2.1 Demographic characteristics of out-of-community medical visits
The proportion of women in out-of-community medical consultation in L District increased year by year, from 49% in 2018 to 55% in 2020. The gender ratio of the out-of-community medical consultation inpatient population in L District did not change significantly. The outpatient and inpatient populations in L District from 2018 to 2020 were mainly aged 46 to 69 and 18 to 45 years old, with the highest proportion of 46 to 69 years old. The age composition of the outpatient population out the medical community did not change much, and the proportion of people older than 69 years old was higher than that of people aged 0 to 17 years old, at about 12%. The proportion of 46 to 69 years old in the inpatient population was generally on the rise. The age composition of the inpatient population is more variable compared to the outpatient population, with a higher proportion of elderly adults older than 69 years old.
2.2 Access To Medical Institutions Outside The Medical Community
2.2.1 Analysis of medical insurance funds costs for medical institutions at all grades outside the medical community
The medical institution practice information query through the China National Government Service Platform was graded according to whether the medical institutions in L District were located in L City and their grades. The grades and costs of medical institutions in L District from 2018 to 2020 are shown in Table 1. There are more than 300 hospitals outside the medical community in L District, of which outpatient visits in L City account for more than 90%, with the largest proportion of hospitals in the city being unclassified hospitals and the number of tertiary hospitals in the city decreasing year by year. In terms of total cost, the total settlement of outpatient visits outside the medical community in L District has increased year by year, with the largest proportion of unclassified hospitals in the city, although the number of tertiary hospitals visited is small, the proportion of total settlement of outpatient visits outside the medical community has increased year by year, from 14.3% in 2018 to 29.7% in 2020.
In terms of hospitalization, only about 40% of the hospitals in L District, the city hospitals with unclassified hospitals accounted for the largest proportion and the tertiary hospitals account for the least. In terms of total costs, the total amount of hospital settlement for medical visits outside the medical community in L District also increased year by year, and the tertiary hospitals accounted for more than 60% of the inpatient medical insurance settlement outside the medical community, despite the small number of visits, and the trend was stable from 2018 to 2020.
2.2.2 Analysis of the number of visits and average cost per visit to medical institutions outside the medical community
In 2018–2020, among the outpatient visits to hospitals outside the community in L District, the number of outpatient visits to unclassified hospitals in the city is the highest, but the proportion decreases year by year, from 85.5% in 2018 to 69.7% in 2020. The number of outpatient visits to tertiary and secondary hospitals in the city has increased year by year. In terms of average costs per visit, the tertiary hospitals had the highest average costs and increased year by year. The rest of the municipal hospitals are about 100 yuan, and the average cost of hospitals outside the city can reach 3,029.3 yuan, but the trend is decreasing year by year.
The number of inpatient visits outside the medical community in L District is stable with the largest number of inpatient visits in tertiary hospitals, accounting for 58.5%-63.1%. In terms of the average costs per visit, all the hospitals in the city are higher than 5,000 yuan except for the primary hospitals and secondary hospitals. The longest average hospitalization days was the unclassified hospitals which up to 41.8 days. (Table 1, Fig. 1)
Table 1
Access to graded hospitals outside the medical community in L District, 2018–2020
| Year | Hospital Grade | Outpatient | | Hospitalization | | Outpatient | | Hospitalization | |
| Quantity | % | Total cost (million) | % | | Quantity | % | Total cost (million) | % | | Number of people | % | Rank | Average cost per visit | | Number of people | % | Rank | Average cost per visit | Average number of days in hospital |
| 2018 | Tertiary | 5 | 2.3% | 72.7 | 14.3% | | 9 | 4.8% | 7565.3 | 64.3% | | 2065 | 6.7% | 3 | 352.1 | | 8376 | 60.6% | 1 | 9032.1 | 8.87 | |
| Secondary | 14 | 6.4% | 26.6 | 5.2% | | 20 | 10.6% | 1444.9 | 12.3% | | 2377 | 7.7% | 2 | 111.7 | | 3330 | 24.1% | 2 | 4338.9 | 7.04 | |
| Primary | 3 | 1.4% | 0.5 | 0.1% | | 12 | 6.3% | 22.1 | 0.2% | | 45 | 0.1% | 4 | 111.6 | | 62 | 0.4% | 5 | 3564.2 | 6.66 | |
| Unclassified | 194 | 88.6% | 407.1 | 80.2% | | 30 | 15.9% | 1305.0 | 11.1% | | 26410 | 85.5% | 1 | 154.1 | | 1254 | 9.1% | 3 | 10406.4 | 41.8 | |
| Outside the city | 3 | 1.4% | 0.9 | 0.2% | | 118 | 62.4% | 1419.7 | 12.1% | | 3 | 0.0% | 5 | 3029.3 | | 800 | 5.8% | 4 | 17745.7 | 11.43 | |
| | Total | 219 | | 507.8 | | | 189 | | 11758.5 | | | 30900 | | | | | 13822 | | | | | |
| 2019 | Tertiary | 5 | 1.7% | 181.4 | 25.5% | | 6 | 2.9% | 8397.0 | 69.4% | | 4943 | 11.3% | 2 | 366.9 | | 9171 | 63.1% | 1 | 9156.0 | 8.93 | |
| Secondary | 17 | 5.9% | 50.6 | 7.1% | | 22 | 10.5% | 1315.2 | 10.9% | | 4300 | 9.8% | 3 | 117.6 | | 3224 | 22.2% | 2 | 4079.4 | 7.08 | |
| Primary | 5 | 1.7% | 1.5 | 0.2% | | 14 | 6.7% | 53.6 | 0.4% | | 97 | 0.2% | 4 | 150.9 | | 101 | 0.7% | 5 | 5309.7 | 7.34 | |
| Unclassified | 252 | 87.5% | 461.1 | 64.9% | | 47 | 22.5% | 931.8 | 7.7% | | 34499 | 78.6% | 1 | 133.6 | | 1097 | 7.6% | 3 | 8494.4 | 33.37 | |
| Outside the city | 9 | 3.1% | 16.2 | 2.3% | | 120 | 57.4% | 1390.8 | 11.5% | | 59 | 0.1% | 5 | 2750.6 | | 930 | 6.4% | 4 | 14954.3 | 9.80 | |
| | Total | 288 | | 710.8 | | | 209 | | 12091.4 | | | 43898 | | | | | 14523 | | | | | |
| 2020 | Tertiary | 4 | 1.2% | 288.1 | 29.7% | | 10 | 4.2% | 8625.5 | 62.9% | | 6169 | 11.3% | 3 | 467.1 | | 9383 | 58.5% | 1 | 9192.7 | 8.32 | |
| | Secondary | 17 | 5.0% | 157.7 | 16.3% | | 20 | 8.3% | 1514.6 | 11.0% | | 10004 | 18.3% | 2 | 157.6 | | 3285 | 20.5% | 2 | 4610.5 | 6.84 | |
| Primary | 5 | 1.5% | 1.8 | 0.2% | | 12 | 5.0% | 35.5 | 0.3% | | 136 | 0.2% | 5 | 129.4 | | 74 | 0.5% | 5 | 4802.4 | 7.86 | |
| Unclassified | 309 | 90.1% | 494.4 | 51.0% | | 40 | 16.7% | 2105.5 | 15.4% | | 38055 | 69.7% | 1 | 129.9 | | 2459 | 15.3% | 3 | 8562.4 | 32.61 | |
| Outside the city | 8 | 2.3% | 27.4 | 2.8% | | 158 | 65.8% | 1428.6 | 10.4% | | 267 | 0.5% | 4 | 1025.2 | | 850 | 5.3% | 4 | 16807.2 | 10.01 | |
| | Total | 343 | | 969.4 | | | 240 | | 13709.7 | | | 54631 | | | | | 16051 | | | | | |
2.2.3 Changes In Indicators Before And After The Reform Of The Medical Community
As for the indicators of outpatient medical insurance funds outside the medical community: after the reform, the number of outpatient visits to medical institutions outside the medical community increased (P < 0.01), and the number of outpatient visits to tertiary and unclassified medical institutions outside the medical community increased (P < 0.01).The outpatient medical insurance funds flowing to medical institutions outside the medical community increased(P = 0.03), and the outpatient medical insurance funds flowing to tertiary hospitals increased (P < 0.01). The average total outpatient cost per visit, average outpatient overall planning fund expenditures and the average outpatient out-of-pocket cost per visit all increased in tertiary hospitals (P < 0.01). As for the indicators of medical insurance funds for hospitalization outside the medical community: after the reform, the number of discharges from unclassified hospitals increased (P < 0.05). The average hospitalization day in tertiary hospitals decreased(P < 0.01), and the average out-of-pocket cost of hospitalization in medical institutions outside the medical community decreased(P < 0.05). (Table 2)
Table 2
Comparison of changes in indicators before and after the reform of medical community in L District
| Indicators | Medical institutions outside the CMC | | Tertiary hospital | | Unclassified hospital |
| Before | After | P | | Before | After | P | | Before | After | P | |
| Outpatient | | | | | | | | | | | | |
| Number of visits | 43899 | 54631 | < 0.001** | | 4944 | 6170 | < 0.001** | | 34500 | 38056 | < 0.001** | |
| Medical insurance funds flowing outside the CMC(million) | 710.7 | 969.4 | 0.03* | | 181.4 | 288.1 | < 0.001** | | 461.1 | 494.4 | 0.64 | |
| Total average cost per visit(yuan) | 161.9 | 177.4 | 0.46 | | 366.9 | 467.1 | < 0.001** | | 133.6 | 129.9 | 0.77 | |
| Average overall planning fund expenditure(yuan) | 106.4 | 113.2 | 0.71 | | 203.8 | 272.1 | 0.001** | | 98.0 | 97.6 | 0.93 | |
| Average out-of-pocket expenses per visit(yuan) | 53.9 | 60.7 | 0.11 | | 152.4 | 169.0 | 0.004** | | 35.6 | 32.3 | 0.32 | |
| Hospitalization | | | | | | | | | | | | |
| Discharges | 14535.0 | 16051.0 | 0.11 | | 9171 | 9383 | 0.18 | | 1097 | 2459.0 | 0.01* | |
| Average hospitalization days | 10.4 | 11.8 | 0.50 | | 8.93 | 8.32 | 0.003** | | 33.37 | 32.61 | 0.57 | |
| Medical insurance funds flowing outside the CMC(million) | 12091.4 | 13709.7 | 0.10 | | 8397 | 8625.5 | 0.29 | | 931.84 | 2105.5 | 0.07 | |
| Average per hospitalization cost(yuan) | 8318.8 | 8541.4 | 0.64 | | 9156 | 9192.7 | 0.42 | | 8494.4 | 8562.4 | 0.91 | |
| Average per hospitalization overall planning fund expenditure(yuan) | 4348.0 | 4533.2 | 0.59 | | 4570.2 | 4412.44 | 0.30 | | 6341.57 | 6462.74 | 0.79 | |
| Average out-of-pocket expenses (yuan) | 3189.0 | 3076.6 | 0.03* | | 3641.60 | 3637.7 | 0.85 | | 1928.74 | 1649.14 | 0.17 | |
| Note: Compared with pre-reform ,*P < 0.05,**P < 0.01 |
2.3 Outpatient medical consultations outside the community
According to the confirmation codes of outpatient and inpatient medical insurance data of L District Medical Community, the disease types were classified according to the International Classification of Diseases (ICD-10) as the classification standard, and the descending order was used for the total number of visits of each disease type.
2.3.1 The Condition Of The Disease System For Medical Treatment Outside The Community
The top five outpatient diseases in the medical community in L District in 2018–2020 were mental disorders, hypertension, diabetes, acute upper respiratory infections, abdominal and pelvic pain. In January 2020, L District implemented the reform of medical insurance funds total package payment. After the reform, the disease ranking of outpatient visits outside the community has not changed much compared with that before the reform, and mental diseases still take the first place. The top five inpatient diseases in L District from 2018 to 2020 are malignant neoplasms, mental and behavioral disorders, single spontaneous delivery, renal failure, and single delivery by cesarean section. The average cost of a spontaneous birth versus a cesarean section is relatively low, and the average cost of malignant neoplasm and mental and behavioral disorders is over 10,000 yuan. After the reform, the ranking of diseases in hospitalization outside the community has changed significantly compared with that before the reform, with the ranking of renal failure and mental disorder diseases rising to the first and second positions respectively, and the ranking of spontaneous delivery and cesarean delivery falling to the fifth and eighth positions respectively (Table 3).
Table 3
Top five outpatient and inpatient diseases outside the community in L District from 2018 to 2020
| Disease system codes and names | 2018 | | 2019 | | 2020 | |
| cases | rank | Average cost | | case | rank | Average cost | | case | rank | Average cost | |
| Outpatient | | |
| F99 Mental disorders, not otherwise specified | 18667 | 1 | 176.4 | | 20102 | 1 | 160.5 | | 12273 | 1 | 156.5 | |
| I10 Essential(primary) hypertension | 1521 | 2 | 224.9 | | 2951 | 2 | 262.0 | | 4333 | 3 | 219.0 | |
| E14 Unspecified diabetes mellitus | 665 | 3 | 252.4 | | 1282 | 3 | 273.9 | | 2350 | 4 | 273.9 | |
| J06 Acute upper respiratory infections of multiple and unspecified sites | 591 | 4 | 38.4 | | 1024 | 4 | 38.5 | | 1800 | 5 | 39.3 | |
| R10 Abdominal and pelvic pain | 341 | 5 | 129.1 | | 571 | 5 | 117.0 | | 1517 | 6 | 129.0 | |
| F00-F99 Mental and behavioral disorders | - | - | - | | - | - | - | | 8361 | 2 | 177.7 | |
| Inpatient | | | | | | | | | | | | | |
| C00-C97 Malignant neoplasms F00-F99 Mental and behavioral disorders O80 Single spontaneous delivery N19 Unspecified renal failure O82 Single delivery by caesarean section | 704 665 584 573 428 | 1 2 3 4 5 | 14672.9 14013.8 2514.3 8945.5 4414.6 | | 740 400 583 663 471 | 1 5 3 2 4 | 13444.5 12072.7 2698.6 9044.0 4454.0 | | 793 1012 664 1113 520 | 3 2 5 1 8 | 13914.3 12103.0 2946.7 8654.0 4499.8 | |
| M48 Other spondylopathies | 118 | 20 | 6652.1 | | 195 | 10 | 8546.5 | | 666 | 4 | 4241.6 | |
2.3.2 Diseases Seen In Medical Institutions Outside The Community
Analysis of the top three outpatient and inpatient diseases to the tertiary, secondary and unclassified hospitals in the top three outpatient and inpatient visits to graded hospitals outside of district.
From 2018 to 2020, the top three diseases in outpatient visits to tertiary hospitals outside L District were essential (primary) hypertension, unspecified diabetes mellitus and malignant neoplasms, with a stable ranking and an overall increasing trend in the average cost per visit. The top three inpatient diseases were malignant neoplasms, renal failure and pneumonia, and the trend was stable, with the average costs of malignant neoplasms and pneumonia decreasing.
The city's unclassified hospital outside the district outpatients’ treatment was mainly mental illness, essential(primary) hypertension and acute upper respiratory infections, with the lowest average cost of acute upper respiratory infections and an overall decreasing trend in the average cost of mental illness and essential(primary) hypertension. The largest proportion of inpatient visits was to the L Psychiatric Hospital, where the main types of illnesses were mental illness, cerebral infarction, hypertension and other spondylopathies, and the average cost of mental illness was higher. (Table 4)
Table 4
Ranking of the outpatient and inpatient disease in hospitals outside the L District Medical Community, 2018–2020
| Hospital | Disease codes and names | 2018 | | 2019 | | 2020 | |
| Cases | Rank | Average cost | | Cases | Rank | Average cost | | Cases | Rank | Average cost |
| Tertiary | Outpatient | | | | | | | | | | | |
| I10 Essential(primary) hypertension | 527 | 1 | 243.5 | | 1287 | 1 | 285.6 | | 1235 | 1 | 271.8 |
| E14 Unspecified diabetes mellitus | 314 | 2 | 270.0 | | 691 | 2 | 305.7 | | 1012 | 2 | 309.2 |
| C00-C97 Malignant neoplasms | 172 | 3 | 422.1 | | 449 | 3 | 372.0 | | 565 | 3 | 803.9 |
| Inpatient | | | | | | | | | | | |
| C00-C97 Malignant neoplasms | 638 | 1 | 13619 | | 670 | 1 | 12495 | | 444 | 1 | 13443 |
| N19 Unspecified renal failure | 557 | 2 | 8775 | | 632 | 2 | 9109 | | 413 | 2 | 9542 |
| J18 Pneumonia, organism unspecified | 215 | 3 | 6342 | | 275 | 3 | 7080 | | 290 | 3 | 5644 |
| Secondary | Outpatient | | | | | | | | | | | |
| Z32 Pregnancy examination and test | 161 | 1 | 84.4 | | 145 | 4 | 101.5 | | 27 | 42 | 155.1 |
| Z00 General examination and investigation of persons without complaint and reported diagnosis | 121 | 2 | 94.9 | | 313 | 1 | 90.0 | | 77 | 15 | 108.7 |
| J06 Acute upper respiratory infections of multiple and unspecified sites | 118 | 3 | 45.3 | | 237 | 2 | 46.3 | | 130 | 8 | 70.5 |
| R10 Abdominal and pelvic pain | 77 | 5 | 126.7 | | 183 | 3 | 115.0 | | 963 | 2 | 135.9 |
| I10 Essential(primary) hypertension | 33 | 8 | 202.7 | | 117 | 5 | 256.2 | | 1311 | 1 | 228.8 |
| E14 Unspecified diabetes mellitus | 10 | 24 | 124.3 | | 101 | 6 | 150.3 | | 677 | 3 | 230.2 |
| Inpatient | | | | | | | | | | | |
| O80 Single spontaneous delivery | 499 | 1 | 2471 | | 505 | 1 | 2673 | | 397 | 1 | 3583 |
| H25 Senile cataract | 399 | 2 | 6030 | | 120 | 4 | 5188 | | 12 | 60 | 5085 |
| O82 Single delivery by caesarean section | 370 | 3 | 3970 | | 393 | 2 | 4024 | | 385 | 2 | 4490 |
| H11 Other disorders of conjunctiva | 257 | 4 | 4466 | | 126 | 3 | 4519 | | 47 | 13 | 4473 |
| M51 Other intervertebral disc disorders | 27 | 19 | 10004 | | 31 | 18 | 3952 | | 239 | 3 | 6078 |
| Unclassified | Outpatient | | | | | | | | | | | |
| | F99 Mental disorder, not otherwise specified | 18659 | 1 | 176.4 | | 20043 | 1 | 160.1 | | 12238 | 1 | 156.3 | |
| I10 Essential(primary) hypertension | 961 | 2 | 215.4 | | 1547 | 2 | 242.9 | | 1787 | 3 | 175.4 | |
| J06 Acute upper respiratory infections of multiple and unspecified sites | 473 | 3 | 36.7 | | 787 | 3 | 36.1 | | 1664 | 4 | 36.7 | |
| F00-F99 Mental and behavioral disorders | - | - | - | | - | - | - | | 8334 | 2 | 177.4 | |
| Inpatient | | | | | | | | | | | | |
| F00-F99 Mental and behavioral disorders | 665 | 1 | 14014 | | 392 | 1 | 12242 | | 1010 | 1 | 12116 | |
| F10 Mental and behavioral disorders due to use of alcohol | 113 | 2 | 8025 | | 125 | 2 | 9780 | | 156 | 2 | 6711 | |
| I63 Cerebral infarction | 57 | 3 | 8822 | | 40 | 5 | 7708 | | 28 | 11 | 9583 | |
| I10 Essential(primary) hypertension | 30 | 6 | 6981 | | 56 | 3 | 7922 | | 49 | 7 | 5194 | |
| M48 Other spondylopathies | 2 | 46 | 3445 | | 7 | 23 | 3410 | | 93 | 2 | 4273 | |
3 Discussions and Recommendations
3.1 The flow of medical insurance funds to tertiary hospitals in L District has increased year by year
By analyzing the medical institutions outside the L District Medical Community from 2018 to 2020, it was found that although the number of tertiary hospitals is small, but the amount and proportion of outpatient medical insurance fund is increasing year by year, while its average cost is also increasing year by year. In the paired t-test of the indicators before and after the reform of the medical community, it was found that the number of outpatient visits ,the outpatient medical insurance funds and the total average outpatient cost, overall planning fund expenditure and the out-of-pocket cost of tertiary hospitals outside the medical community increased after the reform. For the inpatient medical insurance funds, although the number of tertiary hospitals was small, they accounted for more than 60% of the total inpatient medical insurance settlement outside the community and the number of inpatient visits also ranked first and increased steadily. This indicates that there may be a phenomenon of “gathering for medical treatment” outside L District and most of the medical insurance funds flow to tertiary hospitals. The reasons for this may include: ①The concentration of high-quality medical resources in the L District lead to more selectivity of patients in seeking medical treatment and the difficulty in promoting graded diagnosis and controlling the expenditure of medical insurance funds. Research shows that, in addition to the family’s economic level, the level of medical institutions, the convenience of transportation and the distance from medical institutions are also important factors for residents to choose medical institutions when they go out for medical treatment[4]. As the quality of residents’ life is improving, they are more in pursuit of high quality medical services that meet or exceed their consumption level, so under the same conditions, high-graded medical institutions are more favored by residents[5]. ②Insufficient scope of publicity and limited knowledge of medical care in medical communities. A certain percentage of residents have insufficient knowledge of medical care and they may blindly pursue higher-level medical institutions, resulting in the phenomenon of “gathering for medical care” in municipal hospitals[5]. ③The motivation of primary care providers needs to be improved, and the pay and performance system has a limited role in motivation. Primary care providers tend to refer patients to higher-level hospitals in order to avoid medical risks[6].
3.2 The proportion of common diseases and multiple diseases outside L District and chronic diseases in tertiary hospitals outside the district is large
The top five outpatient and inpatient diseases in L District from 2018 to 2020 are common diseases and multiple diseases, and chronic diseases have become the main group of people who seek medical care outside the medical community and occupy an important part of the expenditure of the medical insurance funds. From the analysis of the data, it may suggest that the proportion of common and multiple diseases in L District is high, while the mental health capacity of medical institutions in L District is limited, which cannot fully meet the medical needs of the residents, so patients with mental diseases choose to seek medical treatment outside the medical community. Secondly, L District’s medial resources are gathered in the district. If the family doctor contracting system is not fully implemented and the public’s cognition medical treatment within the medical community is insufficient, the residents may seek medical treatment nearby instead of following the referral process, resulting in unreasonable loss of medical insurance funds.
From 2018 to 2020, the medical insurance funds flowing from outpatient department outside L District to tertiary hospitals kept increasing. Further analysis revealed that the outpatient volume of chronic diseases (such as hypertension, diabetes, and oncology) steadily ranked in the top three and the number of visits increased year by year. Malignant neoplasms always ranked first in the inpatient volume, indicating that L District outpatient department in tertiary hospitals to see a high proportion of chronic diseases. It’s suggested that the medical institutions outside L District may not be in accordance with the standardized referral process and services to treat patients in L District, and chronic diseases that can be solved by primary medical institutions in the district also go to tertiary hospitals outside the district, which may be an unreasonable use of medical insurance funds. In L District, there is only a 10% difference in the reimbursement rate between patients referred and non-referred to the tertiary hospitals. There are no corresponding requirements and control indicators for graded diagnosis in secondary hospitals, and the reimbursement ratio is the same as that of medical institutions outside the community. It leads people to choose hospitals with higher levels or better health service levels outside the community for medical treatment even if the hospitals within the community have horizontal medical treatment, which is consistent with the results of other studies[5].
3.3 The Loss Of Medical Insurance Funds Outside The Community Has Not Improved Significantly
Through the paired t test of the changes in indicators before and after the implementation of the reform of medical insurance packaged payment in medical community, it was found that the medical insurance funds flowing outside the community still showed an increasing trend after the reform. The increase of medical insurance funds flowing to the leading hospitals outside the community not only limited the sustainable development of the medical community, while the basic medical institutions service capacity is difficult to be effectively improved. This suggests that the reform of package payment of medical insurance in L District has not reduced the pressure of medical insurance fund and individual disease burden.
The root of the problem may be related to the special geographical location of L District and the ratio of referral to non-referral reimbursement in the tertiary hospitals mentioned above, followed by the possible reasons: ①Municipal medical institutions (especially secondary hospitals) do not strictly implement the management system of graded diagnosis and treatment to refer and admit patients insured in L District. ②The medical insurance payment method is still dominated by the original project-based payment. Although L District is exploring the establishment of a diversified and composite medical insurance payment mechanism, continue to implement a diversified compound medical insurance payment methods other than package pay by project, by disease, by hospitalization day. But in the final analysis, these payment did not touch the key part of the reform of medical insurance payment methods and project-based payment still occupies the main position. Project-based payment is one of possible causes of over-medication and it will encourage medical institutions in communities to focus on enhancing their own medical business in order to maximize their own interests, which is contrary to the original intention of medical communities to form a community of interests[7]. ③The incentive and restraint mechanism of “retaining(transferring) the balance and paying for overspending” should be further improved. The policy materials of L District stipulate that the balance rate of the urban and rural residents’ medical insurance funds should be limited to 15% in principle, but no specific basis has been given for this rate. In a related study, it was suggested that the rules for setting the balance and overspending ratios in each pilot medical community were usually set unilaterally by the medical insurance institutions in accordance with the spirit of the higher level without consultation with medical institutions[7], indicating that there might be information mismatch between the policy and the market, which is not conductive to the further promotion of related policies.
3.4 Suggestions For The Construction Of Medical Community In L District
The current payment by diagnosis related groups (DRGs) or diagnosis intervention Packet (DIP) has been adopted by more countries. The U.S. Medicare payment reform has reduced medical expenses while improving service quality, and China can refer to its payment reform experience and promote nationwide prepayment reform on the basis of the current DRGs pilot. China's National Health Insurance Administration (NHA) issued a "Three-Year Action Plan for Health Insurance Payment Reform" in 2021, which calls for a nationwide rollout from the current 101 pilot cities within three years. By the end of 2024, payment method reform will be carried out in all coordinated regions nationwide, and by the end of 2025, all eligible medical institutions that conduct inpatient services should be covered.
For the reform of medical insurance payment method in L District, the reform of medical insurance payment method should be deepened continuously to improve the efficiency of fund use. Actively explore the reform of the package payment method of medical insurance, and we can refer to the medical insurance payment reform model of Y County, which is adjacent to L District. Y County actively explored the reform of medical insurance payment package in January 2019 and achieved obvious results while effectively controlling the loss of medical insurance funds[11]. By focusing medical insurance surplus funds more on township health centers, Y County has not only kept more patients in township health centers, but also improved the service capacity and management level of primary medical and health institutions. In addition, chronic diseases are one of the main types of disease that are treated outside the community, and with the current global chronic disease prevalence rate increasing year by year, in order to encourage primary medical staff to pay attention to chronic disease management and prevention strategies, it can be considered to bind public health service funding with medical insurance funds. The rates can be adjusted according to individual health risk levels, and the scope should cover the costs of health promotion, disease prevention, health management and clinical treatment provided by primary medical staff[13]. At the same time, the exploration of diversified and composite medical insurance payment methods should be strengthened and institutionalized and put into practice, and the incentive and constraint system needs to be further improved, all of which depend on the promotion of policies. However, due to the professional nature of medical insurance payment and the different opinions of different regions, the consultation and communication between medical insurance management and medical institutions are crucial in the implementation process. Therefore, the participation of each medical institution should be increased, which is conductive to the smooth implementation of relevant policies and the in-depth promotion of medical insurance payment reform.
In order to further deepen the reform of the medical community and promote the sustainable development of the medical insurance funds in China, there are several other recommendations as follows:
First, strengthen the top-level design and continuously improve the quality of medical and health services. Party committees and governments at all levels to improve their positions and do a good job of top-level design[8]. Work to highlight the promotion of medical-oriented to the combination of prevention and treatment, focusing on the prevention and treatment of chronic diseases. Improve the ability of grassroots personnel to treat common and multiple diseases, and establish a reasonable performance incentive mechanism to mobilize the service motivation of grassroots personnel in order to improve the capacity of primary health services.
Second, the establishment of a unified information platform, precise help mechanism. Giving full play to the supporting role of information technology construction for the medical community. The leading unit of the medical community is responsible for implementing the planning and construction of information technology in medical community, promoting interoperability and mutual recognition and sharing of information in the community[9]. Also in the process of information technology construction, the operational supervision and dynamic analysis of the quality of medical services, the use of drugs and consumables, and medical costs should be strengthened to promote the intelligent and scientific development of medical and health supervision[10]. During the study, it was also found that the records of medical institutions for confirmation codes were not unified and standardized, which led to the complexity of disease statistics. Strengthening the quality control of information data to ensure data standardization, accuracy, and completeness is also an important initiative to improve the reform of the medical community. Not only the L district, but mental illness has become a prominent public health and social problem worldwide. Opening mental health or clinical psychology clinics is a basic requirement for county hospital services and communication can be made with the Psychiatric Specialist Hospital to ask for technical support[11] to improve service capacity in mental health.
Third, taking hypertension, diabetes and other chronic diseases as a grasp, accelerate the promotion of graded diagnosis and treatment system. In view of the phenomenon that the proportion of chronic diseases outside the medical community in L District is large in the city’s tertiary hospitals, the graded diagnosis and treatment management system should be strictly implemented, and it is strictly forbidden to relax the admission indications for patients who should be treated by first and second level hospitals, and it is also possible to refine the referral entries to medical institutions outside the medical community, and consider setting the corresponding reimbursement ratio outside the medical community for different cost. For patients with mental illnesses outside the medical community in L District who go to the Psychiatric Hospital for treatment, consideration can be given formulating medical insurance policies to reduce the outflow of patients, such as increasing the reimbursement ratio for mental illnesses, and also considering the inclusion of the L Psychiatric Hospital in the medical community on a voluntary basis to improve the internal dynamics of the medical community. The same reasoning applies to other county medical communities where there are endemic or specialty diseases, and differentiated policies can be adopted to reduce the pressure on medical insurance funds.
Fourth, promote the family doctor system in depth, and the medical reform work goes deep into the grassroots. Family Doctor Contracting Service provides the basic guarantee for the promotion and implementation of the hierarchical diagnosis and treatment system, deeply promotes the family doctor contracting system under the medical community model, improves the service capacity and the enthusiasm of the grassroots doctors through the performance allocation system. Strengthens the family doctor team, and is more conductive to establishing smooth two-way referral and improving the primary medical institution service efficiency[14]. For the elderly population with a large proportion of medical consultations outside the community and chronic disease patients with a high proportion of medical consultations in tertiary hospitals, they can be used a key intervention group for family doctors, with regular medical checkups, mental health education and tertiary prevention.
Finally, it is equally important to promote the improvement of relevant policies and publicity to improve residents' confidence in primary care. While improving the service capacity of primary medical institutions, we should also pay attention to the promotion of the construction of primary medical institutions, including the situation of equipment, medical personnel and treatment system. In addition, the support and promotion of differentiated policies of medical insurance will guide patients with common diseases, multiple diseases and chronic diseases to seek medical treatment and health management in primary care institutions and promote the smooth operation of the hierarchical diagnosis and treatment system.
3.5 Limitations
There is still a clear lack of literature on the exploration of medical community reform in China, and the reform of medical community needs to be adapted to local conditions[15–16]. This study takes medical insurance funds as the landing point, analyzes the flow of medical insurance funds for all levels of medical institutions and types of diseases visited outside the community in L District on the basis of existing medical insurance settlement data which is limited to a single level of medical institutions and a single type of disease, and does not analyze all types of diseases and the same level of medical institutions. The authors provide possible explanations for the flow of medical insurance funds based on the results of the analysis. However, the exact reasons need to be proven through more future studies and in the contest of the local situation.