapid population aging,the payment crisis of China’s pension insurance fund is increasing yearly.The government adjusts fertility policy to alleviate population aging and improve the solvency of pension insurance fund.On January1,2016,China’s fertility policy was adjusted from“selective two-child policy”to universal two-child policy.This paper establishes actuarial models to analyze how fertility policy adjustment influences the pension insurance fund and concludes as follows:(1)if the“one-child policy”were still employed,the accumulated deficit of pension insurance fund would appear in the year of 2076;(2)if all couples that satisfy the rules of“selective two-child policy”bear the second child,the time of accumulated deficit of pension insurance fund would be postponed by about 9 years;(3)after implementing universal two-child policy,the time of accumulated deficit of pension insurance fund would delay under different situations of fertility intentions,if more than 54% of the qualified couples bear a second child,the accumulated deficit of pension insurance fund would not appear before 2090.The above conclusions have passed the sensitivity tests.Therefore,“two-child policy”can alleviate the payment pressure of pension insurance fund.If the government wants to solve the payment crisis of pension insurance fund,fertility intentions should be improved.

医保真实世界数据质量评估研究——以谈判药品“纳入支付范围的药品费用”为例

目的:以谈判药品“纳入支付范围的药品费用”的统计过程为例,分析归纳医保数据质量问题特征,为医保数据清洗与应用提供参考。方法:通过某地级市医保结算系统采集2018年1月至2024年9月间国家谈判准入协议期内产品结算记录(231305条)为目标数据集,辅以网络检索多源形成若干辅助校验数据集,构建包含完整性、规范性、一致性三个维度的目标数据质量评估框架。结果:数据完整性维度,主要表现为疾病诊断编码、名称缺失,所涉及结算记录条目数占比29.6%和29.7%。规范性维度,药品编码与名称存在一对多的不规范问题,结算条目数占比66.2%;医药机构存在编码内容异常(0.7%)、编码与名称对应关系不规范(43.3%)的问题;疾病诊断中60.3%结算条目存在编码样式不符合规范;患者身份中包含48名非基本医疗保险参保人,涉及405结算条目。一致性维度,对照国谈支付标准发现4.9%结算条目存在支付价格超出±10%范围;药店购药记录中1.4%条目对应的零售药店超出“双通道”资质认定范围;78条记录不符合医保限定支付范围对患者年龄或开具处方医院条件的规定。结论:医保数据可能存在数据缺失、医保信息业务编码应用不规范、患者身份统计混淆以及疑似医保支付不当导致的逻辑错误等质量问题。需加快探索相适应、统一、可操作化的统计规范与数据清洗规则,推动医保数据的决策效能发挥。

医养结合服务支付:长护险与医保的政策边界与协同路径——基于上海市的实践样本分析

医养结合是一项跨领域的政策实践,其服务的有效获取离不开相关支付政策的协同支持。长护险和医保是医养结合服务支付体系中两项重要的政策,但二者在医养结合支付实践中存在内容交叠、待遇差距大、衔接不畅等问题,严重制约医养结合服务的高质量供给。鉴于此,基于政策协同理论,从政策协同目标、协同层次、协同内容,以及信息协同等方面提出促进二者在医养结合支付中有效衔接的路径及建议,包括确立以老年人获取高质量、连续性的医养结合服务为共同目标,厘清二者的支付边界,建立统一的医养结合支付体系,建立多方信息共享机制等,以此实现政策协同效应的最大化,推动医养结合服务的有序开展。

中医优势病种DRG付费:政策、难点及对策

目的:分析各地中医优势病种DRG付费政策,为推进医保支付方式改革提供实证参考。方法:通过政策梳理和案例研究,分析中医DRG付费政策的实施成效及难点,提出对策建议。结果:各地中医DRG付费政策差异较大,存在中医优势病种概念不明、基层医疗机构覆盖不足、治疗质量考核规则不统一、病种遴选机制有待完善、医保-医院协同有待加强等难点。结论:加强部门协同,鼓励医院深度参与中医DRG付费;扩大政策覆盖范围,加大基层倾斜力度;精准界定中医优势病种,完善质量考核规则。

县域医共体医保总额付费效果研究

目的:评价县域医共体实施医保总额付费的政策效果,为推动医疗保险与县域医共体的联动改革提供参考。方法:运用双重差分法,从医疗费用、分级诊疗、医疗质量、医保支出、个人负担五个层面评价县域医共体医保总额付费的效果。结果:与非试点地区相比,试点地区医共体的次均门诊费用和医疗费用自付比例分别降低了15.141元和8.819个百分点,门诊医保基金支出比例和下转转诊率分别提高了12.419个百分点和1.539个百分点。结论:县域医共体开展医保总额付费能够提升患者控费意识,减轻患者疾病经济负担,促进医保基金有效使用,推动分级诊疗制度发展;但也存在改革进展滞后于医共体发展的困境,需因地制宜,完善县域医共体医保支付方式,建立与其适应的配套政策。

医保支付改革视角下DRG成本核算若干问题及建议

在医保支付改革中,高质量的DRG成本核算至关重要。当前,DRG成本核算存在分组器等核心逻辑不透明、没有扣除财政基本拨款收入形成的各项费用、成本核算方法选择困难等问题。对此,各地医保部门应尽量公开DRG分组器和支付标准,提高透明度和公平性,强化监管和审核,并建立反馈机制;基于制定支付标准的目的,DRG成本核算应扣除财政基本拨款收入形成的各项费用,形成精准的成本数据;精益化开展基于项目叠加法的DRG成本核算。

DIP视角下含FFR操作的住院医保支付研究及病种分组优化探讨

目的:冠状动脉血流储备分数(Fractional Flow Reserve,FFR)在临床应用中还处于普及发展阶段。本研究旨在探讨含FFR操作的医保住院病例在广州市2018版及2022版DIP政策下,病种分值及医保标准支付对比,探讨FFR操作相关病种的医保支付效益,提出病种分组优化建议。方法:采用对比分析法,分析比较含FFR操作住院数据在不同版本DIP病种目录的入组差异、标准分值及医保结余差异;采用独立样本t检验,验证不同版本DIP政策下的例均医保标准支付费用是否存在显著差异;采用函数统计法,汇总分析近三年含FFR操作入组病种亏损数据的总值、均值等。结果:相较于2018版DIP病种分值库,2022版DIP病种分值库中含FFR操作的病种数量增加、标准分值支付提高,支付更加充分,医院端亏损减少明显。结论:DIP病种分值库有待更进一步优化;2022版DIP病种库对含FFR操作的病种支付更加充分;含FFR操作的病种组合可通过将手术操作码申请为扩展码或者新增病种组合的方式进行调整,以适应临床实际需求。

循证医学助力超说明书用药医疗保险支付问题的政策研究

超说明书用药的合理性在学术和临床工作中一直存在争议。随着《中华人民共和国医师法》的出台,使超说明书用药具有一定程度的合法性,医疗保险支付政策应该随之及时调整,在保障医疗保险基金合理使用前提下极大地满足患者的支付需求。文章概述了超说明书用药类型、产生的原因及其合理性以及国内外超说明书用药的医疗保险支付现状,阐述了医疗保险部门应该运用循证医学不断优化医疗保险支付制度,加强循证医学研究和临床数据库的建设,更好地平衡医疗保险基金支付制度与循证医学之间的关系,确保医疗保险支付策略有科学依据,保障医疗服务质量,保护患者权益,促进医疗资源的合理分配。

基于间断时间序列分析的医院DRG付费改革成效评价研究

目的:分析DRG付费改革对天津市某三级医疗机构运行的影响。方法:收集2020年1月~2022年12月改革试点医疗机构医疗服务能力、医疗服务效率、医疗服务质量3个维度的月度数据,采用间断时间序列数据模型分析改革前后各类指标趋势的变化。结果:试点医院医疗服务能力提升效果显著,医疗服务效率存在较大提升空间,改革对于医疗服务质量影响甚微。结论:在当前诊疗能力稳步提升的情况下、医保支付改革所倡导的降本增效要求下以及“以治疗为中心”转向“以健康为中心”的医疗服务发展模式下,应完善DRG付费改革促进医疗服务能力、医疗服务效率和医疗服务质量提升的关键机制,多措并举实现公立医院高质量发展。