**2. Process for adaptation of a global format**

MCDA is a method to support decision-making, while allowing for adaptation to a specific decision problem. The methodology, framework, and process applied in the workshop followed a previously developed and validated model (**Figure 1**) [30, 33] for adaptation to a new decision problem and context. Each of the phases will be described in detail below.

#### **2.1 Workshop preparation**

To achieve broad buy-in and acceptance for the tool, many of the important stakeholders should be included. Through participation in an interactive workshop, individual stakeholders will be able to see exactly how the tool was developed and can contribute their perspective to shape the new tool. In order to limit the workshop to less than 1-day preparation prior to the workshop is important. Ideally, the definition of the decision problem should occur prior to the workshop. For the initiative described here, decision problem was the assessment of health-care policy options across China (see Section 1.4).

*Value-Based Evaluation of Chinese Provincial Health Insurance Policy Schemes DOI: http://dx.doi.org/10.5772/intechopen.84373*


#### **Figure 1.**

*Process applied for adapting a previously developed MCDA tool and framework to the decision problem of developing new insurance policies in China.*

#### *2.1.1 Stakeholder engagement*

One of the core principles of designing and implementing change is that the key stakeholders are considered throughout the process according to their respective position in the context of the change. The design and implementation of the new insurance policies will be the responsibility of the provincial insurance authorities under the conditions outlined by the national policy framework. They will not only have to be convinced by the new insurance model and its feasibility, but they will also have to defend any new design versus the outside stakeholders such as provincial policy-makers, provincial urban employers, and provincial urban employees, and toward the inside stakeholders who will be charged with the implementation.

In this initiative, the analysis started by listing all impacted stakeholders who hold influence over the proposed change in program. Each of the stakeholders was rated by their level of interest in the insurance policy and the level of influence (power) they have in relation to the new policies.

For the development of the decision tool, these medical insurance representatives were invited to participate in the workshop. In addition, academic policy influencers and public health experts participated in the presentations and discussions.

In the subsequent steps of piloting, validation, and full implantation (beyond the described workshop), a broader range of stakeholders has to be involved or managed to ensure that their interests are represented, and the decision principles are accepted by expanded stakeholders.

#### *2.1.2 Adaptation of global format to the decision problem*

As outlined in the introduction (see Sections 1.1 and 1.2), the national policies could benefit by improvements in the insurance coverage scheme for urban employees. To accommodate the comparison of alternative insurance policies a multicriteria decision tool was created to test how well each insurance option addressed national and provincial requirements.

For this, a set of requirements was identified through desk research and discussion with policy-makers and academic health policy experts before the workshop by the core team, which led to the base set of evaluation criteria.

#### *2.1.3 Proposed decision criteria*

Preliminary criteria were identified in the five domains presented in **Figure 2**: (1) funding and finance, (2) access, (3) policy priority (access), (4) equity, and (5) likelihood of change. Each of the domains contained two or three criteria as defined below with a total number of 11 criteria. Of the five domains, two ((2) access and (3) policy priority) were related to access. While more criteria had been considered, it was important to manage the number of criteria. The relevance and feasibility of the proposed criteria was further challenged in the workshop by the participating stakeholders.

Under the domain of "funding and finance," two criteria were proposed. The criterion "financial impact for insurance" should help to roughly estimate the financial risk of a potential future health policy on health-care expenditure to be covered by the insurance scheme in comparison to the current insurance expenditure. To estimate the impact of a future insurance model on overall extent of insurance expenditure would be available as funding for healthcare, a criterion "mobilization of funding for outpatient healthcare (HC)" was proposed.

To assess the impact of a future policy on overall "access" for patients to healthcare, three criteria were predefined. With the criterion "access to pharmaceuticals," the impact of a new insurance model on patient access to ambulatory pharmaceutical therapies as compared to the current system should be assessed. As most of the ambulatory care is made up by pharmaceuticals, which currently are to a large extent paid by the patients out-of-pocket, improvement in this area would be a major achievement. To compare the expected impact of the new model on overall coverage for healthcare in the outpatient setting, the second criterion "outpatient coverage" was suggested. The third criterion "economic burden for patients" was introduced to assess the impact of the potential future health policy on the patients' finances in comparison to the current system.

A separate domain named "access/policy priority" was put forward for discussion in the workshop to emphasize the need of meeting the policy priorities set by the national government policy. The first priority to be addressed is "timely interventions" (care when it is needed) to assess the impact of the future model on time to care (initiated by patient, family member, or insurance model). The intent here is to decrease the hurdles or improve the motivation for searching for healthcare early in the disease process instead of waiting until reaching more severe disease states before seeking care. The second criterion in this domain, "primary care utilization" is meant to help determine the impact of the future policy on the use of primary care in comparison to the current system. The policy objective emphasized

**Figure 2.**

*Five domains for assessing the impact of insurance policy options on the intended outcomes of the policy changes.*

#### *Value-Based Evaluation of Chinese Provincial Health Insurance Policy Schemes DOI: http://dx.doi.org/10.5772/intechopen.84373*

by this criterion is to shift care more toward the primary care level with much lower hurdles for patients as opposed to the current practice of accessing care mostly through specialized hospital services.

Two criteria were attributed to the domain of "equity." "Solidarity for outpatient HC" appeared an important criterion to compare the impact of the new policy system on the solidarity principle. Full solidarity would mean equal health-care cost to everybody independent from personal health status. Furthermore, the impact of the future insurance model on health-care equity as compared to the current situation should be captured under the criterion of "equity." This could potentially also imply higher contributions for people with higher income.

An important aspect to look at is the feasibility of introducing a new insurance policy model. This was to be addressed by the domain of "likelihood of change." The criterion "ease of transition," required an estimate of the smoothness of transitioning from the current to the future model. A specific criterion "acceptability to stakeholders" was proposed to account for the resistance of key stakeholders toward changing from the current to the potential future system. The final domains and their related criteria are presented in **Table 2**.
