| Objective: Cost containment has become a major concern worldwide.Diagnosis related groups(DRGs)-based payment is increasingly used worldwide to reimburse hospitals in response to rising hospital costs.The objectives of this study were to systematically review the effects of DRGs-based payment on inpatient healthcare utilization in terms of length of stay(LOS),total inpatient spending per admission and readmission rates,compared with cost-based payment;and to evaluate the economic implications of payments based on Chinese diagnosis-related groups(C-DRG)and China national diagnosis-related groups(CN-DRG)in terms of total hospital expenditure,out-of-pocket(OOP)payments,and LOS,compared with fee-for-service(FFS)payment in Sanming;and to analyze the negative and positive effects of C-DRG in order to provide significant insights for policymakers.Methods: Firstly,we included studies undertaken with designs approved by the Cochrane Effective Practice and Organisation of Care(EPOC)that reported the effects of DRGs-based payment on total inpatient spending per admission,LOS and readmission rates to conduct a systematic review and meta-analysis.Secondly,we performed generalized linear model(GLM)analyses and interrupted time series(ITS)analyses to estimate the different effects among the three payments methods by FFS(Jan 1,2014 –Dec 31,2015),CN-DRG(Jan 1,2016 – Dec 31,2017),and C-DRG(Jan 1,2018 – Dec31,2018)on total hospital expenditure,OOP payments,and LOS.Finally,purposive sampling method and semi-structure interviews were conducted to study the stakeholders including the medical insurance fund center,health care providers and patients to investigate the negative and positive effects of C-DRG based payment in Sanming,and we also analyzed the interests of the stakeholders and the mechanism of effects of C-DRG based payment to provide decision reference for policymakers to deal with the negative effects,based on the interest equilibrium theory.Results: 1)The systematic review and meta-analysis showed that DRGs-based payment was associated with lower LOS(pooled effect:-8.07%),and higher readmission rates(pooled effect: 1.36%).The results of total inpatient spending per admission were not combined due to lack of essential data,and therefore,inferences regarding the impact of DRGs-based payment on total inpatient spending per admission were limited.2)The empirical study in Sanming showed that CN-DRG was associated with a-7.41%(p<0.01)decrease of total hospital expenditures,while no significant changes were found in total hospital expenditures for C-DRG based payment.3)It was showed by GLM that both the absolute amount of OOP payments(-7.23% vs.-3.82%)and its share of total hospital expenditures(-4.78% vs.-0.2%)decreased in the larger magnitude under the C-DRG based payment,compared to that in the CN-DRG based payment.4)It was found that OOP payments decreased in the larger magnitude for patients in childbirth and patients with hip fracture under the C-DRG based payment,compared to the patients under the CN-DRG based payment;while no significant difference occurred in patients with diabetes.5)Total hospital expenditures decreased in the larger magnitude for diabetic patients without complications,compared with patients with acute complications under the two DRGs-based payment.6)It was showed in the interview that the positive effects of C-DRG on the stakeholders included that C-DRG based payment system achieved success in reducing OOP payments without sacrificing clinical quality;C-DRG helped to strengthen internal operations of hospitals;C-DRG improved the level of information technology and supervisor skillfulness in the medical insurance fund center;C-DRG helped the fund balance of the health insurance.Moreover,the negative effects of C-DRG might include that hospitals with more severe patients were under-reimbursed;there were risks of under-treatment due to the providers' intention to contain costs;a small number of upcoding behavior and cost-shifting to post-acute care and home health service existed in some hospitals.Conclusion: 1)The systematic review revealed that DRGs-based payment might have cost-saving implications by lowering LOS,whereas hardly reduce the readmission rates.Policy-makers considering adopting DRGs-based payment should pay more attention to the hospital readmission rates compared with cost-based payment.2)The empirical study in Sanming showed that CN-DRG and C-DRG were associated with decreases of total hospital expenditures and OOP payments,without sacrificing clinical quality.C-DRG system reduced the potential for cost-shifting to patients and therefore decreased the financial burden for patients in the larger magnitude,compared to that in the CN-DRG based payment.OOP payments decreased in the larger magnitude for patients in childbirth and patients with hip fracture under the C-DRG based payment,compared to the patients under the CN-DRG based payment;while no significant difference occurred in patients with diabetes.Moreover,the total hospital expenditures decreased in the larger magnitude for diabetic patients without complications,compared with diabetic patients with acute complications.These results implied that further reform of DRGs-based payment should provide stronger risk protection for patients with chronic illnesses such as diabetes,especially for more seriously ill patients such as diabetic patients with complications,based on quality of care and patient safety.3)Specific measures were needed to deal with the negative effects of C-DRG,in order to make sure the stakeholders including the medical insurance fund center,health care providers and patients consider to provide the high quality and low price of healthcare as the common interest.The future important measures to improve C-DRG should pay attention to the reimbursement in critically ill patients,cost accounting and internal control,medical quality auditing committee,intelligent monitoring,detailed regulatory rules,clinical pathways,and pay for performance,and to build the patient-centered heath care system of value-based payment. |
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