Capitation reform in the Pudong New Area of Shanghai: a retrospective time series analysis.

BACKGROUND: The New Rural Cooperative Medical Scheme (NRCMS) covers 900 million farmers (about 95%) in China, but its fund is at serious risk of deficit. Shanghai, one of the developed cities in China, has developed its Rural Cooperative Medical Scheme and NRCMS as an advanced and exemplary representative of Chinese rural health insurance. The participating rate of NRCMS was 99·90% in Pudong New Area in 2015, which meant 277 310 farmers were involved, accounting for 29% of Shanghai's participants. Pudong New Area of Shanghai implemented NRCMS capitation reform in August, 2012, aimed at controlling the increasing medical costs for farmers and avoid risk to the NRCMS's fund. We aimed to assess long-term effect of the reform.

METHODS: We performed a retrospective time series analysis of the NRCMS fund by examining data acquired from Jan 1, 2011, until Dec 31, 2015 (60 months), in Pudong. The analysis was based on time series data modelling before Aug 1, 2012, and we compared forecast data produced with Winters' additive models and with simple seasonal models with observed data for the 40 months after capitation reform. Outcome measurements included numbers and costs of insured outpatients and inpatients.

FINDINGS: The mean forecasted outpatient cost per visit (¥102·00, mean absolute percentage error [MAPE] 2·9%) and inpatient cost (¥12 836·63, 1·9%) by Winters' additive models were both higher than observed values (outpatient cost ¥90·37, p<0·0001; inpatient: ¥11 176·95, p<0·001). However, visit forecasts based on simple seasonal models did not differ from observed monthly visits (predicted outpatient visits 511 550 vs actual visits 486 976, p=0·121; predicted inpatient visits 2173 vs actual visits 2147, p=0·74). NRCMS fund surplus rate was 8·84% in 2015, which was 6·93 percentage points higher than it was in 2011.

INTERPRETATION: Capitation reform led to declines in per outpatient and inpatient costs, while the medical need remained unchanged. Furthermore, the increased surplus rate ensured the fund's security.

FUNDING: National Nature Science Foundation of China (#71503170; for data interpretation), Shanghai Municipal Commission of Health and Family Planning (#201440036, #2016HP009; for data collection and analysis).