Comparative Study Of Medical Expense In Inpatients With And Without Medical Insurance And Influencing Factors

AimUp to the end of 2004, the population of Chinese city staff with basic medical insurance has reached 116 million, and the medical insurance system has started in most areas (98%) of China. The medical insurance reform has already yielded a gradual result, which basically realized the switch of medical support system and the transformation of the mechanism. However, while the medical insurance reform is making a considerable progress, there are some problems appearing in controlling the expense. According to the up to date statistics from ministry of labour and social security, the medical expense is increasing rapidly in recent years, by the average rate of 13% every year in outpatients and 11% in inpatients. At present, the average expense in city inpatients is 7 600 Yuan, which is higher than the yearly average income 6 500 Yuan; whereas the average expense in countryside inpatients is 2 400 Yuan, which is almost impartial with the yearly average net income of rural population. The overweightmedical burden has become one of the main reasons for the populace poverty. Therefore, the study of controlling expense is the important topic in research of current medical insurance policy. This study precisely aims at this key point controlling expense, taking the self-paying patients as the control and partial staff with medical insurance in Xi'an as the object, evaluates the effect of controlling the expense under medical insurance policy, and simultaneously seeks the main reasons for inpatient medical expense to over increase, so as to propose the control measure and provide the data reference for deepening medical system reform.MethodsTwo third-level and first-class hospitals in Xi'an that were first chosen by the medical insurants were selected. The collected data included the first pages of all 48 565 inpatients' medical records and their balance bills from January 2003 to October 2004 in first hospital, and first pages of all 20 567 inpatients' medical records and their balance bills from January to December 2003 in second hospital. After the material checkup, altogether 68 916 valid cases were gotten. To ensure the comparability of insured and uninsured, we eliminated: (1) inpatients who were younger than 20; (2) inpatients who were for health examination; (3) inpatients who were in hospital longer than 3 months; (4) inpatients who were living outside Xi'an; (5) inpatients who were free of charge. Finally there were 8 789 cases of insured and 51 694 cases of uninsured in this study.The basic information (age, sex and so on) of both insured and uninsured inpatients were statistically described; the distributioncharacteristic of expense and stay were analyzed by the frequency distribution map and the frequency table; multi-regression method were applied to analyze the factors that influenced the expense and the length of stay in hospital of insured and uninsured inpatients. The studied variables included: the sex, the age, the state of the illness, the number of critically ill days, the number of special care days, the coincidence rate of diagnosis, the treatment result, the infection within hospital, the surgery or not, the complication of surgery and the cut healing.In addition, to understand the constitution of different disease expense, the cases were classified according to the international disease classification (ICD-9), and the expense of the first 11 diseases were analyzed: viral hepatitis, tuberculosis, malignant tumor, benign tumor, diabetes, coronary heart disease, hypertension, cholelithiasis, fracture, hematopathy and neck and lumbar vertebra disease.SPSS 12.0 was used as statistical analysis software, and Mann-Whitney U test, Kruskal-Wallis test, x* test and multi-regression analysis were used as statistical methods.Results1 Analysis of expense and length of stay in hospital of insured inpatients(1) The male inpatients are more than female inpatients, and the proportion of 50-69 years old group is 54.7%; (2) The distribution characteristic of expense is positive skew, the proportion of within 10 000 Yuan group is 64.4%, and the proportion of more than 50 000 Yuan group is only 7.7%; (3) Concerning to the constitution of inpatient expense, theaverage constitution ratio of costs on western medicine, treatment, and surgery are 40.7%, 20.4% and 8.2% respectively; (4) The average expense of surgery group is more than that of non- surgery groupCPO.01); (5) The factors influencing the expense of insured inpatients include: the sex, the number of critically ill days, the number of special care days, the coincidence rate of diagnosis, the infection within hospital and the cut healing, in which the most influencing three factors are the number of special care days (0.41), the cut healing (0.33) and the number of critically ill days (0.14); (6) The self-paying part in insured patients is 49.7%, in which the self-paying drug is 15.7%; (7) The factors influencing the length of stay in hospital include: the state of the illness, the number of critically ill days, the number of special care days, the treatment result and the infection within hospital, in which the most influencing three factors are the state of the illness (0.26), the number of special care days (0.17) and the infection within hospital (0.17).2 Analysis of expense and length of stay of self-paying inpatients(1) The male inpatients are more than female inpatients, and the proportion of each group from 20 to 69 years old is over 15%; (2) The distribution characteristic of expense is positive skew, the proportion of within 10 000 Yuan group is 57.6%, and the proportion of more than 50 000 Yuan group is only 6.8%; (3) Concerning to the constitution of inpatient expense, the average constitution ratio of costs on western medicine, treatment, and surgery are 43.1%, 19.2% and 15.3% respectively; (4) The average expense of surgery group is more than that of non- surgerygroupCPO.Ol); (5) The factors influencing the expense of insured inpatients include: the sex, the age, the number of critically ill days, the number of special care days, the coincidence rate of diagnosis, the infection within hospital, the complication of surgery and the cut healing, in which the most influencing three factors are the number of special care days (0.39), the cut healing (0.26) and the number of critically ill days (0.17); (6) The factors influencing the length of stay in hospital include: the sex, the age, the state of the illness, the number of critically ill days, the number of special care days, the treatment result the infection within hospital, the complication of surgery and the cut healing, in which the most influencing three factors are the number of critically ill days(0.22), the infection within hospital (0.13) and the state of the illness (0.13).3 Compare of expense and stay in insured and self-paying inpatients (1) Compare of inpatients' expense and stay?The age distribution of self-paying patients, where the young isrelatively more, is obviously different from that of insured. Taking 20~29 years old group as the example, the proportion of self-paying is 16.2%, but the insured is only 3.6%; ?The sex constitution of insured and self-paying patients are both male primarily; ?The average expense of self-paying patients (16 206.0 Yuan) is more than that of insured (15 657.3 Yuan); ? Concerning to the constitution of inpatient expense, the costs on bed, western medicine, examinations, blood transfusion, surgery, nursing and other things of insured patients are less (P<0.05) comparing to self-paying, while the costs on especial examines and treatments are more (P<0.05); ?Regardless of insured or self-paying patients, the average expense of surgery group is more than that of non- surgery group; ?The results of multi-regression analysis show that, regardless of insured or self-paying inpatients, the first three factors influencing the expense are the number of special care days, the number of critically ill days and the cut healing; ? Regardless of insured or self-paying inpatients, the first two factors influencing the length of stay in hospital are the infection within hospital and the state of the illness.(2) Compare of expense and stay of different diseases(DThe age distribution and the sex constitution are various in different diseases. For example, the viral hepatitis episodes mostly between 30 and 49 years old and male are more than female in the coronary heart disease; ?There is a big difference of self-paying part in insured patients with different diseases. For example, the self-paying part is 62.7% in fracture whereas is only 40.7 % in neck and lumbar vertebra disease; ?The constitution of inpatient expense and the distribution of the length of stay in hospital are various in different diseases. If taking viral hepatitis as the example, the average expense is 8 763.1 Yuan in insured inpatients whereas is 19 706.5 Yuan in self-paying inpatients, the difference is 10 943.3 Yuan, and the difference of the cost on western medicine is 7 805.2 Yuan. There are no statistically differences (P>0.05) in the length of stay, the number of critically ill days, the number of special care days, the number of first and second level nursing days between self-paying inpatients and insured inpatients of viral hepatitis. If taking neck and lumbar vertebra disease asthe example, the average expense is 24 913.7 Yuan in insured inpatients whereas is 17 075.4 Yuan in self-paying inpatients, the difference is 7 838.3 Yuan, and the difference of the cost on treatment is 7 647.7 Yuan. There are statistically differences (P<0.05) only in the length of stay, the number of critically ill days, the number of first level nursing days between self-paying inpatients and insured inpatients of neck and lumbar vertebra disease.Conclusions(1) The average expense of insured patients is less than that ofself-paying patients, it proves that the implementation of medical insurance system help to controll hospitalization expense; (2) The first three proportion of hospitalization expense is the costs on western medicine, treatment and surgery, so decreasing the costs of western medicine, treatment and surgery can reduce hospitalization expense effectively; (3) The cost on treatment in insured patients is obviously more than that of self-paying patients. The rapid rise of treatment cost (caused by the overuse of medical material) is the key factor to impair the effect of controlling the expense under medical insurance policy. For the first time, we put forward that treatment cost is the keystone of controlling the expense, especially in surgery group; (4) There are different characteristics in different groups (various as age, sex and so on), much attention should be paid to emphasis of prophylaxis, which should be launched according to the different characteristics of diseases; (5) The results of multi- regression analysis of expense show that, we can reduce hospitalization expense effectively by changing the nursing level in time, decreasing the number of critically ill days and preventing surgery infection; (6) The results of multi- regression...