Who consumes curative care expenditure of medical institutions in Beijing: a case study based on System of Health Accounts 2011.

BACKGROUND: China's health system is challenged by complex health problems experienced by different population groups and caused by multiple diseases. This study examined the distribution of curative care expenditure (CCE) of medical institutions in Beijing using beneficiary characteristics such as residency, gender, age, and disease. Suggestions are presented for the development of health policies. METHODS: A total of 81 medical institutions with approximately 80 million patients in Beijing, China, were selected via a multistage stratified cluster random sampling approach. Based on this sample, the System of Health Accounts 2011 was used to estimate the CCE of medical institutions. RESULTS: The CCE of medical institutions in Beijing was ¥246.93 billion in 2019. The consumption of patients from other provinces was ¥60.04 billion, accounting for 24.13% of the total CCE. The CCE of female consumption (52.01%/¥128.42 billion) exceeded that of male consumption (47.99%/¥118.51 billion). Almost half of the CCE (45.62%/¥112.64 billion) was consumed by patients aged 60 or above. Adolescent patients up to an age of 14 (including those aged 14) mainly chose secondary or tertiary hospitals for treatment. Chronic non-communicable diseases accounted for the largest share of CCE consumption, with circulatory diseases accounting for the highest proportion. CONCLUSIONS: This study identified significant differences in CCE consumption in Beijing according to region, gender, age, and disease. Currently, the utilization of resources in medical institutions is not reasonable, and the hierarchical medical system is not sufficiently effective. Therefore, the government needs to optimize the allocation of resources according to the needs of different groups and rationalize the institutional process and functions.

The impact of comprehensive public hospital reforms on the direct medical cost of inpatients with coronary heart disease.

Objectives: To curb the unreasonable growth of medical expenses and reduce the burden of medical treatment, Beijing launched two rounds of comprehensive reform of public hospitals. In the two reforms, the addition of drugs and consumables was canceled successively. This study compared the changes in the direct medical cost of inpatients with coronary heart disease (CHD) in the three stages of two comprehensive public hospital reforms in Beijing and provides data support for health reform policies. Setting: CHD diagnosis and treatment data were extracted from the Hospital Information System (HIS) of 33 public hospitals. The total amount and composition of the direct medical expenses of CHD inpatients in the three stages were calculated. Interrupted time series analysis was used to study the instantaneous changes and trend changes in the three stages. Participants: The data were obtained from the HIS system of 33 public hospitals above the second level in Beijing. A total of 66,647 medical and diagnosis records and 24,371,139 charge detail records were included. Results: After the two reforms, the total cost for CHD inpatients with most clinical classifications and treatment methods decreased. The proportion of drug and consumable costs decreased significantly, whereas the proportion of medical consultation service costs increased. Drug-treated patients were mainly affected by the instantaneous reforms, percutaneous coronary intervention-treated patients were simultaneously affected by instantaneous and trending effects, and coronary artery bypass graft-treated patients were mainly affected by the reform trend. Conclusion: The overall change in the direct medical cost of CHD inpatients was consistent with the goal of the comprehensive medical reform of public hospitals in Beijing, which is "total control and structural adjustment."

Danhong Injection Price Trend and Its Utilization by Coronary Heart Disease Patients: Evidence From Hospital Records in China.

Background: Danhong injection (DHI) accounts for the highest proportion of drug costs for inpatients with coronary heart disease (CHD). However, if DHI price influences utilization remains unclear. Objective: The objective was to compare changes in the use of DHI for CHD patients during three stages after two comprehensive reforms of public hospitals in Beijing. These findings will provide support for controlling the drug burden of CHD patients and regulating drug use behavior. Research Design: CHD diagnosis and treatment data were extracted from the Hospital Information System (HIS) of 33 public hospitals. Patients were grouped according to different treatment methods and clinical classifications. Changes in the utilization of DHI, including the use rate (the percentage of CHD patients using DHI), number of prescribed units (average number of units of DHI prescribed per hospital stay), and cost of DHI per hospital stay (equal to the unit price multiplied by the number of prescribed units) between the three stages were statistically analyzed. Association rules were applied to identify changes in drug combinations. Results: After the two reforms, the unit price of DHI dropped from $6.46 to $5.61. At the same time, the use rate increased from 20.77 to 24.00%, the number of prescribed units dropped from 29.76 to 29.21, and the cost of DHI per hospital stay dropped from $192.12 to $163.96. The changes in the use rate and number of prescribed units varied among patients with different clinical types and treatment methods, and the cost of CHI per hospital stay was consistent with the overall situation. The variety of drugs used in combination with DHI remained relatively stable. Conclusion: The use rate of DHI for CHD patients increased, indicating increased applications of DHI in clinical practice. Due to the drop in price, the cost of using DHI decreased, and the financial burden of this drug was reduced.

Do China rural traditional Chinese medicine hospitals provide efficient healthcare to the people? Empirical study from 2013 to 2018 using data envelopment analysis.

Rural traditional Chinese medicine hospitals bear responsibilities of providing efficient medical services for rural residents. Efficiency assessments have previously been conducted in single province. This study aimed to investigate the technical efficiency of rural traditional Chinese medicine hospitals across China from 2013 to 2018, with the application of super slack-based measure data envelopment analysis. In total, 1219 hospitals covering 28 provinces were included as sample hospitals. Overall, hospitals performed technically less efficiently but presented with an increasing trend. Redundancy and insufficiency existed in health input and output variables, respectively. Notably, optimizing input variables was found to make more substantial improvement in hospital efficiency. Provincial and regional disparities were also observed in hospital efficiency. In conclusion, rural traditional Chinese medicine hospitals have experienced slight improvement in efficiency during the study period, however, their efficiency was still in a relatively low level with ample room for improvement. Meanwhile, regional coordinated development should also be noticed in this process.

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

BACKGROUND: Stroke is one of the leading public health issues in China and imposes a heavy financial burden on patients and the healthcare system. This study assess which payment method provides the lowest hospital costs for China's healthcare system and the lowest out-of-pocket (OOP) expense for insured patients. METHODS: This is a 4-year cross-sectional study. From the China Health Insurance Research Association (CHIRA) database, a 5% random sample of urban health insurance claims was obtained. Descriptive analysis was conducted and a generalized linear model (GLM) with a gamma distribution and a log link was estimated. RESULTS: For outpatients, capitation payment had the lowest hospital cost (RMB180.9/US$28.8) and lowest OOP expenses (RMB75.6/US$12.0) per patient visit in primary hospitals compared with fee-for-service (FFS) payments. The global budget (GB) displayed the lowest total hospital costs (RMB344.7/US$54.8) in secondary hospitals, and was 27.4% (95% CI=-0.32, -0.29) lower than FFS. FFS had the lowest OOP expenses (RMB123.4/US$19.6 vs. RMB151.8/US$24.1) in secondary and tertiary hospitals. For inpatients, FFS had the lowest total hospital costs (RMB5918.7/US$941.1) per visit and capitation payments had the lowest OOP expenses (RMB876.5/US$139.4, 40.1% lower than FFS, 95% CI=-0.58, -0.15) in primary hospitals. Capitation payment had both the lowest hospital costs (RMB7342.9/US$1167.5 vs. RMB17 711.7/US$2816.2) and the lowest OOP expenses (RMB1664.2/US$264.6 vs. RMB3276.3/US$520.9) for both secondary and tertiary hospitals. CONCLUSION: For outpatients in primary hospitals and inpatients in secondary and tertiary hospitals, the capitation payment was the most money-saving payment method delivering both the lowest OOP expenses for patients and the lowest hospital total costs for hospitals. We recommend that health policymakers prioritize the implementation of the payment method with the lowest OOP expenses when the payment method does not deliver both the lowest hospital costs for the health system and lowest OOP expenses for patients.

Strengthening of Traditional Chinese Medicine in the Health System Reform: Effect on Health Outcomes and Financial Protection.

BACKGROUND: The challenges of modern medicine in addressing chronic diseases necessitate a shift of attention towards traditional medicine (TM) and other supplementary care systems. China has prioritized the strengthening of traditional Chinese medicine (TCM) in the health system reform since 2009. This study sought to assess the effects of the reform on TCM and the resultant effect of a strengthened TCM on health outcomes and financial protection. METHODS: Longitudinal data were obtained from the China Statistical Yearbook, China Health Statistical Yearbook, China Population Statistical Yearbook, and Statistical Extract of Traditional Chinese Medicine in 31 provinces of mainland China between 2002 and 2016. Dependent variables included health outcomes measured by age-standardized excess mortality and life expectancy at birth and financial protection measured by the proportion of health expenses in total consumption expenses. The independent variables consisted of the number and proportion of TCM physicians. The fixed effects (FEs) models were established to identify the effect of the independent variables on outcomes. RESULTS: From 2009 to 2016, the number and proportion of TCM physicians increased from 22 to 36 physicians per 100,000 population and from <12% to >15%, respectively. The changes were more rapid and higher than that in the period before the reform. An increase of 1 TCM physician per 100,000 population was associated with a decrease of 1.944 excess deaths, a 5.84-day increase in male life expectancy, and a decrease of 0.051% of health expenses among both urban and rural residents. An increase in proportion of 1% of TCM physicians was associated with a decrease of 5.097 excess deaths, a 17.52-day increase of life expectancy (both genders), an increase of 21.535-day in life expectancy (males) per 100,000 population, and a decrease of 0.082% of health expenses among rural residents. CONCLUSION: During China's health system reform, the increased physician number has strengthened TCM. Higher TCM physician supply was associated with improved health outcomes and financial protection, which implies that the reform may have important implications on health system performance in China.

Impact of Beijing healthcare reform on the curative care expenditure of outpatients with noncommunicable diseases based on SHA2011 and interrupted time series analysis.

BACKGROUND: To analyse the changes in curative care expenditure (CCE) associated with noncommunicable diseases (NCDs) before and after the Beijing healthcare reform, thus providing a reference for the healthcare system. METHODS: A total of 60 medical institutions were selected using multistage stratified cluster random sampling in Beijing, China. The records of approximately 100 million outpatients with NCDs in 2016-2018 were extracted. System of Health Accounts 2011 (SHA2011) was used to estimate the CCE. The segmented regression model was established to observe both the instant change and the slope change of intervention in interrupted time series analysis (ITSA). The study was conducted from December 2019 to May 2020 in Beijing, China. RESULTS: From SHA2011, we found that the CCE for outpatients with NCDs in Beijing were 58.59, 61.46 and 71.96 billion RMB in 2016, 2017 and 2018, respectively. The CCE continued to rise at all hospital levels, namely, tertiary, secondary, and community-level hospitals. However, the proportion of CCE in tertiary hospitals decreased. From ITSA, we can also conclude that the CCE showed a significant increasing trend change at the three hospital levels after the intervention. The drug proportion showed a significant decreasing trend change in secondary and tertiary hospitals. CONCLUSIONS: Beijing healthcare reform does have an impact on the CCE of NCDs.

Cost-utility analysis of newborn hepatitis B immunization in Beijing.

OBJECTIVES: To evaluate cost-utility of universal Hepatitis B vaccination program in the Beijing city (Beijing). METHODS: A decision-Markov model was constructed to determine the cost-utility of the universal immunization program for infants (universal vaccination program) by comparing with a hypothetic nonvaccination strategy in Beijing. Parameters in models were extracted from Beijing Center for Disease Control and Prevention (CDC) annual work report, Beijing health statistical yearbook, National Health Survey report, Beijing 1% population sample survey report, Beijing Health and Medical Price Monitoring Data Platform, and public literatures. The incremental cost­utility ratio (ICUR) was used to compare alternative scenarios. One-way sensitivity analysis and probabilistic sensitivity analysis were used to assess parameter uncertainties. RESULTS: The universal vaccination program had increased the utility and reduced cost among infants born in 2016 in Beijing. The ICUR was CNY -24,576.61 (US$ -3779.16) per QALY for universal vaccination program comparing with non-vaccination scenario from healthcare perspective. It was estimated that the universal vaccination would save direct medical treatment cost of CNY 2,262,869,173.50 (US$ 347,962,414.43) and prevent loss of 18322.25 QALYs within lifetime of target cohort. Discount rate accounted for the most remarkable influence on ICUR in one-way sensitivity analysis. The result of probabilistic sensitivity analysis illustrated that all of the ICURs were located in the fourth quadrant of the cost-utility incremental plot undergone 5000 times of Monte Carlo simulation. CONCLUSIONS: Current universal hepatitis B vaccination program in Beijing was highly cost utility. The investment was reasonable for current universal vaccination program in Beijing.

Utilisation of health services among urban patients who had an ischaemic stroke with different health insurance - a cross-sectional study in China.

OBJECTIVES: This study investigates the disparities in the utilisation of patient health services for patients who had a stroke covered by different urban basic health insurance schemes in China. DESIGN: We conducted descriptive analysis based on a 5% random sample from claims data of China Urban Employees' Basic Medical Insurance (UEBMI) and Urban Residents' Basic Medical Insurance (URBMI) in 2015, supplied by the China Health Insurance Research Association. SETTING: Chinese urban social insurance system. PARTICIPANTS: A total of 56 485 patients who had a stroke were identified, including 36 487 UEBMI patients and 19 998 URBMI patients. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measures include annual number of hospitalisations, average length of stay (ALOS) and average hospitalisation cost. Out-of-pocket (OOP) cost is the secondary outcome measure. RESULTS: The annual mean number of hospitalisations of UEBMI patients was 1.21 and 1.15 for URBMI patients. The ALOS was significantly longer for UEBMI than for URBMI patients (13.93 vs 10.82, p<0.001). Hospital costs were significantly higher for UEBMI than for URBMI patients (US$1724.02 vs US$986.59 (p<0.001), while the OOP costs were significantly higher for URBMI than for UEBMI patients (US$423.17 vs US$407.81 (p<0.001). Patients with UEBMI had higher reimbursement rate than URBMI patients (79.41% vs 66.92%, p<0.001) and a lower self-paid ratio than URBMI patients (23.65% vs 42.89%, p<0.001). CONCLUSIONS: Significant disparities were found in the utilisation of hospital services between UEBMI and URBMI patients. Our results call for a systemic strategy to improve the fragmented social health insurance system and narrow the gaps in China's health insurance schemes.

Is Traditional Chinese Medicine "Mainstream" in China? Trends in Traditional Chinese Medicine Health Resources and Their Utilization in Traditional Chinese Medicine Hospitals from 2004 to 2016.

BACKGROUND: Traditional, complementary, and alternative medicine (TCAM) has attracted increasing attention in developed countries, but its mainstream status in China, the home of TCAM, is unclear. Over the period of 2004-2016, we analyze the health resources and health resource utilization of traditional medicine in traditional Chinese medicine (TCM) hospitals in China. METHODS: Over 2004-2016, we obtained data from all TCM hospitals in all Chinese provinces to create a hospital-based, longitudinal dataset. TCM health resources and their utilization were measured by two outcome variables: (1) primary outcome variables comprising the proportion of TCM physicians, TCM pharmacists, revenue from TCM drugs, and TCM prescriptions and (2) the secondary outcome variables, as proxies of westernization for TCM hospitals, comprising the number of medical equipment above RMB 10,000 and the proportion of surgery in inpatient visits. We used linear regression models with hospital-fixed effects to analyze time trends for the outcome variables. RESULTS: The number of public TCM hospitals remained stable from 2004 to 2016, while the number of private TCM hospitals increased from 294 in 2004 to 1560 in 2016. There was a small percentage increase in the proportion of TCM physicians (0.280%), TCM pharmacists (0.298%), and revenue from Chinese medicines (0.331%) and TCM prescriptions (1.613%) per hospital per year. Chinese drugs accounted for less than a half of the total drug prescriptions, and accordingly, just one-third of the drug revenue was from Chinese medicines at TCM hospitals. The proportions of physicians, pharmacists, revenue from Chinese drug sales, and traditional medicine prescriptions never reach the 60% benchmark target for mainstream in TCM hospitals. As proxies for Western medicine practices in TCM hospitals, the number of medical equipment above RMB 10,000 rapidly rose by over 13 percent per hospital per year, but the proportion of inpatient surgeries declined by 0.830 percentage points per hospital per year, reflecting a mixed trend in the use of Western medicine practices. CONCLUSION: For the 2004-2016 period, traditional medicine, although making progress towards the mainstream benchmark of 60% TCM services, was still not mainstream at TCM hospitals.

"The biggest reform to China's health system": did the zero-markup drug policy achieve its goal at traditional Chinese medicines county hospitals?

The zero-markup drug policy (ZMDP) was heralded as the biggest reform to China's modern health system. However, there have been a very limited number of investigations of the ZMDP at county hospital level, and those limited county hospital studies have several limitations in terms of sample representativeness and study design. We investigated the overall and dynamic effects of ZMDP at traditional Chinese medicine (TCM) county hospitals. We obtained longitudinal data from all TCM county hospitals in 2004-16 and the implementation year of ZMDP for each hospital. We used differences-in-difference methods to identify the overall and dynamic effects of ZMDP. On average, the ZMDP reform was associated with the reduction in the share of revenue from drug sales (3.1%), revenue from western medicines sales (12.7%), revenue from medical care services (3.6%) and gross hospital revenue (3.4%), as well as increased government subsidies (24.4%). The ZMDP reform was not significantly associated with the number of annual outpatient and inpatient visits. In terms of dynamic effects, the share of revenue from drug sales decreased by 2.5% in the implementation year and by about 5% in the subsequent years. Revenue from western medicine sales fell substantially in the short term and continued to drop in the long term. Government subsidies went up strikingly in the short term and long term, and revenue from medical care services and gross revenue decreased only in the implementation year. The ZMDP achieved its stated goal through reducing the share of revenue from drug sales without disrupting the availability of healthcare services at TCM county hospitals. The success of ZMDP was mainly due to the huge growth in the government's financial investment in TCM hospitals.

Direct costs of both inpatient and outpatient care for all type cancers: The evidence from Beijing, China.

BACKGROUND: Cancer is a major public health issue worldwide. The cost of cancer care imposes a substantial economic burden on society and patient, but it has not been thoroughly studied in China. This study aimed to describe direct cost and cost elements of all cancer types by different beneficial characteristics. METHODS: The research was a retrospective observational study based on inpatient and outpatient records with a primary diagnosis of cancer from 31 hospitals in 2016. Total cost and cost per time were analyzed by cancer type, sources (prescription medicines, consumables fee for diagnosis and surgery, and other health services), and beneficial characteristics (gender and age). RESULTS: A total of 30 224 eligible inpatient admissions and 485 391 outpatient visits were identified during the study period. Inpatient care costs account for 58.6% cancer treatment costs. Nearly 70% of the total expenditure is spent on patients aged 50-79 years. Lung cancer had the highest economic cost (15% of overall cancer costs), followed by breast cancer (12%), and colorectal cancer (10%). Anticancer drug cost accounted a large proportion in both inpatient (37.7%) and outpatient care (64.6%). The average cost per inpatient admission was estimated to be $4590.1 (5621.9), ranging from $1157.7 (1349.8) for testis cancer to $7975 (7343.9) for stomach cancer. The regression analyses revealed that length of hospital stay, cancer type, age, payment type, and hospital level were highly correlated with the expenditure per admission (P < 0.001). CONCLUSIONS: The cancer care cost is substantial and varies with cancer type. Our findings provide important information for health service planning, allowing more efficient allocation of health resources for the care of people with cancer.

Inpatient Cost of Stroke in Beijing: A Descriptive Analysis.

BACKGROUND: Stroke has been the leading cause of death in China and contributed almost one-third to stroke deaths worldwide. The rising cost of stroke treatment is of great concern, but has not been thoroughly studied. This study aimed to analyze stroke in-hospital charges by subtypes, age, and sex and investigate potential factors associated with the cost of per stay. METHODS: The research was a retrospective observational study based on patients with a primary diagnosis of stroke from 31 hospitals in Beijing. Characteristics of total treatment cost and cost of per stay were analyzed. The potential influences on hospital charges were explored using a stepwise multiple regression model. RESULTS: A total of 16,111 stroke in-patient admissions were identified among which 8.3% was subarachnoid hemorrhage, 22.4% intracerebral hemorrhage, and 69.1% cerebral infarction. The average length of stay (LoS) was 14.5 (11.9) days. The cost of per stay was USD 4,423.9 (6,684.4) among which the out-of-pocket expenses were USD 1,640.2 (3,118.0). Stroke type, age, medical insurance, treatment results, and hospital level were significantly associated with the cost of stroke (p < 0.001). CONCLUSION: Hospitalization cost of stroke was substantial. These findings provide health policymakers and healthcare professionals with evidence to help guide future spending.