Research On The Effect Of Case-based Payment On Medical Quality

[Purpose]In December 2017,Wuhan City,Hubei Province began to implement the reform of basic medical insurance Case-based payment.This study analyzing the effect of the reform of Case-based Payment on medical quality,and providing suggestions for improving the reform of payment and the supervision of medical quality.[Methods]This study taking a top-level Hospital in Wuhan as an example.(1)Through on-the-spot investigation,the details of patients during the period from January 1,2018 to October 31,2019 was collected from the hospital information system,including the medical record front sheet,the details of the medical fee,the first course record and the discharge summary.(2)According to the principles of high incidence of disease and data availability,the representative diseases of the study were as follows:(1)The main diagnosis of discharged patients was cataract,and the surgical operation was cataract extraction with intraocular lens implantation(ICD-10:H25/H26;ICD-9-cm-3:13.71001;(2)The discharge is mainly diagnosed as colorectal polyp,and the operation is the disease type of electronic enteroscope colorectal polypectomy(ICD-10:k63.5;ICD-9-cm-3:45.42);(3)The discharge is mainly diagnosed as hemorrhoid,and the operation is the procedure for prolapse and hemorrhoids(ICD-10:I84;ICD-9-cm-3:48.41).There were 4566 cases,including 2333 cataract,1646colorectal polyp and 587 hemorrhoids.(3)Spss25.0 and stata15.0 software were used for statistical analysis:(1)According to the characteristics of different diseases,the confounding factors affecting the medical quality were screened through logit model,and the confounding factors including the basic situation of patients,the health status of patients were included in the matching;(2)The method of propensity score matching and Coarsened Exact Matching are used to estimate the effect of Case-based payment on medical quality;(3)Count data forχ~~2 test,measurement data for two independent sample t-test.[Results]The results of Propensity Score Matching and Coarsened Exact Matching remain robust,and the results are as follows:(1)Effect of of Case-based payment on process medical quality:The effect on the use of drugs:(1)Days of antimicrobial drugs use:The results of PSM showed that ATT was-0.081,the difference was not statistically significant(P>0.05).After CEM matching,the experimental group was 3.56±0.04,and the control group was 4.20±0.07,the difference was statistically significant(P<0.05).(2)The rate of pathogenic examination:The results of PSM showed that ATT was 0.003,the difference was not statistically significant(P>0.05).After CEM matching,the experimental group was 1.89%and the control group was 9.61%,the difference was statistically significant(P<0.05).(3)Combination rate of antibacterial drugs:The results of PSM showed that ATT=-1.167,the difference was statistically significant(P<0.05).After CEM matching,the experimental group was 8.14%and the control group was 53.67%,the difference was statistically significant P<0.05.(4)Utilization rate of essential drugs:The results of PSM showed that ATT was-0.196,the difference was statistically significant(P<0.05).After CEM matching,the experimental group was 59.61%and the control group was 80.11%,the difference was statistically significant(P<0.05).The effect on the diagnostic accordance rate:The results of PSM showed that ATT=0.169,the difference was statistically significant(P<0.05).After CEM matching,the experimental group was 1640(96.70%)and the control group was 2290(96.10%).The difference was not statistically significant(P>0.05).(2)The effect of case-based payment on the outcome quality:The effect on readmission indicators:The results of PSM showed that ATT=-0.177,the difference was statistically significant(P<0.05).After CEM matching,the experimental group was 73.23%and the control group was 73.86%.The difference was not statistically significant(P>0.05).The effect on hospital infection indicators:The results of PSM showed that ATT=0.008,and the difference was statistically significant at 0.1 level(P<0.10).After CEM matching,the experimental group was 98.53%and the control group was 97.90,with no statistically significant difference(P>0.05).The effect on medical cost indicators:The total cost,western medicine cost and antibacterial drug cost PSM showed that ATT was-95.561,-424.748 and-83.602,respectively,the total cost and antimicrobial drugs cost were not statistically different(P>0.05),the western medicine cost was statistically significant(P<0.05).After CEM matching,the total cost,western medicine cost and antibacterial drugs cost were reduced by 1198.59,527.58 and 162.76,respectively,and the differences were statistically significant(P<0.05).Effect on efficiency indicators:The average length of stay PSM showed that the ATT=-2.259,the difference was statistically significant(P<0.05).After CEM matching,the experimental group was 3.44±0.03 and the control group was 5.68±0.06,with no statistically significant difference(P>0.05).[Conclusion]Case-based payment reform can play a positive role in regulating medical behavior and improving medical quality.In particular,in the preoperative and postoperative diagnostic accordance rate,and the combined use of antibacterial drugs.(2)Case-based payment reform can play a important role in rationally using medical resources and reducing hospital infections.The specific manifestations,including the control of medical expenses and hospitalization days.(3)However,the case-based payment still has a negative effect on the medical quality.In general,the utilization rate of essential drugs needs to be further improved.From the perspective of different diseases,the colorectal polyp has not improved in the incision healing,and hemorrhoids have not improved in western medicine cost,and average hospital stay.(4)Based on the above research results,the following Suggestions are put forward in this study:(1)Design an adjustable grouping system incorporating various confounding factors and develop dynamic payment standards;(2)Change to the concept of"quality"payment,balance the contradiction between cost control and medical quality;(3)Apply the results of performance appraisal to the reform of payment mode,and strengthen the supervision of medical quality;We will further promote the reform of multiple and complex payment methods to complement each other’s different functions.[innovation and deficiency]The innovation of this research are as follows:(1)From the research content presprctive,the previous research focused on exploring the medical expenses control and reform effectiveness of the NCMS reform.(2)From the research methods presprctive,in order to ensure that the experimental group and the control group are more comparable,based on the use of PSM to control confounding factors,combined with the CEM method,to further ensure the robustness of the analysis results.(3)From the research conclusion presprctive,this study found that the basic medical insurance by macro-reforms reforms can have standard medical practice to a certain extent,improve the quality of medical treatment,can reduce hospital infection in medical resources reasonable use and have a positive impact on,but the reform still has a certain negative impact on the medical quality,especially need to be monitored changes of the indexes for the rational use of drugs.At the same time,the study found that the impact of reform on the quality of medical care for different diseases is different.The deficiencies of this study are as follows:(1)The shortcomings of cross-sectional research design.Cross-sectional data has limitations in analyzing causality.In the future,prospective research design should be designed,and panel data should be used to further explore the internal relationship between payment by disease and medical quality of disease.(2)The matching and the evaluation indicators of the medical quality are not comprehensive enough.Although the matching indicators are selected based on multiple dimensions,there are still potential confounding factors that are not included in the matching due to limited data availability and other reasons.In addition,for different diseases,the evaluation indicators with higher sensitivity should be selected according to its disease characteristics.(3)Limited sample range.In this study,only the reform group and the control group in one hospital were selected for a cross-sectional study of the same period,with a small sample range and certain limitations in the representativeness of the research conclusions.In the future,other hospitals that have not implemented the pay-per-disease reform can be included as the control group for in-depth comparison and analysis.(4)This study lacks consideration of difficult and complicated cases,which may overestimate the medical quality.