Please wait a minute...
Frontiers of Medicine

ISSN 2095-0217

ISSN 2095-0225(Online)

CN 11-5983/R

Postal Subscription Code 80-967

2018 Impact Factor: 1.847

Front. Med.    2016, Vol. 10 Issue (4) : 473-480     DOI: 10.1007/s11684-016-0479-2
RESEARCH ARTICLE |
Effect of the new maternity insurance scheme on medical expenditures for caesarean delivery in Wuxi, China: a retrospective pre/post-reform case study
Chun Chen1,2,Zhihong Cheng3,Ping Jiang3,Mei Sun2,Qi Zhang4(),Jun Lv2()
1. School of Public Health and Management, Wenzhou Medical University, Wenzhou 325035, China
2. Research Institute of Health Development Strategies, Fudan University, Shanghai 200032, China
3. Affiliated Hospital, Jiangnan University, Wuxi 214062, China
4. School of Community and Environmental Health, Old Dominion University, Norfolk, VA 23529, USA
Download: PDF(130 KB)   HTML
Export: BibTeX | EndNote | Reference Manager | ProCite | RefWorks
Abstract  

Aiming to control rising medical expenditures and help improve China’s healthcare systems, this study examined whether a cap-based medical insurance scheme with shared financial interest between the insurance and healthcare providers is effective in containing hospitals’ C-section medical expenditures. We used 6547 caesarean delivery case records from a teaching tertiary-level general public hospital located in Wuxi, China (2004–2013), and used the Chow test to investigate the possibility of significant variation in mean medical expenditures for caesarean deliveries pre- and post-reform. We also used paired sample t-tests and linear regression models to compare the mean medical expenditures between insured and uninsured women undergoing caesarean delivery during the post-reform period. After the scheme’s implementation, medical expenditures for caesarean deliveries declined and the medical expenditures of women covered by the scheme were significantly lower than those of uninsured patients. These findings indicated the scheme’s effectiveness in minimizing caesarean delivery expenditures. The cap-based medical insurance scheme with shared financial interest between insurance and healthcare providers would likely steer healthcare providers’ behaviors in a more cost-effective direction.

Keywords maternity insurance scheme      financial incentive      caesarean delivery      medical expenditure      China     
Corresponding Authors: Qi Zhang,Jun Lv   
Just Accepted Date: 03 November 2016   Online First Date: 25 November 2016    Issue Date: 01 December 2016
URL:  
http://academic.hep.com.cn/fmd/EN/10.1007/s11684-016-0479-2     OR     http://academic.hep.com.cn/fmd/EN/Y2016/V10/I4/473
Pre-reform (2004–2008) Post-reform (2009–2013)
Patients pay upfront Patients do not pay upfront
Patients reimbursed by insurance Hospitals reimbursed by insurance
Fixed-fee payment method Cap-based payment method
Patients’ cap: reimbursement per delivering woman CNY 2300 (2001–2004) and CNY3000 (2005–2008) Hospital’s cap (using tertiary-level hospitals and C-sections as an example): reimbursement to the hospital per C-section CNY 5300 (2009.01–2010.09), CNY5400 (2010.10–2011.12), and CNY 6100 (2012.01–2013.12)
Reimburse the same fixed amount cost to patients based on a fixed-fee reimbursement scheme regardless if the actual medical expenditure of the patients is above or below the cap If the total cost is above the cap, insurance reimburses the cost to the hospital up to the total monthly cap, i.e., per capita cap
Number of patients whose total cost is above the cap
If the total cost is below the cap, insurance reimburses the cost to the hospital directly every month
MIS only provided indirect and weak incentives for hospitals to provide cost-effective medical services. The economic incentives of NMIS: if the total cost is below the total cap at the end of the year: from 2009 to 2011, 60% of the total reimbursement balance of insured deliveries between the total cap and the actual reimbursed amount was distributed by Wuxi’s insurance bureau to the hospitals as a cash rebate for their positive performance on cost control; since 2012, the rewards have been changed from cash rebate to budget reimbursement, which can only be used in the following year
Tab.1  Reimbursement mode of MIS in Wuxi: pre- and post-reform (2004–2013)
Variables Pre-reform Post-reform
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
No. of hospital beds 893 893 873 873 873 887 887 1145 1145 1145
No. of outpatients 561 066 570 960 590 940 606 351 666 994 708 049 730 502 765 854 742 813 661 764
No. of inpatients 24 959 26 310 25 742 28 153 29 695 30 144 33 360 36 328 37 623 38 102
Average length of stay (day) 13.7 13.6 14.1 14 13.3 12.3 11.6 10.8 10.3 10
Total revenue (million USD) 41.69 44.40 49.30 57.33 68.96 80.47 94.66 109.48 125.52 136.40
Average medical expense per outpatient (USD)a 18.47 18.67 18.09 20.60 25.18 28.09 28.42 30.46 44.15 55.60
Average medical expense per inpatient (USD)a 1273.34 1266.13 1481.50 1554.32 1740.07 1838.25 2075.89 2256.16 2408.34 2614.17
No. of total delivery 947 971 1308 1462 1323 1393 1206 1224 1232 1443
No. of C-section patients 567 510 650 807 706 664 635 679 653 676
Average expenditure of C-section patients (USD)a 862.92 839.01 953.85 1029.62 1133.69 1113.02 1170.05 1218.86 1167.13 1202.55
Tab.2  Baseline characteristics of the sample hospital (2004–2013)
Independent variable Reduced formula Full formula F P
Constant 833.999***
(<0.001)
738.192***
(<0.001)
16.254 <0.001
Time= 1–10 (2004–2013) 41.370***
(<0.001)
72.697***
(<0.001)
Risky age group (≥35) 167.154***
(<0.001)
158.677***
(<0.001)
Group with clinical risk factors 5.335
(0.606)
2.424
(0.866)
Reform ? 319.144***
(<0.001)
Time*Reform ? -55.810***
(<0.001)
Risky age group*Reform ? 15.407
(0.724)
Group with clinical risk factors*Reform ? 0.772
(0.970)
R2 0.087 0.096
Tab.3  Chow test results for medical expenditures for caesarean delivery: pre- and post-reform (2004–2013)
Fig.1  Simulation results for pre- and post-reform (2004–2014) medical expenditures related to C-sections based on the Chow test model.
Year Uninsured Insured Difference
n MEPa n MEPa
2009 327 1245.137
(565.432)
337 984.822
(284.385)
260.315***
(34.583)
2010 260 1385.718
(441.310)
375 1020.516
(179.353)
365.202***
(25.352)
2011 259 1463.235
(335.638)
420 1068.177
(199.505)
395.044***
(20.537)
2012 263 1430.832
(663.815)
390 989.293
(172.985)
441.539***
(35.255)
2013 284 1474.430
(618.492)
392 1005.581
(196.075)
468.850***
(33.327)
Total 1393 1393.731
(548.076)
1914 1015.269
(209.987)
378.462***
(13.733)
Tab.4  Medical expenditures (USD) per caesarean delivery for uninsured and insured patients (2009–2013)
Variables Pooled Insured Uninsured
Constant 1318.288***
(<0.001)
1019.541***
(<0.001)
1224.074***
(<0.001)
Time= 1–5 (2009–2013) 23.147***
(<0.001)
0.076
(0.983)
51.565***
(<0.001)
Risky age group (≥35) 64.936*
(0.026)
-23.569
(0.396)
97.791*
(0.049)
Group with clinical risk factors 3.780
(0.793)
11.567
(0.259)
26.958
(0.386)
Insurance status
(Insured= 1, Uninsured= 0)
-377.207***
(<0.001)
? ?
Tab.5  Coefficients for pooled and stratified models of medical expenditures for caesarean delivery post-reform (2009–2013)
1 Yip WCM, Hsiao WC, Chen W, Hu S, Ma J, Maynard A. Early appraisal of China’s huge and complex health-care reforms. Lancet 2012; 379(9818): 833–842
doi: 10.1016/S0140-6736(11)61880-1 pmid: 22386036
2 Chen C, Dong W, Shen JJ, Cochran C, Wang Y, Hao M. Is the prescribing behavior of Chinese physicians driven by financial incentives? Soc Sci Med 2014; 120: 40–48
doi: 10.1016/j.socscimed.2014.05.033 pmid: 25218152
3 Grant D. Physician financial incentives and cesarean delivery: new conclusions from the healthcare cost and utilization project. J Health Econ 2009; 28(1): 244–250
doi: 10.1016/j.jhealeco.2008.09.005 pmid: 19027184
4 Tsai YW, Hu TW. National health insurance, physician financial incentives, and primary cesarean deliveries in Taiwan. Am J Public Health 2002; 92(9): 1514–1517
doi: 10.2105/AJPH.92.9.1514 pmid: 12197985
5 Río I, Castelló A, Barona C, Jané M, Más R, Rebagliato M, Bosch S, Martínez E, Bolúmar F. Caesarean section rates in immigrant and native women in Spain: the importance of geographical origin and type of hospital for delivery. Eur J Public Health 2010; 20(5): 524–529
doi: 10.1093/eurpub/ckq067 pmid: 20522515
6 Adinma ED, Nwakoby BA, Adinma BD. Integrating maternal health services into a health insurance scheme: effect on healthcare delivery. Nig Q J Hosp Med 2010; 20(2): 86–93
doi: 10.4314/nqjhm.v20i2.58041 pmid: 21243858
7 Criel B, Van der Stuyft P, Van Lerberghe W. The Bwamanda hospital insurance scheme: effective for whom? A study of its impact on hospital utilization patterns. Soc Sci Med 1999; 48(7): 897–911
doi: 10.1016/S0277-9536(98)00391-8 pmid: 10192557
8 Mensah J, Oppong JR, Schmidt CM. Ghana’s National Health Insurance Scheme in the context of the health MDGs: an empirical evaluation using propensity score matching. Health Econ 2010; 19(S1 Suppl): 95–106
doi: 10.1002/hec.1633 pmid: 20730999
9 Richard F, Witter S, de Brouwere V. Innovative approaches to reducing financial barriers to obstetric care in low-income countries. Am J Public Health 2010; 100(10): 1845–1852
doi: 10.2105/AJPH.2009.179689 pmid: 20724689
10 West LA. Pension reform in China: preparing for the future. J Dev Stud 1999; 35(3): 153–183
doi: 10.1080/00220389908422577
11 Bogg L, Wang K, Diwan V. Chinese maternal health in adjustment: claim for life. Reprod Health Matters 2002; 10(20): 95–107
doi: 10.1016/S0968-8080(02)00076-9 pmid: 12557646
12 Ramesh M, Wu X. Health policy reform in China: lessons from Asia. Soc Sci Med 2009; 68(12): 2256–2262
doi: 10.1016/j.socscimed.2009.03.038 pmid: 19419809
13 Feldman R. The economics of provider payment reform: are accountable care organizations the answer? J Health Polit Policy Law 2015; 40(4): 745–760
doi: 10.1215/03616878-3150038 pmid: 26124297
14 Wuxi Statistic Bureau. Wuxi Statistical Yearbook (Wuxi Tong Ji Nian Jian). Beijing: China Statistics Press, 2014 (in Chinese)
15 Richardson JR, Peacock SJ. Supplier-induced demand: reconsidering the theories and new Australian evidence. Appl Health Econ Health Policy 2006; 5(2): 87–98
doi: 10.2165/00148365-200605020-00003 pmid: 16872250
16 Blaug M. Where are we now in British health economics? Health Econ 1998; 7(S1 Suppl 1): S63–S78
doi: 10.1002/hec.4730070906 pmid: 9744717
17 Ren Y. Community Health Service. Dalian: Liaoning Science and Technology Press, 2011
18 Wuxi Statistic Bureau. Wuxi Statistical Yearbook (Wuxi Tong Ji Nian Jian). Beijing: China Statistics Press, 2013 (in Chinese)
19 Wuxi Statistic Bureau. A Briefing on the Development of Wuxi’s Economy in 2013 (2013 Wuxi Guo Ming Jing Ji She Hui Fa Zhan Tong Ji Gong Bao). . Wuxi Statistic Bureau, 2014 (in Chinese)
20 Wang H, Xu T, Xu J. Factors contributing to high costs and inequality in China’s health care system. JAMA 2007; 298(16): 1928–1930
doi: 10.1001/jama.298.16.1928 pmid: 17954544
21 Zhang P. Disscuss on the expense of cesarean delivery. China Pract Med (Zhongguo Shi Yong Yi Yao) 2010; 5: 257–258 (in Chinese)
22 Ma X, Qi L. Grey analysis of the causes of single disease hospitalization expenses increase in the hospital. Chin Health Econ (Zhongguo Wei Sheng Jing Ji) 2011; 30: 71 (in Chinese)
23 Guterman S, Davis K, Schoenbaum S, Shih A. Using Medicare payment policy to transform the health system: a framework for improving performance. Health Aff (Millwood) 2009; 28(2): w238–w250
doi: 10.1377/hlthaff.28.2.w238 pmid: 19174386
[1] Huiqin Zhong,Ya Shao,Ling Fan,Tangshen Zhong,Lu Ren,Yan Wang. Perceived resource support for chronic illnesses among diabetics in north-western China[J]. Front. Med., 2016, 10(2): 219-227.
[2] Xijin Xu,Xiang Zeng,H. Marike Boezen,Xia Huo. E-waste environmental contamination and harm to public health in China[J]. Front. Med., 2015, 9(2): 220-228.
[3] Lizhe Ai, Yaqin Yu, Xiaoli Liu, Chong Wang, Jieping Shi, Hui Sun, Qiong Yu. Are the SNPs of NKX2-1 associated with papillary thyroid carcinoma in the Han population of Northern China?[J]. Front Med, 2014, 8(1): 113-117.
[4] Xiangwei Li, Yu Yang, Jianmin Liu, Feng Zhou, Wei Cui, Ling Guan, Fei Shen, Cong Gao, Mufei Li, Qi Jin, Lei Gao. Treatment outcomes of pulmonary tuberculosis in the past decade in the mainland of China: a meta-analysis[J]. Front Med, 2013, 7(3): 354-366.
[5] Wei Li, Shan Lu, Zhigang Cui, Jinghua Cui, Haijian Zhou, Yiqing Wang, Zhujun Shao, Changyun Ye, Biao Kan, Jianguo Xu. PulseNet China, a model for future laboratory-based bacterial infectious disease surveillance in China[J]. Front Med, 2012, 6(4): 366-375.
[6] Kai Gao, Junzhi Wang. The biopharmaceutical industry in China: history and future perspectives[J]. Front Med, 2012, 6(2): 101-111.
[7] Zhiping Yang, Qiong Wu, Kaichun Wu, Daiming Fan. Scientific publications on systematic review and meta-analysis from Chinese authors: a 10-year survey of the English literature[J]. Front Med, 2012, 6(1): 94-99.
[8] Min ZHANG, Hong SHANG, Zhe WANG, Wei-Guo CUI, Qing-Hai HU. Natural history of HIV infection in former plasma donors in rural China[J]. Front Med Chin, 2010, 4(3): 346-350.
[9] Xu-Ming BIAN, Qi GUO, Qing-Wei QI. Current situation and development of prenatal diagnosis in China[J]. Front Med Chin, 2010, 4(3): 271-274.
[10] Li-Guang TIAN MPH, Jia-Xu CHEN PhD, Yu-Chun CAI BM, Jian GUO MPH, Xiao-Mei TONG, Qin LIU DVM, Xiao-Nong ZHOU PhD, Tian-Ping WANG PhD, Xiao-Mei YIN, Wei-Duo WU, Li ZHOU, Feng-Feng WANG, Zhen-Li WANG MSc, Guo-Jin CHENG, Peter STEINMANN PhD, Lan-Hua LI MSc, . Co-infection of HIV and parasites in China: Results from an epidemiological survey in rural areas of Fuyang city, Anhui province, China[J]. Front. Med., 2010, 4(2): 192-198.
[11] Jun-Jie XIAO MD, Yi-Han CHEN MD, PhD, . Prevalence of cardiovascular diseases in China[J]. Front. Med., 2010, 4(1): 16-20.
[12] Shilin DENG MD, Tongyuan LIU, . A survey of physical activity among urban women in China[J]. Front. Med., 2009, 3(4): 463-469.
[13] WANG Shiliang. Achievements in burn surgery over the past 50 years in China[J]. Front. Med., 2008, 2(4): 332-336.
[14] YAO Dingkang, ZHU Liang, YU Renqian, MEI Changlin. Current progress on internal medicine in China—2006 Part II[J]. Front. Med., 2007, 1(4): 343-351.
[15] YAO Dingkang, ZHU Liang, ZHAO Xue, MEI Changlin. Current progress on internal medicine in China—2006 Part I[J]. Front. Med., 2007, 1(3): 235-247.
Viewed
Full text


Abstract

Cited

  Shared   
  Discussed