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Abstract

The soaring cost of healthcare service demands alternative payment schemes to control expenditures while maintaining quality of service. The capitation payment scheme is a tentative substitute for the Fee-For-Service (FFS) scheme. A pilot capitation program study was conducted by the Bureau of National Health Insurance (BNHI) to evaluate the feasibility of a national rollout. Estimating the potential outcomes of a specific pilot program, the multi-agent simulation approach is used to model and simulate the service system under different settings. In this study, we chose the Zhishan Community Healthcare Group (CHG) service system as an example. The model was built and validated according to publicly available statistical and transactional data from Zhishan-CHG, and estimated the system’s financial sustainability under different conditions. Five scenarios were explored in the experiment, simulating the capitation payment scheme over a period of three years. The results are summarized as follows: (1) medical cost expenditure per person can be reduced as more patients are enrolled in the capitation program; (2) the service model with a health promotion agent outperforms the model without one in an FFS cost control system; (3) higher quality and retention rate improve capitation income; (4) the financial risk of the CHG service system can be mitigated by excluding inpatient medical costs from the virtual points assigned by BNHI, and (5) simulation results show a positive financial outcome for Zhishan-CHG. These simulation results could be potentially used by the BNHI to revise its policy in terms of the population for one CHG and the coverage of medical services of a capitation payment system, such that the financial risk of the CHG could be reduced and the capitation policy sustained.

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