Zhi Yuanyuan,Dou Lele,Xing Miaomiao,Wang Shuling

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

Abstract Objective To provide a reference for future budget of health insurance fund for the COVID-19 pandemic in other parts of China or other major public health events.Meanwhile,it also offers a reference for the government to introduce and adjust the policy of health insurance funds after the pandemic.Methods Models of the income,expenditure and cumulative balance of health insurance fund in Hubei Province in 2020 were established and compared.The former was mainly established and tested using SPSS 26.0 and Excel,while the latter was obtained by inferential analysis.Results and Conclusion The COVID-19 pandemic reduced the income and increased expenditure of the health insurance fund in Hubei Province in 2020,resulting in a deficit.The COVID-19 outbreak has caused a deficit in health insurance fund of Hubei Province in the short term,but in the long term,the outbreak will not have a major impact on the health insurance fund.

Keywords:COVID-19;major public health events;health insurance fund;linear regression

Before the arrival of New Year in 2020,the outbreak of the novel coronavirus-19 (COVID-19)suddenly brought China,which was immersed in joy and peace,into a wartime state.The speed,scope and difficulty in control,the number of infected people,the high funds,and the profound impact are unprecedented since the founding of New China.The Chinese central government has always put people’s life safety and health first,and made countermeasures in the first time,leading the people of the whole country to launch an overall battle of pandemic prevention and control[1].Although “zero personal payment” was implemented in this pandemic,it involved a large number of personnel and high costs,so the medical insurance fund was under considerable pressure[2].

At present,many documents show that the medical insurance fund will be in deficit in 2020,but there is no data to support it.This article selects Hubei Province,which is most severely affected by the pandemic,and combines existing data to establish models of income,expenditure and cumulative balance of medical insurance fund (A,B,C) before the pandemic.Meanwhile,models of income,expenditure,and cumulative balance of medical insurance fund (D,E,F) after the pandemic were established to conduct a comparative analysis,which could reveal the impact of the COVID-19 pandemic on medical insurance fund of Hubei Province in 2020.This research can provide a reference for future budget of medical insurance fund for COVID-19 pandemic in other provinces and some future major public health events.Besides,the government can use it to introduce and adjust relevant policies for medical insurance funds after the pandemic.

The Hubei Provincial Health Commission issued daily pandemic notifications from January 20,2020.Fortunately,the pandemic situation stabilized on March 18 (the first zero new cases).As of June 30,2020,a total of 68 135 COVID-19 patients were diagnosed in Hubei Province.Among them,63 623 were cured,and 4 512 died.The specific situation is shown in Fig.1.

Fig.1 COVID-19 pandemic situation in Hubei Province

On February 12,the fifth edition of the diagnosis and treatment plan added clinical diagnosis to the diagnostic criteria.On April 16,Wuhan city revised the data previously released[3],so the data changed a bit.Wuhan,where the pandemic broke out,is the most severely affected area in the country.As of June 30,2020,Wuhan had a total of 50 340 confirmed COVID-19 patients,46 471 of whom were cured,and a total of 3 869 people died.

1 Forecast of Hubei medical insurance fund in 2020 without COVID-19

1.1 Research methods and data sources

1.1.1 Research methods

Univariate linear regression model is a model that uses the least square function to perform regression analysis on an independent variable and a dependent variable[4],and its general form is:

In the formula,Yis the dependent variable,Xis the independent variable,εis the random variable,andkis the model parameter.The general steps of establishing a linear regression model[5]are:(1) Select dependent variables and independent variables for a model;(2) Calculate the estimated value of model parameterk;(3) Perform statistical test on the model;(4) Perform data prediction and test errors.The statistical tools of this article are SPSS 26.0 and Excel.

1.1.2 Selection of data sources and variables

By the end of 2019,a total of 10.932 million people participated in the basic medical insurance for urban workers and 44.694 million people participated in the basic medical insurance for urban and rural residents in Hubei Province,with a participation rate of 94%[6].By the end of 2018,the total accumulated balance of the medical insurance fund was 65.53 billion yuan.In the same year,the operation risk of medical insurance fund for urban workers in Wuhan was relatively high,with an overrun of about 5 billion yuan[7].The sample data in this article of Hubei Province come from “China Statistical Yearbook”,from 2011 to 2018,as shown in Table 1.This paper selects the year as the dependent variable (X1),fund income (Y1),fund expenditure (Y2),and accumulated balance (Y3) as independent variables.

Table 1 Definition of rare diseases in some foreign countries or regions

Due to the integration of urban and rural residents’ medical insurance policies,2011-2016 is urban basic medical insurance data,and 2017-2018 is urban and rural basic medical insurance data.Therefore,segmented modeling is used to set up model A and B in this article for prediction.It means if there is no pandemic in 2020,model A1for urban basic medical insurance fund income forecast,A2for new rural cooperative medical insurance fund income forecast,B1for urban basic medical insurance fund expenditure forecast,and B2for new rural cooperative medical insurance fund expenditure forecast are established respectively.

1.2 Fund income forecast

(1) Establishing model A1.The year (X1) and fund income (Y1) are used to develop a model through SPSS 26.0,the medical insurance fund income forecast model A1of Hubei Province in 2020 is obtained:Y1=36.623X1–73 483.990.

(2) Testing model A1.The goodness-of-fit test,DW test,analysis of variance,and collinearity test are performed on the univariate linear regression model A1[8].The goodness-of-fitR2(0.980) andR2(0.975)after adjustment are all close to 1,which shows that the goodness-of-fit of the model is high,and the independent variable can explain 98% of the changes in the dependent variable.The DW value is close to 2,indicating that the autocorrelation of the independent variable is not obvious.When significanceP=0.000 <0.01,it indicates the difference between the dependent variable and the independent variable have a significant linear relationship.When the statistical variance inflation factor VIF value is 1.000 <10,it indicates that there is no multicollinearity between the variables.Therefore,the model constructed by these two variables (year and medical insurance fund income) is relatively stable.

(3) Data prediction and error test of model A1.According to model A1,it can be predicted that the 2017-2020 urban basic medical insurance fund income of Hubei Province without a pandemic is shown in Table 2.The forecast error is 2.01%-6.49%,and the overall error is small,so the forecast value is more accurate.Substituting the relevant data in the above table into the model for testing,and the effect diagram shown in Fig.2 is produced by Excel.

Fig.2 Forecast effect chart of Hubei urban basic medical insurance fund income

Table 2 Forecast of Hubei urban basic medical insurance fund income

(4) The establishment of model A2.From Table 1 and Table 2,we can get the estimated new rural cooperative medical insurance fund income from 2017 to 2018,as shown in Table 3.

From the above data analysis,it can be seen that income,expenditure,and accumulated balance roughly increase in proportion,and a linear equation can be established.According to Table 3,the year is set asxand the income of the new rural cooperative fund asy,theny=19.769x– 39 561.274.According to this equation,the forecast value of the new rural cooperative fund income in Hubei Province in 2019 is 35.27 billion yuan and 37.27 billion yuan in 2020.Combining the data from the 2019-2020 urban basic medical insurance fund revenue forecast in Table 2,we can get the forecast value of Hubei medical insurance fund income from 2019 to 2020 without pandemic,81.06 billion yuan in 2019 and 86.72 billion yuan in 2020 respectively.

1.3 Fund expenditure forecast

(1) Constructing model B1.Using SPSS 26.0 to develop a model of the year (X1) and fund income(Y2),the Hubei Province medical insurance fund expenditure forecast model B1 in 2020 is obtained:Y2=33.186X1– 66 595.719.

(2) Testing model B1.The goodness-of-fit test,DW test,analysis of variance and collinearity test are performed on this unary linear regression model B1:The goodness-of-fitR2(0.995) andR2(0.994)after adjustment are both close to 1.It can be seen that the goodness-of-fit of the model is high,and the independent variable can explain 99.5% of the changes in the dependent variable.The DW comparison value is close to 2,indicating that the autocorrelation of the independent variable is not obvious.When the significanceP=0.000 <0.01,it indicates that there is a significant linear relationship between the dependent variable and the independent variable.When the statistical variance inflation factor VIF value is 1.000 <10,it indicates that there is no multicollinearity between the variables,and the model constructed by these two variables (year and medical insurance fund expenditure) is relatively stable.

(3) Error test of data prediction and model B1.According to model B1,the value of Hubei Province’s urban basic medical insurance fund expenditure from 2017 to 2020 without a pandemic can be estimated.According to the unary linear regression equation,Table 4 below can be obtained.It can be seen that the prediction error is 0.29%-3.61%,and the overall error is small,so the predicted value is more accurate.Fig.3 is produced by Excel.

Fig.3 Forecast effect chart of Hubei urban basic medical insurance fund expenditure

(4) Prediction of B2value.From Table 1 and Table 4,the estimated expenditure of the new rural cooperative medical system fund can be obtained,as shown in Table 5.

Table 5 2017–2018 estimated new rural cooperative medical insurance fund expenditure in Hubei Province

According to Table 5,assuming that the year isxand the expenditure of the new rural cooperative medical insurance fund isy,theny=56.414x–113 548.881.Based on this,we can predict that the expenditure of the new rural cooperative medical insurance fund of Hubei Province in 2019 will be 35.10 billion yuan,and 40.74 billion yuan in 2020.Combining the forecast expenditures of the urban basic medical insurance fund from 2019 to 2020 in Table 4,we can obtain the estimated expenditures of Hubei provincial medical insurance fund without an epidemic,75.78 billion yuan in 2019 and 84.74 billion yuan in 2020.

1.4 Forecast of cumulative fund balance

Constructing model C for the forecast of Hubei provincial medical insurance fund cumulative balance in 2020 without an epidemic,according to the definition of cumulative balance,it can be obtained:predicted cumulative balance=predicted income-predicted expenditure+predicted cumulative balance of the previous period.From model A and model B,the cumulative balance in 2019 is about 70.81 billion yuan,so the cumulative balance in 2020 is 72.79 billion yuan.

2 Forecast of Hubei medical insurance fund in 2020 with COVID-19

Since the outbreak of the pandemic,the central government of China had given Hubei Province vigorous financial support.In terms of medical insurance funds,the provincial government allocated a total of 3.7 billion yuan in medical insurance funds[9].On February 21,the National Healthcare Security Administration and other three departments jointly issued a document to reduce the basic medical insurance premiums for employees,thus cutting the burden of payment for enterprises[10].In terms of medical insurance reimbursement,medicines and diagnosis and treatment service covered by the COVID-19 diagnosis and treatment plan formulated by the health department can be included in the payment scope of the medical insurance fund.Patients and suspected patients (including medical treatment in different places) enjoyed a “personal zero payment” policy,after being reimbursed by basic medical insurance,critical illness insurance,and medical assistance[11],the part paid by individuals is reimbursed by financial contributions.In summary,medical insurance fund income will decrease and expenditure will increase in the short term.The following cases and cost data are from Hubei Provincial Health Commission,Healthcare Security Administration of Hubei Province,and National Bureau of Statistics.

2.1 Forecast of fund income

Based on the existing data and published policies,revenue forecasting model D is established:Income=Hubei Province’s medical insurance fund income forecast from January to April (I)+Hubei Province’s medical insurance fund income forecast from May to December (II)+financial assistance(Ⅲ)– “phase reduction of employee basic medical insurance premiums” influence (Ⅳ).

Ⅰ:The latest data released by the state is the operation of the medical insurance fund from January to April 2020[12],which is 8.53% less than the income of the medical insurance fund in 2019[13](the income of the medical insurance fund from January to April 2019 is 824.67 billion yuan,the medical insurance fund income from January to April 2020 is 754.33 billion yuan).According to model A,without an epidemic,the income of Hubei Province’s medical insurance fund in 2019 is about 81.06 billion yuan,which is about 27.02 billion yuan from January to April.Assuming that Hubei Province has the same year-on-year reduction ratio as other provinces in China,it is predicted that Hubei Province medical insurance fund income from January to April 2020 will be approximately 24.72 billion yuan with a pandemic.

Ⅱ:Since the epidemic situation in Hubei has stabilized on March 18,and there have been no new cases for 43 consecutive days from May 19 to June 30,it is considered that the fund income is similar to the fund income without an epidemic (similarly,by model A can get fund income about 57.81 billion yuan from May to December),but we have to substract the fund income from the dead patients after May(the total number of death cases is 4 512).Model D1(y=-29.8x+65 727,according to the number of participants in 2017-2019,set the year asxand the number of participants asy,and use Excel to obtain the equationy=-29.8x+65 727.Model test:DW=3.0,close to 2,R2=0.986,R2=0.972 after adjustment,the independent variable can represent the change of the dependent variable 98.6%;due to policy reasons,the sample size is small,significanceP=0.076 >0.01,VIF=1 <10,the linear relationship between variables is not very significant,but the model is relatively stable and the model is available) is established to predict the number of insured persons in 2020.It can be obtained that the number of insured persons in 2020 is about 55.31 million.And the death cases are about 0.008% of the number of insured persons in 2020.Therefore,the underpaid medical insurance fund is about 0.05 billion.

Ⅲ:The total pre-allocated medical insurance funds is about 3.7 billion yuan in Hubei Province.

Ⅳ:Cities in Hubei Province actively responded to the national policies for five months with an average tax reduction rate of 4% .Model D2is established to predict the income of the basic medical insurance fund for urban employees in 2020 (Fig.4 is based on the urban employee medical insurance fund from 2014 to 2018).The available equationy=52.29x-105 099 (suppose the year isxand the income of the medical insurance fund for urban employees in Hubei Province isy,the equationy=52.29x– 105 099 can be obtained.Model test:DW=2.053,close to 2,R2=0.984,R2=0.979 after adjustment,independent variable can represent 98.4% change of dependent variable,significanceP=0.001 <0.01,VIF=1 <10,indicating the existence of variables significant linear relationship,the model is stable and usable),and the income of the basic medical insurance fund for urban employees in 2020 is about 52.68 billion yuan.Therefore,the reduction of basic medical insurance for urban employees is about 2.11 billion yuan.

Fig.4 Forecast scatter chart of Hubei urban employee medical insurance fund revenue

In summary,model D predicts that the medical insurance fund income with an epidemic in Hubei Province in 2020 will be approximately 247.2+578.1-0.05+37-21.1=841.2 (billion yuan).

2.2 Fund expenditure forecast

Based on the existing data and published policies,an expenditure forecast model E is established:Expenses=number of COVID-19 patients * average cost (17 000) * 65% (Ⅰ)+testing costs for patients,suspected patients and Wuhan national testing (Ⅱ)+patient reexamination costs(Ⅲ)+model B results (Ⅳ))-death cases in 2020 medical insurance reimbursement expenses (Ⅴ).

Ⅰ:As of June 30,a total of 68 135 cases of COVID-19 patients had been confirmed in Hubei Province.The average treatment cost for one patient is 17 000 yuan,and the medical insurance payment ratio is about 65%[14],and the treatment expenditure is about 750 million yuan.

Ⅱ:By June 30,a total of 285 075 close contacts was tracked in Hubei,with an average cost of 260 yuan for one inspection[15](using data before April 27).There is an average of two tests for each person[16],and the cost of close contact testing is 150 million yuan.From May 14th to June 1st,Wuhan conducted a nationwide test.A total of 9 998 828 people were tested and 1 174 close contacts were traced (without repeated calculations).The test cost was 2.57 billion yuan.In summary,the test cost was about 2 720 million yuan.

Ⅲ:By the end of June 30,a total of 63 623 patients with COVID-19 in Hubei were discharged from hospitals.The re-examination is generally carried out in the second and fourth weeks[17],and the re-examination cost is 30 million yuan.

Ⅳ:It is predicted that medical insurance expenditures in 2020 will be 84.74 billion yuan without an epidemic.

Ⅴ:According to the “China Statistical Yearbook”,the per capita health care payment expenses from 2008 to 2018 is obtained,as shown in Fig.5.A budget model E (y=160.98x-323 014,suppose the year isx,the per capita medical insurance cost in Hubei Province isy,and the equation isy=160.98x-323 014.Model test:DW=1.466,close to 2,R2=0.942,R2=0.932 after adjustment,the independent variable can represent the 94.2% change of the dependent variable,significanceP=0.00 <0.01,VIF=1 <10,indicating that there is a significant linear relationship between variables,and the model is stable and usable) is established for health care payment per capita in 2020,we can get that the cost of health care payment per capita in 2020 is about 2 165.6 yuan.So the cost reduction due to death cases is about 10 million yuan.

Fig.5 Scatter chart of per capita health care costs in Hubei Province

In summary,model E predicts that the medical insurance fund expenditure with an epidemic in Hubei Province in 2020 will be about 7.5+27.2+0.3 +847.4-0.1=882.3 (billion yuan).

2.3 Forecast of fund balance

A balance prediction model F is established:Cumulative balance=model D result-model E result +model C fund balance in 2019.In summary,the medical insurance fund balance under the epidemic situation in Hubei Province in 2020 is about 841.2-882.3=-4.11 (billion yuan),and the cumulative balance is about-41.1+708.1=667.0 (billion yuan).

3 Analysis of the impact of the COVID-19 pandemic on medical insurance fund of Hubei Province in 2020

From the above data,the impact of the COVID-19 pandemic on medical insurance fund in Hubei Province can be obtained,as shown in Table 6.It can be seen that the outbreak of the pandemic may lead to a decrease of Hubei medical insurance fund income in 2020,an increase in expenditure,causing a deficit in the fund balance for the year.However,due to the strong government support[18],the fund income will still increase by about 4.0% over the same period in 2019.The “zero personal expenditure”policy increased expenditures by approximately 16.4% compared to the same period in 2019,but the cumulative balance is still much larger than the expenses consumed by the pandemic this year.Therefore,in the long run,as the pandemic gradually stabilizes,the medical insurance fund will gradually recover its vitality.There will be no major fund deficit due to the pandemic,and it will not affect the people’s daily medical insurance reimbursement.

Table 6 The impact of the COVID-19 pandemic on health insurance fund in Hubei Province

4 Limitations and availability of data

The data in this article has certain limitations that make fund income unpredictable and accurate.(1) It has to be verified whether the pandemic causes an increase in the mortality of patients suffering from other diseases (especially chronic diseases,cancer,rare diseases,and certain diseases that rely on imported drugs).(2) There are few official reports that the government directly supports the medical insurance fund,and the data may differ from the actual number.(3) The pandemic caused some companies to close down,and the reduction in the income of the basic medical insurance fund for urban employees cannot be calculated.(4) It is difficult to obtain official data of the new rural cooperative medical insurance fund due to the integration of urban and rural medical insurance.

Besides,there are other limitations that make fund expenditures unpredictable and accurate.(1)During the pandemic,people went out less,and the hospitalization rate and the rate of medical visits decreased.Therefore,the cost of the reduced expenditure cannot be calculated.(2) The impact of the pandemic on medical treatment of patients suffering from other diseases (especially chronic diseases,cancer,rare diseases,and certain diseases that rely on imported drugs) is unproven.(3) We are not sure whether COVID-19 patients who are cured have some sequelae.(4) The impact of advance payment for medical treatment in different places.(5)The actual severity and epidemiological history of COVID-19 patients are different,and the actual cost may vary greatly.(6) The price of COVID-19 testing and medical services in cities of Hubei (and even hospitals) varies within a certain period of time.

5 Recommendations for the impact of the COVID-19 pandemic on medical insurance fund

5.1 Solving the problem of advance payment made by patients or medical institutions during the pandemic as soon as possible

In the early stage of the COVID-19 pandemic,some patients who did not carry relevant documents,such as ID cards or medical insurance cards had to pay medical institutions in advance when seeking medical treatment.Because the cost of treatment was relatively high,especially for poor families or critically infected persons,it was an economic burden for them.Therefore,medical insurance agencies need to cooperate with patients and medical institutions to reimburse through medical insurance funds.If there are more cases like this,priority should be given to local patients and patients with simple procedures for medical treatment in different places to reimburse their payment.At the same time,the local government should also issue detailed policies related to medical insurance management as soon as possible,such as detailing the documents,reimbursement vouchers,working hours and working locations to maximize working efficiency.

5.2 Establishing and improving medical insurance emergency mechanisms for major public health incidents

The government should issue relevant policies for major pandemics as soon as possible to fully implement the “Opinions on Deepening the Reform of the Medical Security System”.Additionally,it can establish and improve the medical insurance emergency mechanism for major public health incidents.

We believe that it is necessary to establish a medical insurance emergency mechanism (referred to as “emergency mechanism”).But first of all,we have to issue a higher level law for the emergency response mechanism,which will clarify the rights and responsibilities of the relevant departments (such as the government,social forces,etc.).Besides,the rapid handling process of the emergency response mechanism has to be clarified.Some supporting mechanisms such as early warning,aftermath of a public health emergency should be set up as well.Lastly,the sources and destination of funds for the normal operation of the mechanism should be diversified with the help of supervision organizations.

As to medical insurance emergency mechanism for major public health incidents,the relevant departments responsible for the normal operation of the mechanism must be clarified.Besides,we should establish a supervision mechanism and diversified financing channels,which can include government special funds,part of the annual balance of the national medical insurance fund,donations from charities,personal donations,and corporate donations.In addition,we should give full play to the role of commercial insurance,improving and optimizing medical insurance management and offsite reimbursement services.Meanwhile,we can develop telemedicine,and hierarchical diagnosis and treatment.The operation and supervision of online pharmacies governance must be carried out as well.Once a major pandemic breaks out,normal diagnosis and treatment with medical insurance reimbursement services can be given to the infected groups to reduce unnecessary losses and deaths.

5.3 Vigorously promoting the stability of medical insurance fund

It can be seen from the conclusions of this study that there will be no deficit in the medical insurance fund this year.However,some people and companies may lose confidence in the medical insurance fund or the entire medical insurance business.Therefore,vigorous publicity by the mainstream media is needed to stabilize the public.It was discovered through the pandemic that the power of the media should not be underestimated.During the pandemic,people were closed at home,and their access to outside information mainly relied on mainstream media reports or some gossip.

The government should make full use of the media such as TV,newspapers,public accounts,Weibo,major news software,and search engine,which will enhance public confidence in medical insurance funds and medical insurance undertakings.It is conducive to the further development of medical insurance reforms.

5.4 Tracking the recovery of COVID-19 patients

The COVID-19 virus is still unconquered,and no specific medicine has been found so far.Some patients will have strong side effects when taking the medicine.There are also some patients with other diseases.Although they recovered from COVID-19,their physical conditions are not as good as before,and their chronic diseases have become more serious or even worse.

In view of this,medical institutions in various regions should further track the recovery of patients.More attention should be paid to the patients with poor recovery by the medical institutions,especially those who return to poverty due to COVID-19.Local medical insurance bureaus should introduce corresponding measures and provide further financial support for these patients,which is also the further implementation of poverty alleviation work.

5.5 Strengthening China’s medical security and the informatization construction

Establishing a high-tech informatization team for medical insurance departments can provide medicinal insurance funds with refined and systematic support.It is necessary to integrate resources and strengthen the informatization construction of China’s medical insurance now.Therefore,we still needs to improve the following aspects.

First,the informatization of the entire medical insurance service must be realized.The current information of medical insurance department is in a fragmented state.Local medical insurance bureaus should realize regional information sharing by establishing a platform for information automation.When major emergencies occur,people can have online medical diagnosis in different cities,online instant settlement of drug purchases,and online query of settlement data.The goal is to make people actually enjoy the convenience brought by the informatization of medical insurance,and the public service offered by the government.

The second is to improve the operating mechanism of medical insurance agencies and strengthen the security of medical insurance information system.The coverage of medical insurance is so wide that medical insurance information is constantly changing with the movement of people.In order to avoid the occurrence of medical insurance fraud when a major pandemic comes,the boundary of resources sharing should be clarified.The security and timeliness of information should be strengthened to ensure people privacy and security of the medical security information.

In addition,the methods and formulas used in the data processing in this article can be extended to the budget research of the medical insurance fund in other regions.The idea of establishing the formula in this article also can be used to promote the medical insurance fund budget when other major public health events occur.