Impacts of Health Insurance Benefit Design on Percutaneous Coronary Intervention Use and Inpatient Costs among Patients with Acute Myocardial Infarction in Shanghai, China
Impacts of Health Insurance Benefit Design on Percutaneous Coronary Intervention Use and Inpatient Costs among Patients with Acute Myocardial Infarction in Shanghai, China
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健康保险福利设计对中国上海急性心肌梗死患者经皮冠状动脉介入治疗使用和住院费用的影响
DOI：
10.1007/s40273-013-0079-9
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发表时间：
2014-03
影响因子：
4.4
通讯作者：
Jin Ma
中科院分区：
文献类型：
--
作者：
Lizheng Shi;Hude Quan;Mingshan Lu;Jin Ma
背景目前，中国最流行的医院支付方式是按服务收费（FFS），具有全球预算上限。截至2009年12月，一项政策变化意味着心脏支架纳入公共健康保险，而以前则没有。这一政策的变化为我们提供了一个机会，研究如何改变保险利益影响医院服务的数量和质量。新政策为患者和供应商引入了激励措施：它鼓励患者对经皮冠状动脉介入治疗（PCI）服务和支架使用的需求（道德风险效应），并由于全球上限的财务压力而阻碍医院供应（供应商博弈效应）。如果供应商的博弈效应超过道德风险效应，实际利用率和成本可能会下降，反之亦然。我们的假设是，较高报销组的患者将有较少的PCI和较低的住院费用。我们的目的是检查健康保险福利设计对PCI和支架使用的影响，方法对720例急性心肌梗死（AMI）患者的住院费用和自付费用进行分析（福利变更前467例，变更后253例）来自上海一家大型教学三级医院。通过审查医院病历和医院账单数据库收集数据。收集的患者信息包括人口统计学特征、病史和手术信息。所有患者根据其实际报销比例分为四组：高（90- 100%）、中等（80- 90%）、低（0- 80%）和无（自费患者）。采用多元回归和差异中差异（DID）模型研究医疗保险福利设计对PCI和支架使用的影响，以及对总住院费用和患者自付费用的影响。结果保险福利政策改变后，与自费组相比，中、低报销组的PCI率分别增加了22.2%和20.3%，高报销组下降48.7%。保险福利政策的变化对支架使用数量没有影响。无论福利政策如何变化，高报销组的住院费用最低，低报销组的住院费用最高。一般线性回归结果显示，高报销组的住院总费用高于自费组，但在福利政策变化后是所有报销组中最低的（DIDh= 1，202.21，P = 0.0096）。有没有显着的变化，在其他两个组，并没有任何差异的自付费用在任何的投保groups.ConclusionsOur研究结果表明，福利政策的变化并没有影响挽救生命的程序或减少患者的疾病负担AMI患者。由于全球预算上限的压力，“供应商博弈”对高报销组的影响最大。目前的FFS与全球预算上限是低效率的成本控制和公平的改善。中国需要改革支付方式，调整财政激励措施，以改善提供者在实践循证医学方面的行为。
BackgroundCurrently, the most popular hospital payment method in China is fee-for-service (FFS) with a global budget cap. As of December 2009, a policy change means that heart stents are covered by public health insurance, whereas previously they were not. This policy change provides us an opportunity to study how a change in insurance benefit affected the quantity and quality of hospital services. The new policy introduced incentives for both patients and providers: it encourages patient demand for percutaneous coronary intervention (PCI) services and stent use (moral hazard effect), and discourages hospital supply due to the financial pressures of the global cap (provider gaming effect). If the provider’s gaming effect dominates the moral hazard effect, actual utilisation and costs might go down, and vice versa. Our hypothesis is that patients in the higher reimbursement groups will have fewer PCIs and lower inpatient costs.ObjectiveWe aimed to examine the impact of health insurance benefit design on PCI and stent use, and on inpatient costs and out-of-pocket expenses for patients with acute myocardial infarction (AMI) in Shanghai.MethodsWe included 720 patients with AMI (467 before the benefit change and 253 after) from a large teaching tertiary hospital in Shanghai. Data were collected via review of hospital medical charts, and from the hospital billing database. Patient information collected included demographic characteristics, medical history and procedure information. All patients were categorised into four groups according to their actual reimbursement ratio: high (90–100 %), moderate (80–90 %), low (0–80 %) and none (self-paid patients). Multiple regression and difference-in-difference (DID) models were used to investigate the impacts of the health insurance benefit design on PCI and stent use, and on total hospital costs and patients’ out-of-pocket expenses.ResultsAfter the change in insurance benefit policy, compared with the self-paid group, PCI rates for the moderate and low reimbursement groups increased by 22.2 and 20.3 %, respectively, and decreased by 48.7 % for the high reimbursement group. The change in insurance benefit policy had no impact on the number of stents used. The high reimbursement group had the lowest hospital costs, and the low reimbursement group had the highest hospital costs, regardless of benefit policy change. The general linear regression results showed that the high reimbursement group had higher total hospital costs than the self-paid group, but were the lowest among all reimbursement groups after the benefit policy change (DIDh= 1,202.21,P= 0.0096). There were no significant changes in the other two groups, and there were no differences in the out-of-pocket costs across any of the insured groups.ConclusionsOur results suggest that the benefit policy change did not impact life-saving procedures or reduce patients’ burden of disease among AMI patients. The effect of ‘provider gaming’ was the strongest for the high reimbursement group as a result of the global budget cap pressure. The current FFS with a global budget cap is of low efficiency for cost containment and equity improvement. Payment method reforms with alignment of financial incentives to improve provider behaviour in practicing evidence-based medicine are needed in China.
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影响因子：
9.7
作者：
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通讯作者：
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