A calculation of capitation-based payment standardto chronic disease cases in primary care settings^☆

Abstract

Background: Outpatient medical care payment play a pivotal role in the reform of medical insurance payment methods. With ongoing reforms in China, a variety of payment strategies, including capitation and the ambulatory patient groups (APG) point method, are being progressively implemented.
Objective: This study aims to identify appropriate capitation calculation methods for chronic diseases in Beijing and to provide recommendations for implementing capitation payments reforms in the city.
Methods: We focused on four prevalent chronic diseases—hypertension, diabetes, coronary heart disease, and stroke—and analyzed basic medical data and public health funding in Beijing's districts C and H as case studies. This research was aimed at developing a capitation calculation method tailored to these locales, determining payment standards for major chronic diseases in primary care clinics, and thus supporting the advancement of capitation reform for outpatient chronic diseases.
Results: Using medical insurance data and public health funding data from 2017 to 2019, a top-down allocation was employed to determine the capitation payment standards in district H: 4,693.11 Yuan for hypertension, 6,597.70 Yuan for diabetes, 5,644.46 Yuan for coronary heart disease, and 6,437.78 Yuan for stroke. A bottom-up costing approach was used in district C, resulting in payment standards of 4,884.18 Yuan for hypertension, 5,960.63 Yuan for diabetes, 3,733.93 Yuan for coronary heart disease, and 3,886.66 Yuan for stroke.
Conclusion: The outpatient costs associated with different chronic disease populations vary considerably. In view of maintaining equity in medical insurance and the fairness of capitation fees, it is imperative to apply risk adjustments to the benchmark capitation fee. Personalized services should be tailored to the diverse types and severities of chronic diseases. It is also crucial to provide customized basic medical and public health services to various chronic disease patients as part of the capitation payment reform for outpatient services. Additionally, enhancing the capabilities of community health services in managing chronic diseases, improving contracting percentages, and establishing effective incentive and evaluation mechanisms for general practitioners are essential for equitable distribution of surplus from capitation payments.

Keywords

Universal health coverage / Health care reform / Chronic disease / Ambulatory care / Capitation / Health management

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data and materials

Not applicable.

Funding

This research was supported by grants from National Natural Science Foundation of China (72274129) and National Medical Security Research Institute of Capital Medical University (YB2020B04, YB2020B05).

Declarations of competing interest

The authors declare that they have no competing interests.

Authors' contributions

Conceptualization, Y.J.; Methodology, Y.J.; Datacuration, W.N.; Formal analysis, Z.N. and L.J.; Funding acquisition, not applicable; Project administration, not applicable; Resources,not applicable; Supervision, N.J.; Validation, N.J.; Writingoriginal draft, N.J.; Writingreview and editing,N.J. All authors have read and agreed to the published version of the manuscript.

Acknowledgements

Not applicable.

References

[1] National Health Commission. Healthy China initiative (2019-2030). (Chinese). [2022-06-13]. Available from: http://www.gov.cn/xinwen/2019-07/15/content_5409694.htm?msclkid=3af03936b25c11ecb5543b1f15c25507.

[2] Chen ZP, Yang JX. International experience and inspiration of medical insurance payment on promoting chronic disease management. (Chinese). Health Econ Res. 2021; 38(2):38-40.

[3] Dong MY. Study On Capitation Payment Method of Outpatient co-ordination. (Chinese). Wuhan: Wuhan University; 2015.

[4] Lu CL, Mo JJ. Strengthening medical insurance expense management from the perspective of chronic disease health management. (Chinese). Chin Commun Doctors. 2020; 36(8):184-185.

[5] Ding S. The Development and Status of Medical Payment System in UK. (Chinese). China Heal Insur. 2012; 10(6):68-70.

[6] Hu SY, Liu YM. Features and pros and cons of the American managed care model. (Chinese). Chin Heal Resour. 1999; 2(4):46-47.

[7] Liu YJ. The inspiration of Thailand’s "30 Baht Plan" for China’s medical insurance. (Chinese). Health Economics Research. 2011; 28(4):45-47.

[8] Zhu ML, Wang EN, Qiu XY. Effectiveness evaluation of the capitation on diabetes in Tianjin. (Chinese). Chin Heal Econ. 2021; 40(2):26-29.

[9] Lin F, Wang HR. Exploration of chronic disease management and medical insurance payment methods in Zhenjiang. (Chinese). Chin Heal Resour. 2014; 17(3):211-212.

[10] Cai GC, Dong ZH. The "Changde Model" of capitation payment. (Chinese). China Social Security. 2014; 21(2):76-79.

[11] Jinhua Medical Insurance Bureau. Zhejiang Jinhua: "APG Scoring method" Promotes Medical Insurance Fund reform. (Chinese). Zhongguo Renli Ziyuan ShehuiBaozhang. 2021; 12(5):19-20.

[12] Zhai M, Zhao H, Tian Z, et al. Behavior and influencing factors of primary level medical treatment among residents under the background of hierarchical medical system. (Chinese). Chin J Public Heal Manage. 2019; 35(5):585-588.

[13] Wang J. The Recent Evalution of National Chronic Non-communicable Diseases Comprehensive Prevention and Control Demonstration Area in Chaoyang District of Beijing. Beijing. (Chinese). Zhengzhou: Zhengzhou University; 2017.

[14] Zhang WL. Discussion on the management mechanism of chronic disease prevention and treatment in Huairou District, Beijing. (Chinese). Chronic Pathematol J. 2014; 15(8):654-657.

[15] Ai LH, Wu RH, Xiao L, et al. A study on methods of risk-adjusted capitation fee of risk pooling for outpatient services in basic medical insurance: a case study of Shenzhen city. (Chinese). Chin J Heal Policy. 2017; 10(9):39-45.

[16] Jiang Q, Zhang ZZ, Zhao YX, et al. Thoughts on principles and designing of capitation in China. (Chinese). Chin Heal Econ. 2013; 32(1):34-38.

[17] Liu MY. The Impact On Diabetes Medical Expenses of Capitation Payment reform: a Case Study of the Reform in ST Hospital of Tianjin. (Chinese). Tianjin: Tianjin University; 2014.

[18] Deng M, Zhang N. Consultation status in community healthcare settings in urban and inner suburban areas of Beijing’s Chaoyang District:a comparative study. (Chinese). Chin General Prac. 2018; 21(16):2013-2016.

[19] Liu YQ, Liu Y.Survey and analysis of chronic diseases and their risk factors among adults in Huairou District, Beijing in 2016. (Chinese). Chron Pathematol J. 2018; 19(5):554-557.

[20] The state council report on the nutrition and chronic disease status of chinese residents (2015). (Chinese). [2022-06-13]. Available from: http://www.gov.cn/xinwen/2015-06/30/content_2887030.htm.

[21] National Center for Cardiovascular Diseases; 2021:26-37.

[22] Diabetes Branch of the Chinese Medical AssociationOffice for diabetes prevention and management at primary level. National guidelines for primary prevention and management of diabetes (2018). (Chinese). Chin J Inter Med. 2018; 57(12): 885-893.

[23] Chinese Medical AssociationChinese medical association publishing house, general medicine branch of the Chinese medical association, et al. Guidelines for primary diagnosis and treatment of stable coronary artery disease (2020). (Chinese). Chin J General Practit. 2021; 20(3):265-273.

[24] Peng B, Wu B. Guidelines for the diagnosis and treatment of acute ischemic stroke in China 2018. (Chinese). Chin J Neurol. 2018; 51(9):666-682.

[25] Schauffler HH, Howland J, Cobb J. Using chronic disease risk factors to adjust medicare capitation payments. (Chinese). Heal Care Financ Rev. 1992; 14(1):79-90.

[26] Liang H, He XL. A comparative analysis of pooling outpatient service policy in community health services. (Chinese). Chin J Heal Policy. 2011; 4(4):9-15.