The effects of global budget on cost control and readmission in rural China: a difference-in-difference analysis

County Hospital Responses to Funding Reforms in Zhejiang, China: An Interrupted Time-Series Analysis

This study aimed to assess the effects of a two-stage funding reform, involving DRGs-based (Diagnostic Related Groups) payments for inpatient care and capitation funding for outpatient care, respectively, on services volume and care expenditure of county hospitals in Zhejiang province, China. A quasi-experimental design was adopted, involving 6 hospitals from 2 counties in the intervention group and 12 hospitals from 5 counties in the control group. The DRGs-based payments for inpatient care and capitation funding for outpatient care were introduced in January 2018 and January 2019, respectively. Controlled interrupted time-series analyses were performed to determine the effects of the funding reforms using monthly data over the period from January 2017 to December 2019. The volume of inpatient care decreased after the introduction of the first-stage DRGs-based payments, which was accompanied by an increase in the volume of outpatient visits. The DRGs-based payments led to a reduction of on average 1390 Yuan total expenditure per episode of inpatient care and 1116 Yuan out-of-pocket (OOP) payment per episode of inpatient care. However, the average outpatient expenditure per visit increased. So did the corresponding OOP payment per outpatient visit. The introduction of the second-stage capitation funding for outpatient care reversed the increasing trend of outpatient care. The average expenditure and OOP payment per outpatient visit decreased. The funding reforms create a significant effect on service volumes and expenditures in county hospitals. A coordinated approach to both inpatient and outpatient funding mechanisms is needed to minimize cost-shifting between inpatient and outpatient care and to achieve the intended policy outcomes.

Current status of rehabilitation services and problems in Yunnan Province, Southwest China: a general doctors' questionnaire-based study

OBJECTIVES

Community-based hospitals in China lack physicians, especially rehabilitation physicians. Recently, several financial resources have been developed to prepare general doctors for community-based hospitals. These doctors seem to be the best choices for assuming the role of a rehabilitation physician. However, their willingness and in-depth information from their perspectives have not been previously investigated.

MATERIALS AND METHODS

We conducted a general investigation of rehabilitation resources in Yunnan, a province located in Southwest China with a population of more than 40 million. Our investigation covered the entire Yunnan Province from December 2020 to May 2022. The questionnaire was administered to 670 general doctors in 112 community hospitals randomly selected in Yunnan Province based on their willingness to assume the role of rehabilitation physicians and obstructive factors to process the rehabilitation services. The reliability and validity of the questionnaire were evaluated, and items regarding their general condition were analyzed.

RESULTS

Cronbach's alpha and Kaiser-Meyer-Olkin values were 0.748 and 0.729, respectively. The measure comprises four factors: common disease, demand for training to improve skills, subjective/objective factors, and proactivity to recommend rehabilitation therapy. More than 20% of general doctors were unwilling to take on the role of rehabilitation physicians, and their willingness was related to satisfaction with their current job, comprehension of community-based rehabilitation, and comprehension of government support (p < .05).

CONCLUSIONS

From the perspective of general doctors, the reimbursement rate for medical insurance, which burdens patients, is the greatest problem in the process of developing community-based hospital rehabilitation services. Offering professional training to increase their capacity and developing common practices to increase doctors' proactivity to recommend rehabilitation therapy may help increase the future support of medical insurance and increase general doctors' willingness to take on the role of a rehabilitation physician.

Association of Job Characteristics and Burnout of Healthcare Workers in Different Positions in Rural China: A Cross-Sectional Study

Objectives: Health workers in rural primary care systems are at increased risk of job burnout, but their associations with different positions have received scant attention in the literature. Thus, this study aims to measure job burnout in different positions in rural China and to identify factors associated with it. Methods: A cross-sectional survey was conducted with a total of 15,627 participants from six provinces in China. And job burnout was measured using the Chinese version of the Maslach Burnout Inventory-General Scale (MBI-GS). Multilevel regression analyses were used in examining factors potentially associated with job burnout in different positions. Results: Overall, more than half of providers suffered from moderate burnout. The degree of job burnout varied among different positions. Middle managers showed higher levels personal stress, while general staff showed the lowest interpersonal and self-evaluation dimensions of burnout. Job duty, job capability, job treatment, and career advancement are potential factors affecting these results. Conclusion: Interventions aimed at providing appropriate training and development opportunities, developing relevant career planning and management strategies, and implementing reasonable staffing and job design may be promising strategies for alleviating burnout in different positions and improving health system performance.

Does prospective payment influence quality of care? A systematic review of the literature

In the light of rising health expenditures, the cost-efficient provision of high-quality inpatient care is on the agenda of policy-makers worldwide. In the last decades, prospective payment systems (PPS) for inpatient care were used as an instrument to contain costs and increase transparency of provided services. It is well documented in the literature that prospective payment has an impact on structure and processes of inpatient care. However, less is known about its effect on key outcome indicators of quality of care. In this systematic review, we synthesize evidence from studies investigating how financial incentives induced by PPS affect indicators of outcome quality domains of care, i.e. health status and user evaluation outcomes. We conduct a review of evidence published in English, German, French, Portuguese and Spanish language produced since 1983 and synthesize results of the studies narratively by comparing direction of effects and statistical significance of different PPS interventions. We included 64 studies, where 10 are of high, 18 of moderate and 36 of low quality. The most commonly observed PPS intervention is the introduction of per-case payment with prospectively set reimbursement rates. Abstracting evidence on mortality, readmission, complications, discharge disposition and discharge destination, we find the evidence to be inconclusive. Thus, claims that PPS either cause great harm or significantly improve the quality of care are not supported by our findings. Further, the results suggest that reductions of length of stay and shifting treatment to post-acute care facilities may occur in the course of PPS implementations. Accordingly, decision-makers should avoid low capacity in this area.

Managing Urban Stroke Health Expenditures in China: Role of Payment Method and Hospital Level

BACKGROUND

Stroke is one of the leading public health issues in China and imposes a heavy financial burden on patients and the healthcare system. This study assess which payment method provides the lowest hospital costs for China's healthcare system and the lowest out-of-pocket (OOP) expense for insured patients.

METHODS

This is a 4-year cross-sectional study. From the China Health Insurance Research Association (CHIRA) database, a 5% random sample of urban health insurance claims was obtained. Descriptive analysis was conducted and a generalized linear model (GLM) with a gamma distribution and a log link was estimated.

RESULTS

For outpatients, capitation payment had the lowest hospital cost (RMB180.9/US$28.8) and lowest OOP expenses (RMB75.6/US$12.0) per patient visit in primary hospitals compared with fee-for-service (FFS) payments. The global budget (GB) displayed the lowest total hospital costs (RMB344.7/US$54.8) in secondary hospitals, and was 27.4% (95% CI=-0.32, -0.29) lower than FFS. FFS had the lowest OOP expenses (RMB123.4/US$19.6 vs. RMB151.8/US$24.1) in secondary and tertiary hospitals. For inpatients, FFS had the lowest total hospital costs (RMB5918.7/US$941.1) per visit and capitation payments had the lowest OOP expenses (RMB876.5/US$139.4, 40.1% lower than FFS, 95% CI=-0.58, -0.15) in primary hospitals. Capitation payment had both the lowest hospital costs (RMB7342.9/US$1167.5 vs. RMB17 711.7/US$2816.2) and the lowest OOP expenses (RMB1664.2/US$264.6 vs. RMB3276.3/US$520.9) for both secondary and tertiary hospitals.

CONCLUSION

For outpatients in primary hospitals and inpatients in secondary and tertiary hospitals, the capitation payment was the most money-saving payment method delivering both the lowest OOP expenses for patients and the lowest hospital total costs for hospitals. We recommend that health policymakers prioritize the implementation of the payment method with the lowest OOP expenses when the payment method does not deliver both the lowest hospital costs for the health system and lowest OOP expenses for patients.

Association between service scope of primary care facilities and prevalence of high-cost population: a retrospective study in rural Guizhou, China

BACKGROUND

High-cost (HC) patients, defined as the small percentage of the population that accounts for a high proportion of health care expenditures, are a concern worldwide. Previous studies have found that the occurrence of HC population is partially preventable by providing a greater scope of primary health care services. However, no study has examined the association between the service scope of primary care facilities and the prevalence of HC populations. Therefore, this study aimed to investigate the association between the service scope of primary care facilities (PCFs) and the prevalence of HC populations within the same communities.

METHODS

A multistage, stratified, clustered sampling method was used to identify the service scope of PCFs as of 2017 in rural Guizhou, China. The claims data of 299,633 patients were obtained from the local information system of the New Rural Cooperation Medical Scheme. Patients were sorted by per capita inpatient medical expenditures in descending order, and the top 1%, top 5% and top 10% of patients who had incurred the highest costs were defined as the HC population. Logistic regression models were used to assess the association between the service scope of PCFs and the prevalence of the HC population.

RESULTS

Compared with those in the 95% of the sample deemed as the general population, those in the top 5% of the sample deemed as the HC population were more likely to be over the age of 30 (P <  0.001), to be female (P = 0.014) and to be referred to high-level hospitals (P <  0.001). After controlling for other covariates, patients who lived in the communities serviced by the PCFs with the smallest service scope were more likely to be in the top 1%, top 5% and top 10% of the HC population.

CONCLUSION

A greater PCF service scope was associated with a reduction in the prevalence of the HC population, which would mean that providing a broader PCF service scope could reduce some preventable costs, thus reducing the prevalence of the HC population. Future policy efforts should focus on expanding the service scope of primary care providers to achieve better patient outcomes.

Healthcare Professionals’ Views of the Integrated County Healthcare Consortium in Zhejiang, China

Introduction:

The integrated county healthcare consortium (ICHC) is becoming an important measure to improve the capacity of primary-level medical services and to achieve grading diagnosis and treatment system in China. However, it is not clear whether health professionals are satisfied with this reform and what are the problems with it. This study aimed to understand the satisfaction of healthcare professionals to the ICHC in Zhejiang Province, China, and analyze the problems and improvement measures of the ICHC.

Methods:

A cross-sectional study was carried out in the 11 pilot counties (cities and districts) implementing the construction of the ICHC in Zhejiang in November 2019. Healthcare professionals from the leading county-level hospital, three township health centers (THCs) or community health centers (CHCs) in each ICHC were invited to participate in this survey.

Results:

A total of 3531 healthcare professionals were included, 85.92% of the participants agreed that the integration of the Centers for Disease Control and Prevention (CDC) and other professional public health institutions into the construction of ICHC could actively promote basic public health work. The most severe problem was the lack of financial guarantee fund input (severity score: 2.92 ± 1.76). The most crucial measure to promote the construction of the ICHC was to increase government financial input and improve the security mechanism (importance score: 4.81 ± 0.47). The satisfaction of the healthcare professionals to the ICHC was 89.41%. The satisfaction of healthcare professionals from county-level hospitals was 2.37 (95% CI: 1.760–3.238) times higher than that of healthcare professionals from the township health centers (THCs) or community health centers (CHCs). The satisfaction of health professionals with a college degree or below was 3.215 (95% CI: 1.413–6.786) times higher than that of health professionals with a master’s degree or above.

Conclusions:

Zhejiang Province has taken adequate measures to promote the construction of the ICHC. However, there are still some problems. Appropriate and effective policies should be implemented to enhance policy coordination and promote competition among ICHCs, as well as to strengthen medical service quality management and improve performance appraisal scheme.

Cost of postoperative complications of lower anterior resection for rectal cancer: a nationwide registry study of 15,187 patients

PURPOSE

To assess the increase in hospital costs associated with postoperative complications after lower anterior resection (LAR) for rectal cancer.

METHODS

The subjects of this retrospective analysis were patients who underwent elective LAR surgery between April, 2015 and March, 2017, collected from a Japanese nationwide gastroenterological surgery registry linked to hospital-based claims data. We evaluated total and category-specific hospitalization costs based on the level of postoperative complications categorized using the Clavien-Dindo (CD) classification. We assessed the relative increase in hospital costs, adjusting for preoperative factors and hospital case volume.

RESULTS

We identified 15,187 patients (mean age 66.8) treated at 884 hospitals. Overall, 71.8% had no recorded complications, whereas 7.6%, 10.8%, 9.0%, 0.6%, and 0.2% had postoperative complications of CD grades I-V, respectively. The median (25th-75th percentiles) hospital costs were $17.3 K (16.1-19.3) for the no-complications group, and $19.1 K (17.3-22.2), $21.0 K (18.5-25.0), $27.4 K (22.4-33.9), $41.8 K (291-618), and $22.7 K (183-421) for the CD grades I-V complication groups, respectively. The multivariable model identified that complications of CD grades I-V were associated with 11%, 21%, 61%, 142%, and 70% increases in in-hospital costs compared with no complications.

CONCLUSIONS

Postoperative complications and their severity are strongly associated with increased hospital costs and health-care resource utilization. Implementing strategies to prevent postoperative complications will improve patients' clinical outcomes and reduce hospital care costs substantially.

Associations of Chinese diagnosis-related group systems with inpatient expenditures for older people with hip fracture

Background

Hip fracture is frequent in older people and represents a major public health issue worldwide. The increasing incidence of hip fracture and the associated hospitalization costs place a significant economic burden on older patients and their families. On January 1, 2018, the Chinese diagnosis-related group (C-DRG) payment system, which aims to reduce financial barriers, was implemented in Sanming City, southern China. This study aimed to evaluate the associations of C-DRG system with inpatient expenditures for older people with hip fracture.

Methods

An uncontrolled before-and-after study employed data of all the patients with hip fracture aged 60 years or older from all the public hospitals enrolled in the Sanming Basic Health Insurance Scheme from January 1, 2016 to December 31, 2018. The ‘pre C-DRG sample’ included patients from January 1, 2016 to December 31, 2017. The ‘post C-DRG sample’ included patients from January 1, 2018 to December 31, 2018. A propensity score matching analysis was used to adjust the difference in baseline characteristic parameters between the pre and post samples. Data were analyzed using generalized linear models adjusted for the demographic, clinical, and institutional factors. Robust tests were performed by accounting for time trend, the fixed effects of the year and hospitals, and clustering effect within hospitals.

Results

After propensity score matching, we obtained two homogeneous groups of 1123 patients each, and the characteristic variables of the two matched groups were similar. We found that C-DRG reform was associated with a 19.51% decrease in out-of-pocket (OOP) payments (p < 0.001) and a 99.93% decrease in OOP payments as a share of total inpatient expenditure (p < 0.001); whereas total inpatient expenditure was not significantly associated with the C-DRG reform. All the sensitivity analyses did not change the results significantly.

Conclusion

The implementation of C-DRG payment system reduced both the absolute amount of OOP payments and OOP payments as a share of total inpatient expenditure for older patients with hip fracture, without affecting total inpatient expenditure. These results may provide significant insights for policymakers in reducing the financial burden on older patients with hip fracture in other countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02865-3.

Trends in disparities in healthcare utilisation between and within health insurances in China between 2008 and 2018: a repeated cross-sectional study

Background

Fragmentation in China’s social health insurance schemes and income gap have been recognised as important factors for the inequitable use of healthcare. This study assessed trends in disparities in healthcare utilisation between and within health insurances in China between 2008 and 2018.

Methods

We used data from the 2008, 2013, and 2018 China National Health Services Survey. Outpatient visit, inpatient admission and foregone inpatient care were chosen to measure healthcare utilisation and underutilisation by health insurances. Absolute differences and rate ratios were generated to examine disparities between and within health insurances, and changes in disparities were analysed descriptively. Pearson χ2 tests were used to test for statistical significance of differences.

Results

The outpatient visit rate for respondents covered by the urban resident-based basic medical insurance scheme (URBMI) more than doubled between 2008 and 2018, increasing from 10.5% (9.7-11.2) to 23.5% (23.1-23.8). Inpatient admission rates for respondents covered by URBMI and the new rural cooperative medical scheme (NRCMS) more than doubled between 2008 and 2018, increasing by 7.2 (p < 0.0001) and 7.4 (p < 0.0001) percentage points, respectively. Gaps in outpatient visits and inpatient admissions narrowed across the urban employee-based basic medical insurance scheme (UEBMI), URBMI, and NRCMS through 2008 to 2018, and by 2018 the gaps were small. The rate ratios of foregone inpatient care between NRCMS and UEBMI fell from 0.9 (p > 0.1) in 2008 to 0.8 (p < 0.0001) in 2018. Faster increases in outpatient and inpatient utilisation and greater reductions in foregone inpatient care were observed in poor groups than in wealthy groups within URBMI and NRCMS. However, the poor groups within UEBMI, URBMI, and NRCMS were always more likely to forego inpatient care in comparison with their wealthy counterparts.

Conclusions

Remarkable increases in healthcare utilisation of URBMI and NRCMS, especially among the poorest groups, were accompanied by improvements in inequality in healthcare utilisation across UEBMI, URBMI, and NRCMS, and in income-based inequality in healthcare utilisation within URBMI and NRCMS. However, the poor groups were always more likely to forego admission to hospital, as recommended by doctors. We suggest further focus on the foregoing admission care of the poor groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01633-4.

Impact of global budget combined with pay-for-performance on the quality of care in county hospitals: a difference-in-differences study design with a propaensity-score-matched control group using data from Guizhou province, China

BACKGROUND

Provider payment system has a profound impact on health system performance. In 2016, a number of counties in rural Guizhou, China, implemented global budget (GB) for county hospitals with quality control measures. The aim of this study is to measure the impact of GB combined with pay-for-performance on the quality of care of inpatients in county-level hospitals in China.

METHODS

Inpatient cases of four diseases, including pneumonia, chronic asthma, acute myocardial infarction and stroke, from 16 county-level hospitals in Guizhou province that implemented GB in 2016 were selected as the intervention group, and similar inpatient cases from 10 county-level hospitals that still implemented fee-for-services were used as the control group. Propensity matching score (PSM) was used for data matching to control for age factors, and difference-in-differences (DID) models were constructed using the matched samples to perform regression analysis on quality of care for the four diseases.

RESULTS

After the implementation of GB, rate of sputum culture in patients with pneumonia, rate of aspirin at discharge, rate of discharge with β-blocker and rate of smoking cessation advice in patients with acute myocardial infarction increased. Rate of oxygenation index assessment in patient with chronic asthma decreased 20.3%. There are no significant changes in other indicators of process quality.

CONCLUSIONS

The inclusion of pay-for-performance in the global budget payment system will help to reduce the quality risks associated with the reform of the payment system and improve the quality of care. Future reform should also consider the inclusion of the pay-for-performance mechanism.

Association between service scope of primary care facilities and patient outcomes: a retrospective study in rural Guizhou, China

BACKGROUND

Extending service scope of primary care facilities (PCFs) has been widely concerned in China. However, no current data about association between service scope of PCFs with patient outcomes are available. This study aims to investigate association between service scope of PCFs and patient outcomes.

METHODS

A multistage, stratified clustered sampling method was used to collect information about service scope of PCFs from rural Guizhou, China. Claim data of 299,633 inpatient cases covered by 64 PCFs were derived from local information system of New Rural Cooperation Medical Scheme. Service scope of PCFs was collected with self-administrated questionnaires. Primary outcomes were (1) level of inpatient institutions, (2) length of stay, (3) per capita total health cost, (4) per capita out-of-pocket cost, (5) reimbursement ratio, (6) 30-day readmission. A total of 64 PCFs were categorized into five groups per facility-level service scope scores. Generalized linear regression models, logistic regression model, and ordinal regression model were conducted to identify association between service scope of PCFs and patient outcomes.

RESULTS

On average, the median service scope score of PCFs was 20, with wide variation across PCFs. After controlling for demographic and clinical characteristics, patients living in communities with PCFs of greatest service scope (Quintile V vs. I) tended to have smaller rates of admission by county-level hospitals (-6.2 % [-6.5 %, -5.9 %], city-level hospitals (-1.9 % [-2.0 %, -1.8 %]), and provincial hospitals (-2.1 % [-2.2 %, -2.0 %]), smaller rate of 30-day readmission (-0.5 % [-0.7 %, -0.2 %]), less total health cost (-201.8 [-257.9, -145.8]) and out-of-pocket cost (-210.2 [-237.2, -183.2]), and greater reimbursement ratio (2.3 % [1.9 %, 2.8 %]) than their counterparts from communities with PCFs of least service scope.

CONCLUSIONS

Service scope of PCFs varied a lot in rural Guizhou, China. Greater service scope was associated with a reduction in secondary and tertiary hospital admission, reduced total cost and out-of-pocket cost, and 30-day readmission and increased reimbursement ratio. These results raised concerns about access to care for patients discharged from hospitals, which suggests potential opportunities for cost savings and improvement of quality of care. However, further evidence is warranted to investigate whether extending service scope of PCFs is cost-effective and sustainable.

The impacts of multiple healthcare reforms on catastrophic health spending for poor households in China

Many developing nations witness systemic healthcare reforms where the expansion of health financing mechanisms and reforms of the service delivery system are being rolled out simultaneously. Yet, poorly coordinated reforms and negative interactions between multiple policies may offset synergies and undermine intended reform outcomes. This study examines how multiple healthcare reforms affect catastrophic health spending of low-income households in China. We characterize two broad types of health policy reforms: expansion- and constraint-oriented policies in the domains of financing, services delivery, and pharmaceuticals introduced since 2009. We adopt an innovative methodology by matching macro-level policy text data collected using big data techniques with micro-level health expenditure data drawn from a nationally representative survey. Employing a linear probability analysis and controlling for household and year fixed effects, we find that more expansion-oriented policies, especially in the domain of financing, increased the incidence of catastrophic health spending of poor households. In contrast, constraint-oriented policies, particularly in the domain of health services delivery, lead to a lower incidence of catastrophic health spending. This type of policy is thus better able to mitigate the positive relationship between expansion-oriented policies and the incidence of catastrophic health spending. This study suggests that while the expansion of benefit package in the domain of financing is indeed a decisive move towards universal health coverage, the essential financial protection of the poor cannot be achieved without strong and coordinated supply-side reforms towards cost containment. Health policy makers must take a strategic view of the complex interactions of multiple policy interventions in both financing and service delivery domains.

Economic Implications of Chinese Diagnosis-Related Group-Based Payment Systems for Critically Ill Patients in ICUs

OBJECTIVES

To evaluate the economic implications of payments based on Chinese diagnosis-related groups for critically ill patients in ICUs in terms of total hospital expenditure, out-of-pocket payments, and length of stay.

DESIGN

A pre-post comparison of patient cohorts admitted to ICUs 1 year before and 1 year after Chinese diagnosis-related group reform was undertaken. Demographic characteristics, clinical data, and medical expenditures were collated from a health insurance database.

SETTING

Twenty-two public hospitals in Sanming, Southern China.

PATIENTS

All patients admitted to ICUs from January 1, 2017, to December 31, 2018.

INTERVENTION

The implementation of Chinese diagnosis-related group-based payments on January 1, 2018.

MEASUREMENTS AND MAIN RESULTS

Economic variables (total expenditures, out-of-pocket payments, and length of stay) were calculated for each patient from the day of hospital admission to the day of hospital discharge. Adjusted mean out-of-pocket payment estimates were 29.46% (p < 0.001) lower following reform. Adjusted mean out-of-pocket payments fell by 41.32% for patients in neonatal ICU, whereas there were no significant decreases in out-of-pocket payments for patients in PICU and adult ICU. Furthermore, adjusted mean out-of-pocket payments decreased by 55.74% in secondary hospitals, but there was no significant change in tertiary hospitals after Chinese diagnosis-related group reform. No significant changes were found in total expenditures and length of stay.

CONCLUSIONS

Chinese diagnosis-related group policy provided an opportunity for critically ill patients in ICUs to achieve at least short-term financial benefits in reducing out-of-pocket payments, without affecting the total expenditures and length of stay. Chinese diagnosis-related group-based payment significantly relieved financial burdens for patients with lower illness severities, such as patients in neonatal ICU. The results of this study can offer significant insights for policymakers in reducing the financial burden on critically ill patients, both in China and in other countries with similar systems.

Effectiveness of hospital payment reforms in low- and middle-income countries: a systematic review

Payment mechanisms have attracted substantial research interest because of their consequent effect on care outcomes, including treatment costs, admission and readmission rates and patient satisfaction. Those mechanisms create the incentive environment within which health workers operate and can influence provider behaviour in ways that can facilitate achievement of national health policy goals. This systematic review aims to understand the effects of changes in hospital payment mechanisms introduced in low- and middle-income countries (LMICs) on hospital- and patient-level outcomes. A standardised search of seven databases and a manual search of the grey literature and reference lists of existing reviews were performed to identify relevant articles published between January 2000 and July 2019. We included original studies focused on hospital payment reforms and their effect on hospital and patient outcomes in LMICs. Narrative descriptions or studies focusing only on provider payments or primary care settings were excluded. The authors used the Risk of Bias in Non-Randomized Studies of Interventions tool to assess the risk of bias and quality. Results were synthesized in a narrative description due to methodological heterogeneity. A total of 24 articles from seven middle-income countries were included, the majority of which are from Asia. In most cases, hospital payment reforms included shifts from passive (fee-for-service) to active payment models-the most common being diagnosis-related group payments, capitation and global budget. In general, hospital payment reforms were associated with decreases in hospital expenditures, out-of-pocket payments, length of hospital stay and readmission rates. The majority of the articles scored low on quality due to weak study design. A shift from passive to active hospital payment methods in LMICs has been associated with lower hospital and patient costs as well as increased efficiency without any apparent compromise on quality. However, there is an important need for high-quality studies in this area.

The impact of global budget on expenditure, service volume, and quality of care among patients with pneumonia in a secondary hospital in China: a retrospective study

BACKGROUND

The Chinese government has begun to dampen the growth of health expenditure by implementing Global Budgets (GB). Concerns were raised about whether reductions in expenditure would lead to a deterioration of quality of care. This paper aims to evaluate the impact of GB on health expenditure, service volume and quality of care among Chinese pneumonia patients.

METHODS

A secondary hospital that replaced Fee-For-Service (FFS) with GB in China in 2016 was sampled. We used daily expenditure to assess health expenditure; monthly admission, length of stay (LOS), number of drugs per record and record containing antibiotics to evaluate service volume; record with multiple antibiotics and readmission to assess quality of care. Descriptive analyses were adopted to evaluate changes after the reform, logistic regression and multivariable linear regressions were used to analyze changes associated with the reform.

RESULTS

In 2015 and 2016, 3400 admissions from 3173 inpatients and 2342 admissions from 2246 inpatients were admitted, respectively. According to regression analyses, daily expenditure, LOS, readmission, and records with multiple antibiotic usages significantly declined after the reform. However, no significant relation was observed between GB and the number of drugs per record or record containing antibiotics.

CONCLUSIONS

When compared with FFS, GB can curtail health expenditure and improve quality of care. As far as service volume was concerned, LOS and monthly admission declined, while number of drugs per record and record containing antibiotics were not affected.

The impact of global budget on expenditure, service volume, and quality of care among patients with pneumonia in a secondary hospital in China: a retrospective study

BACKGROUND

The Chinese government has begun to dampen the growth of health expenditure by implementing Global Budgets (GB). Concerns were raised about whether reductions in expenditure would lead to a deterioration of quality of care. This paper aims to evaluate the impact of GB on health expenditure, service volume and quality of care among Chinese pneumonia patients.

METHODS

A secondary hospital that replaced Fee-For-Service (FFS) with GB in China in 2016 was sampled. We used daily expenditure to assess health expenditure; monthly admission, length of stay (LOS), number of drugs per record and record containing antibiotics to evaluate service volume; record with multiple antibiotics and readmission to assess quality of care. Descriptive analyses were adopted to evaluate changes after the reform, logistic regression and multivariable linear regressions were used to analyze changes associated with the reform.

RESULTS

In 2015 and 2016, 3400 admissions from 3173 inpatients and 2342 admissions from 2246 inpatients were admitted, respectively. According to regression analyses, daily expenditure, LOS, readmission, and records with multiple antibiotic usages significantly declined after the reform. However, no significant relation was observed between GB and the number of drugs per record or record containing antibiotics.

CONCLUSIONS

When compared with FFS, GB can curtail health expenditure and improve quality of care. As far as service volume was concerned, LOS and monthly admission declined, while number of drugs per record and record containing antibiotics were not affected.

Prioritizing the perceived equity of the residents to construct an equitable health care system: evidence from a national cross-sectional study in China

BACKGROUND

Building an equitable health care system involves both the promotion of social justice in health and people's subjective perception of the promotion. This study aimed to analyze the overall status and associated factors of the perceived equity of the Chinese health care system, and then to offer policy recommendations for health care reform.

METHODS

Information on the perceived equity score (scale 0 to 10) of 10,243 valid cases in total were derived from the data set of Chinese Social Survey 2015. Univariate analysis methods were applied to present respondents' overall perceived equity of the Chinese health care system. Multivariate linear regression method was used to explore the associated factors of the perceived equity and examine their independent effect.

RESULTS

The respondents gave positive but relatively low marks (6.7 ± 2.6, 95% CI: = 6.64~6.74) of the equity of the Chinese health care system. Younger respondents reported a higher score of perceived equity than their elder counterparts (β = - 0.132, 95% CI: - 0.203~ - 0.062, P < 0.001). Respondents with lower education level were significantly more likely to consider the Chinese health care system equitable (β = - 0.104, 95% CI: - 0.153~ - 0.056, P < 0.001). Respondents satisfied with the Social Health Insurance reimbursement ratio tended to score the system higher in the survey (β = 0.044, 95% CI: 0.024~0.063, P < 0.001). Respondents residing in eastern China and rural areas were significantly more likely to consider the Chinese health care system equitable (β = - 0.268, 95% CI: - 0.338~ - 0.199, P < 0.001). Meanwhile, rural respondents reported higher scores of the perceived equity than urban respondents did (β = 0.348, 95% CI: 0.237~0.458, P < 0.001). Respondents from regions with adequate GPs scored the system higher in this survey (β = 0.087, 95% CI: 0.008~0.165, P < 0.001). The present study found no influence of gender, economic status, Social Health Insurance coverage, or satisfaction with the latest treatment on perceived equity.

CONCLUSIONS

Eliminating the sense of inequity among a range of populations should be prioritized in health care reform. A national-level investigation system to rate residents' perceived equity was necessary for global health care reform.

Job Burnout Among Primary Healthcare Workers in Rural China: A Multilevel Analysis

The health workers in rural primary care systems are at the increasing risk of job burnout. To explore the prevalence and associated factors of the job burnout among the primary healthcare worker in rural China, a cross-sectional survey was conducted among 15,627 participants in 459 township hospitals from six provinces. A combination of stratified multi-stage sampling and cluster sampling method, and a self-administrated questionnaire with the Chinese version of the Maslach Burnout Inventory-General Scale (MBI-GS) were used in the investigation. Multilevel regression analyses were used to examine the potential associated factors on both individual and organisational levels. 47.6% of respondents were experiencing moderate burnout, and 3.3% were in severe burnout. Professionals working for over 40 h per week, at young age, with a college degree, and with professional titles at medium or high rank reported a higher degree of job burnout. At the institutional level, the high ratio of performance-based salary was associated with a higher level of depersonalization. Burnout has become prevalent among the primary healthcare workers in rural China, and multiple strategies are needed to reduce the work stress and some high-risk groups’ vulnerability to job burnout.

Impacts of government supervision on hospitalization costs for inpatients with COPD: An interrupted time series study

To address the remaining medical misconducts after the zero-makeup drug policy (ZMDP), e.g., over-examinations, China has given the priority to government supervision on medical institutions. This study evaluated the effect of government supervision on medical costs among inpatients with chronic obstructive pulmonary disease (COPD) in Sichuan province, the first province in China where the medical supervision was conducted.A linear interrupted time series (ITS) model was employed to analyze data about 72,113 inpatients from 32 hospitals. Monthly average medicine costs, diagnostic costs, and medical services costs, nursing costs from January 2015 to June 2018 were analyzed, respectively.The average hospitalization costs fell with a monthly trend of 42.90Yuan before the implementation of supervision (P < .001), and the declining trend remained with the more dramatic rate (-158.70Yuan, P < .001) after the government audit carried out. For western medicine costs, the monthly decreasing trend remained after the implementation of supervision (-66.44Yuan, P < .001); meanwhile, the monthly upward trend was changed into a downtrend trend for traditional Chinese medicine costs (-11.80Yuan, P = .009). Additionally, the increasing monthly trend in average diagnostics costs disappeared after government supervision, and was inversed to an insignificant decreasing trend at the rate of 26.18Yuan per month. Moreover, the previous upward trends were changed into downward trends for both medical service costs and nursing costs (P = .056, -44.71Yuan; P = .007, -11.17Yuan, respectively) after the supervision carried out.Our findings reveal that government supervision in Sichuan province was applicable to curb the growth of medical costs for inpatients with COPD, which may reflect its role in restraining physicians' compensating behaviors after the ZMDP. The government medical supervision holds promise to dismiss medical misconducts in Sichuan province, the experience of which may offer implications for other regions of China as well as other low- and middle-income countries.

10 years of health-care reform in China: progress and gaps in Universal Health Coverage

In 2009, China launched a major health-care reform and pledged to provide all citizens with equal access to basic health care with reasonable quality and financial risk protection. The government has since quadrupled its funding for health. The reform's first phase (2009-11) emphasised expanding social health insurance coverage for all and strengthening infrastructure. The second phase (2012 onwards) prioritised reforming its health-care delivery system through: (1) systemic reform of public hospitals by removing mark-up for drug sales, adjusting fee schedules, and reforming provider payment and governance structures; and (2) overhaul of its hospital-centric and treatment-based delivery system. In the past 10 years, China has made substantial progress in improving equal access to care and enhancing financial protection, especially for people of a lower socioeconomic status. However, gaps remain in quality of care, control of non-communicable diseases (NCDs), efficiency in delivery, control of health expenditures, and public satisfaction. To meet the needs of China's ageing population that is facing an increased NCD burden, we recommend leveraging strategic purchasing, information technology, and local pilots to build a primary health-care (PHC)-based integrated delivery system by aligning the incentives and governance of hospitals and PHC systems, improving the quality of PHC providers, and educating the public on the value of prevention and health maintenance.

Research in Integrated Health Care and Publication Trends from the Perspective of Global Informatics

BACKGROUND

Integrated care has gained popularity in recent decades and is advocated by the World Health Organization. This study examined the global progress, current foci, and the future of integrated care.

METHODS

We conducted a scientometric analysis of data exported from the Web of Science database. Publication number and citations, co-authorship between countries and institutions and cluster analysis were calculated and clustered using Histcite12.03.07 and VOS viewer1.6.4.

RESULTS

We retrieved 6127 articles from 1997 to 2016. We found the following. (1) The United States, United Kingdom, and Canada had the most publications, citations, and productive institutions. (2) The top 10 cited papers and journals were crucial for knowledge distribution. (3) The 50 author keywords were clustered into 6 groups: digital medicine and e-health, community health and chronic disease management, primary health care and mental health, healthcare system for infectious diseases, healthcare reform and qualitative research, and social care and health policy services.

CONCLUSIONS

This paper confirmed that integrated care is undergoing rapid development: more categories are involved and collaborative networks are being established. Various research foci have formed, such as economic incentive mechanisms for integration, e-health data mining, and quantitative studies. There is an urgent need to develop performance measurements for policies and models.

Cesarean delivery rates, costs and readmission of childbirth in the new cooperative medical scheme after implementation of an episode-based bundled payment (EBP) policy

BACKGROUND

In the past decade, the rate of cesarean delivery increased dramatically in rural China under the fee-for-service (FFS) system. In September 2011, the New Cooperative Medical Scheme (NCMS) agency in Yong'an county in Fujian province of China adopted a policy of reforming payment for childbirth by transforming the FFS payment into episode-based bundled payment (EBP), which made the cesarean deliveries less profitable. Thus, this study was conducted to determine the effect of EBP policy on reducing cesarean use and controlling delivery costs for rural patients in the NCMS.

METHODS

Data from the inpatient information database of the NCMS agency from January 2010 to March 2013 was collected, in which Yong'an county was employed as a reform county and 2 other counties as controls. We investigated the effects of EBP on cesarean delivery rate, costs of childbirth and readmission for rural patients in the NCMS using a natural experiment design and difference in differences (DID) analysis method.

RESULTS

The EBP reform was associated with 33.97% (p<0.01) decrease in the probability of cesarean delivery. The EBP reform, on average, reduced the total spending per admission, government reimbursement expenses per admission, and out-of-pocket (OOP) payments per admission by ¥ 649.61, ¥ 575.01, and ¥ 74.59, respectively. The OOP payments had a net decrease of 14.24% (p<0.01); whereas the OOP payments as a share of total spending had a net increase of 8.72% (p<0.01). There was no evidence of increase in readmission rates.

CONCLUSIONS

These results indicate that the EBP policy has achieved at least a short-term success in lowering the increase of cesarean delivery rate and costs of childbirth. Considering both the cesarean rate and the OOP payments as a share of total spending after the reform were still high, China still has a long way to go to achieve the ideal level of cesarean rate and improve the benefits of deliveries for rural population.

Effects of expanding outpatient benefit package on the rationality of medical service utilisation of patients with hypertension: a quasi-experimental trial in rural China

OBJECTIVE

To estimate the effects of expanding outpatient benefit package on ameliorating the issues of over-reliance on inpatient services and seeking higher level medical services in rural China.

DESIGN

A quasi-experimental design.

SETTING AND PARTICIPANTS

1673 pairs of patients with hypertension were selected after using propensity score matching from Dangyang county (intervention group) and Zhijiang (control group) county, Hubei province.

INTERVENTION

The outpatient annual reimbursement capping line was expanding from ¥300 to ¥600, daily capping line from ¥10/12 to ¥150. The compensation scope and institution were also enlarged from January 2016.

OUTCOME MEASURES

The difference-in-differences model was used to estimate the effects on medical service type selection. χ2 test was used to verify the effects on medical institution selection. We also examined the effects on health outcomes through the length of stay and blood pressure changes.

RESULTS

The intervention was associated with 3.225 times (p=0.001) increase in total visits. Outpatient visits increased by 3.3 times (p=0.008), whereas the township level presented a maximum increase of 1.932 times (p=0.001). The inpatient visits declined by 0.075 times (p=0.000), whereas county-level inpatient visits reached a maximum decrease of 0.042 times (p=0.033). Meanwhile, the township level exhibited a maximum proportion growth of 14.8% in outpatient (p=0.000) and 13.3% in inpatient visits (p=0.048). Outpatient visits at the county level dropped at 13.2% (p=0.000), whereas inpatients visits declined by 7.7% (p=0.040). The length of stay and blood pressure were decreased, respectively, compared with the control group.

CONCLUSION

Improving outpatient benefit package alleviated patient dependence on inpatient services through motivating outpatient service utilisation, consolidated the primacy of township health centres and guided patients to return to primary medical institutions. The health insurance reform should 'take the long view' in the future, and more attention should be paid to the rationality of medical service utilisation.

Is There a Difference in the Utilisation of Inpatient Services Between Two Typical Payment Methods of Health Insurance? Evidence from the New Rural Cooperative Medical Scheme in China

This study aimed to evaluate the effects of the differences between two typical payment methods for the new rural cooperative medical scheme (NRCMS) in China on the utilisation of inpatient services. Interrupted time-series analysis (ITSA) and propensity score matching (PSM) were used to measure the difference between two typical payment methods for the NRCMS with regard to the utilisation of inpatient services. After the reform was formally implemented, the level and slope difference after reform compared with pre-intervention (distribution of inpatients in county hospitals (DIC), distribution of inpatients in township hospitals (DIT) and the actual compensation ratio of inpatients (ARCI)) were not statistically significant. Kernel matching obtained better results in reducing the mean and median of the absolute standardised bias of covariates of appropriateness of admission (AA), appropriateness of disease (AD). The difference in AA and AD of the matched inpatients between two groups was −0.03 (p-value = 0.042, 95% CI: −0.08 to 0.02) and 0.21 (p-value < 0.001, 95% CI: −0.17 to 0.25), respectively. The differences in the utilisation of inpatient services may arise owing to the system designs of different payment methods for NRCMS in China. The causes of these differences can be used to guide inpatients to better use medical services, through the transformation and integration of payment systems.

Impact of the Global Budget Payment System on Expenditure of Cardiovascular Diseases: An Interrupted Time Series Analysis in Shanghai, China

Since few studies evaluated the impact of the global budget payment system (GBPS) over time, and by expenditure type, this paper aims to evaluate the impact of the GBPS on expenditure of inpatients, and explores how hospitals curb the expenditure in patients with cardiovascular diseases (CVDs) in Shanghai. We built a time series model with the monthly expenditure of CVDs from 2009 to 2012. We evaluated the instant impact and trends impact of the GBPS and analyzed results based on medical expenditure types (e.g., drug, examination, cure, unclassified items), discharge number, and expenditure per capita. We found GBPS instantly dropped the medical expenditure by Chinese Yuan (CNY) 55.71 million (p < 0.001), and decreased the monthly increasing trend by CNY 4.23 million (p = 0.011). The discharge number had 10.4% instant reduction and 225.55 monthly decrease (p = 0.021) while the expenditure per capita experienced fewer changes. Moreover, the expenditure of drug and cure had an instant reduction of CNY 28.31 million and 16.28 million (p < 0.001). In conclusion, we considered the GBPS is an effective solution to control the expenditure of CVDs by decreasing the discharge number, and a focus on the drug and cure expenditures lead to greater spend reduction than other types of expenditures.

Medical Service Quality, Efficiency and Cost Control Effectiveness of Upgraded Case Payment in Rural China: A Retrospective Study

Background: As the principal means of reimbursing medical institutions, the effects of case payment still need to be evaluated due to special environments and short exploration periods, especially in rural China. Methods: Xi County was chosen as the intervention group, with 36,104, 48,316, and 59,087 inpatients from the years 2011 to 2013, respectively. Huaibin County acted as the control group, with 33,073, 48,122, and 51,325 inpatients, respectively, from the same period. The inpatients' information was collected from local insurance agencies. After controlling for age, gender, institution level, season fixed effects, disease severity, and compensation type, the generalised additive models (GAMs) and difference-in-differences approach (DID) were used to measure the changing trends and policy net effects from two levels (the whole county level and each institution level) and three dimensions (cost, quality and efficiency). Results: At the whole-county level, the cost-related indicators of the intervention group showed downward trends compared to the control group. Total spending, reimbursement fee and out-of-pocket expense declined by ¥346.59 (p < 0.001), ¥105.39 (p < 0.001) and ¥241.2 (p < 0.001), respectively (the symbol ¥ represents Chinese yuan). Actual compensation ratio, length of stay, and readmission rates exhibited ascending trends, with increases of 7% (p < 0.001), 2.18 days (p < 0.001), and 1.5% (p < 0.001), respectively. The intervention group at county level hospital had greater length of stay reduction (¥792.97 p < 0.001) and readmission rate growth (3.3% p < 0.001) and lower reimbursement fee reduction (¥150.16 p < 0.001) and length of stay growth (1.24 days p < 0.001) than those at the township level. Conclusions: Upgraded case payment is more reasonable and suitable for rural areas than simple quota payment or cap payment. It has successfully curbed the growth of medical expenses, improved the efficiency of medical insurance fund utilisation, and alleviated patients' economic burden of disease. However, no positive effects on service quality and efficiency were observed. The increase in readmission rate and potential hidden dangers for primary health care institutions should be given attention.

Effectiveness evaluation of quota payment for specific diseases under global budget: a typical provider payment system reform in rural China

BACKGROUND

Quota payment for specific diseases under global budget is one of the most typical modes of provider payment system reform in rural China. This study aimed to assess this reform mode from aspects of the total fee, structure of the fee and enrollees' benefits.

METHODS

A total of 127,491 inpatient records from 2014 to 2016 were extracted from the New Rural Cooperative Medical Scheme (NRCMS) database in Weiyuan County, Gansu Province. Total fee, actual compensation ratio, out-of-pocket ratio, constituent ratio of the treatment fee, constituent ratio of the inspection and laboratory fee, and length of stay were selected as dependent variables. Both generalized additive models (GAMs) and multiple linear regression models were used to measure the change in dependent variables along with year.

RESULTS

Prior to the adjustment of the compensation type, out-of-pocket ratio and length of stay decreased, while total fee, actual compensation ratio, constituent ratio of the treatment fee, and constituent ratio of the inspection and laboratory fee increased. After the compensation type was adjusted, the mean of the total fee increased rapidly in 2015 and remained stable in 2016. The mean length of stay increased in 2015 but decreased in 2016. A comparison of inpatients suffering from diseases covered by quota payments and those suffering from general diseases revealed that total fee, out-of-pocket ratio, and length of stay decreased and actual compensation ratio increased for the former, whereas the opposite was true for the latter. Constituent ratio of the treatment fee and constituent ratio of the inspection and laboratory fee increased for both samples, except for the constituent ratio of the inspection and laboratory fee of quota payment diseases in 2016, which did not change.

CONCLUSIONS

Quota payment for specific diseases under global budget had obviously positive effects on cost control in Weiyuan, Gansu. Considering the limited coverage of quota payment for diseases, the long-term effect of this reform mode and its replicability awaits further evaluation.

A trend analysis of surgical operations under a global payment system in Tehran, Iran (2005-2015)

Background

Global payment system is a first example of per-case payment system that contains 60 commonly used surgical operations for which payment is based on the average cost per case in Iran.

Objective

The aim of the study was to determine the amount of reduction, increase or no change in the trend of global operations.

Methods

In this retrospective longitudinal study, data on the 60 primary global surgery codes was gathered from Tehran Health Insurance Organization within the ten-year period of 2005–2015 separately, for each month. Out of 60 surgery codes, only acceptable data for 46 codes were available based on the insurance documents sent by medical centers. A quantitative analysis of time series through Regression Analysis Model using STATA software v.11 was performed.

Results

Some global surgery codes had an upward trend and some were downwards. Of N Codes, N83, N20, N28, N63, and N93 had an upward trend (p<0.05) and N32, N43, N81 and N90 showed a significant downward trend (p<0.05). Similarly, all H Codes except for H18 had a significant upward trend (p<0.000). As such, K Codes including K45, K56 and K81 had an increasing movement. S Codes also experienced both increasing and decreasing trends. However, none of the O Codes changed according to time. Other global surgical codes like C61, E07, M51, L60, J98 (p<0.000), I84 (p<0.031) and I86 (p<0.000) shown upward and downward trends. Total global surgeries trend was significantly upwards (B=24.26109, p<0.000).

Conclusion

The varying trend of global surgeries can partly reflect the behavior of service providers in order to increase their profits and minimize their costs.