Evaluating the long-term care insurance policy from medical expenses and health security equity perspective: evidence from China

Background Since the national long-term care (LTCI) policy pilot in 2016 of China, the LTCI policy has had significant impact on the residents in the pilot area. Methods From the perspective of medical expenses and health security equity, this study selects tracking survey data from the CHARLS database in 2013, 2015, and 2018 and empirically investigates the effect of LTCI policy pilot by using differences-in-differences method (DID). Moreover, this study measures the economic distribution and health equity of the treated and untreated groups using the concentration and Theil indices. Results The results showed that group heterogeneity of medical expenses and health level of elderly in the treatment group were narrowing. Moreover, the policy results showed that the LTCI policy pilot significantly affects the outpatient, hospital expenses, and length of stay of elders. Residence registration, income level, and basic medical insurance play a significant regulatory role. Additionally, LTCI policy pilot significantly improved the overall health of the elderly. Conclusions The measurement results of inequality show that the policy increases the income of low-income people, lowers the inequality level of outpatient and inpatient reimbursement, and reduces the concentration index of ADL disability and serious diseases. However, the inequality of serious diseases is becoming higher. Based on this, this paper provides several suggestions on optimizing the pilot policy of LTCI.

EXPOSURE OF PEDIATRIC EMERGENCY PATIENTS TO IMAGING EXAMS, NOWADAYS AND IN TIMES OF COVID-19: AN INTEGRATIVE REVIEW

ABSTRACT Objective: To analyze literature data about unnecessary exposure of pediatric emergency patients to ionizing agents from imaging examinations, nowadays and during times of COVID-19. Data sources: Between April and July 2020, articles were selected using the databases: Virtual Health Library, PubMed and Scientific Electronic Library Online. The following descriptors were used: [(pediatrics) AND (emergencies) AND (diagnostic imaging) AND (medical overuse)] and [(Coronavirus infections) OR (COVID-19) AND (pediatrics) AND (emergencies) AND (diagnostic imaging)]. Inclusion criteria were articles available in full, in Portuguese or English, published from 2016 to 2020 or from 2019 to 2020, and articles that covered the theme. Articles without adherence to the theme and duplicate texts in the databases were excluded. Data synthesis: 61 publications were identified, of which 17 were comprised in this review. Some imaging tests used in pediatric emergency departments increase the possibility of developing future malignancies in patients, since they emit ionizing radiation. There are clinical decision instruments that allow reducing unnecessary exam requests, avoiding over-medicalization, and hospital expenses. Moreover, with the COVID-19 pandemic, there was a growing concern about the overuse of imaging exams in the pediatric population, which highlights the problems pointed out by this review. Conclusions: It is necessary to improve hospital staff training, use clinical decision instruments and develop guidelines to reduce the number of exams required, allowing hospital cost savings; and reducing children’s exposure to ionizing agents.

Prediction of total hospital expenses of patients undergoing breast cancer surgery in Shanghai, China by comparing three models

Background Breast cancer imposes a considerable burden on both the health care system and society, and becomes increasingly severe among women in China. To reduce the economic burden of this disease is crucial for patients undergoing the breast cancer surgery, hospital managers, and medical insurance providers. However, few studies have evidenced the prediction of the total hospital expenses (THE) for breast cancer surgery. The aim of the study is to predict THE for breast cancer surgery and identify the main influencing factors. Methods Data were retrieved from the first page of medical records of 3699 patients undergoing breast cancer surgery in one tertiary hospital from 2017 to 2018. Multiple liner regression (MLR), artificial neural networks (ANNs), and classification and regression tree (CART) were constructed and compared. Results The dataset from 3699 patients were randomly divided into training and test sets at a 70:30 ratio (2599 and 1100 records, respectively). The average total hospital expenses were 12520.54 ± 7844.88 ¥ (US$ 1929.20 ± 1208.11). MLR results revealed six factors to be significantly associated with THE: age, LOS, type of disease, having medical insurance, minimally invasive surgery, and receiving general anesthesia. After comparing three models, ANNs was the best model to predict THEs in patients undergoing breast cancer surgery, and its strong predictive performance was also validated. Conclusions To reduce the THEs, more attention should be paid to related factors of LOS, major and minimally invasive surgeries, and general anesthesia for these patient groups undergoing breast cancer surgery. This may reduce the information asymmetry between doctors and patients and provide more reliable cost, practical inpatient medical consumption standards and reimbursement standards reference for patients, hospital managers, and medical insurance providers ,respectively.

Emphasizing Health Insurance as Social Security System of Unorganized Sector in Maharashtra: The Case of the Ragpickers

The Indian economy is categorized into two sectors, namely: organized and unorganized sectors. The unorganized sector consists of a pivotal part of the Indian economy. Ragpickers are that class of employees who can be considered as an organized-unorganized labor class. Ragpicking business entails collecting, sorting, and selling various waste materials, mainly plastics or metals. After doing all this work, they sell recyclable material to the junkyard dealers at very petty prices, making them economically poor. Ragpickers are a major contributor to the Indian economy, as they are involved in recycling. Ragpickers mostly work without being equipped with any protective gear and are exposed to many health hazards while doing their role. They suffer from occupational risks and are often found hospitalized paying their bills from their pockets. There are times when they even do not go to hospitals because of hospital expenses. The paper primarily focuses on analyzing the different health insurance schemes, which are provided as social security by the Maharashtra Government and tries to find out the possible loopholes in health insurance policies because of which the ragpickers are not able to utilize or avail the benefits of the policies for which they are eligible. For developing a better understanding of the subject, the researcher has conducted an empirical survey on the ragpickers of Pune. Based on this, the researcher has recommended some policy changes, which can prove beneficial for the welfare of the Ragpickers.

Impact of vaccination in reducing Hospital expenses, Mortality and Average length of stay among COVID 19 patients. A retrospective cohort study from India

Background & Aim: WHO listed vaccine hesitancy among the top 10 global threats to health and there are very few reports highlighting vaccine benefits against COVID-19. The aim of this study was to study the impact of vaccination on reducing the average length of stay (ALOS), intensive care unit (ICU) requirement, mortality and cost of the treatment among COVID-19 patients. Methods: In this retrospective cohort study all the patients above 45 years who underwent treatment for COVID-19 were included. The data of patients treated pan India during the period March & April 2021 with the diagnosis of COVID-19, under health insurance cover, were extracted to study parameters like the ALOS, mortality, ICU requirement, total hospital expenses incurred and the vaccination status. Results: Among 3820 patients with COVID-19, 3301 (86.4%) were unvaccinated while 519 (13.6%) were vaccinated. Among the unvaccinated the mean (s.d) ALOS was 7 days. Fourteen days after second dose of vaccination this was significantly less (p=0.01) at 4.9. The mean total hospital expense among the unvaccinated was Rs. 277850. Fourteen days after second dose of vaccination this was further less (p=0.001) at Rs. 217850. Among the unvaccinated population 291/3301 (8.8%) required ICU and this was significantly less (p=0.03) at 31/519 (6%) among the vaccinated. Among those who received two doses of vaccination it was further less at 1/33 (3%). The mortality among unvaccinated patients was 16/3301 (0.5%) while there was no mortality among the vaccinated. Among those who received two doses of vaccination there was a 66% relative risk reduction in ICU stay and 81% relative risk reduction in mortality. Conclusions: There was a significant reduction in ALOS, ICU requirement, mortality & treatment cost in patients who had completed two doses of vaccination. These findings may be used in motivating public and promoting vaccination drive.

The Cough Reflex Intensity Score in Critically Ill Patients’ Airway Management: Study Protocol for a Multicenter, Prospective, Observational Trial

Background A patient’s ability to cough is important for assessing a patient’s airway condition and likely mechanical ventilation outcome,there is still a lack of data comparing patients’ initial cough ability and outcomes. Methods The study is a prospective, observational trial which includes 144 patients from Xinjiang Medical University. After a patients is assigned a cough strength score, the cough intensity assessments will be implemented every other day for a week. The primary endpoint is whether the patient requires endotracheal intubation (including tracheostomy). Secondary endpoints include time spent under mechanical ventilation (excluding noninvasive ventilation), ICU and hospital lengths of stay, hospital expenses and in-hospital 30-day mortality. Discussion Anecdotally in our practice, we found that patients with a high Cough Reflex Intensity Score don't require endotracheal intubation, while patients with a low score always need to be intubated. This trial will test to what degree cough intensity is correlated to patient’s outcomes. Trial registration: Chinese Clinical Trial Registry,ChiCTR1900028265. Registered 16 December 2019

Hospitalization Expenditure of COVID-19 Patients at the University of the Philippines-Philippine General Hospital (UP-PGH) with PhilHealth Coverage

Objective. This research aimed to determine the in-patient expenditure of COVID-19 adult patient s and their out-of-pocket (OOP) payments at the University of the Philippines-Philippine General Hospital (UP-PGH) after the new PhilHealth case rate coverage was instituted last 15 April 2020. It also intended to present the preliminary data on the expenses incurred by COVID patients during the initial phase of the pandemic in the country. Methods. This study was a retrospective chart review of admitted COVID-19 patients aged 19 years old and above from 15 April to 14 August 2020 at UP-PGH that availed of PhilHealth COVID-19 case rate benefits package (C19C1-C4). Data were analyzed to extract overall expenses, out-of-pocket (OOP) charges, cost centers utilization, and other hospitalization expenditure sources. Results. Of the 691 COVID-19 patients included during the study period, 55.72% were male, mostly belonging to the 61-70 age range with a median age of 58. The average in-hospital stay was 14.20 days, and 76.99% were under charity services, with the moderate (42.84%) and mild (25.33%) pneumonia cases accounting for 68.17% of the admissions. Total hospital expenses clustered around Php51,000 to 200,000 (~USD 1,041 to 4,156), most spending between Php101,000 to 150,000 (~USD 2,078 to 3,118). The top three cost centers and expenditure sources were pharmacies, personal protective equipment (PPE) usage, and laboratory. The average OOP payment for patients less than 60 years old was higher, ranging from Php 25,899 to Php 44,428.63 (USD 538 to USD 924.44) compared to patients older than 60 (Php4,005.60 to Php 32,920.20 ~ USD 83.35 to 684.98). The most OOP charges were for the age group 19-30, amounting to Php 44,428.63 (USD 924.44). Conclusion. Preliminary findings of this study gave an actual representation of the expenses of COVID-19 patients, which can guide future utilization of the national health insurance during unexpected pandemics. Early price regulation of new therapeutic interventions, diagnostic tests, and medical supplies, e.g., PPEs, disinfectants, air filters, are measures that can be implemented.

Evidence of the effect of primary care expansion on hospitalizations: Panel analysis of 143 municipalities in the Brazilian Amazon

Background The Family Health Strategy (FHS) became consolidated as a primary care model and gatekeeper for the Unified Health System (Sistema Único de Saúde, SUS) in the Brazil and it is considered one of the largest primary health care programmes in the world. Its rapid expansion allowed the SUS to meet the changing health care needs of the population remote localities of Brazilian municipalities. Methods In the present study, exploratory data analysis was performed using modelling to provide a general overview of the study and to delineate possible structural characteristics of the cross-sectional time-series data. Panel regression methods were used to assess the association between FHS coverage and ambulatory care-sensitive hospitalizations (ACSH rates) in the municipalities of Pará, in the Brazilian Amazon, from 2008 to 2017. Results The results showed strong evidence for the association between FHS coverage and ACSH rates, including reductions of 22% in preventable hospitalizations and 15% in hospital expenses that were directly linked to the 40% increase in FHS population coverage during the evaluated period. This expansion of primary care has mainly benefitted areas that are difficult to access and populations that were previously deprived of health care in the vast Amazon territory. Conclusions The findings of this study show that the increase of the expansion of primary care reduces the preventable hospitalization and the hospital expenses. This reinforces the need for public protection of the health of populations at risk and the positive impacts of primary care in the Brazilian Amazon.

Differences in Hospital Costs among Octogenarians and Nonagenarians Following Primary Total Joint Arthroplasty

The proportion of patients over the age of 90 years continues to grow, and the anticipated demand for total joint arthroplasty (TJA) in this population is expected to rise concomitantly. As the country shifts to alternative reimbursement models, data regarding hospital expenses is needed for accurate risk-adjusted stratification. The aim of this study was to compare total in-hospital costs following primary TJA in octogenarians and nonagenarians, and to determine the primary drivers of cost. This was a retrospective analysis from a single institution in the U.S. We used time-drive activity-based costing (TDABC) to capture granular total hospital costs for each patient. 889 TJA’s were included in the study, with 841 octogenarians and 48 nonagenarians. Nonagenarians were more likely to undergo total hip arthroplasty (THA) (70.8% vs. 42.4%; p < 0.0001), had higher ASA classification (2.6 vs. 2.4; p = 0.049), and were more often privately insured (35.4% vs. 27.8%; p = 0.0001) as compared to octogenarians. Nonagenarians were more often discharged to skilled nursing facilities (56.2% vs. 37.5%; p = 0.0011), experienced longer operating room (OR) time (142 vs. 133; p = 0.0201) and length of stay (3.7 vs. 3.1; p = 0.0003), and had higher implant and total in-hospital costs (p < 0.0001 and 0.0001). Multivariate linear regression showed implant cost (0.700; p < 0.0001), length of stay (0.546; p < 0.0001), and OR time (0.288; p < 0.0001) to be the strongest associations with overall costs. Primary TJA for nonagenarians was more expensive than octogenarians. Targeting implant costs, length of stay, and OR time can reduce costs for nonagenarians in order to provide cost-effective value-based care.

Health Economic Aspects of Aneurysmal Subarachnoid Hemorrhage: Factors Determining First Year In-Hospital Treatment Expenses

Background Spontaneous aneurysmal subarachnoid hemorrhage (SAH) is a common neurosurgical emergency with a high case fatality rate. The clinical course of SAH generates high health economic expenses. Here we highlight possible cost-driving factors for in-hospital care expenses for the first year. Furthermore, results are compared with ischemic stroke treatment. Methods One hundred and one patients with aneurysmal SAH treated in our hospital from 2007 through 2009 were included. The Hunt and Hess (HH) scale, World Federation of Neurosurgical Societies (WFNS) scale, Fisher Scale, and further outcome-relevant data were recorded. Expenses were calculated using the German fixed case rate classification system consisting of Diagnosis-Related Groups (DRG) and the Operation and Procedure catalogue (OPS). Overall acute length of stay (LOS) and LOS on the intensive care unit (ICU) were separately evaluated. Expenses were compared with formerly published first-year costs of ischemic stroke. Results Fifty-four percent of the patients (median age 52 years, 69% females) received coiling and 46% clipping. Acute in-hospital treatment accounted for 82% of total in-hospital expenses, while consequential in-hospital treatment accounted only for 18%. Altogether, the total first-year in-hospital expenses for all patients were as high as €2,650,002, resulting in average SAH in-hospital treatment expenses of €26,238 per patient for the first year. Poor clinical condition on admission and longer stay in ICU are the main cost-driving factors. The impact of the aneurysm treatment method is debatable. Only a poor HH grade and longer ICU stay are independent cost-driving factors. SAH treatment expenses are far higher than treatment costs for ischemic stroke in the literature (€6,731 for first-year inpatient and €3,287 for outpatient treatment). Conclusions Clinical condition and LOS determine in-hospital expenses after SAH. Aneurysmal SAH prevalently results in a relevant economic impact on the health system exceeding formerly published treatment expenses for ischemic stroke.