DU Li-zhe, SUN Li-hua

(School of Business Administration, Shenyang Pharmaceutical University, Shenyang 110016, China)

Countermeasures to Reduce Economic Burden of the Schizophrenia in China

DU Li-zhe, SUN Li-hua

(School of Business Administration, Shenyang Pharmaceutical University, Shenyang 110016, China)

Objective To provide a theoretical reference and decision support for health care policy makers so as to reduce economic burden of the Schizophrenia. Methods Retrospective study was conducted to analyze measures to reduce the economic burden of the schizophrenia, and suggestions were raised based on learning experiences from other countries and practices in China. Results and Conclusion Comprehensive intervention of hospitals and communities as well as the policy system of basic health care insurance and social assistance can signif i cantly reduce the economic burden of the schizophrenia.

schizophrenia; economic burden; countermeasure

1 Current situation of mental health resource allocation

Currently, most countries do not have a comprehensive, well-funded mental health services network, China is no exception, and her mental health resource allocation is far behind the developed countries, see Figure 1. The fund for mental health is less than 2% of their total healthcare expenditures in most countries. It is estimated that there are around 1/3 schizophrenia patients can not get the basic and affordable treatment or care[1]. With limited medical resources, the priority of the government is to take measures to reduce the biggest part of disease burden to generate the greatest possible social and economic benef i ts. Patients and their families should select cost-effective services. These are inseparable from wellmanaged healthcare system. Some of the common treatment management systems and medical insurance systems in the world will be reviewed.

2 Management model of schizophrenia treatment

Figure 1 Mental health resource allocation in 2005 (1/10,000)

There are several indicators for a schizophrenia patient being well cured, mainly including clinical rehabilitation and social rehabilitation. The ideal standard for schizophrenia treatment should be safe, effective and economical and the patient can return to the society f i nally. It is still diff i cult to realize this goal. The currently accepted mental health service model is a comprehensive therapy. A timely, safe and effective treatment for mental illness can be provided by psychiatric hospitals and general hospital, and chronic stable phase treatment come from families, communities and social forces. Finally patients can be able to return to the society.

2.1 International model of schizophrenia intervention from community and hospital

At present, many countries have implemented the integration of community-based rehabilitation intervention, like the United States, Britain, Japan, Sweden, Hong Kong, Australia, Brazil, France, Lithuania, and Taiwan, namely, the intervention such as prevention, care, treatment, rehabilitation and supervision occur in the community.Many studies showed that the community mental health service system include mental health centers, acute care wards, day hospital, (patients accept a variety of treatment and rehabilitation in hospital during the day and go home at night) day care centers and family support. The successful implementation of intervention is based on perfect network of community service and two-way referral system. Patients can be referred to each other under different circumstances (acute patients choose in-patient treatment, while the stable patients can be treated in community mental health centers). Patients can obtain health care services more economically and it’s of good flexibility and practicality. After decades of practice, community mental health model in western countries developed quickly and got a big improvement which has achieved good results in recent years.

In 1960s, the United States launched“deinstitutionalization movement”. After 40 years of practice, the total number of beds for psychiatric patients decreased from 560,000 to 140,000 and it continues to decline, while outpatient services rose from 22.6% to 71.6%. Patients receiving community psychiatric services can have access to effective treatment, and the cost is only $ 900 per person per year, which declined by 94% compared to the cost of hospitalization ($ 15,600 per person per year)[2]. In late 1980s, the Australian government shifted from hospitalized service-oriented paradigm to community-based services, and mental health services provided by hospitals accounted for only about 20% of the total cost of mental health services. Except for acute exacerbation of mental illness that needs short-term inpatient treatment, most treatment happens in community and family and the average length of hospital stay is only 16 days per person[3]. The model of combining community mental health service with acute hospitalized system is the direction of the psychiatric treatment. Such successful experiences of community mental health services provide a good reference to China.

2.2 The formation of China’s model of comprehensive intervention for schizophrenia

In recent years, the government gradually put emphasis on people’s mental health problems and made some policies for it. For example, since 2005 Chinese central government has carried out several programs concerning disease prevention and control. Severe Mental Disease Treatment Program (referred to 686 project), was one of China’s first mental health practices and it was a representative of chronic mental disease treatment and management. The project vigorously promoted mental health services from simple hospital model to the integration of hospital and community model so that China can make a change in the f i eld of mental illness[4,5]. Unfortunately, due to the lack of expertise, funds and talent, this project has not been involved in early rehabilitation of mental illness, which is the key to preventing chronic, malignant process. At present, China still lacks research and services for an early comprehensive intervention of mental illness. Since 80% of patients need psychiatric rehabilitation lifetime[6], many families can not bear the long-term standard treatment due to economic pressures. Under such a circumstance, community mental health service center with low cost, wide coverage and focusing on psychological and social rehabilitation becomes increasingly important.

3 Healthcare system of schizophrenia

3.1 Four typical medical insurance systems

Health insurance mainly refers to the social health insurance, which aims to compensate patient’ s for medical expenses, thereby it shares the risk of economic losses caused by disease with the patients. Different countries established diversified health insurance models due to different levels of economic development, political and cultural background and social health status. Four health care systems are more popular among them, namely, they are government insurance, social insurance, endowment insurance and commercial insurance represented by the United Kingdom, Germany, Singapore and the United States respectively. By analyzing several major medical insurance systems implemented in developed countries, we can draw some useful experience and provide a reference for China’s medical insurance system reform. See Table 1.

After a hundred years of development, the four medical insurance systems have got great achievements in improving patient treatment quality and reducing economic burden. But with the increasing medical costs in recent years, these medical insurance systems expose their limitations. Therefore, these countries have taken some measures to reduce patient economic burden and government pressure from both suppliers and buyers. For suppliers, the initiatives include the non-residential treatment programs, such as strengthening health insurance management, reforming payment models, promoting family beds and day hospitalization. As to the buyers, the government enhances patient's consciousness of controlling costs and increase self-pay proportion, establishing the system of community hospitals first so that patientstreatment behavior can be changed to reduce unreasonable medical expenses.

Table 1 Comparison among international medical insurance systems

3.2 Chinese healthcare system of schizophrenia

China has more than 7.8 million schizophrenia patients and the number increases year by year. A large number of patients have a huge demand for medical resources, which has caused attention of relevant sections. The governments put schizophrenia into major disease insurance to compensate for the cost of hospitalization and general out-patient so that patients can reduce the f i nancial burden to the maximum extent.

3.2.1 Putting schizophrenia into out-patient major disease insurance

Out-patient major disease insurance can be understood as the long-term out-patient treatment with higher cost and the chronic illness is added to outpatient major disease insurance so that a higher reimbursement can be made for patients. Despite there is an increase in overall outpatient fund by adding schizophrenia to outpatient major disease insurance, some recovering patients are guided to clinic treatment to cut hospitalization expenses, which can reduce the economic burden of patients and relieve the pressure on the health insurance fund. Currently, the general outpatient reimbursement policies or out-patient major disease insurance rules are different and they include the cancellation of outpatient fees and an increase of reimbursement proportion within an annual limit.

Lowering the outpatient cost can make patients enjoy good services, especially for urban residents with lower reimbursement when they are hospitalized; outpatient treatment is more in line with the economic interests of patient. Increasing compensation ratio according to the institution level and cost so that patients can be guided to have the treatment in primary health care institutions which will reduce the outpatient and inpatient costs. However, the implementation of this measure should be based on the actual economic conditions. The maximum payment is set to avoid medical resources waste and reduce the pressure on health insurance fund. When the patients are reimbursed for their medical expenses, insurance company should minimize patients’ burden as well as to prevent excessive medical treatment.

3.2.2 Putting schizophrenia into in-patient major disease insurance

China’s basic medical insurance system makes healthcare treatment affordable for patients. However, due to different economic development and health funding levels, there is a big difference for medical reimbursement and self-pay proportion is high, particularly for urban residents and new rural medical insurance patients. Therefore, some provinces or cities with better conditions established URBMI or NCMS insurance with higher reimbursement, which includes 20 kinds of diseases and schizophrenia is one of them. In addition, in 2012, China introduced rural supplementary medical insurance which covers a large part of self-pay items. In 2013, the National People's Congress report issued that government will build universal health care system to improve major diseases insurance and rescuemechanism. 20 kinds of diseases including schizophrenia will be added to the comprehensive major disease insurance. These measures will play a significant role in reducing patient economic burden.

3.2.3 Reforming schizophrenia payment

To guide patient’s reasonable medical demands and to control the rapid growth of treatment costs, many local governments reformed health care payment from both demand and supply sides in recent years. For suppliers, with reference to the international experience, the afterpaid system was changed into the prepaid system, i.e., total budget for the hospitalization instead of pay for services, such as beds, days, or per patient etc. For demandside, lowering outpatient cost, raising payment ratio and maximum payment limit is the best option. Different methods of Medicare payment lead to different economic incentives, thus affecting the supply and demand sides of the medical services. The data analysis shows if such reforms were carried out smoothly, the overall medical costs would be under control. But there were some irrational phenomena, such as rejecting severe illness patients, increasing the number of clinic visits and reducing quality of medical services, which affect the vital interests of the patients.

4 Conclusions

Nowadays, the government gradually increases emphasis on people’s mental health problems, releasing some policies to improve the treatment of mental illness and medical reimbursement, which indeed plays a significant role in reducing economic burden. But at the same time, China is still at the elementary stage. It is hard to ensure fund balance and to reduce patients’ economic burden as well. So it’s not enough to rely solely on the medical insurance system for reducing economic burden of schizophrenia. Government should provide free treatment and health care for poor patients and broaden the costsharing pipeline by making other medical assistance policy to reduce the pressure on the health insurance fund. At the same time, it also can reduce economic burden of schizophrenia patients.

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Author’s information: SUN Li-hua, Professor. Major research area: Investment and efficiency management in the field of medicine, pharmacoeconomics and technology innovation management. Tel: 024-23986553, E-mail:slh-3632@163.com