Study On Medical Expense Construction And Influencing Factors In Inpatients With And Without Medical Insurance

ObjectiveUp 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 7600 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 overweight medical 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 Changsha 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.Methods Two third-level and first-class hospitals in Changsha 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 68916 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 changsha;(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 uninsured inpatients were statistically described;the insured and characteristic of expense and stay were analyzed by the frequency distribution map and the frequency table;mufti-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 I1 diseases were analyzed:viral hepatitis,tuberculosis, malignant tumor,benign tumor,diabetes,coronary heart disease, hypertension,cholelithiasis,fracture,hematopathy and neck and lumbar vertebra disease.SPSS12.0 was used as statistical analysis software,and Mann-Whitney U test,Kruskal-Wallis test,x~2 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 5069 years old group is 54.7%;(2)The distribution characteristic of expense is positive skew,the proportion of within 10000 Yuan group is 64.4%,and the proportion of more than 50000 Yuan group is only 7.7%;(3)Concerning to the constitution of inpatient expense,the average 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 group(P＜0.01);(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 10000 Yuan group is 57.6%,and the proportion of more than 50000 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-surgery group(P＜0.01);(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 stay①The age distribution of self-paying patients,where the young is relatively 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%,②The sex constitution of insured and self-paying patients are both male primarily;③The average expense of self-paying patients(16 206.0 Yuan) is more than that of insured(15 657.3 Yuan);④Concerning 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);⑤Regardless of insured or self-paying patients,the average expense of surgery group is more than that of non- surgery group;⑥The 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;⑦Regardless 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 diseases①The 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;②There 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;③The 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 19706.5 Yuan in self-paying inpatients,the difference is 10943.3 Yuan,and the difference of the cost on western medicine is 7805.2 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 as the 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 7 838.3Yuan,and the difference of the cost on treatment is 7 647.? Yuan.There are statistically differences (P＜0.05)only in the length of stay,the number of critically inpatients ill days,the number of first level nursing days between self-paying and insured inpatients of neck and lumbar vertebral disease.Conclusions(1)The average expense of insured patients is less than that of self-paying patients,it proves that the implementation of medical insurance system help to control 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 multiregression 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 mufti- regression analysis of expense show that,we can reduce the length of stay in hospital effectively by controlling infection within hospital and alleviating the state of the illness.The mufti- regression analysis results of the length of stay has not been reported;(7)The number of critically ill days and the number of special care days are the key factors to influence the expense,so reducing them(equal to reduce the length of stay in hospital) can decrease hospitalization expense;(8) The proportion of personal self-paying part in insured patients is relatively high,it should be gradually reduced,and the excessive use of self-paying drugs and over-extent expense should be strictly patients controlled; (9)The study of hospitalization expense of insured patients which includes mass insured patients and multiple diseases has not been reported.Our study finds that,according to the expense characteristic of each disease,we can establish controlling and supervising steps respectively,so that we can use the hygeian resource reasonably.Taking viral hepatitis and neck and lumbar vertebra disease as the example:there are no statistically differences in the state of the illness and the clinical outcome,but the average expense is much higher in self-paying group (the difference is 10943.3 Yuan) of viral hepatitis patients,and the average expense is much lower in self-paying group(the difference is 7838.3 Yuan) of neck and lumbar vertebra disease patients.So, self-paying group of viral hepatitis patients and insured group of neck and lumbar vertebra disease are out of expense control,we can decrease hospitalization expense prominently by restricting the cost on western medicine of self-paying viral hepatitis patients and the cost on medical materials of insured neck and lumbar vertebra disease.