Differences in inpatient performance of public general hospitals following implementation of a points-counting payment based on diagnosis-related group: a robust multiple interrupted time series study in Wenzhou, China

Abstract

Objectives: This study measures the differences in inpatient performance after a points-counting payment policy based on diagnosis-related group (DRG) was implemented. The point value is dynamic; its change depends on the annual DRGs' cost settlements and points of the current year, which are calculated at the beginning of the following year.

Design: A longitudinal study using a robust multiple interrupted time series model to evaluate service performance following policy implementation.

Setting: Twenty-two public general hospitals (8 tertiary institutions and 14 secondary institutions) in Wenzhou, China.

Intervention: The intervention was implemented in January 2020.

Outcome measures: The indicators were case mix index (CMI), cost per hospitalisation (CPH), average length of stay (ALOS), cost efficiency index (CEI) and time efficiency index (TEI). The study employed the means of these indicators.

Results: The impact of COVID-19, which reached Zhejiang Province at the end of January 2020, was temporary given rapid containment following strict control measures. After the intervention, except for the ALOS mean, the change-points for the other outcomes (p<0.05) in tertiary and secondary institutions were inconsistent. The CMI mean turned to uptrend in tertiary (p<0.01) and secondary (p<0.0001) institutions compared with before. Although the slope of the CPH mean did not change (p>0.05), the uptrend of the CEI mean in tertiary institutions alleviated (p<0.05) and further increased (p<0.05) in secondary institutions. The slopes of the ALOS and TEI mean in secondary institutions changed (p<0.05), but not in tertiary institutions (p>0.05).

Conclusions: This study showed a positive effect of the DRG policy in Wenzhou, even during COVID-19. The policy can motivate public general hospitals to improve their comprehensive capacity and mitigate discrepancies in treatment expenses efficiency for similar diseases. Policymakers are interested in whether the reform successfully motivates hospitals to strengthen their internal impetus and improve their performance, and this is supported by this study.

Keywords: Health Services; Health policy; Hospitalization; Organisation of health services; Public Hospitals.

Figure 1

Implementation process for the diagnosis-related group (DRG) payment policy in 2019 in Wenzhou.

Figure 2

Fitted regression lines for institutions before and after change-points. A_i, B_i, C_i, D_i and E_i are the fitted regression lines of the outcomes (CMI mean, CPH mean, CEI mean, ALOS mean, TEI mean) in total institutions (i=1), tertiary institutions (i=2) and secondary institutions (i=3), respectively. ALOS, average length of stay; CEI, cost efficiency index; CMI, case mix index; CPH, cost per hospitalisation; TEI, time efficiency index.