Yanghaotian Wu,1,2 Shuting Zheng,3 Jingfu Qiu1 

1School of Public Health, Chongqing Medical University, Chongqing, People’s Republic of China; 2School of Public Health, Southwest Medical University, Luzhou, People’s Republic of China; 3Chengdu Center for Disease Control and Prevention (Chengdu Institute of Health Supervision), Chengdu, People’s Republic of China

Correspondence: Jingfu Qiu, School of Public Health, Chongqing Medical University, Daxuecheng Middle Road, Shapingba District, Chongqing, 401331, People’s Republic of China, Email jfqiucqmu@163.com

Background: China introduced the outpatient pooling fund model into Urban Employee Basic Medical Insurance (UEBMI) to increase the compensation level for outpatient costs, but the empirical evidence is extremely limited. As an early adopter of China’s healthcare reform, Sanming City increased the reimbursement rate of general outpatient visits for UEBMI enrollee in August 2016. The reimbursement rate for UEBMI enrollees seeking general outpatient care at primary hospitals increased from 40% to 90%, and for secondary and above hospitals from 30% to 70%. This study aimed to assess the changes in medical service utilization, medical costs, and medical insurance fund expenditures among UEBMI enrollees after the improvement of outpatient pooling level for employees.
Methods: A retrospective analysis was conducted using monthly monitoring data on public hospitals from August 2015 to August 2017 in Sanming City, China. An interrupted time-series analysis was performed to evaluate the level and trend changes in medical services utilization, medical costs, and UEBMI fund expenditures before and after the improvement of outpatient pooling level.
Results: After the intervention, the number of monthly outpatient visits per capita for UEBMI enrollees increased by 0.047 immediately (P< 0.05), while the change in inpatient demand was insignificant (P> 0.05). The medical cost per outpatient visit increased by 0.6% per month (P< 0.001). The out-of-pocket (OOP) cost per outpatient visit decreased by 23.66% immediately (P< 0.001), with a monthly increase of 1.61% afterward (P< 0.001). The outpatient fund expenditures increased by 151.68% immediately (P< 0.001), but decreased by 2.37% per month in the long term (P< 0.01). The total and inpatient fund expenditures varied insignificantly (P> 0.05).
Conclusion: The improvement of outpatient pooling level for urban employees had positive effects on stimulating the demand for outpatient medical services, reducing OOP costs, and maintaining the sustainability of UEBMI funds, while the long-term effect was weakened, and the substitution effect between inpatient and outpatient healthcare was insignificant. There is an urgent need to improve the outpatient benefits, establish a value-based outpatient payment method and an intelligent medical insurance fund monitoring system.

Keywords: outpatient pooling, medical services utilization, out-of-pocket expenditures, medical insurance fund, interrupted time series, China