Hospital response to prospective financing of in-patient days: the Belgian case

OBJECTIVES: In Belgium, a prospective payment system (PPS) has been implemented for in-patient non-medical costs since 1995, aimed at improving efficiency in the management of in-patient stays. We analyze the hospital's response in terms of in-patient length of stay (LOS) and medical and surgical expenditures. METHODS: We use data for all Belgian in-patient discharges over the 1991-1998 period. In-patient stays are aggregated according to pathology, age, year and hospital. Estimates are obtained using panel data regressions with fixed effects. RESULTS: The in-patient length of stay is significantly reduced after the reform. However, the impact is low in magnitude. In addition, medical and surgical expenditures increase, probably reflecting a profit-compensation effect, as medical and surgical services are paid by fee-for-service. Finally, hospitals receiving higher percentages of underprivileged cases, for which the financing scheme is not risk-adjusted, experience a larger decrease in length of stay in the years following the reform. This last finding may be the sign of patient's indirect selection. CONCLUSION: The reform towards more hospital financial responsibility did not allow achieve high reductions in resource use. The non-inclusion of medical services in the new financing and the imperfections of risk-adjustment may largely explain this finding.     

Associations Between End-of-Life Expenditures and Hospice Stay Length Vary by Clinical Condition and Expenditure Duration

ObjectivesHospice use reduces costly aggressive end-of-life (EOL) care (eg, repeated hospitalizations, intensive care unit care, and emergency department visits). Nevertheless, associations between hospice stays and EOL expenditures in prior research have been inconsistent. We examined the differential associations between hospice stay duration and EOL expenditures among newly diagnosed patients with cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and dementia.MethodsIn the Surveillance, Epidemiology, and End Results–Medicare data, we identified 240 246 decedents diagnosed with the aforementioned conditions during 2001 to 2013. We used zero-inflated negative binomial regression models to examine the differential associations between hospice length of services and EOL expenditures incurred during the last 90, 180, and 360 days of life.ResultsFor the last 360 days of expenditures, hospice stays beyond 30 days were positively associated with expenditures for decedents with COPD, CHF, and dementia but were negatively associated for cancer decedents (all P<.001) after adjusting for demographic and medical covariates. In contrast, for the last 90 days of expenditures, hospice stay duration and expenditures were consistently negatively associated for each of the 4 patient disease groups.ConclusionsLonger hospice stays were associated with lower 360-day expenditures for cancer patients but higher expenditures for other patients. We recommend that Medicare hospice payment reforms take distinct disease trajectories into account. The relationship between expenditures and hospice stay length also depended on the measurement duration, such that measuring expenditures for the last 6 months of life or less overstates the cost-saving benefit of lengthy hospice stays.     

International comparisons of institutional medical care expenditures--an analysis using the OECD health data bank

Expenditures for institutional medical care of eleven OECD countries including Japan were studied using the OECD health data bank. Objectives of this study were to clarify the factors associated with increases in institutional medical care expenditures, and to compare these expenditures between Japan and other OECD countries. The main findings were as follows; 1) Expenditures for institutional medical care per person for the entire population were positively correlated with expenditures per day per in-patient, but not significantly correlated with hospital bed-days per person. 2) Hospital bed-days were strongly correlated with the numbers of beds per 1000 population. 3) There was a negative correlation between expenditures per day per in-patient and average length of stay. 4) Increases in expenditure for institutional medical care per person in 1970s were mainly due to increases in expenditures per day per in-patient. 5) Expenditure per day per in-patient in Japan was the lowest except for Austria and the number of hospital admissions as percentage of the total population was the lowest among the eleven countries surveyed.     

The current situation of older hospitalized patients in a cadre ward in Jilin, China

OBJECTIVE: The proportion of elderly people and the nation's medical expenditures are rapidly increasing in China. The existence of cadre wards, where retired members of the cadre of the Communist Party of China are hospitalized and receive careful treatment, helps in providing care for the elderly. Elderly retired cadre patients are thought to be more frequently hospitalized and to stay in the hospital longer than elderly non-cadre patients on general hospital wards, and therefore might be expected make an important contribution to the increase in the nation's medical expenditures. However the current situation is not well characterized. The aim of this study was to provide a basis for possible solutions related to the cadre patient burden by determining the circumstances and background of these patients with long hospital stays and investigating their needs. METHODS: We analyzed the medical records of hospital discharges from a cadre ward from 2000 to 2004, and from general wards in 2004 at a large university-affiliated hospital in Jilin, China. Additionally, a questionnaire survey including an interview concerning needs was carried out in August 2005 for 100 elderly patients on the cadre ward (91% of the total patients on this ward) of the same hospital at that time. RESULTS: The mean length of hospital stays of patients on the cadre ward decreased by half during the study period, but remained longer than that of patients on general hospital wards. Regression analysis showed that of all the variables measured, the type of ward (cadre vs. general) was the most influential on the mean length of hospital stay. Moreover, patients who were hospitalized more often, males and older individuals showed longer hospital stays. The questionnaire survey showed that there are many patients who could be discharged from the hospital based on their health condition but are not discharged because outside care or welfare services are insufficient, or because there is little information available on social resources. CONCLUSIONS: Although medical policy, by which elderly retired cadre patients receive careful treatment, may contribute to the longer length of the hospital stay of the patients on the cadre ward, it was thought to be important to construct appropriate discharge plans and a support system after discharge to the community. The results provide important information for solution of medical problems related to elderly retired cadre patients in China.     

Using administrative data to assess the impact of length of stay on readmissions: study of two procedures in surgery and obstetrics

BackgroundThe prospective payment system for the French short-stay hospitals creates a financial incentive to reduce length of stay. The potential impact of the resulting decrease in length of stay on the quality of healthcare is unknown. Readmission rates are valid outcome indicators for some clinical procedures.MethodsRetrospective study of the association between length of stay and unplanned readmissions related to the initial stay, for two procedures: cholecystectomy and vaginal delivery.DataAdministrative diagnosis-related groups database of “Assistance publique–Hôpitaux de Paris”, a large teaching hospital, for years 2002 to 2005.ResultsThe risk of readmission according to length of stay, taking age, sex, comorbidity, hospital and year of admission into account, followed a J-shaped curve for both procedures. The probability of readmission was higher for very short stays, with odds ratios and 95% confidence intervals of 6.03 [2.67–13.59] for cholecystectomies (1- versus 3-night stays), and of 1.74 [1.05–2.91] for vaginal deliveries (2- versus 3-night stays).ConclusionFor both procedures, the shortest lengths of stay are associated with a higher readmission probability. Suitable indicators derived from administrative databases would enable monitoring of the association between length of stay and readmissions.     

What has influenced patient health‐care expenditures in Japan?: variables of age,death, length of stay,and medical care

This study considers variables related to health-care expenditures associated with aging and long-term hospitalization in Japan. We focused on daily per capita inpatient health-care expenditures, and examined the impact of inpatient characteristics such as sex, age, survived or deceased, length of stay, adult disease, and type of medical care received during the duration of each stay. We analyzed data from the Survey of Medical-Care Activities in Public Health Insurance by multinomial logistic regression analyses. Age of patient had little impact on per capita inpatient health-care expenditures per day. As regards length of stay, inpatient stays of 8-14 days had a little impact on health-care expenditures. This study suggested that these results might be due to the kind of medical care received. More research is needed to determine the appropriate medical services to reduce long-term hospitalization. In the last month of care for patients who died, medical examinations had a great influence on health-care expenditures. This study showed that increasing medical examinations in the end-of-life care needs further investigation.     

军队医疗保障制度改革对住院费用影响研究

目的：本课题针对军队医改的具体措施和对住院费用所产生的影响，根据医改前后医院运行状况的实际变化，对军队医改所产生的影响和效果进行实证分析，拟探索军队医改政策对医院医疗模式与费用所产生的影响，以及相关的政策建议。方法：对军队医改前后的医疗特征、医疗费用水平及构成特点进行分析后，进行多因素分析。结论：住院费用的主要影响因素有住院天数、年龄、手术情况和医改政策。     

公立医院DRG病组成本-效益分析探索*

目的：为适应医改变化,提升医院精细化管理水平,进一步强化业财融合,为医院病种结构优化和专科发展方向提供参数依据,为DRG预付费改革提供数据参考。方法：运用作业成本法、项目叠加法和象限分析法,开展基于DRG病组的成本核算与效益分析。结果：生成院、科两级DRG病组及相关医疗、财务关键数据;通过院级专科和DRG病组的象限划分区别优劣类型,实施战略分析;随着病种并发症和伴随症的发生以及严重程度加深,住院平均天数、CMI升高,病种效益下降。结论：典型病组(专病)专科专治,效益更具优势;现行医疗服务项目价格与国家病种付费及分级诊疗改革方向存在差距;对DRG病组效益分析、象限分析和收支来源进行解读,呼吁杜绝医疗浪费、控制成本消耗,促进临床诊疗与经济运营的结合,获得临床科室的认可,起到了为临床提示病种结构优劣调整和专科建设发展方向的作用。     

The impact of hospital financing on the length of stay: evidence from Austria

In 1997, Austria has changed the hospital financing system from a per diem-based payment scheme to a per case-based one. This paper assesses whether this reform has influenced the hospital length of stay. Empirically, we use data for 20 diagnostic groups (according to the ICD10) from the nine Austrian provinces (Bundesländer) between 1989 and 2003. Our findings suggest that the change of the hospital financing system has induced a substantial decrease in the average hospital length of stay. This effect is more pronounced for diagnostic groups with a longer length of stay.     

内蒙古自治区某三级医院住院患者常见医院感染的直接经济损失

目的对住院患者常见医院感染造成的直接经济损失进行研究,为增强医务人员医院感染防控意识,提升医院感染防控能力提供参考依据。方法回顾性调查2017年1月1日—12月31日内蒙古自治区某三级医院发生呼吸道医院感染、血流医院感染、消化道医院感染、手术部位感染、泌尿道医院感染的住院患者,按照配对标准1∶1配对病例组(医院感染)和对照组(非医院感染),采用配对资料Wilcoxon检验分析医院感染造成的直接经济损失。结果最终匹配成功262对,每例患者由医院感染所造成的直接经济损失为31 300元,其中重症监护病房(ICU)医院感染直接经济损失最大(100 857元)。两组患者住院总费用、住院日数比较,差异均有统计学意义(均P0.05);两组患者床位费、护理费、西药费、手术费、治疗费、化验费、检查费比较,差异均有统计学意义(均P0.05),各项费用中以西药费最高(14 378元)。两组患者不同医院感染部位造成的平均住院总费用和住院日数比较,差异均有统计学意义(均P0.05)。不同医院感染部位的平均住院总费用由高至低依次为手术部位(47 469元)、血液(42 498元)、泌尿道(34 598元)、消化道(33 296元)、呼吸道(31 058元)。病例组患者延长平均住院日数7 d,两组患者平均住院日数比较,差异有统计学意义(P0.05)。结论住院患者发生医院感染后可导致医疗费用增加,平均住院日延长,给患者带来了较大损失。     

Hospital supplements in Belgium: Price variation and regulation

ObjectivesAlthough there is a comprehensive public health insurance system in Belgium, out-of-pocket expenditures can be very high, mainly for inpatients. While a large part of the official price is reimbursed, patients are confronted with increased extra billing (supplements). Therefore, the government imposed various restrictions on the amount of supplements to be charged, related to the type of room and the patient's insurance status. We investigate how prices are set and whether the restrictions have been effective.MethodsWe use an administrative dataset of the Belgian sickness funds for the year 2003 with billing data per hospitalisation and hospital characteristics. Boxplots describe the distribution of several categories of supplements. OLS is used to explore the relationship between hospital characteristics and extra billing.ResultsThere is a large and intransparent variation in extra billing practices among different hospitals. Given the room type, supplements per day are smaller for patients qualifying for protection, confirming that the regulation is applied quite well. However, because of their longer length of stay this does not result in lower supplements per stay for these patients.ConclusionsCurrently the price setting behavior of providers lacks transparency. Protective regulation could be refined by taking into account the longer length of stay of vulnerable groups.     

Investigating technical efficiency and its determinants: The Case of New Zealand District Health Boards

This study investigates the technical efficiency of New Zealand's District Health Boards (DHBs) in providing hospital services, as well as the effect of certain environmental factors on efficiency. This study is the first to use quarterly data on New Zealand DHBs from 2011 to 2017 and apply the two-stage double-bootstrap methodology of Simar and Wilson. The bias-corrected technical efficiency estimates show that on average, DHBs in the areas with high socioeconomic deprivation operate with low technical efficiency. Furthermore, DHB providing secondary hospital services are less efficient than tertiary DHBs. The result from truncated regression indicates that a higher proportion of surgical, elderly, and acute inpatients is associated with increasing levels of technical efficiency. In contrast, the high average length of hospital stay negatively impacts technical efficiency levels. The findings of this study urge policymakers to adopt policies to address the shortages of healthcare staff, barriers to primary healthcare, lack of investment in hospital capacity, and technology to enhance healthcare sector's long-run technical efficiency. In addition, the existing DHB funding formula needs to be revisited as this tends to include perverse incentives for secondary DHBs where patients are kept longer in hospitals, leading to a higher average length of stays in hospitals and is associated with increasing levels of inefficiency.     

Effectiveness of Comanagement Model: Geriatric Medicine and Vascular Surgery

ObjectivesOlder surgical patients frequently develop postoperative complications due to their frailty and multiple comorbidities. Geriatric medicine consultation helps to optimize risk factors and improve outcomes in patients with hip fracture. This study aimed to evaluate patient outcomes before and after comanagement model implementation between geriatric medicine (Geriatric Surgical Service) and vascular surgery services.DesignThis was a case-control study involving emergency vascular surgical patients who were comanaged by vascular surgery, geriatric medicine, and geriatric nursing services.Settings and ParticipantsThis study was conducted in a tertiary hospital in Singapore from 2015 to 2018 with acute vascular surgical patients aged older than 65 years.MethodsA retrospective cohort of 135 patients from 2013 to 2014 (control group) who fulfilled the criteria for the comanagement model was compared with a prospective cohort of 348 patients who were comanaged by a geriatric surgical service from 2015 to 2018, and a further subgroup analysis of patients between 2015 and 2016 (n = 150) (early intervention group) and between 2017 and 2018 (n = 198) (late intervention group) was performed.ResultsComanaged patients had a significantly shorter length of hospital stay (11.6 vs 20.8 days, P = .001), reduced nosocomial infections (3% vs 12% for urinary tract infection, P = .003) and decreased 30-day readmission rates (22% vs 34%, P = .011). A trend of a decreased incidence of fluid overload was noted in patients comanaged with the geriatric surgical service (3% vs 7%, P = .073). Subgroup analysis showed progressive reductions in the length of stay (15.4 vs 11.6 days, P = .001), 30-day readmission rate (35% vs 22%, P = .01), and nosocomial urinary tract infection (8% vs 3%, P = .003) between the early intervention group and the late intervention group. Although they were not statistically significant, reductions were also observed in the delirium rate (13% vs 11%) and other postoperative medical complications in the early intervention group and the late intervention group.Conclusion and ImplicationsDespite having increasing comorbidities, older vascular surgical inpatients had a significantly shorter length of stay, reduced nosocomial infections, and decreased 30-day readmission rates through a comanagement model with vascular surgery and geriatric medicine services. Improvements in outcomes were observed over time as the model of care evolved. Geriatric medicine intervention in the perioperative period improves the outcomes of older acute vascular surgical patients.     

Effects of Copayment in Long-Term Care Insurance on Long-Term Care and Medical Care Expenditure

ObjectiveThis study aimed to clarify the difference in (1) long-term care (LTC) usage and expenditure and (2) medical care service usage and expenditure before and after the change in the copayment limit for qualifying individuals from 10% to 20%.Setting and ParticipantsThis quasi-experimental longitudinal design used the database from 1 prefecture of Japan that included 570,434 person-month records of 23,879 insured individuals (in August 2014) who used LTC services between August 2014 and July 2015 and were aged 65 years and older on August 1, 2014.MethodsWe conducted difference-in-difference estimations to compare “before” and “after” outcome differences between insured individuals whose LTC copayment increased to 20% and those whose copayment remained at 10%. Sex, age, Care Needs Level, subsidy, and public assistance were adjusted in the models, along with robustness checks.ResultsDifferences in both insurer's payment and insured's copayment indicated statistical significance between those whose copayment increased and those whose copayment did not increase. We found no significant difference in the number of minutes of home care service use, days of facility care service use, and LTC expenditures among those with copayment increases as well as those with no increase in copayment following the insured's copayment increase policy implementation. In contrast, the policy implementation caused significant differences in the number of days of hospitalization, medical care expenditures, and total expenditures.Conclusions and ImplicationsThe increase in insured individuals' copayment decreased LTC insurer's payment. However, total LTC expenditure increased over time although the increase trend slowed down in the treatment group after the copayment increase policy implemented. Besides, medical care expenditure increased consistently among insured individuals whose copayment increased. As there appears to be a “balloon effect” between LTC and medical care services, it is important to discuss the medical care system while considering the LTC insurance system comprehensively.     

The long-term effects of Medicaid managed care on obstetrics care in three California counties

OBJECTIVE: To evaluate the long-term effects of Medicaid managed care (MMC) on obstetric service use and program costs in California. DATA SOURCES/STUDY SETTING: Longitudinal administrative data on Medi-Cal enrollment and claims and encounters related to pregnancy and delivery services were gathered from three counties--two long-standing MMC counties and one traditional fee-for-service Medicaid county--in California between 1987 and 1992. STUDY DESIGN: We studied Aid to Families with Dependent Children (AFDC) beneficiaries with live singleton vaginal deliveries with associated hospital stays of 14 days or less. Effects of managed care were examined with respect to prenatal visits, length of stay for delivery, maternal postpartum readmission rates, and total program expenditures. Multivariate analyses examined how the relative effect of managed care on service use and program expenditures in each MMC county evolves over time in comparison to fee-for-service. We controlled for length of Medi-Cal enrollment prior to delivery, data censoring, and individual characteristics such as race and age. PRINCIPAL FINDINGS: Prenatal care use is consistently lower in the MMC counties, although all three counties' prenatal care provision is well below the national standard. Drastic increases in one-day-stay deliveries were found: up to almost 50 percent of deliveries in MMC counties were one-day stays. Program cost savings associated with MMC enrollment are unambiguous. CONCLUSIONS: MMC cost savings might have come at the expense of reduced provision of prenatal care and shorter delivery length of stay. Future studies should verify any possible causal link and the effects on maternal and infant health outcomes.     

Introduction of diagnosis-related groups in Germany: evaluation of impact on in-patient care in a dermatological setting

BACKGROUND: German diagnosis-related groups (G-DRG) have been introduced in Germany as a reimbursement system for in-patient care. The aim of this study was to report data-based experiences from the introduction process and to evaluate the impact on in-patient dermatology. METHODS: A quantitative analysis including clinical data from two large university centres of dermatology over a time period of 4 years (2003-06) has been performed. Characteristics and trends of case-mix index, number of cases, average age, length of stay (LOS), surgical and medical treatments and in-patient case groups were studied in detail. RESULTS: It was found that the case-mix index values increased after the introduction period, but subsequently declined on the initial value. At the same time, an increase of dermatological hospital admissions can be noticed parallel to a significant reduction of LOS (P < 0.001) and a moderate increase of average age (P < 0.001). Analysis of DRG assignment revealed an initial significant decline of surgical in-patient procedures and increasing medical treatments, however, without obvious long-term changes. Furthermore, a growing importance for dermatological oncology and inflammable skin diseases within the in-patient setting could be observed. CONCLUSIONS: The introduction of the G-DRG system in Germany induced changes in in-patient care affecting hospital admission rates, LOS and cases treated in an in-patient setting. In-patient activities have not been reduced with the DRG introduction; however, long-term interdisciplinary research approaches are needed to explore the future impact on health care providing and quality of health care in depth.     

Hospitalization for urinary tract infections and the quality of preventive health care received by people with spina bifida

BackgroundThe preventive health care needs of people with disabilities often go unmet, resulting in medical complications that may require hospitalization. Such complications could be due, in part, to difficulty accessing care or the quality of ambulatory care services received.ObjectiveTo use hospitalizations for urinary tract infections (UTIs) as a marker of the potential quality of ambulatory care services received by people affected by spina bifida.MethodsMarketScan inpatient and outpatient medical claims data for 2000 through 2003 were used to identify hospitalizations for UTI, which is an ambulatory care sensitive condition, for people affected by spina bifida and to calculate inpatient discharge rates, average lengths of stay, and average medical care expenditures for such hospitalizations.ResultsPeople affected by spina bifida averaged 0.5 hospitalizations per year, and there were 22.8 inpatient admissions with UTI per 1000 persons with spina bifida during the period 2000–2003, in comparison to an average of 0.44 admission with UTI per 1000 persons for those without spina bifida. If the number of UTI hospitalizations among people affected by spina bifida were reduced by 50%, expenditures could be reduced by $4.4 million per 1000 patients.ConclusionsConsensus on the evaluation and management of bacteriuria could enhance clinical care and reduce the disparity in UTI discharge rates among people affected by spina bifida compared to those without spina bifida. National evidence-based guidelines are needed.     

A cost-minimization analysis of diuretic-based antihypertensive therapy reducing cardiovascular events in older adults with isolated systolic hypertension

OBJECTIVE: This study investigated a) the amount and types of out-of-pocket expenditures by patients for nominally free services in a large public hospital in Bangladesh, b) the factors influencing these expenses, and c) the impact of these expenses on household income. METHODS: Eighty-one maternity patients were interviewed during their hospitalization in the Dhaka Medical College Hospital. Patients were selected by quota sample to match the distribution of maternity patient categories in the hospital. Patients were interviewed with a semi-structured, in-depth questionnaire. RESULTS: All interviewees incurred substantial out-of-pocket expenditures for travel, hospital admission fees, medicine, tests, food, and tips. Only two of the expenditures, travel expenses and admission fees, were not supposed to be provided free of charge by the hospital. The median total per-patient expenditure was $65 (range $2-$350), equivalent to 7% (range 0.04%-225%) of annual household income. Half of all patients reported that their families had to borrow to pay for care at interest rates of 5%-30% per month. A third of these families reported selling jewelry, land or household items to moneylenders. The rural patients reported more difficulty in paying for care than the urban patients. Factors increasing the expenditures were duration of hospitalization, rural residence, and necessary (e.g. C-section, hysterectomy) and unnecessary (e.g. episiotomy) medical procedures. CONCLUSION: Free maternity services in Bangladesh impose large out-of-pocket expenditures on patients. Authorities could reduce the burden by reducing the duration of hospital stays, limiting use of medical procedures, eliminating tips, and moving routine services closer to potential users. Fee for service could reduce unofficial expenditures if the fee were lower than and replaced typical unofficial expenditures, otherwise adding service fees without reform of current hospital practices would lead to even more burdensome expenditures and inequities.     

The Great Recession in Portugal: Impact on hospital care use

The Great Recession started in Portugal in 2009, coupled with severe austerity. This study examines its impact on hospital care utilization, interpreted as caused by demand-side effects (related to variations in population income and health) and supply-side effects (related to hospitals’ tighter budgets and reduced capacity).The database included all in-patient stays at all Portuguese NHS hospitals over the 2001–2012 period (n = 17.7 millions). We analyzed changes in discharge rates, casemix index, and length of stay (LOS), using a before–after methodology. We additionally measured the association of health care indicators to unemployment.A 3.2% higher rate of discharges was observed after 2009. Urgent stays increased by 2.5%, while elective in-patient stays decreased by 1.4% after 2011. The LOS was 2.8% shorter after the crisis onset, essentially driven by the 4.5% decrease among non-elective stays. A one percentage point increase in unemployment rate was associated to a 0.4% increase in total volume, a 2.3% decrease in day cases, and a 0.1% decrease in LOS.The increase in total and urgent cases may reflect delayed out-patient care and health deterioration; the reduced volume of elective stays possibly signal a reduced capacity; finally, the shorter stays may indicate either efficiency-enhancing measures or reduced quality.