Measurement of the Capitation-based Reimbursement Standard for Chronic Disease Management in Primary Care Clinics

Background The reimbursement of outpatient services is an essential part of the reform of medical insurance payment methods. With the comprehensive promotion of the reform on the medical insurance payment methods for inpatient services in China, the reform on insurance payment methods for outpatient services, such as capitation-based reimbursement and ambulatory patient groups (APG) point method, will gradually be put on the agenda. Objective To explore a capitation-based reimbursement scheme for chronic diseases applicable to Beijing based on an analysis of capitation-based reimbursement implemented in different countries and regions and the current situation of chronic disease management in Beijing, to provide a reference for implementing the capitation-based reimbursement reform for chronic diseases in Beijing. Methods This study used information related to essential medical services, reimbursement by health insurance, and essential public health service funds in Beijing's C and H districts. Then through an analysis of the information, the calculation method for capitation-based reimbursement standard for four common chronic diseases (hypertension, diabetes, coronary heart disease and stroke were selected in this study) applicable in the districts was designed to calculate the capitation-based reimbursement standard for major chronic diseases in primary outpatient clinics, providing a reference for promoting the capitation reform for chronic diseases in outpatient clinics. Results By analyzing the above-mentioned information in 2017—2019, the capitation-based reimbursement standard was 4 693.11 yuan/person for hypertension, 6 597.70 yuan/person for diabetes, 5 644.46 yuan/person for coronary heart disease, and 6 437.78 yuan/person for stroke in H district calculated using the bottom-up costing, and was 4 884.18 yuan/person for hypertension, 5 960.63 yuan/person for diabetes, 3 733.93 yuan/person for coronary heart disease, and 3 886.66 yuan/person for stroke in C district calculated using the top-down estimating. Conclusion In calculating the capitation-based reimbursement standard, as different chronic disease patient groups have different outpatient costs, considering the equity of medical insurance reimbursement and the rationality of capitation-based reimbursement, it is necessary to adjust the risk of the benchmark capitation, and develop personalized service packages for different types and severity of chronic diseases. In the promotion of capitation payment for chronic disease patients, it is necessary to provide personalized essential medical service and public health service packages for patients with different chronic diseases, further improve the chronic disease management capacity of community health institutions to improve the contracting rate and establish an effective incentive and assessment mechanism for general practitioners to rationally allocate capitation balance.