| Backgroud:The core of health system reform in the world is the innovation of financing and payment system.Under the influence of aging population,changing spectrum of diseases,economic and social development,scientific and technological innovation and other factors,the demand for diagnosis and treatment,rehabilitation and nursing,as well as the total health costs are increasing rapidly in China,and the proportion of medical insurance is also on the rise.It is urgent to reform the traditional payment method of "pay-per-project",which is easy to stimulate providers to provide more services or even prescribe "large prescriptions".At present,in view of the compensation for the cost of hospitalization service,our country is vigorously promoting the packaging payment method which takes Diagnosis Related Groups(DRGs)and Diagnosis Intervention Packet(DIP)as the main body.However,health care services include not only typical acute care such as hospitalization,but also rehabilitation and nursing service,which is an important link between acute care and long-term care,namely,Post-Acute Care(PAC).Due to the long course of hospitalization of PAC patients,high requirements for continuous service,complex rehabilitation programs and other characteristics,DRG/DIP payment cannot effectively solve the problem of frequent transfer and decomposition of hospitalization of PAC patients,which not only affects the use efficiency of medical insurance funds,but also affects the sense of access to medical treatment of patients.Therefore,it has become an important task to innovate and improve the reform of medical insurance payment methods to establish a more scientific and reasonable per-diem payment system for PAC and improve the level of fine management.Objective:Combining theory with practice,on the basis of learning from international advanced experience and combining with China’s national conditions,this paper constructed a case-mix grouping model suitable for Chinese PAC patients.On this basis,a new payment method for PAC was proposed,and the effect of the new payment method implemented in pilot cities was scientifically evaluated.It provided the basis and reference for the reform and innovation of medical insurance payment system for PAC service at the national level.Contents:First,literature and empirical research.The applicability of the Patient Driven Payment Model(PDPM)in China was verified by the framework of value-driven medicine theory,and on this basis,a new medical insurance payment reform and innovation scheme for PAC was proposed.The second was intervention and evaluation research.The Medical Insurance Bureau of Jinhua,Zhejiang Province adopted our plan and implemented it on October 1,202 1.We carried out scientific evaluation on the impact of the implementation of the new medical insurance payment method on the satisfaction of patients’ medical needs and the allocation efficiency of medical resources.Methods:1.① Data extraction and processing.The homepage data of medical records,medical insurance settlement and cost details of PAC inpatients with the scale assessment data(including the Barthel Index,Mini-Mental State Examination,Gugging Swallowing Screen,Hamilton Depression Scale)in 7 medical institutions(mainly including rehabilitation wards of general hospitals,independent rehabilitation institutions,skilled nursing institutions)in Jinhua City in the past three years(January 1,2018 to December 31,2020)were extracted.The relevant primary key was used to accurately correlate and match the scale information with the settlement list and the homepage information of medical records.A total of 13496 cases were included.②Model construction.Generalized linear model(GLM)and quantile regression(QR)were conducted to determine the predictors of cost of 5401 PAC stroke patients,and a case-mix classification model was established using the decision-tree analysis.③ Model verification and adjustment.After the 13496 cases were standardized and mapped,the Patient Driven Payment Model(PDPM)from the United States was introduced,and the data were grouped by the Structured Query Language(SQL)editor.Under PDPM,each patient was classified into a group for each of the four case-mix adjusted components:physical therapy(PT)and occupational therapy(OT),speech-language pathology(SLP),nursing,non-therapy ancillary(NTA)and a non-case-mix adjusted component.Each component utilized different criteria as the basis for patient classification.After statistical description of the data,the middle segment method was used to cut the enrolled data.Then,the effectiveness of grouping was analyzed by the percentage of variance in resource use explained by the classification(R2),the reduction in variance(RIV),the class-specific coefficients of variation(CV),and the weighted means for each group(case-mix indexes,CMI).After adjusting with the local situation of Jinhua,the PAC case-mix grouping model was established,and the payment standard was calculated.2.The effect evaluation after the implementation of the new medical insurance payment method.A total of 26,171 PAC patients admitted to 92 medical institutions during the period from October 1,2021 to December 31,2022 when Jinhua Basic Medical Insurance Payment Method for Post-acute Hospitalization(Trial)was officially put into operation.Trained and qualified doctors,rehabilitation therapists,and nurses were used as evaluators to evaluate the patients using the PAC(rehabilitation and nursing)standardized assessment scale,and the scale data were accurately correlated and matched with the medical record homepage data,medical insurance settlement,and cost details data.By combining quantitative analysis and qualitative analysis,relevant data were collected through medical insurance data extraction,discussion and interview,and evaluation indicators were designed from the aspects of medical expenses,economic burden,service breadth,institutional efficiency,patient outcome and satisfaction,to evaluate the operation effect of PDPM payment reform in Jinhua City.Results:1.Each grouping model of PDPM has good explanatory power.A total of 13496 PAC cases were included.There were 7325 males and 6171 females,with an average age of 79.84 years.The average daily cost was 526.69 yuan/day,and the average length of hospital stay was 23.83 days.There were 5401 patients in the recovery period or sequelae of acute neurologic,accounting for 40.02%.Under PDPM,each patient was classified into a group for each of the four case-mix adjusted components:PT&OT,SLP,nursing,NTA and a non-case-mix adjusted component.Each component utilized different criteria as the basis for patient classification.①The PT&OT grouping model had a good explanatory power(R2=11.1%,p<0.001).The CV values of the 10 groups ranged from 0.17 to 0.69,and 71%of the groups had good intra-group consistency.Among the 14 groups,CMI values ranged from 0.22(TL)to 1.96(TN),indicating good grouping.②The fitting effect of SLP group model was general(R2=6.1%,p<0.001).Due to the small number of SLP programs in China and the lack of cost data,the explanatory power and CV value were affected.However,the trend of CMI value was basically consistent with that of the United States,ranging from 0.06(S1)to 6.17(S7).The higher the CMI,the higher the resource consumption.③The nursing grouping model had a good explanatory power(RIV=14.0%,p<0.001).The CV values of the 12 groups ranged from 0.09 to 0.66,and the homogeneity was good within each group.CMI values ranged from 0.59(ADA)to 6.33(HS2),with good grouping.④ The NTA grouping model had a good explanatory power(R2=10.6%,p<0.001).The CV values of the six groups ranged from 0.38 to 0.64,and the CMI values ranged from 0.72(NF)to 2.91(NA),indicating good grouping.The change trend of data in each group was highly consistent with the public data in the United States.2.Based on the regression model,the grouping effect is better.The patients with the recovery period/aftereffects of the acute nervous system were 5401,accounting for 40.02%.The GLM regression revealed that gender,tracheostomy,complication or comorbidity(CC),activities of daily living(ADL),and cognitive impairment were the main variables significantly affecting the hospitalization expenses of post-acute stroke patients.The QR model showed that the gender,tracheostomy and CC factors had a more significant impact on per-diem costs on the upper quantiles.In contrast,cognitive impairment had a more substantial effect on the lower quantiles,and ADL significantly impacted the central quantile.Using tracheostomy,CC,and ADL as node variables of the regression tree,12 classes were generated.The case-mix classification performed reliably and robustly,as measured by the reduction in the variation statistic(RIV=0.46)and class-specific coefficients of variation(CV less than 1.0;range:0.18-0.81).3.Model localization adjustment results are good.According to the local situation in Jinhua after data analysis,expert consultation and clinical demonstration,the grouping model was adjusted to ensure the rationality of clinical and payment.Finally,four rehabilitation groups,six nursing groups and five NTA groups were formed.① The rehabilitation group was finally adjusted to four groups(R2=9.1%,p<0.001).Except for group T2,the CV values of the three groups were all less than 0.8,and the CMI values ranged from 0.21(T4)to 1.73(T3),which was basically consistent with the United States,and the grouping effect was good.②The nursing group was finally adjusted to 6 groups(RIV=12.6%,p<0.001),with CV values ranging from 0.15 to 0.77 and CMI values ranging from 0.58(ADAC)to 6.33(HS2),and the grouping effect was good.③The NTA group was finally adjusted to 5 groups(R2=9.3%,p<0.001),with CV values ranging from 0.38 to 0.72,and CMI values ranging from 1.13(NEF)to 2.91(NA),which showed good grouping effect.After the grouping results were calculated according to the level of medical institutions,the daily cost of a case was calculated by summing the daily cost of the five components.4.The implementation of the new policy has produced certain results.A total of 26,171 PAC patients admitted to 92 medical institutions during the period from October 1,2021 to December 31,2022 when Jinhua Basic Medical Insurance Payment Method for Post-acute Hospitalization(Trial)was officially put into operation.There were 12,637 males and 13,534 females,with an average age of 77.11 years.There were 13,846 patients in the recovery period or sequelae of acute neurologic,accounting for 52.91%.① The average daily cost decreased from 526.69 yuan per day to 417.74 yuan per day.49.81%of the patients’ daily payment standard was 201-400 yuan/day,and 31.31%of the patients’ daily payment standard was 401-600 yuan/day.② The average length of hospital stay increased from 23.83 days to 60.47 days,frequent hospital transfers and fragmented hospitalization were significantly alleviated,and patients’ long-term hospitalization needs were greatly improved.③ The PAC patients admitted to tertiary institutions decreased from 49.08%to 14.05%,and the patients admitted to secondary and primary institutions increased from 50.92%to 85.95%.④ Compared with before the implementation of the policy,the proportion of disabled patients with high medical needs increased significantly,the proportion of patients with completely independent activities of daily living decreased from 44.84%to 12.22%,and the proportion of patients with completely dependent activities of daily living increased from 15.60%to 57.34%.⑤ The proportion of patients with mental disorders increased significantly,from 5.99%to 24.06%.⑥ Using the scale to evaluate the status of patients at discharge and admission,24.21%of the patients’ condition improved,67.74%of the patients maintained the status quo,and only 8.15%of the patients’ condition deteriorated.⑦ In the questionnaire survey of 1464 patients/family members,92.9%were relatively satisfied or very satisfied with the PDPM payment reform policy.⑧ The PAC cost accounted for 35.9%-37.9%of the total medical cost in the United States,while the proportion in Jinhua City was only 4.7%.With the aging of the population,the demand for PAC in China will also increase sharply.Conclusions:1.The model suits national conditions.This study is the first to validate the Patient Driven Payment Model(PDPM)from the United States in China,and explore the establishment of medical insurance payment method in line with the characteristics of PAC services.The results show that PDPM group has good results,and can accurately identify patients’ diseases and functional status to achieve more refined payment,which is suitable for China.After data calculation and expert demonstration and debugging,the PDPM Chinese grouping system is more reasonable and more suitable for China’s national conditions.This study provides a basis and reference for the feasibility of using PDPM payment method in PAC services in China,and provides reference,replicable and generalizable experience for building a digital closed-loop payment system of medical insurance and improving the governance capacity of medical insurance.This study can also provide reference for the future reform of medical insurance payment system and the planning of medical care system in China.2.The reform has yielded initial results.After the PDPM payment reform,the average length of hospital stay of PAC patients has increased,the patients’ long-term hospitalization needs have been greatly improved,the frequent transfer and decomposition of hospitalization have been significantly eased,and the average daily hospitalization cost is lower than before,and the number of DRG high-rate cases has also decreased.Among the admitted PAC patients,the proportion of disabled patients with high demand for medical rehabilitation and nursing increased significantly.The precise payment method of PDPM guided the hospital to admit the disabled elderly who really needed medical rehabilitation and nursing for inpatient treatment.Tertiary medical institutions admitted fewer PAC patients,and the bed turnover was improved.The PDPM payment reform policy guided tertiary hospitals to treat acute and critical diseases,further promoted the hierarchical medical system,and let PAC patients sink to secondary and primary medical institutions.It not only helps to save medical insurance costs,but also effectively improves the treatment effect and health outcome of patients,and promotes the improvement of the quality of PAC services.The PDPM payment reform stimulates the endogenous motivation of PAC institutions,guides medical institutions to standardize rehabilitation and nursing service behaviors,improves the quality of medical services,improves patients’ health outcomes and sense of gain,realizes patient-centered"value-based programs",and promotes the development of PAC services in China.It should be pointed out that there are some limitations in this study.First of all,the empirical data of this study come from a prefecture-level city in both model construction and implementation effect evaluation,so the research results cannot be simply extrapolated to all parts of the country.Secondly,the core basis of PDPM model grouping includes objective needs assessment of patients and average cost calculation.As the former is based on functional assessment of patients,it can better reflect objective clinical needs.However,the latter is based on historical data analysis,and does not do in-depth research on the existing technical means,service mode,the advanced nature and rationality of pricing mechanism reflected in the cost data.These important fields are still to be explored and worthy of further research. |
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