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Li L, Zhang S. Understanding the Public Policy of Global Budget Payment Reform Improves the Quality of Public Healthcare From the Perspective of Patients in China. Front Psychol 2022; 13:911197. [PMID: 35936284 PMCID: PMC9355385 DOI: 10.3389/fpsyg.2022.911197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 06/07/2022] [Indexed: 12/03/2022] Open
Abstract
The transformation from the retrospective to the prospective payment system is significant to improve the quality of public healthcare (QPH). This article used the quasi-natural experiment of the global budget payment reform of government (GBPRG) in Chengdu, adopted the difference in difference (DID) method to estimate the effect of the GBPRG on the QPH, and concluded that GBPRG has a significant positive impact on the healthcare outcome and has a significant effect on improving the QPH. Policy implications drawn from the results show that the government should continue to explore compound healthcare insurance payment method (HIPM), improve the governance capabilities of the government, reduce transaction costs, improve healthcare insurance reimbursement policies, adjust the proportion of healthcare insurance reimbursements, continuously optimize the allocation of healthcare resources, establish an incentive mechanism to improve the QPH, and realize the pareto optimal choice of healthcare resource allocation.
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Affiliation(s)
- Lele Li
- School of Labor and Human Resources, Renmin University of China, Beijing, China
| | - Shuo Zhang
- School of Economics and Management, Tsinghua University, Beijing, China
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2
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Lai CH, Hsieh CY, Barnado A, Huang LC, Chen SC, Tsai LM, Shyr Y, Li CY. Outcomes of acute cardiovascular events in rheumatoid arthritis and systemic lupus erythematosus: a population-based study. Rheumatology (Oxford) 2020; 59:1355-1363. [PMID: 31600392 DOI: 10.1093/rheumatology/kez456] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 09/04/2019] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES Patients with RA and SLE have an excess cardiovascular risk. We aimed to evaluate outcomes of acute cardiovascular events in these patients. METHODS Using a nationwide database of Taiwan, we identified adult patients who experienced first-time acute myocardial infarction (n = 191 008), intracranial haemorrhage (n = 169 923) and ischaemic stroke (n = 486 890) over a 13-year period. Odds ratios (ORs) of in-hospital mortality and hazard ratios (HRs) of overall mortality and adverse outcomes during long-term follow-up in relation to RA and SLE were estimated with adjustment for potential confounders. RESULTS In each cohort, 748, 410 and 1419 patients had established RA; 256, 292 and 622 patients had SLE. Among acute myocardial infarction patients, RA and SLE were associated with in-hospital mortality (RA: OR 1.61, 95% CI 1.33, 1.95; SLE: OR 2.31, 95% CI 1.62, 3.28) and overall mortality. Additionally, RA (HR 1.28, 95% CI 1.18, 1.38) and SLE (HR 1.46, 95% CI 1.27, 1.69) increased the risk of major adverse cardiac events. After intracranial haemorrhage, patients with RA and SLE had higher risks of in-hospital mortality (RA: OR 1.61, 95% CI 1.26, 2.06; SLE: OR 3.00, 95% CI 2.33, 3.86) and overall mortality. After ischaemic stroke, RA and SLE increased in-hospital mortality (RA: OR 1.45, 95% CI 1.15, 1.83; SLE: OR 2.18, 95% CI 1.57, 3.02), overall mortality and recurrent cerebrovascular events (RA: HR 1.10, 95% CI 1.002, 1.21; SLE: HR 1.31, 95% CI 1.14, 1.51), among which ischaemic stroke (HR 1.39, 95% CI 1.19, 1.62) was more likely to recur in SLE patients. CONCLUSION Both RA and SLE are consistently associated with adverse outcomes following acute cardiovascular events, highlighting the necessity of integrated care for affected patients.
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Affiliation(s)
- Chao-Han Lai
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan
| | - April Barnado
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Li-Ching Huang
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sheau-Chiann Chen
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Liang-Miin Tsai
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan
| | - Yu Shyr
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
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3
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Wang M, Lin EPY, Huang LC, Li CY, Shyr Y, Lai CH. Mortality of Cardiovascular Events in Patients With COPD and Preceding Hospitalization for Acute Exacerbation. Chest 2020; 158:973-985. [PMID: 32184108 DOI: 10.1016/j.chest.2020.02.046] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 01/25/2020] [Accepted: 02/09/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Acute exacerbation (AE) of COPD may be accompanied by the deterioration of cardiovascular comorbidities, as evidenced by the increased incidence of acute cardiovascular events. RESEARCH QUESTION The goal of this study was to determine whether preceding AE might be associated with mortality of cardiovascular events. STUDY DESIGN AND METHODS Using a health insurance research database in Taiwan, patients with COPD were identified who experienced first-time acute myocardial infarction (AMI; n = 26,442), ischemic stroke (n = 54,959), and intracranial hemorrhage (ICH; n = 14,893) over a 13-year period. In each cohort, 4,356, 6,655, and 1,727 patients, respectively, had been hospitalized for AE within the previous year prior to the index cardiovascular events, and patients with COPD but without hospitalization for AEs constituted the control subjects. ORs of 90-day mortality and hazard ratios (HRs) of overall mortality during follow-up in relation to hospitalization for an AE and the frequency of hospitalization for AEs (ie, 1 and ≥ 2 hospitalizations for AEs) were estimated with adjustment for potential confounders. RESULTS Hospitalization for an AE was independently associated with 90-day mortality of AMI (OR, 1.33; 95% CI, 1.24-1.43), ischemic stroke (OR, 1.46; 95% CI, 1.36-1.56), and ICH (OR, 1.19; 95% CI, 1.06-1.32). Hospitalization for an AE was associated with overall mortality of AMI (HR, 1.23; 95% CI, 1.19-1.27), ischemic stroke (HR, 1.29; 95% CI, 1.26-1.33), and ICH (HR, 1.19; 95% CI, 1.13-1.26). In addition, compared with control subjects, patients with more frequent hospitalizations for AEs exhibited significant trends at higher risk of 90-day and overall mortality of AMI, ischemic stroke, and ICH. Finally, these results were consistent with propensity score matching-based estimates. INTERPRETATION Preceding hospitalization for AEs is associated with 90-day and overall mortality of cardiovascular events in COPD.
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Affiliation(s)
- Mai Wang
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Emily Pei-Ying Lin
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN; Department of Medical Research, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan; Division of Chest Medicine, Department of Internal Medicine, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan; Big Data Research Center, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Li-Ching Huang
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan; Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan; Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Yu Shyr
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Chao-Han Lai
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN; Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Lai CH, Huang LC, Holby SN, Lai YJ, Su PF, Cheng YS, Shyr Y, Hsi RS. Kidney Stone History and Adverse Outcomes After Percutaneous Coronary Intervention. Urology 2020; 136:75-81. [PMID: 31697954 PMCID: PMC7008077 DOI: 10.1016/j.urology.2019.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 10/02/2019] [Accepted: 10/15/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine whether kidney stone history is associated with adverse outcomes after percutaneous coronary intervention (PCI). Kidney stone formers have an increased risk of developing coronary artery disease; however, whether these patients have worse cardiac outcomes is unknown. MATERIALS AND METHODS We identified adult patients who underwent first-time PCI in Vanderbilt University Medical Center (VUMC) Synthetic Derivative from 2008 to 2016 (n = 11,289) and in a nationwide database of Taiwan (NHIRD) from 2005 to 2012 (n = 155,762). Odds ratios (ORs) of 30-day in-hospital mortality and hazard ratios (HRs) of 1-year and 3-year adverse outcomes associated with kidney stone history were estimated using a propensity score approach. RESULTS Overall, 294 and 12,286 stone formers undergoing PCI were identified in the VUMC and NHIRD, respectively. After matching, stone formers at VUMC were at higher risks of 30-day in-hospital mortality (OR 2.79, 95% CI 1.15-6.69) and 1-year (HR 1.59, 95% CI 1.13-2.24) and 3-year (HR 1.36, 95% CI 1.02-1.81) myocardial infarction. In the NHIRD, kidney stone history was associated with 1-year (HR 1.12, 95% CI 1.03-1.21) and 3-year (HR 1.14, 95% CI 1.06-1.22) myocardial infarction. In a sensitivity analysis, stone formers undergoing kidney stone surgery were marginally associated with 30-day in-hospital mortality (OR 1.21, 95% CI 0.99-1.48) and were associated with 3-year myocardial infarction (HR 1.13, 95% CI 1.02-1.25). CONCLUSION Kidney stone history is associated with poorer cardiac outcomes after PCI. Improving secondary cardiac prevention strategies after PCI may be necessary for patients with a history of kidney stone disease.
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Affiliation(s)
- Chao-Han Lai
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN; Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Li-Ching Huang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN; Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - S Neil Holby
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ying-Ju Lai
- Department of Statistics, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Fang Su
- Department of Statistics, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Sheng Cheng
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu Shyr
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN; Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Ryan S Hsi
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN.
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Kini V, Viragh T, Magid D, Masoudi FA, Moghtaderi A, Black B. Trends in High- and Low-Value Cardiovascular Diagnostic Testing in Fee-for-Service Medicare, 2000-2016. JAMA Netw Open 2019; 2:e1913070. [PMID: 31603486 PMCID: PMC6804029 DOI: 10.1001/jamanetworkopen.2019.13070] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
IMPORTANCE Owing to a rapid increase in rates of diagnostic cardiovascular testing in the 1990s and early 2000s, the Centers for Medicare & Medicaid Services implemented a series of payment changes intended to reduce overall spending on fee-for-service testing. Whether guideline-concordant testing has been subsequently affected is unknown to date. OBJECTIVE To determine whether changes in overall rates of use of diagnostic cardiovascular tests were associated with changes in high-value testing recommended by guidelines and low-value testing that is expected to provide minimal benefits. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study assessed a national 5% random sample of Medicare fee-for-service beneficiaries aged 65 to 95 years from January 1, 1999, through December 31, 2016. Data were analyzed from February 15, 2018, through August 15, 2019. EXPOSURES Eligibility to receive high-value testing (assessment of left ventricular systolic function among patients hospitalized with acute myocardial infarction or heart failure) and low-value testing (stress testing before low-risk noncardiac surgery and routine stress testing within 2 years of coronary revascularization not associated with acute care visits). MAIN OUTCOMES AND MEASURES Age- and sex-adjusted annual rates of overall, high-value, and low-value diagnostic cardiovascular testing. RESULTS Mean (SD) age was similar over time (75.57 [7.32] years in 2000-2003; 74.82 [7.79] years in 2012-2016); the proportion of women slightly declined over time (63.23% in 2000 to 2003; 57.27% in 2012 to 2016). The rate of overall diagnostic cardiovascular testing per 1000 patient-years among the 5% sample of Medicare beneficiaries increased from 275 in 2000 to 359 in 2008 (P < .001) and then declined to 316 in 2016 (P < .001). High-value testing increased steadily over the entire study period for patients with acute myocardial infarction (85.7% to 89.5%; P < .001) and heart failure (72.6% to 80.1%; P < .001). Low-value testing among patients undergoing low-risk surgery increased from 2.4% in 2000 to 3.8% in 2008 (P < .001) but then declined to 2.5% in 2016 (P < .001). Low-value testing within 2 years of coronary revascularization slightly increased from 47.4% in 2000 to 49.2% in 2003 (P = .03) but then declined to 30.8% in 2014 (P < .001). CONCLUSIONS AND RELEVANCE Rates of overall and low-value diagnostic cardiovascular testing appear to have declined considerably and rates of high-value testing have increased slightly. Payment changes intended to reduce spending on overall testing may not have adversely affected testing recommended by guidelines.
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Affiliation(s)
- Vinay Kini
- Department of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | - Timea Viragh
- Northwestern University School of Education and Social Policy, Evanston, Illinois
| | - David Magid
- Department of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | - Frederick A. Masoudi
- Department of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | - Ali Moghtaderi
- George Washington University School of Public Health, Washington, DC
| | - Bernard Black
- Institute for Policy Research and Kellogg School of Management, Northwestern University Pritzker School of Law, Chicago, Illinois
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Lin WC, Chen CW, Lu CL, Lai WW, Huang MH, Tsai LM, Li CY, Lai CH. The association between recent hospitalized COPD exacerbations and adverse outcomes after percutaneous coronary intervention: a nationwide cohort study. Int J Chron Obstruct Pulmon Dis 2019; 14:169-179. [PMID: 30655664 PMCID: PMC6322514 DOI: 10.2147/copd.s187345] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose COPD is associated with coronary artery disease, and exacerbations are major events in COPD. However, the impact of recent hospitalized exacerbations on outcomes of percutaneous coronary intervention (PCI) remains underdetermined. Patients and methods Using the National Health Insurance Research Database of Taiwan, we identified 215,275 adult patients who underwent first-time PCI between 2000 and 2012. Among these patients, 15,485 patients had COPD. The risks of hospital mortality, overall mortality, and adverse cardiovascular outcomes after PCI (ie, ischemic events, repeat revascularization, cerebrovascular events, and major adverse cardiac and cerebrovascular events [MACCEs]) in relation to COPD, and the frequency and timing of recent hospitalized exacerbations within 1 year before PCI were estimated. Results COPD was independently associated with increased risks of hospital mortality, overall mortality, ischemic events, cerebrovascular events, and MACCE during follow-up after PCI. Among cerebrovascular events, ischemic rather than hemorrhagic stroke was more likely to occur. In COPD patients, recent hospitalized exacerbations further increased the risks of overall mortality, ischemic events, and MACCE following PCI. Notably, patients with more frequent or more recent hospitalized exacerbations had a trend toward higher risks of these adverse events (all P-values for trend <0.0001), especially those with ≥2 exacerbations within 1 year or any exacerbation within 1 month before PCI. Conclusion Integrated care is urgently needed to alleviate COPD-related morbidity and mortality after PCI, especially for patients with a recent hospitalized exacerbation.
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Affiliation(s)
- Wei-Chieh Lin
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chang-Wen Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chin-Li Lu
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan, .,Graduate Institute of Food Safety, College of Agriculture and Nature Resources, National Chung Hsing University, Taichung, Taiwan
| | - Wu-Wei Lai
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan,
| | - Min-Hsin Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan,
| | - Liang-Miin Tsai
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan, .,Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan,
| | - Chao-Han Lai
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan,
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Tung YC, Chang HY, Chang GM. Impact of bundled payments on hip fracture outcomes: a nationwide population-based study. Int J Qual Health Care 2018; 30:23-31. [PMID: 29194494 DOI: 10.1093/intqhc/mzx158] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 10/13/2017] [Indexed: 01/26/2023] Open
Abstract
Objective Establishing one price for all bundled services for a particular illness, which has become the key to healthcare reform efforts, is designed to encourage health professionals to coordinate their care for patients. Limited information is available, however, concerning whether bundled payments are associated with changes in patient outcomes. Nationwide longitudinal population-based data were used to examine the effect of bundled payments on hip fracture outcomes. Design An interrupted time series design with a comparison group. Setting General acute care hospitals throughout Taiwan. Participants A total of 178 586 hip fracture patients admitted over the period 2007-12 identified from the Taiwan's National Health Insurance Research Database. Intervention Bundled payments for hip fractures were implemented in Taiwan in January 2010. Main Outcome Measures The 30-day unplanned readmission and postdischarge mortality. Segmented generalized estimating equation regression models were used after adjustment for trends, patient, physician and hospital characteristics to assess the effect of bundled payments on 30-day outcomes for hip fracture compared with a reference condition. Results The 30-day unplanned readmission rate for hip fracture showed a relative decreasing trend after the implementation of bundled payments compared with the trend before the implementation relative to that of the reference condition. Conclusions This finding might imply that the implementation of bundled payments encourages health professionals to coordinate their care, leading to reduced readmission for hip fracture.
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Affiliation(s)
- Yu-Chi Tung
- Institute of Health Policy and Management, National Taiwan University, No.17, Xu-Zhou Road, Taipei 100, Taiwan
| | - Hsien-Yen Chang
- Department of Health Policy and Management, Johns Hopkins School of Public Health, 624 North Broadway, Hampton House 682, Baltimore, MD 21205, USA
| | - Guann-Ming Chang
- Department of Family Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan.,School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
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Managing health expenditure inflation under a single-payer system: Taiwan's National Health Insurance. Soc Sci Med 2017; 233:272-280. [PMID: 29548564 DOI: 10.1016/j.socscimed.2017.11.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 11/11/2017] [Accepted: 11/14/2017] [Indexed: 11/21/2022]
Abstract
As nations strive to achieve and sustain universal health coverage (UHC), they seek answers as to what health system structures are more effective in managing health expenditure inflation. A fundamental macro-level choice a nation has to make is whether to adopt a single- or a multiple-payer health system. Using Taiwan's National Health Insurance (NHI) as a case, this paper examines how a single-payer system manages its health expenditure growth and draws lessons for other countries whose socioeconomic development is similar to Taiwan's. Our analyses show that as a single payer, Taiwan's NHI is able to exercise its monopsony power to manage its health expenditure growth. This is achieved primarily through the adoption of a system-wide global budget. The global budget sets a hard aggregate budget cap to limit NHI's total spending to its expected revenue, with the annual budget growth rate established by a process of negotiation among key stakeholders. The global budget system is complemented by comprehensive and continuous monitoring and review of encounter records of all providers and patients, enabled by the NHI's advanced information technology. However, by paying its providers using a point-based fee schedule, Taiwan's NHI suffers from inefficient service provision. In particular, providers have incentives to increase use of services and drugs with positive profit margins. Furthermore, Taiwan demonstrates that its control of NHI expenditure growth might be leading it to inadequately meet the changing needs of the population, resulting in the rapid growth of private insurance to cover services excluded or not fully covered by the NHI. If this trend persists and results in a two-tier system, Taiwan's NHI may risk compromising the equity it has achieved in the past two decades.
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The effects of patient cost sharing on inpatient utilization, cost, and outcome. PLoS One 2017; 12:e0187096. [PMID: 29073234 PMCID: PMC5658166 DOI: 10.1371/journal.pone.0187096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 10/15/2017] [Indexed: 11/19/2022] Open
Abstract
Background Health insurance and provider payment reforms all over the world beg a key empirical question: what are the potential impacts of patient cost-sharing on health care utilization, cost and outcomes? The unique health insurance system and rich electronic medical record (EMR) data in China provides us a unique opportunity to study this topic. Methods Four years (2010 to 2014) of EMR data from one medical center in China were utilized, including 10,858 adult patients with liver diseases. We measured patient cost-sharing using actual reimbursement ratio (RR) which is allowed us to better capture financial incentive than using type of health insurance. A rigorous risk adjustment method was employed with both comorbidities and disease severity measures acting as risk adjustors. Associations between RR and health use, costs and outcome were analyzed by multivariate analyses. Results After risk adjustment, patients with more generous health insurance coverage (higher RR) were found to have longer hospital stay, higher total cost, higher medication cost, and higher ratio of medication to total cost, as well as higher number and likelihood that specific procedures were performed. Conclusion Our study implied that patient cost-sharing affects health care services use and cost. This reflects how patients and physicians respond to financial incentives in the current healthcare system in China, and the responses could be a joint effect of both demand and supply side moral hazard. In order to contain cost and improve efficiency in the system, reforming provide payment and insurance scheme is urgently needed.
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Chang CH, Chen SW, Fan PC, Lee CC, Yang HY, Chang SW, Pan HC, Tsai FC, Yang CW, Chen YC. Sequential organ failure assessment score predicts mortality after coronary artery bypass grafting. BMC Surg 2017; 17:22. [PMID: 28264675 PMCID: PMC5339985 DOI: 10.1186/s12893-017-0219-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 02/25/2017] [Indexed: 01/14/2023] Open
Abstract
Background Mortality after coronary artery bypass grafting (CABG) is generally associated with underlying disease and surgical factors overlooked in preoperative prognostic models. Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE II) scores are widely used in intensive care units for outcome prediction. This study investigated the accuracy of these models in predicting mortality. Methods Between January 2010 and April 2013, 483 patients who underwent isolated CABG were enrolled. The clinical characteristics, outcomes, and prognostic model scores of the patients were collected. Discrimination was assessed using the area under the curve approach. Results Both SOFA and APACHE II scores were effective for predicting in-hospital mortality. Among the organ systems examined in the SOFA, the cardiac and renal systems were the strongest predictors of CABG mortality. Multivariate analysis identified only the SOFA score as being an independent risk factor for mortality. Conclusion In summary, the SOFA score can be used to accurately identify mortality after isolated CABG.
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Affiliation(s)
- Chih-Hsiang Chang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,School of medicine, College of Medicine, Chang Gung University, 199 Tung Hwa North Road, Taoyuan, Taipei, 105, Taiwan
| | - Shao-Wei Chen
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,School of medicine, College of Medicine, Chang Gung University, 199 Tung Hwa North Road, Taoyuan, Taipei, 105, Taiwan
| | - Pei-Chun Fan
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,School of medicine, College of Medicine, Chang Gung University, 199 Tung Hwa North Road, Taoyuan, Taipei, 105, Taiwan
| | - Cheng-Chia Lee
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,School of medicine, College of Medicine, Chang Gung University, 199 Tung Hwa North Road, Taoyuan, Taipei, 105, Taiwan
| | - Huang-Yu Yang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,School of medicine, College of Medicine, Chang Gung University, 199 Tung Hwa North Road, Taoyuan, Taipei, 105, Taiwan
| | - Su-Wei Chang
- Clinical Informatics and Medical Statistics Research Center, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Heng-Chih Pan
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung branch, New Taipei City, Taiwan.,School of medicine, College of Medicine, Chang Gung University, 199 Tung Hwa North Road, Taoyuan, Taipei, 105, Taiwan
| | - Feng-Chun Tsai
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,School of medicine, College of Medicine, Chang Gung University, 199 Tung Hwa North Road, Taoyuan, Taipei, 105, Taiwan
| | - Chih-Wei Yang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,School of medicine, College of Medicine, Chang Gung University, 199 Tung Hwa North Road, Taoyuan, Taipei, 105, Taiwan
| | - Yung-Chang Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan. .,School of medicine, College of Medicine, Chang Gung University, 199 Tung Hwa North Road, Taoyuan, Taipei, 105, Taiwan.
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11
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Chou AH, Chen TH, Chen CY, Chen SW, Lee CW, Liao CH, Wang SY. Long-Term Outcome of Cardiac Surgery in 1,040 Liver Cirrhosis Patient ― Nationwide Population-Based Cohort Study ―. Circ J 2017; 81:476-484. [DOI: 10.1253/circj.cj-16-0849] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- An-Hsun Chou
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
- Department of Medicine, Chang Gung University
- Transgenic and Molecular Immunogenetics Laboratory, Chang Gung Memorial Hospital
| | - Tien-Hsing Chen
- Department of Cardiology, Chang Gung Memorial Hospital, Keelung Branch and Linkou Medical Center
| | - Chun-Yu Chen
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
- Graduate Institute of Clinical Medical Sciences College of Medicine, Chang Gung University
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Chao-Wei Lee
- Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center
| | - Chien-Hung Liao
- Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center
| | - Shang-Yu Wang
- Graduate Institute of Clinical Medical Sciences College of Medicine, Chang Gung University
- Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center
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12
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Yin WH, Lu TH, Chen KC, Cheng CF, Lee JC, Liang FW, Huang YT, Yang LT. The temporal trends of incidence, treatment, and in-hospital mortality of acute myocardial infarction over 15years in a Taiwanese population. Int J Cardiol 2016; 209:103-13. [PMID: 26889592 DOI: 10.1016/j.ijcard.2016.02.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/08/2016] [Accepted: 02/01/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The study was conducted to examine the nationwide temporal trends of incidence, treatment, and short-term outcomes for acute myocardial infarction (AMI) over a 15-year period in Taiwan. METHODS We identified patients who were hospitalized for incident AMI between 1997 and 2011 from the inpatient medical claim dataset of the National Health Insurance Research Database. Age- and sex-adjusted incidence and in-hospital mortality rates were calculated for AMI, and separately for ST-segment elevation and non-ST-segment elevation myocardial infarction (STEMI and NSTEMI). RESULTS A total of 144,634 patients were identified. The incidence rates (per 100,000 population) of AMI increased from 30 in 1997 to 42 in 2011, which was mainly driven by the increase of NSTEMI. The in-hospital mortality rate after AMI decreased from 9.1% in 1997 to 6.5% in 2011, which was also driven by the case mortality rate for NSTEMI. Although the in-hospital mortality rates significantly decreased from 7.3% to 5.1% between 1997 and 2003 for STEMI, it did not change significantly from 2004 to 2011. Moreover, AMI patients undergoing revascularization treatment, particularly PCI, was the most important independent predictor for improved in-hospital survival. CONCLUSION The results of this study demonstrated a recent dramatic increase in the incidence rates and a decrease in short-term mortality in patients with NSTEMI; while the incidence and in-hospital morality of STEMI only modestly changed over time in Taiwan. Further quality improvement approaches for AMI prevention and treatment to favorably affect the incidence and outcomes from both major types of AMI are highly recommended.
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Affiliation(s)
- Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Tsung-Hsueh Lu
- Department of Public Health, National Cheng Kung University, Tainan, Taiwan
| | - Kuan-Chun Chen
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | | | - Jo-Chi Lee
- Department of Public Health, National Cheng Kung University, Tainan, Taiwan
| | - Fu-Wen Liang
- Department of Public Health, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Tung Huang
- Program in Ageing and Long-term Care, Kaohsiuang Medical University, Kaohsiung, Taiwan
| | - Li-Tan Yang
- Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan
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13
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Lai CH, Lai WW, Chiou MJ, Lin WC, Yang YJ, Li CY, Tsai LM. Outcomes of percutaneous coronary intervention in patients with rheumatoid arthritis and systemic lupus erythematosus: an 11-year nationwide cohort study. Ann Rheum Dis 2015; 75:1350-6. [DOI: 10.1136/annrheumdis-2015-207719] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 07/30/2015] [Indexed: 12/17/2022]
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14
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Tung YC, Jeng JS, Chang GM, Chung KP. Processes and outcomes of ischemic stroke care: the influence of hospital level of care. Int J Qual Health Care 2015; 27:260-6. [DOI: 10.1093/intqhc/mzv038] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2015] [Indexed: 11/14/2022] Open
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15
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Chang YK, Hsu CC, Chen PC, Chen YS, Hwang SJ, Li TC, Huang CC, Li CY, Sung FC. Trends of cost and mortality of patients on haemodialysis with end stage renal disease. Nephrology (Carlton) 2015; 20:243-9. [DOI: 10.1111/nep.12380] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Yu-Kang Chang
- Division of Geriatrics and Gerontology, Institute of Population Health Sciences; National Health Research Institutes; Chunan Taiwan
| | - Chih-Cheng Hsu
- Division of Geriatrics and Gerontology, Institute of Population Health Sciences; National Health Research Institutes; Chunan Taiwan
- Department of Health Administration; China Medical University; Taichung Taiwan
| | - Pei-Chun Chen
- Clinical Informatics & Medical Statistics Research, Center; Chang Gung University; Taoyuan Taiwan
| | - Yi-Shan Chen
- Department of Health Administration; China Medical University; Taichung Taiwan
| | - Shang-Jyh Hwang
- Division of Nephrology; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
| | - Tsai-Chung Li
- Institute of Biostatistics; China Medical University; Taichung Taiwan
| | - Chiu-Ching Huang
- Division of Nephrology; China Medical University Hospital; Taichung Taiwan
| | - Chung-Yi Li
- Institute of Public Health; National Cheng Kung University; Tainan Taiwan
| | - Fung-Chang Sung
- Institute of Clinical Medical Science; China Medical University College of Medicine; Taichung Taiwan
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Outcomes of coronary artery bypass grafting in patients with inflammatory rheumatic diseases: An 11-year nationwide cohort study. J Thorac Cardiovasc Surg 2015; 149:859-66.e1-2. [DOI: 10.1016/j.jtcvs.2014.11.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 11/01/2014] [Accepted: 11/14/2014] [Indexed: 02/05/2023]
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Tung YC, Chang GM, Cheng SH. Long-Term Effect of Fee-For-Service–Based Reimbursement Cuts on Processes and Outcomes of Care for Stroke. Circ Cardiovasc Qual Outcomes 2015; 8:30-7. [DOI: 10.1161/circoutcomes.114.001086] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yu-Chi Tung
- From the Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan (Y.-C.T., S.-H.C.); Department of Family Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan (G.-M.C.); and School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan (G.-M.C.)
| | - Guann-Ming Chang
- From the Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan (Y.-C.T., S.-H.C.); Department of Family Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan (G.-M.C.); and School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan (G.-M.C.)
| | - Shou-Hsia Cheng
- From the Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan (Y.-C.T., S.-H.C.); Department of Family Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan (G.-M.C.); and School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan (G.-M.C.)
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18
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Li TY, Hsieh JS, Lee KT, Hou MF, Wu CL, Kao HY, Shi HY. Cost trend analysis of initial cancer treatment in Taiwan. PLoS One 2014; 9:e108432. [PMID: 25279947 PMCID: PMC4184791 DOI: 10.1371/journal.pone.0108432] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 08/29/2014] [Indexed: 12/02/2022] Open
Abstract
Background Despite the high cost of initial cancer care, that is, care in the first year after diagnosis, limited information is available for specific categories of cancer-related costs, especially costs for specific services. This study purposed to identify causes of change in cancer treatment costs over time and to perform trend analyses of the percentage of cancer patients who had received a specific treatment type and the mean cost of care for patients who had received that treatment. Methodology/Principal Findings The analysis of trends in initial treatment costs focused on cancer-related surgery, chemotherapy, radiation therapy, and treatments other than active treatments. For each cancer-specific trend, slopes were calculated for regression models with 95% confidence intervals. Analyses of patients diagnosed in 2007 showed that the National Health Insurance (NHI) system paid, on average, $10,780 for initial care of a gastric cancer patient and $10,681 for initial care of a lung cancer patient, which were inflation-adjusted increases of $6,234 and $5,522, respectively, over the 1996 care costs. During the same interval, the mean NHI payment for initial care for the five specific cancers increased significantly (p<0.05). Hospitalization costs comprised the largest portion of payments for all cancers. During 1996–2007, the use of chemotherapy and radiation therapy significantly increased in all cancer types (p<0.05). In 2007, NHI payments for initial care for these five cancers exceeded $12 billion, and gastric and lung cancers accounted for the largest share. Conclusions/Significance In addition to the growing number of NHI beneficiaries with cancer, treatment costs and the percentage of patients who undergo treatment are growing. Therefore, the NHI must accurately predict the economic burden of new chemotherapy agents and radiation therapies and may need to develop programs for stratifying patients according to their potential benefit from these expensive treatments.
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Affiliation(s)
- Tsai-Yun Li
- Department of General Affairs, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jan-Sing Hsieh
- Division of Gastrointestinal and General Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - King-Teh Lee
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Hepatobiliary Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ming-Feng Hou
- Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
- National Sun Yat-Sen University-Kaohsiung Medical University Joint Research Center, Kaohsiung, Taiwan
- Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chia-Ling Wu
- Department of Neurosurgery, Chimei Medical Center, Yongkang, Taiwan
| | - Hao-Yun Kao
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hon-Yi Shi
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan
- * E-mail:
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19
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The impact of global budgeting on treatment intensity and outcomes. ACTA ACUST UNITED AC 2014; 14:311-37. [DOI: 10.1007/s10754-014-9150-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Accepted: 06/06/2014] [Indexed: 10/25/2022]
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20
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The Relationships Among Physician and Hospital Volume, Processes, and Outcomes of Care for Acute Myocardial Infarction. Med Care 2014; 52:519-27. [DOI: 10.1097/mlr.0000000000000132] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yuan S, Liu Y, Li N, Zhang Y, Zhang Z, Tao J, Shi L, Quan H, Lu M, Ma J. Impacts of health insurance benefit design on percutaneous coronary intervention use and inpatient costs among patients with acute myocardial infarction in Shanghai, China. PHARMACOECONOMICS 2014; 32:265-275. [PMID: 23975740 DOI: 10.1007/s40273-013-0079-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Currently, 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. OBJECTIVE We 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. METHODS We 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. RESULTS After 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. CONCLUSIONS Our 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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Affiliation(s)
- Suwei Yuan
- Shanghai Jiao Tong University School of Public Health, No.227 South Chong Qing Road, Huang Pu District, Shanghai, 200025, China
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