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Frontiers of Medicine

ISSN 2095-0217

ISSN 2095-0225(Online)

CN 11-5983/R

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Front. Med.    2016, Vol. 10 Issue (4) : 473-480    https://doi.org/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
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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 Author(s): Qi Zhang,Jun Lv   
Just Accepted Date: 03 November 2016   Online First Date: 25 November 2016    Issue Date: 01 December 2016
 Cite this article:   
Chun Chen,Zhihong Cheng,Ping Jiang, et al. Effect of the new maternity insurance scheme on medical expenditures for caesarean delivery in Wuxi, China: a retrospective pre/post-reform case study[J]. Front. Med., 2016, 10(4): 473-480.
 URL:  
https://academic.hep.com.cn/fmd/EN/10.1007/s11684-016-0479-2
https://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)
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