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Background:
In China, increases in both the caesarean section (CS) rates and delivery costs have raised questions regarding the reform of the medical insurance payment system. Case payment is useful for regulating the behaviour of health providers and for controlling the CS rates and excessive increases in medical expenses. New Cooperative Medical...
Context in source publication
Context 1
... number of cases in the VD and CS groups increased after the CPR, but there was a statistically significant increase in the CS rates of rural women in Xi County from 26.1% before the CPR to 32.5% after the CPR. Table 2 presents the variable differences between the pre-CPR and post-CPR of the CS and VD groups, re- spectively. All the variables, except age, showed signifi- cant differences in the CS and VD groups between the pre-CPR and post-CPR, respectively. ...
Citations
... This is thought to be a result of the prolonged use of fee-for-service (FFS) payments for inpatient care (6,7), which has been associated with over-treatment and induced demand (8,9). In an effort to curb the increase of the health expenditure, many cities throughout China have tried to design and implement various casebased payment methods (10,11). The design frameworks of these case-based payments were based on the characteristics of local healthcare service markets, and as a result, it is difficult to generate generalizable findings from their implementation. ...
Background
In 2020, the Chinese government developed and implemented an innovative case-based payment method under the regional global budget called the diagnosis-intervention packet (DIP) payment to pay for inpatient care. This study aims to assess the changes to inpatient care provision in hospitals after the DIP payment reform was implemented.
Methods
This study used inpatient medical costs per case, the proportion of the out-of-pocket (OOP) expenditure in inpatient medical costs, and the average length of stay (LOS) of inpatient care as outcome variables, and conducted an interrupted time series analysis to evaluate changes after the DIP payment reform. January 2021 was taken as the intervention point when a national pilot city of the DIP payment reform in the Shandong province began using the DIP payment to pay for inpatient care of secondary and tertiary hospitals. The data used in this study were obtained from the aggregated monthly claim data of inpatient care of secondary and tertiary hospitals.
Results
Compared to the pre-intervention trend, the inpatient medical costs per case, the proportion of the OOP expenditure in inpatient medical costs both in tertiary and secondary hospitals significantly decreased after the intervention. After the intervention, the reduction in the inpatient medical costs per case, the proportion of the OOP expenditure in inpatient medical costs in tertiary hospital were both higher than those in secondary hospital (p < 0.001). The average LOS of inpatient care in secondary hospital significantly increased after the intervention, and it immediately increase 0.44 day after intervention (p = 0.211). Moreover, the change of average LOS of inpatient care in secondary hospital after intervention was opposite to that in tertiary hospital, it had no statistical difference (p = 0.269).
Conclusion
In the short term, the DIP payment reform could not only effectively regulate provider behavior of inpatient care in hospitals, but also improves the rational allocation of the regional healthcare resources. However, the long-term effects of the DIP payment reform need to be investigated in the future.
... 7,8 In 1985, to balance the risks and benefits of CS, the World Health Organization (WHO) and the United Nations Population Fund recommended a target CS rate of 5% -15% of deliveries based on the estimated number of births that required medically necessary CS. 9 National CS rates above 15% were found to offer no additional benefits on maternal and neonatal outcomes, while rates below 5% were inadequate for reducing maternal and neonatal mortality and morbidity. [10][11][12] Thus, national CS rates above 50% in Latin American countries such as Brazil and below 5% in Sub-Saharan Africa and South-East Asia are both concerning. [7][8][9][10] In contrast, Nordic countries such as Norway have managed to achieve a combination of rather low CS rates of 15% to 17% of all live births and low perinatal and maternal mortality rates. ...
... The most recent WHO statement recommends providing CS to women in need of it rather than striving to achieve specific rates. [10][11][12][13] Our effort to reduce CS rates should therefore concentrate on women without previous CS or those with one previous CS who are also suitable for vaginal birth after a previous CS (VBAC). An appropriate rate can be achieved in those without previous CS by preventing unnecessary primary CSs through implementation of various non-clinical interventions to reduce CS rates, such as adherence to departmental guidelines on labor induction and management, obtaining second opinions for CS indications, rigorous review of primary CS, and provision of appropriate feedback. ...
Background: Caesarean section (CS) rates have been reported to differ between immigrants and native-born women in high-income countries.
Objective: We assessed the CS rate and its relationship with the CS rate in country of nationality and other explanatory factors among women of different nationalities including Qatari women who underwent deliveries at our hospital to generate evidence that will quantify and help explain the observed CS rates in our hospital.
Methods: In this retrospective cross-sectional study conducted at the second-largest public maternity hospital in Qatar, Al-Wakra Hospital (AWH), data for all births delivered in 2019 were retrieved from the hospital's electronic medical records. The CS rates and the crude and adjusted risks of Caesarean delivery for mothers from each nationality were determined, and the common indications for CS were analyzed based on nationality. The association between nationality and Caesarean delivery was examined using binomial logistic regression analysis, with Qatari women as the reference group. The correlation between CS rate in country of nationality and observed CS rates in Qatar was also examined using Pearson's correlation.
Results: The study population consisted of 4816 births by women of 68 nationalities, of which 4513 births were by women from 25 countries. The highest proportion of deliveries (n-1247, 25.9%) was by Indian women. The frequency of CS was the highest and lowest among Egyptian (49.6%) and Yemeni women (17.9%), respectively. Elective CS was predominantly performed in women of Arab nationalities; the most common indication was a history of previous multiple CSs. Emergency CS was primarily performed in women of Asian and Sub-Saharan African nationalities; the most common indications were failure to progress and fetal distress. For most nationalities, the CS rate in Qatar was associated with those of the countries of nationality.
Conclusions: The observed CS rates varied widely among women of different nationalities. The variation was influenced by maternal factors and medical indications as well as the CS rates in the country of nationality. We posit that cultural preferences, acculturation, and patient expectations influenced observed findings. More efforts are required to reduce primary CS rates and to help women make the most informed decisions regarding modes of delivery.
Key Message: CS rates varied widely among women of different nationalities. The variation was influenced by medical indications, maternal preferences, and CS rate in countries of nationality. The solution to reducing CS rates should be a culturally informed response.
... Previous studies have focused on the determinants of service scope of PCFs. Ineffective incentives, insufficient reimbursement by the health insurance schemes have caused the closure of surgical care and obstetric care in rural facilities [13,16]. Disproportionate proportion of direct government subsides to financial revenue is also associated with narrowed service scope [17]. ...
... Disproportionate proportion of direct government subsides to financial revenue is also associated with narrowed service scope [17]. Narrowed service scope of PCFs in China has been well documented [13,16]. However, these studies have concentrated on the outcome evaluation of implementing different payment methods on the service quality, utilization of inpatient services by different level hospitals, length of stay, cost, and other patient outcomes [18][19][20]. ...
... (Appendix Table 1). Third, service scope of PCFs in 2017 was collected by a web-based survey with self-administrated questionnaires under the coordination of chief or deputy chief of each facility [16]. In this study, because some communities located between the urban and rural areas, PCFs located in these commnuties also served the rural residents. ...
Background
Extending service scope of primary care facilities (PCFs) has been widely concerned in China. However, no current data about association between service scope of PCFs with patient outcomes are available. This study aims to investigate association between service scope of PCFs and patient outcomes.
Methods
A multistage, stratified clustered sampling method was used to collect information about service scope of PCFs from rural Guizhou, China. Claim data of 299,633 inpatient cases covered by 64 PCFs were derived from local information system of New Rural Cooperation Medical Scheme. Service scope of PCFs was collected with self-administrated questionnaires. Primary outcomes were (1) level of inpatient institutions, (2) length of stay, (3) per capita total health cost, (4) per capita out-of-pocket cost, (5) reimbursement ratio, (6) 30-day readmission. A total of 64 PCFs were categorized into five groups per facility-level service scope scores. Generalized linear regression models, logistic regression model, and ordinal regression model were conducted to identify association between service scope of PCFs and patient outcomes.
Results
On average, the median service scope score of PCFs was 20, with wide variation across PCFs. After controlling for demographic and clinical characteristics, patients living in communities with PCFs of greatest service scope (Quintile V vs. I) tended to have smaller rates of admission by county-level hospitals (-6.2 % [-6.5 %, -5.9 %], city-level hospitals (-1.9 % [-2.0 %, -1.8 %]), and provincial hospitals (-2.1 % [-2.2 %, -2.0 %]), smaller rate of 30-day readmission (-0.5 % [-0.7 %, -0.2 %]), less total health cost (-201.8 [-257.9, -145.8]) and out-of-pocket cost (-210.2 [-237.2, -183.2]), and greater reimbursement ratio (2.3 % [1.9 %, 2.8 %]) than their counterparts from communities with PCFs of least service scope.
Conclusions
Service scope of PCFs varied a lot in rural Guizhou, China. Greater service scope was associated with a reduction in secondary and tertiary hospital admission, reduced total cost and out-of-pocket cost, and 30-day readmission and increased reimbursement ratio. These results raised concerns about access to care for patients discharged from hospitals, which suggests potential opportunities for cost savings and improvement of quality of care. However, further evidence is warranted to investigate whether extending service scope of PCFs is cost-effective and sustainable.
... In China, previous studies have focused on the determinants of service scope of PCFs. Ineffective incentives, insu cient reimbursement by the health insurance schemes have caused the closure of surgical care and obstetric care in rural facilities [12,13]. Narrowed scope of practice of primary care facilities in China has been well documented [12,13]. ...
... Ineffective incentives, insu cient reimbursement by the health insurance schemes have caused the closure of surgical care and obstetric care in rural facilities [12,13]. Narrowed scope of practice of primary care facilities in China has been well documented [12,13]. However, these studies have concentrated on the outcome evaluation of implementing different payment methods on the service quality, utilization of inpatient services by different level hospitals, length of stay, cost, and other patient outcomes [14][15][16]. ...
... It may be related to improved accessibility to care provided by PCFs for patients with common illness or continuity of care discharged from high-level hospitals [26]. These results might also be caused by a greater reimbursement ratio for inpatient services provided by PCFs than high-level hospitals, which are more attractive to low-income residents [12,13]. These results are similar to ndings of one previous study in the US that expanded service scope of nurse practitioners could reduce unnecessary utilization of hospitalization [5], and comprehensive care by family practitioners is associated with reduced utilization of services and decreased cost [6]. ...
Background: Extending the service scope of primary care facilities (PCFs) has been widely concerned in China. However, no current data about the association between service scope of PCFs with patient outcomes are available. This study aims to investigate the association between service scope of PCFs and patient outcomes.
Methods: We first sampled four counties randomly from rural Guizhou, China. Claim data of 299,633 inpatient cases covered by 64 PCFs were derived from the local information system of New Rural Cooperation Medical Scheme. The service scope of PCFs was collected with self-administrated questionnaires. Primary outcomes were 1) level of inpatient institutions, 2) length of stay, 3) per capita total health cost, 4) per capita out-of-pocket cost, 5) reimbursement ratio, 6) 30-day readmission. A total of 64 PCFs were categorized into five groups per facility-level service scope scores. Generalized linear regression models, logistic regression model, and ordered regression model were conducted to identify the association between service scope of PCFs and patient outcomes.
Results: On average, the median service scope score of PCFs was 20, with wide variation across PCFs. After controlling for demographic and clinical characteristics, patients living in communities with PCFs of greatest service scope (Quintile V vs. I) tended to have smaller rates of admission by county-level hospitals (-6.2% [-6.5%, -5.9%], city-level hospitals (-1.9% [-2.0%, -1.8%]), and provincial hospitals (-2.1% [-2.2%, -2.0%]), smaller rate of 30-day readmission (-0.5% [-0.7%, -0.3%]), less total health cost (-201.8 [-257.9, -145.8]) and out-of-pocket cost (-210.2 [-237.2, -183.2]), and greater reimbursement ratio (2.3% [1.9%, 2.8%]) than their counterparts from communities with PCFs of least service scope.
Conclusion: The service scope of PCFs varied a lot in rural Guizhou, China. PCFs' greater service scope was associated with a reduction in secondary and tertiary hospital admission, reduced total cost and out-of-pocket cost, and 30-day readmission and increased reimbursement ratio. These results raised concerns about access to care for patients discharged from hospitals, which suggests potential opportunities for cost savings and improvement of quality of care. However, further evidence is warranted to investigate whether extending the service scope of PCFs is cost-effective and sustainable.
... Contrary to expectation, this policy change was not followed by a significant increase in the birth rate. According to the annual Statistical Bulletin on National Economic and Social Development, despite a brief increase in 2016, the number of newborn babies in China fell considerably in the following years: with 16.87 million in 2015 [4], 17.86 million in 2016 [5], 17.23 million in 2017 [6], and finally 15.23 million in 2018 [7]. Liaoning province has been experiencing a negative year-on natural population growth rate since 2015, and in particular, its birth rate (6.49‰) was only half of the national birth rate (12.43‰) in 2017 [8]. ...
... Delivery cost should also be considered in conjunction with the quality and outcomes of health care, as lower prices may not reflect high-value care [16]. Compared to per capita disposable income, the costs incurred by delivery are not very high in China, and the expenditure of giving birth may not bring substantial family economic burden [17]. However, among the top four factors considered by 80% of parents to influence the childbirth were: fertility cost, economic burden, care burden, and public service factors [18]. ...
Background
This study aimed to analyze the status of birthrates and the characteristics of child delivery expenditure under the Chinese two-child policy’s transition period. We evaluated the socioeconomic factors associated with child delivery and provide evidence for decisions relating to health support for childbirth.
Methods
Child delivery expense data were obtained from 2015 to 2017 in Dalian, China. A total of 13,535 obstetric records were enrolled using stratified random sampling and the proportional probability to size method. First, we calculated the current curative expenditure of child delivery and health financing in childbirth costs based on the System of Health Accounts 2011 (SHA 2011). Second, univariate analysis of variance and generalized linear modeling were performed to examine factors associated with child delivery expenditure. Third, we classified the included hospitals into the county, district, and municipal hospitals and compared maternal characteristics between these categories.
Results
Overall, out-of-pocket payments accounted for more than 35% of the total expenditure on child delivery. Median (interquartile range) delivery expenditure at the county and district level hospitals [county-level: 5128.50 (3311.75–5769.00) CNY; district-level: 4064.00 (2824.00–6599.00) CNY] was higher than that at the municipal level hospitals: 3824.50 (2096.50–5908.00) CNY. The increase of child delivery expenditure was associated with an increased ratio of reimbursement, admissions to county and district level hospitals, cesarean sections, and length of stay, as well as a decline in average maternal age ( p < 0.05).
Conclusions
Health financing for childbirth expenditure was not rational during the transition period of the family planning policy in China. Higher delivery expenditure at county and district level hospitals may indicate variations in medical professionalism. Poorly managed hospitalization expenditure and/or nonstandard medical charges for childbirth, all of which may require the development of appropriate public health policies to regulate such emerging phenomena.
... These benefits include 'significant decreases in outpatient expenditure and financial strain, and improvements in public health services provision, as well as in two out of five dimensions of the EQ5D model for health-related quality of life (mobility, and pain/discomfort)' [15]. Evidence of these results is further strengthened by evaluation studies of specific interventions [14,16,17]. The official evaluation by the World Bank reports that, with one exception, all performance targets on the 22 project indicators were either 'achieved' or 'surpassed' [4]. ...
... Despite their initial struggles, Jiulongpo, Mei Xian and Xi Xian were among the first counties to report progress towards their performance targets [17,18]. These accomplishments were achieved with extensive expert assistance. ...
... As argued in the introduction, this change in approach is ambitious, as it appears to match poorly with the culture and traditions of rural China [19][20][21]. In view of the effectiveness of HXI [4,[14][15][16][17] and our findings above, which indicate that the three studied pilot counties have in some respects advanced beyond the HXI objectives, we therefore set out to understand how the effective implementation of health reform interventions occurred in the hybrid bottom-up/top-down approach taken by HXI in the context of rural China. ...
Introduction:
China has made considerable progress with health system reforms in recent years. Rural China, however, has lagged behind as the diversity of needs of China's 3,000 rural counties were not always well addressed by national top-down reforms. China's Rural Health Reform Project Health XI (HXI) piloted a hybrid process of top down and bottom up implementation of health system reforms which were tailored to rural county level needs and covered a population of more than 21 million. Different studies provide evidence that HXI counties have achieved substantial benefits given the relatively limited investment. The Effectiveness of HXI subsequently raises the question how the hybrid approach may have resulted in effective implementation of interventions. We answer this question to advance understanding of hybrid approaches in general and in the rural Chinese context in particular, where the bottom-up elements might match poorly with the traditional organisational culture and learning style.
Materials & methods:
We conducted an in-depth qualitative analysis in three 'best practice' counties, performing document-analyses, observations, semi-structured individual and group interviews. In alignment with the research question, this study is of an explorative nature and follows a sequence of deductive and inductive steps.
Results:
HXI struggled initially as counties had difficulties to take initiative and autonomously select and adapt their own reforms. The initial reforms required multiple improvement iterations before achieving the planned results. The effectiveness of these bottom up reform processes has been aided by tight top down supervision and extensive domestic expert involvement. County level leadership is seen as essential to align the top down and bottom up structures and processes. Where successful, HXI has changed mind-sets and counties developed generic health improvement capabilities.
Conclusion:
Tailoring innovations to fit local needs formed a severe challenge for the three 'best practice' counties studied. A 'change of mindset' to actively take initiative and assume autonomy was needed to advance. Top down supervision and extensive support of experts was required to overcome the barriers. The studied counties finally achieved sustainable improvements and developed double loop learning capabilities beyond HXI objectives. Taken together, the above findings suggest that the continuum of healthcare reform implementation approaches in which hybrid approaches reside-from bottom up to top down-has two dimensions: a content dimension and a procedural dimension. Enabled by top down procedures, counties were able to bottom up tailor the content of best practice innovations to fit local needs.
... First, PCFs generally did not link too many quality indicators with the PBS system, which might be a disincentive for healthcare providers to deliver more quality care [17]. A large proportion of PCFs are closing their surgical services [6], obstetrics and gynaecology services and other services [18]. Second, although the current payment system has set a higher reimbursement ratio for primary care services, primary healthcare providers are not adequately paid to provide services [17]. ...
... Broader services have been proposed, such as Traditional Chinese Medicine (TCM), rehabilitation, hospice care, and home care. However, no definitive evidence on its service scope has been determined, although abundant studies revealed that training, patients' or physicians' preference, inappropriate insurance reimbursement, and salary incentives were associated with the decreased utilization of primary care [6,18,21]. One previous study indicated that primary care providers' incentives will be distorted if financial support from government cannot be guaranteed [22]. ...
Background:
Comprehensive primary care practices, through preconception, preventive, curative, and rehabilitative care, have been a global priority in the promotion of health. However, the scope of primary care services has still been in decline in China. Studies on the factors for primary care service scope have centred on human resources and infrastructure; the role of direct government subsidies (DGS) on services scope of primary care facilities were left unanswered. This study aimed to explore the association between the DGS and services scope of primary care facilities in China.
Methods:
A multi-stage, clustered cross-sectional survey using self-administrated questionnaire was conducted among primary care facilities of 36 districts/counties in China. A total of 770 primary care facilities were surveyed with 757 (98.3%) valid respondents. Of the 757 primary care facilities, 469 (62.0%) provided us detailed information of financial revenue and DGS from 2009 to 2016. Therefore, 469 primary care facilities from 31 counties/districts were included in this study. Sasabuchi-Lind-Mehlum tests and multivariate regression models were used to examine the inverted U-shaped relationship between the DGS and service scope.
Results:
Of 469 PCFs, 332 (70.8%) were township health centres. Proportion of annul DGS to FR arose from 26.5% in 2009 to 50.5% in 2016. At the low proportion of DGS to financial revenue, an increase in DGS was associated with an increased service scope of primary care facilities, whereas the proportion of DGS to financial revenue over 42.5% might cause narrowed service scope (P = 0.023, 95% CI 11.59-51.74%); for the basic medical care dimension, the cut point is 42.6%. However, association between DGS and service scope of public health by primary care facilities is statistically insignificant.
Conclusion:
While the DGS successfully achieved equalization of basic preventive and public health services, the disproportionate proportion of DGS to financial revenue is associated with narrowed service scope, which might cause underutilization of primary care and distorted incentive structure of primary care. Future improvements of DGS should focus on the incentive of broader basic medical services provision, such as clarifying service scope of primary care facilities and strategic procurement with a performance-based subsidies system to determine resource allocation.
... 29 Economic and financial intervention strategies have been identified as one of the factors affecting the choice of cesarean section versus vaginal delivery. 30,31 To avoid unnecessary cesarean section, health-care service providers, especially gynecologists and midwives, have been offered good financial incentives to increase vaginal delivery rate. In public hospitals, the rate of natural childbirth increased dramatically. ...
Background:
The high prevalence of cesarean section represents a major public health challenge worldwide. In 2014, the Iranian Health Transformation Plan (HTP) included programs promoting vaginal delivery.
Aim:
The aim of this study was to investigate the effect of the HTP on the rate of cesarean section in Iran.
Method:
The interrupted time series analysis (ITSA) was used. Cesarean section- and vaginal delivery-related monthly data were collected from eight public hospitals affiliated with the Lorestan University of Medical Sciences, from March 2012 to February 2019. The autocorrelation plots and the Durbin-Watson test were used for evaluating the autocorrelation between data points in the generalized least squares regression model.
Results:
The ITSA showed that the rate of cesarean section decreased immediately after the HTP, by -0.002 per 1000 persons (95% CI, -0.004 to -0.001; P = .069). After the HTP, a significant decreasing trend of cesarean section per month was computed (-0.003; 95% CI, -0.005 to 0.012; P = .043).
Conclusion:
The present study showed that the implementation of the HTP policy was effective in reducing the rate of cesarean section. This policy should continue, involving relevant stakeholders, raising mothers' awareness and motivation, and providing financial support.
... It is worth noting that another high certainty evidence from Kozhimannil [37] showed that an equality fee intervention conducted by Minnesota's Medicaid Program, which raised both facility fees and professional fees, significantly decreased the CS rate. Four of the studies examined the effect of payment reform for reducing the CS rate [31,33,35,36]. In Taiwan, China, Liu et al. [33] evaluated the effectiveness of the hospital global budget system (GBS) reform to reduce the caesarean section rates in a tertiary hospital was uncertain in 2002 (low certainty evidence). ...
... In Taiwan, China, Liu et al. [33] evaluated the effectiveness of the hospital global budget system (GBS) reform to reduce the caesarean section rates in a tertiary hospital was uncertain in 2002 (low certainty evidence). In Henan, China, Liu et al. [36] described that payment reform from 2009 to 2011 that transforming a fee-for-service payment policy into a case payment policy has the opposite effect of increased the CS rate (moderate certainty evidence). However, two high-certainty studies revealed that risk-adjusted payment could be effective for controlling the CS rate [31,35]. ...
... which is much higher than vaginal delivery ($197.39) [36]. Thus, the healthcare setting and physicians may prefer CS over vaginal deliveries for financial reasons [51]. ...
Background:
The increasing trend of Caesarean section (CS) in childbirth has become a global public health challenge. Previous studies have proposed financial intervention strategies for reducing CS rates by limiting caesarean delivery on maternal request (CDMR). This study synthesizes such strategies while evaluating their effectiveness.
Methods:
The sources of data for this study are Cochrane Library, PubMed, EMBASE, and CINAHL. The publication period included in this study is from January 1991 to November 2018. The financial intervention strategies are divide into two categories: healthcare provider interventions and patient interventions. Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) was employed to assess the risk of bias of included studies. The outcome of each study was evaluated with Grades of Recommendation, Assessment, Development and Evaluation (GRADE) through the GRADEpro Guideline Development Tool software.
Results:
Nine studies were included in this systematic review: five with high certainty evidence (HCE), three with moderate certainty evidence (MCE), and one with low certainty evidence (LCE). Of the nine studies, seven are centered on the effect of provider-side interventions. Three of the HCE studies found that the diagnosis-related group payment system, risk-adjusted capitation, and equalizing fee for both facilities and physicians were effective intervention strategies. One HCE and one MCE study showed that only equalizing facility fees between vaginal and CS deliveries in healthcare service settings had no significant effect on reducing the CS rate. The MCE study showed that case payment had a negative effect on reducing the CS rates. One LCE study revealed that the effect of a global budget system was uncertain, and one HCE and one MCE study focused on combining both provider and patient-side interventions. However, equalizing fees for vaginal and CS deliveries and a co-payment policy for CDMRs failed to reduce the CS rate.
Conclusions:
The effectiveness of risk-adjusted payment methods appears promising and should be the subject of further research. Financial interventions should consider stakeholders' characteristics, especially the personal interests of doctors. Finally, high-quality randomized control trials and comparative studies on different financial intervention methods are needed to confirm or refute previous studies' outcomes.
... Some countries are experimenting with measures to reduce the use of cesareans and control delivery costs [16][17][18]. According to the Stafford study [16], the measures to decrease cesarean delivery rate were roughly classified into six strategies: (1) education and peer evaluation, (2) external review, (3) medical malpractice reform, (4) changes in physician reimbursement, (5) changes in hospital reimbursement, and (6) public dissemination of cesarean delivery rate. ...
Background
In the past decade, the rate of cesarean delivery increased dramatically in rural China under the fee-for-service (FFS) system. In September 2011, the New Cooperative Medical Scheme (NCMS) agency in Yong’an county in Fujian province of China adopted a policy of reforming payment for childbirth by transforming the FFS payment into episode-based bundled payment (EBP), which made the cesarean deliveries less profitable. Thus, this study was conducted to determine the effect of EBP policy on reducing cesarean use and controlling delivery costs for rural patients in the NCMS.
Methods
Data from the inpatient information database of the NCMS agency from January 2010 to March 2013 was collected, in which Yong’an county was employed as a reform county and 2 other counties as controls. We investigated the effects of EBP on cesarean delivery rate, costs of childbirth and readmission for rural patients in the NCMS using a natural experiment design and difference in differences (DID) analysis method.
Results
The EBP reform was associated with 33.97% (p<0.01) decrease in the probability of cesarean delivery. The EBP reform, on average, reduced the total spending per admission, government reimbursement expenses per admission, and out-of-pocket (OOP) payments per admission by ¥ 649.61, ¥ 575.01, and ¥ 74.59, respectively. The OOP payments had a net decrease of 14.24% (p<0.01); whereas the OOP payments as a share of total spending had a net increase of 8.72% (p<0.01). There was no evidence of increase in readmission rates.
Conclusions
These results indicate that the EBP policy has achieved at least a short-term success in lowering the increase of cesarean delivery rate and costs of childbirth. Considering both the cesarean rate and the OOP payments as a share of total spending after the reform were still high, China still has a long way to go to achieve the ideal level of cesarean rate and improve the benefits of deliveries for rural population.
