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

Abstract

Objective: To examine the association between reimbursement rates and the length of stay (LOS).

Design: A retrospective cohort study.

Setting: The study was conducted in Shenzhen, China by using health administrative database from 1 January 2015 to 31 December 2017.

Participants: 6583 patients with acute myocardial infarction (AMI), 12 395 patients with pneumonia and 10 485 patients who received percutaneous coronary intervention (PCI) surgery.

Measures: The 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.

Results: Each 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).

Conclusions: The 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.

Keywords: length of stay; low-income and middle-income countries; moral hazard; reimbursement rates.

Figure 1

Flow diagram of patient selection. AMI, acute myocardial infarction; ICD-9, International Classification of Disease, Ninth Revision; ICD-10, ICD, Tenth Revision; LOS, length of stay; PCI, percutaneous coronary intervention.