A new insurance benefit with capitated provider payment to enhance access to primary care and improve quality of medication prescribing in China

In Zhuhai, a municipality of 1.58 million in southern China, health insurance for common diseases treated in primary care settings was introduced in 2009. Prior to this, health insurance focused on inpatient and outpatient care for a limited number of chronic conditions, excluding outpatient care for common primary care diseases such as diabetes and hypertension at an early stage. The new insurance benefit with capitated provider payment was designed to enhance access to primary care and improve quality of medication prescribing. The pooled fund for common primary care disease outpatient care comprises pooled insurance funds, medical savings accounts, government subsidies, and individual contributions. All insured individuals could voluntarily enroll in the common primary care disease outpatient benefit and register themselves with one preferred affiliated primary care facility. The benefit covers all diagnostics and treatments, including medicines, as listed by the insurance programs for primary care services. Implementation of the common primary care disease outpatient benefit involved an annual capitated provider payment replacing the fee-for-service system. Of the total common primary care disease outpatient expenditures, insurance pays 70% and patients pay 30%. There is no reimbursement maximum, and referrals are allowed when needed. A pay-for-performance system was implemented with the capitated provider payment, with the results of scheduled, unscheduled, and year-end inspections determining the level of year-end settlement. A longitudinal study of healthcare utilization, expenditures, and quality of medication prescribing in Zhuhai was conducted between August 1, 2008, and July 31, 2012. The study used health administrative data and insurance claims data to measure the impact of the new health insurance benefit package with the capitation payment reform. The results showed that enrollment in the common primary care disease outpatient benefit increased to 76% of the insured population in 2012. The number of outpatient visits paid by the pooled common primary care disease outpatient fund rose from 6.7% in 2009 to 24.3% in 2012. The study also found that the average total expenditure per common primary care disease outpatient visit dropped by CNY 15.40 in August 2009, followed by a slight increase at a lower rate. The proportion of common primary care disease outpatient visits with at least one antibiotic prescribed dropped slightly in August 2009 and then reversed into a significant increasing trend. The proportion of common primary care disease outpatient visits with at least one injectable prescribed dropped suddenly in August 2009, followed by a downward trend. Despite a modest decrease after the introduction of the common primary care disease outpatient benefit, the levels of antibiotic and injectable use remained much higher than the local target of 20% set by the Zhuhai Health Bureau in 2011.