1. Evaluation of the New Rural Cooperative Medical Scheme Outpatient Capitation Payment Reform in Qianjiang District of Chongqing, China Qu, Qian (1);  Sun, Jing (2); Kang, Jun (3); Zhang, Weibin (1); Tan, Yongqian (4); Xiang, Wenxian (4) 1: Chongqing Health Bureau, P.R. China; 2: National Institute of Hospital Administration, MOH, P.R. China;  Corresponding author: e-mail: sunjingx@yahoo.com 3: Chongqing Medical University, P.R. China; 4: Qianjiang District Health Bureau, Chongqing, P.R. China 16 Nov. 2011 Antalya, Turkey 13c-Economics: Health Insurance Coverage for Medicines in LMIC

2. Background There has been an increasing cost containment pressure for the New Rural Cooperative Medical Scheme in China The fee-for-service payment and other factors create perverse incentives, which drive the irrational provider behaviours 2 3c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey

3. Setting Capitation payment reform is piloted in Qianjiang where there are 30 township/community health centres and 169 village clinics 3 3c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey

4. Study Aims This study evaluates if the capitation payment reform in Qianjiang: -Contained the cost -Rationalized the providers’ behaviour -Caused income losing of the health workers and facilities 43c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey

5. Methods-1 The effect of the policy is measured with the changes of the following indicators before and after the reform in Qianjiang : -cost per visit; -quality of care; -income of facilities and health workers 53c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey

6. Methods-2 ● The effect of the policy is also showed by comparing the cost and hospitalization data of Qianjiang with that of Southeast Chongqing where has similar social and economical development situations with Qianjiang 63c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey

7. Methods-3 Quality of care is evaluated with: -Prescription indicators to show medicines use status; -Referral rate, proportions of appropriate referrals and hospitalization rate show if patients are selected and shifted from outpatient to inpatient 73c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey

8. Methods-4 Cost is measured with: - Annual average cost of all facilities of Qianjiang and compared with Southeast Chongqing during 2006-9; - Annual median cost of all and sample facilities in Qianjiang during 2007-9; - Both costs are compared with the prescription caps 83c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey

9. Methods-5 Quality of care and income data of Qianjiang are collected from sample facilities Interviews provide complementary information 93c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey

10. Results-1 The average cost per visit of all THC/CHCs and village clinics in Qianjiang is at the same level of Southeast Chongqing in 2006, getting much lower in 2009 103c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey

11. Results-2 The median cost per visit of all THC/CHC and sample THC/CHC in Qianjiang both are with an increasing trend during 2007-9. Both increases are statistically significant ( Ⅹ ² = 851.7614, P<0.0001 and Ⅹ ² =1078.8001, P<0.0001) 113c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey

12. Results-3 Both average and median cost of Qianjiang keep within the prescription caps during 2007-9, when costs of Southeast Chongqing far exceed 123c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey

13. Results-4 There are no significant changes of referral and prescription data in Qianjiang during 2007-9 ( Ⅹ ² test, P>0.05) 133c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey 2007 20082009 Ⅹ²Ⅹ² P Referral rate in township/community health centers (%) 37.1636.4536.24 0.0180.8928 Appropriate referral rate in township/community health centers (%) 9295 0.79520.3725 % of essential medicines township/community health centers 95100 7.60170.0058 village clinics98100 3.01010.0827 % of prescriptions with steroids in township/community health centers 3.583.192.59 0.16160.6877 % of prescriptions with antibiotics in township/community health centers 24.11 19.9316.57 1.75730.185 % of prescriptions with infusions in township/community health centers 13.69 12.9211.90 0.14270.7056

14. Results-5 The qualitative interviews and group discussions show that, doctors are more likely to adopt less costly alternative treatments, and are more willing to provide outreach services for preventive care 143c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey

15. Results-6 There are no significant differences between the average hospitalization rates of sample township/community health centers of Qianjiang and Southeast Chongqing in 2006 and 2009 ( Ⅹ ² test, P>0.05) 153c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey

16. Results-7 The monthly income of the health workers and the outpatient revenue of facilities in Qianjiang keep growing during 2007-9 There are no overruns in all the sample facilities in Qianjiang 163c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey

17. Summary-1 The cost containment objective is achieved Provider behaviours are partially improved but with limited affect on prescriptions 173c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey

18. Summary-2 The reform does not bring financial loss to both the facilities and the individuals, but creates incentive for less costly alternative treatments and more attention to prevention 183c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey

19. Policy Implications and Conclusions Capitation payment dose raise the cost awareness of providers Comprehensive performance assessment system and other supporting policies could help address the unexpected side effects of the capitation payment Changing prescription behaviors needs more comprehensive interventions 193c-Economics: Health Insurance Coverage for Medicines in LMIC 16 Nov. 2011 Antalya, Turkey