Effects of Integrated Case Payment on Medical Expenditure and Readmission of Inpatients with Chronic Obstructive Pulmonary Disease: A Nonrandomized, Comparative Study in Xi County, China

Abstract

In the past few decades, Chinese government attempted to reduce the economic burden of chronic diseases and lower family financial risk of patients by establishing a nationwide coverage of Social Health Insurance system. However, the payment mode of Social Health Insurance varies across Chinese healthcare settings, and the effectiveness of each mode differs. This study aimed to evaluate the effects of integrated case payment on medical expenditure and readmission of inpatients with chronic obstructive pulmonary disease (COPD), a complex, multicomponent, chronic condition. A nonrandomized, comparative method was used in this study. Inpatients with COPD before (n=1569) and after the integrated case payment reform (n=4764) were selected from the inpatient information database of the New Cooperative Medical Scheme Agency of Xi County. The integrated case payment comprises the case payment (including price-cap case payment and fixed-reimbursement case payment) and clinical pathway (including clinical pathway A, clinical pathway B and clinical pathway C). Effects of integrated case payment were evaluated with indicators of per capita total medical expense and readmission within 30 days. A multivariate linear regression and a binary logistic regression were used to conduct statistical analysis. The results showed that case payment, comprising price-cap case payment β=2382.988, P<0.001) and fixed-reimbursement case payment β=2613.564, P<0.001), and clinical pathway C β=1996.467, P<0.001) were risk factors of per capita total medical expenses. Clinical pathway A β=1443.409, P<0.001) and clinical pathway B β=1583.791, P<0.001) were protective factors. The interactive effects of case payment with hospital level β=0.710, P<0.001) lowered the readmission rate within 30 days. Meanwhile, clinical pathways A β=18.949, P<0.001), B (β=19.152, PO.OOl) and C β=1.882, P<0.001) were associated with the rate increase. The findings revealed that integrated case payment ensured the quality of care for inpatients with COPD to some extent. However, this payment mode increased the per capita total medical expense. Further, policy-makers should set reasonable reimbursement standards of case payment, unify the type of case payment, and strengthen the supervision of the reform to enhance its function on medical cost control.

Keywords

chronic obstructive pulmonary disease / integrated case payment / clinical pathway / Xi county

References

[1] DansA, NgN, VargheseC, et al.. The rise of chronic non-communicable diseases in southeast Asia: time for action. Lancet, 2011, 377(9766): 680-689

[2] DecramerM, AgustiA, BourbeauJ, et al.. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 2007, 176: 532-555

[3] GoldPM. The 2007 GOLD Guidelines: a comprehensive care framework. Respir Care, 2009, 54(8): 1040-1049

[4] BuistAS, McBurnieMA, VollmerWM, et al.. International variation in the prevalence of COPD (the BOLD Study): a population-based prevalence study. Lancet, 2007, 370(9589): 741-750

[5] MortazE, LazarZ, KoendermanL, et al.. Cigarette smoke attenuates the production of cytokines by human plasmacytoid dendritic cells and enhances the release of IL-8 in response to TLR-9 stimulation. Respir Res, 2009, 10(1): 47

[6] EhteshamiafsharS, FitzgeraldJM, DoylewatersMM, et al.. The global economic burden of asthma and chronic obstructive pulmonary disease. Int J Tuberc LungDis, 2016, 20(1): 11-23

[7] HoongJM, FergusonM, HukinsC, et al.. Economic and operational burden associated with malnutrition in chronic obstructive pulmonary disease. Clin Nutr, 2017, 36(4): 1105-1109

[8] National Heart L, Institute B. Morbidity and mortality: 2002 chart book on cardiovascular, lung, and blood diseases. Bethesda, MD: National Institutes of Health 2002:32

[9] GuarascioAJ, RaySM, FinchCK, et al.. The clinical and economic burden of chronic obstructive pulmonary disease in the USA. Clinicoecon Outcomes Res, 2013, 5(1): 235-245

[10] LoddenkemperR, LoddenkemperR. European Lung White Book. The first comprehensive survey on respiratory health in Europe, 2003107

[11] RobertsCM, LoweD, BucknallCE, et al.. Clinical audit indicators of outcome following admission to hospital with acute exacerbation of chronic obstructive pulmonary disease. Thorax, 2002, 57(2): 137

[12] SeemungalTA, HurstJR, WedzichaJA. Exacerbation rate, health status and mortality in COPD~a review of potential interventions. COPD, 2009, 4(1): 203-223

[13] Garcia-AymerichJ, FarreroE, FêlezMA, et al.. Risk factors of readmission to hospital for a COPD exacerbation: a prospective study. Thorax, 2003, 58(2): 100-105

[14] CaoZ, OngK C, EngP, et al.. Frequent hospital readmissions for acute exacerbation of COPD and their associated factors. Respirology, 2005, 11(2): 188-195

[15] SorianoJB, MaierWC, EggerP, et al.. Recent trends in physician diagnosed COPD in women and men in the UK. Thorax, 2000, 55(9): 789-794

[16] HarrisonSL, GoldsteinR, DesveauxL, et al.. Optimizing nonpharmacological management following an acute exacerbation of chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis, 2014, 9(9): 1197-1205

[17] LiangX, HongG, JinC, et al.. The effect of new cooperative medical scheme on health outcomes and alleviating catastrophic health expenditure in China: A systematic review. Plos One, 2012, 7(8): e40850

[18] AdeloyeD, ChuaS, ChinweiL, et al.. Global and regional estimates of COPD prevalence: systematic review and meta-analysis. J Glob Health, 2015, 5(2): 020415

[19] ChanyeungM, AïtkhaledN, WhiteN, et al.. The burden and impact of COPD in Asia and Africa. Int J Tuberc Lung D, 2004, 8(1): 2-14

[20] FeethamL v, DomA. Chronic obstructive pulmonary disease (COPD). Lancet Rest Med, 2017, 5(1): 18-19

[21] FangX, WangX, BaiC. COPD in China: The burden and importance of proper management. Chest, 2011, 139(4): 920

[22] EgglestonK, LingL, QingyueM, et al.. Health service delivery in China: a literature review. Health Econ, 2008, 17(2): 149-165

[23] YipWC, HsiaoW, MengQ Y, et al.. Realignment of incentives for health-care providers in China. Lancet, 2010, 375(9720): 1120-1130

[24] YipWC, HsiaoWC, ChenW, et al.. Early appraisal of China's huge and complex health-care reforms. Lancet, 2012, 379(9818): 833-842

[25] VanhaechtK. The impact of clinical pathways on the organisation of care processes, 200725-26

[26] VestboJ, HurdSS, AgustiAG, et al.. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med, 2013, 187(4): 347-365

[27] SmithBJ, CheokF, HeardAR, et al.. Impact on readmission rates and mortality of a chronic obstructive pulmonary disease inpatient management guideline. Chron Resp Dis, 2004, l(1): 17-28

[28] FarleyK. The COPD critical pathway: a case study in progress. Qual Manag Health Ca, 1995, 3(2): 43

[29] SantamariaN, ConnersAM, OsteraasJ, et al.. A prospective cohort study of the effectiveness of clinical pathways for the in-patient management of acute exacerbation of chronic obstructive pulmonary disease (COPD). Collegian, 2004, 11(1): 12-16

[30] McmanusTE, MarleyAM, KidneyJC. The mater hospital multiprofessional care pathway for acute exacerbations of chronic obstructive pulmonary disease. Int J Care Pathways, 2005, 9(9): 32-36

[31] LodewijckxC, SermeusW, PanellaM, et al.. Impact of care pathways for in-hospital management of COPD exacerbation: a systematic review. Int J Nurs Stud, 2011, 48(11): 1445-1456

[32] BanA, IsmailA, HarunR, et al.. Impact of clinical pathway on clinical outcomes in the management of COPD exacerbation. Bmc PulmMed, 2012, 12(1): 1-8

[33] Statistical Communique on National Economic and Social Development of Henan Province, 2009–2014. https://doi.org/www.ha.stats.gov.cn/sitesources/

[34] RamosMC. The successful utilization of financial data in the support of care management. Fam Commun Health, 1999, 22(3): 49-63

[35] LeeKH, AndersonYM. The association between clinical pathways and hospital length of stay: a case study. J Med Syst, 2007, 31(1): 79-83

[36] CheneyJ, BarberS, AltamiranoL, et al.. A clinical pathway for bronchiolitis is effective in reducing readmission rates. J Pediatr, 2005, 147(5): 622-626

[37] LembergDA, DayAS, BrydonM. The role of a clinical pathway in curtailing unnecessary investigations in children with gastroenteritis. Am J Med Qual, 2005, 20(2): 83-89

[38] WongAW, GanWQ, BumsJ, et al.. Acute exacerbation of chronic obstructive pulmonary disease: influence of social factors in determining length of hospital stay and readmission rates. Can Respir J, 2008, 15(7): 361-364

[39] LodewijckxC, SermeusW, VanhaechtK, et al.. Inhospital management of COPD exacerbations: a systematic review of the literature with regard to adherence to international guidelines. J Eval Clin Pract, 2009, 15(6): 1101-1110