An empirical study on the payment effect of hospitalization expense under the urban employee basic medical insurance in Guangzhou / 中华医院管理杂志

ABSTRACT

Objective To evaluate the payment effect of hospitalization expense under the urban employee basic medical insurance in Guangzhou.Methods Analyze the differences between the expenses paid by medical insurance with actual hospitalization expenses of the 22 settlement units from 1 5 tertiary hospitals,and the expense settlement data of the insured patients,based on the early,the mid-term,and the recent periods since the urban employee basic medical insurance was implemented since 2002.Results The ratio of good payment effect units reduced to 9.09%(the recent)from 42.86%(the earlier).The ratio of poor payment effect units was 42.86% in the early,to mid-term 18.18%,and sharply increased to 77.27%in the near term.The settlement units which exceeded its flat standard accounted for 52%,50%, and 91%respectively(in the early,the mid-term,and the recent).The medical insurance agency and the hospital shared the overrun costs by 52.88%and 47.12%respectively in 201 1.Conclusion The payment effect of the urban employee medical insurance was greatly influenced by the adjustment of medical insurance policy and the payment ability of the pooling fund.It should improve the payment effect of the medical insurance timely,so as to ensure the hospitals’operation normally.The hospitals should take the effective cost management measures so as to deal with the increasing cost control pressure.