Summary:
The distribution of high-quality medical resources in China is regionally uneven. When patients seek health care in other regions, they must pay their medical expenses upfront and then undergo complex reimbursement procedures, which affects the accessibility of high-quality medical resources. Against this background, China has been continuously improving its policy for cross-provincial direct settlement of inpatient expenses since 2016. In 2018, China launched a pilot project for the direct settlement of outpatient expenses. Since the implementation of this policy, patients who meet the referral standards have not needed to pay upfront and the reimbursement rate follows the policy in the home city, and the medical insurance directory of the visiting city is used. Regions with relatively scarce medical resources are not only the main sources of patients seeking cross-regional medical treatment but also face significant pressures on their operation of medical insurance funds. While the direct settlement of outpatient expenses is convenient for patients to seek health care in other regions, it may lead to a burden on regional medical insurance funds, which is a problem that deserves attention. We evaluate the effect of the direct settlement of cross-provincial outpatient expenses using a regression discontinuity design for the reimbursement data from the urban employee basic medical insurance (UEBMI) fund for a third-tier city in the Yangtze River Delta. After the policy was implemented, we find that cross-provincial outpatient visits increased while inpatient admissions decreased. The total outpatient visits and inpatient admissions, medical expenses, medical insurance expenditures, and out-of-pocket expenses all decreased. These results indicate that cross-provincial inpatient admissions substitute for outpatient visits before outpatient direct settlements. This paper shows that the direct settlement policy encourages patients in areas lacking medical resources to seek cross-provincial medical treatment. In addition, the policy can significantly reduce medical insurance expenses by decreasing the number of medical visits. Also, the policy has a more significant impact on patients with high health-care demand and social status than patients with mild illness. These results suggest that the policy does not have the effect of siphoning mildly ill patients from the local area. This paper provides policy implications for the policy development for the cross-provincial direct settlement of medical expenses in China. First, continuously improve the direct settlement for outpatient expenses and expand the scope of direct settlement for outpatient clinics. Second, accelerate the construction of national and provincial regional medical centers, promote the expansion and sinking of high-quality medical resources, and extend them to patients. Third, improve the hierarchical diagnosis and treatment system and strictly regulate the referral system to promote the referral system to promote the diversion and referral of patients with mild illness and reduce the phenomenon of disorderly medical treatment. Fourth, promote the unification of the national medical insurance the unification of the national medical insurance reimbursement directory to improve the phenomenon of “different prices for the same treatment for the same disease.” Fifth, construct medical insurance payment methods and medical insurance supervision mechanisms that are compatible with direct settlement of medical expenses, effectively preventing and controlling risks in fund operations, and optimizing the allocation of medical resources. This paper makes three main contributions to the literature. First, we use empirical methods to investigate the effect of the cross-provincial direct settlement of the outpatient expenses policy on medical insurance expenditure. Second, this paper compares and explores the different impacts of this policy on different patients. Third, this paper examines whether the direct settlement policy has led to a significant outflow of patients with mild illnesses and evaluates the negative impact that it may have on local medical institutions.
吕思诺, 封进. 异地就医门诊直接结算政策对医保基金支出的影响[J]. 金融研究, 2023, 517(7): 97-115.
LV Sinuo, FENG Jin. Effect of the Policy for Cross-provincial Direct Settlement of Outpatient Expenses on Basic Medical Insurance Expenditure. Journal of Financial Research, 2023, 517(7): 97-115.
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