Impact of hierarchical hospital reform on patients with diabetes in China: a retrospective observational analysis

ObjectivesWe assess whether China’s diabetes pilot hierarchical diagnosis and treatment reforms shifted patient healthcare-seeking behaviour towards primary health institutions (PHIs) and away from secondary and tertiary hospitals. From the patients’ perspective, we evaluate whether the hierarchical system saw the decline of average hospital cost, out-of-pocket (OOP) expenses and the increase of reimbursement rate in PHIs. From the health system’s perspective, we also assessed whether the share of PHIs in total costs, total visits and reimbursement rate increased and the share of secondary and tertiary hospitals decreased.MethodsData were collected from the health insurance bureau of 11 cities in Shandong Province, China between 2015 and 2017, which included 9 118 518 outpatient visits and 622 739 inpatient visits. For both inpatients and outpatients and the health system, we analysed health services-seeking characteristics including hospital costs, hospital visits, OOP expense and reimbursements of hospital costs. Binary logistic regression was conducted to analyse the influencing factors of seeking PHI health services.ResultsPHIs remained the lowest hospital cost provider, but average hospital costs declined across all three healthcare levels of PHIs, secondary hospitals and tertiary hospitals from 2015 to 2017. The hierarchical system aimed to shift patients to PHIs, increasing PHIs’ share of total hospital costs. However, the PHI share of total outpatient costs declined 12.0%, while rising 15.0% in secondary hospitals, the opposite of the goal of the hierarchical medical system. Average outpatient visits rose roughly at the same rate in PHIs (5.1%) as secondary hospitals (6.8%), with no evidence of a shift in patient visits between hospital levels over 2015–2017. Average inpatient visits fell across all levels of hospitals, with no significant difference in the rate of decline between PHIs (9.4%) and secondary (7.5%) and tertiary (7.8%) hospitals. For outpatient and inpatient services, the binary logistic regression showed that over the 2015–2017 period patients with diabetes increasingly used higher level hospitals rather than PHIs (p<0.05). The only success of the hierarchical medical system was the relative fall of OOP outpatient expenses, which fell more rapidly in PHIs (13.7%) than secondary (5.0%) and tertiary (3.5%) hospitals. However, inpatient OOP expenses fell only 2.2% for PHIs, less than half that of secondary (5.5%) and tertiary (7.4%) hospitals, the opposite of the aim of the hierarchical system reform.ConclusionsThe implementation of the hierarchical medical system for patients with diabetes did not achieve its goal of increasing PHI utilisation and decreasing secondary and tertiary hospital utilisation. Enhancing the utilisation of PHIs for diabetes and other patients requires further health reform, including educating patients on PHI use, further reforming the health insurance schemes, improving PHI facilities and encouraging referrals to PHIs from higher level hospitals.

Ambulatory cardiology telemedicine: a large academic pediatric center experience

We performed a retrospective study of cardiology telemedicine visits at a large academic pediatric center between 2016 and 2019 (pre COVID-19). Telemedicine patient visits were matched to data from their previous in-person visits, to evaluate any significant differences in total charge, insurance compensation, patient payment, percent reimbursement and zero reimbursement. Miles were measured between patient’s home and the address of previous visit. We found statistically significant differences in mean charges of telemedicine versus in-person visits (2019US$) (172.95 vs 218.27, p=0.0046), patient payment for telemedicine visits versus in-person visits (2019US$) (11.13 vs 62.83, p≤0.001), insurance reimbursement (2019US$) (65.18 vs 110.85, p≤0.001) and insurance reimbursement rate (43% vs 61%, p=0.0029). Rate of zero reimbursement was not different. Mean distance from cardiology clinic was 35 miles. No adverse outcomes were detected. This small retrospective study showed cost reduction and a decrease in travel time for families participating in telemedicine visits. Future work is needed to enhance compensation for telemedicine visits.

An Analysis of Procedural Medicare Reimbursement Rates in Hand Surgery: 2000 to 2019

Background: Medicare reimbursement trends across multiple surgical subspecialties have been analyzed; however, little has been reported regarding the long-term trends in reimbursement of hand surgery procedures. The aim of this study is to analyze trends in Medicare reimbursement for commonly performed hand surgeries. Methods: Using the Centers for Medicare and Medicaid Services Physician and Other Supplier Public Use File, we determined the 20 hand surgery procedure codes most commonly billed to Medicare in 2016. Reimbursement rates were collected and analyzed for each code from The Physician Fee Schedule Look-Up Tool for years 2000 to 2019. We compared the change in reimbursement rate for each procedure to the rate of inflation in US dollars, using the Consumer Price Index (CPI) over the same time period. Results: The reimbursement rate for each procedure increased on average by 13.9% during the study period while the United States CPI increased significantly more by 46.7% ( P < .0001). When all reimbursement data were adjusted for inflation to 2019 dollars, the average reimbursement for all included procedures in this study decreased by 22.6% from 2000 to 2019. The average adjusted reimbursement rate for all procedures decreased by 21.92% from 2000 to 2009 and decreased by 0.86% on average from 2009 to 2019 ( P < .0001). Conclusion: When adjusted for inflation, Medicare reimbursement for hand surgery has steadily decreased over the past 20 years. It will be important to consider the implications of these trends when evaluating healthcare policies and the impact this has on access to hand surgery.

Analysis of 20-Year Trends in Medicare Reimbursement for Reconstructive Microsurgery

Background Microsurgery is being increasingly utilized across surgical specialties, including plastic surgery. Microsurgical techniques require greater time and financial investment compared with traditional methods. This study aimed to evaluate 20-year trends in Medicare reimbursement and utilization for commonly billed reconstructive microsurgery procedures from 2000 to 2019. Materials and Methods Microsurgical procedures commonly billed by plastic surgeons were identified. Reimbursement data were extracted from The Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services for each current procedural terminology (CPT) code. All monetary data were adjusted for inflation to 2019 U.S. dollars. The average annual and total percentage changes in reimbursement were calculated based on these adjusted trends. To assess utilization trends, CMS physician/supplier procedure summary files were queried for the number of procedures billed by plastic surgeons from 2010 to 2018. Results After adjusting for inflation, the average reimbursement for all procedures decreased by 26.92% from 2000 to 2019. The greatest mean decrease was observed in CPT 20969 free osteocutaneous flaps with microvascular anastomosis (−36.93%). The smallest mean decrease was observed in repair of blood vessels with vein graft (−9.28%). None of the included procedures saw an increase in reimbursement rate over the study period. From 2000 to 2019, the adjusted reimbursement rate for all procedures decreased by an average of 1.35% annually. Meanwhile, the number of services billed to Medicare by plastic surgeons across the included CPT codes increased by 42.17% from 2010 to 2018. Conclusion This is the first study evaluating 20-year trends in inflation-adjusted Medicare reimbursement and utilization in reconstructive microsurgery. Reimbursement for all included procedures decreased over 20% during the study period, while number of services increased. Increased consideration of these trends will be important for U.S. policymakers, hospitals, and surgeons to assure continued access and reconstructive options for patients.

Effect of critical illness insurance on the medical expenditures of rural patients in China: an interrupted time series study for universal health insurance coverage

ObjectiveThe objective of this study is to determine if critical illness insurance (CII) promotes the universal health coverage to reduce out-of-pocket (OOP) medical expenditures and improve the effective reimbursement rate (ERR) in rural China.Study designThe 5-year monthly hospitalisation data, starting 2 years before the CII (ie, the ‘intervention’) began, were collected. Interrupted time series analysis models were used to evaluate the immediate and gradual effects of CII on OOP payment and ERR.SettingThe study was conducted in Xiantao County, Hubei Province, China.ParticipantsA total of 511 221 inpatients within 5 years were included in the analysis.ResultsIn 2016, 100 288 patients received in-patient services, among which 4137 benefited from CII. After the implementation of CII, OOP expenses increased 32.2% (95% CI 24.8% to 39.5%, p<0.001). Compared with the preintervention periods, the trend changes decline at a rate of 0.7% per month after the implementation of CII. Similarly, a significant decrease was observed in log ERR after the intervention started. The rate of level change is 16% change (95% CI −20.0% to −12.1%, p<0.001).ConclusionCII did not decrease the OOP payments of rural inpatients in 2011–2016 periods. The limited extents of population coverage and financing resources can be attributed to these results. Therefore, the Chinese government must urgently raise the funds of CII and improve the CII policy reimbursement rate.

Factors Associated with Rural Residents’ Contract Behavior with Village Doctors in Three Counties: A Cross-Sectional Study from China

Historically, cooperative medical insurance and village doctors are considered two powerful factors in protecting rural residents’ health. However, with the central government of China’s implementation of new economic policies in the 1980s, cooperative medical insurance collapsed and rural residents fell into poverty because of sickness. In 2009, the New Rural Cooperative Medical Insurance (NRCMI) was implemented to provide healthcare for rural residents. Moreover, the National Basic Drug System was implemented in the same year to protect rural residents’ right to basic drugs. In 2013, a village doctor contract service was implemented after the publication of the Guidance on Pilot Contract Services for Rural Doctors. This contract service aimed to retain patients in rural primary healthcare systems and change private practice village doctors into general practitioners (GPs) under government management. Objectives: This study investigates the factors associated with rural residents’ contract behavior toward village doctors. Further, we explore the relationships between trust, NRCMI reimbursement rate, and drug treatment effect. We used a qualitative approach, and twenty-five village clinics were chosen from three counties as our study sites using a random sampling method. A total of 625 villagers participated in the investigation. Descriptive analysis, chi-squared test, t-test, and hierarchical logistic analyses were used to analyze the data. Results: The chi-squared test showed no significant difference in demographic characteristics, and the t-test showed a significant difference between signed and unsigned contract services. The results of the hierarchical logistic analysis showed that trust significantly influenced patients’ willingness to contract services, and the drug treatment effect and NRCMI reimbursement rate moderated the influence of trust. Conclusion: Our findings suggest that the government should aim to strengthen trust in the doctor–patient relationship in rural areas and increase the NRCMI reimbursement rate. Moreover, health officers should perfect the contract service package by offering tailored contract services or expanding service packages.

Leveraging Advanced Practice Providers in an Otolaryngology Practice

Objective Advanced practice providers (APPs) may see patients independently or assist in “collaborative” clinics in otolaryngology practices. Our goal was to redesign the collaborative physician-APP clinic model to increase patient access, maintain financial sustainability, and optimize patient and staff experience. Methods The study was performed in a tertiary care academic rhinology clinic seeing adult patients. The DMAIC framework (define, measure, analyze, improve, control) was used to develop the new model. The process shift between old and new models was analyzed by utilizing a statistical process control chart. Patient and staff surveys were tracked. Results The collaborative physician-APP model was redesigned into 2 parallel and independently run (“concurrent”) physician and APP clinics. Patient access increased by 38.9% from a mean of 17.9 patients per collaborative clinic (n = 15 days, 269 patients) to 29.3 patients per concurrent clinic (n = 12 days, 352 patients). Medicare reimbursement rate modeling showed the collaborative clinic to operate at a loss of $1341.51 per day, while the concurrent clinic model operated at a $1309.88 gain (200% positive change). Patient and staff experience tracked positively. Discussion Otolaryngology clinics can become overwhelmed by the volume of empaneled established patients. Traditional collaborative physician-APP clinics see the same panel of patients together. However, these can be successfully redesigned to a concurrent model. Concurrent clinics improve patient access and provider satisfaction while maintaining patient satisfaction and fiscal performance. Implications for Practice Leveraging an experienced APP to run a parallel and independent clinic alongside the physician (concurrent clinic model) may improve patient access, financial metrics, and patient/staff experience.

Impact of reimbursement rates on the length of stay in tertiary public hospitals: a retrospective cohort study in Shenzhen, China

ObjectiveTo examine the association between reimbursement rates and the length of stay (LOS).DesignA retrospective cohort study.SettingThe study was conducted in Shenzhen, China by using health administrative database from 1 January 2015 to 31 December 2017.Participants6583 patients with acute myocardial infarction (AMI), 12 395 patients with pneumonia and 10 485 patients who received percutaneous coronary intervention (PCI) surgery.MeasuresThe reimbursement rate was defined as one minus the ratio of out-of-pocket to the total expenditure, multiplied by 100%. The outcome of interest was the LOS. Multilevel negative binomial regression models were constructed to control for patient-level and hospital-level characteristics, and the marginal effect was reported when non-linear terms were available.ResultsEach additional unit of the reimbursement rate was associated with an average of an additional increase of 0.019 (95% CI, 0.015 to 0.023), 0.011 (95% CI, 0.009 to 0.014) and 0.013 (95% CI, 0.010 to 0.016) in the LOS for inpatients with AMI, pneumonia and PCI surgery, respectively. Adding the interaction term between the reimbursement rate and in-hospital survival, the average marginal effects for the deceased inpatients with AMI and PCI surgery were 0.044 (95% CI, 0.031 to 0.058) and 0.034 (95% CI, 0.017 to 0.051), respectively. However, there was no evidence that higher reimbursement rates prolonged the LOS of the patients who died of pneumonia (95% CI, −0.013 to 0.016).ConclusionsThe findings indicate that the higher the reimbursement rate, the longer the LOS; and implementing dynamic supervision and improving the service capabilities of primary healthcare providers may be an important strategy for reducing moral hazard in low-income and middle-income countries including China.

The economic value of an on-call neurosurgical resident physician

OBJECTIVEThe cost of training neurosurgical residents is especially high considering the duration of training and the technical nature of the specialty. Despite these costs, on-call residents are a source of significant economic value, through both indirectly and directly supervised activities. The authors sought to identify the economic value of on-call services provided by neurosurgical residents.METHODSA personal call log kept by a single junior neurosurgical resident over a 2-year period was used to obtain the total number of consultations, admissions, and procedures. Current Procedural Terminology (CPT) codes were used to estimate the resident’s on-call economic value.RESULTSA single on-call neurosurgical resident at the authors’ institution produced 8172 work relative value units (wRVUs) over the study period from indirectly and directly supervised activities. Indirectly supervised procedures produced 7052 wRVUs, and directly supervised activities using the CPT modifier 80 yielded an additional 1120 wRVUs. Using the assistant surgeon billing rate for directly supervised activities and the Medical Group Management Association nationwide median neurosurgery reimbursement rate, the on-call activities of a single resident generated a theoretical billing value of $689,514 over the 2-year period, or $344,757 annually. As a program, the on-call residents collectively produced 39,550 wRVUs over the study period, or 19,775 wRVUs annually, which equates to potential reimbursements of $1,668,386 annually.CONCLUSIONSNeurosurgery residents at the authors’ institution theoretically produce enough economic value exclusively from on-call activities to far exceed the cost of their education. This information could be used to more precisely estimate the true overall cost of neurosurgical training and determine future graduate medical education funding.