| Summary: | 碩士 === 國立陽明大學 === 醫務管理研究所 === 105 === Background
Given the limited health care resources, increasing financial pressure promotes health care system to contain cost while improving quality of care. Discouraging the provision of low-value services is a prominent solution to improve efficiency of health care. Implementing payment reform is one of the strategies to reduce low-value care. Inpatient prospective payment method is regarded as a policy instrument to reduce unnecessary services and contain cost. Following other developed countries, the Tw-DRG payment was launched in 2010 in Taiwan, and there were 164 surgical procedure items introduced in the first phase. However, it is unclear whether such inpatient prospective payment policy does reduce the use of low-value services. In addition, although the increasing finding related to low-value service was inspiring, the existing literatures still remain limited in their study scope and setting. Very limited understanding is available in Asian countries with universal insurance coverage. The incremental implementation of the DRGs payment scheme on surgical procedures in Taiwan in 2010 serves an interesting example to examine how financial incentives may be associated with low-value service use.
Objectives
To assess utilization and correlates of low-value care in surgical admissions in Taiwan and investigate whether the implementation of the inpatient prospective payment method (i.e. Tw-DRGs payment scheme) was associated with a reduction in use of low-value services among surgical inpatients.
Methods
Patients receiving low to intermediate risk surgical procedures were recruited in our study. Because of the incremental implementation of the Tw-DRGs scheme, not all surgical conditions and procedures were included the 2010 policy reform. The difference-in-difference method was adopted to compare use of low-value services between surgical inpatients that later reimbursed by prospective DRG payments (DRG group) and surgical inpatients that remained to be paid by traditional fee-for-service payment (comparison group) before (2008-2009) and after (2010-2013) the implementation of Tw-DRGs policy. Three commonly studied surgical-related low value services were investigated: preoperative chest x-ray, preoperative echocardiogram and preoperative stress testing. To investigate potential cost-shifting, the use of these three services 30 and 14 days prior to the index admission were also included for analyses. The National Health Insurance Research Database in Taiwan from 2008 to 2013 was the main data source. Main outcomes were measured as annual count per 100 admissions and predicted probability of use of selected low value services. Multilevel logistic regression model was applied to account for possible clustering of inpatients within hospitals.
Results
The overall annual count of low value service was 81.6 per 100 admissions. The use of low-value preoperative testing mainly occurred during hospitalization. The prevalence of the three preoperative testing ranged from 0.1% (preoperative stress testing) to 83.2% (preoperative chest x-ray). Patients with elder age and higher income are more likely to receive low-value preoperative testing. In contrast, presence of other comorbidities was negatively associated with use of any preoperative testing. Higher volume providers were associated with a higher use of any of the three preoperative testing services. During the pre-Tw-DRGs period, after adjusting for other factors, the predicted probabilities of any use of the three preoperative testing in the DRG group (0.674) and the control group (0.690) were similar. In the first year following Tw-DRGs policy, the use among the DRG group significantly dropped to 0.640 (p=0.004), whereas the use in the control group remained relatively unchanged (0.681). However, the net decrease became insignificant (p=0.064) in difference in difference analysis. In the post-DRG year 2, the predicted probability had a dramatic rebound to 0.742 which exceeded the pre-DRG level. The comparison group had an increased probability as well, and the increment continued until the end of study in 2013.
Conclusion
Our study findings revealed that overuse of low-value preoperative chest x-ray was common among surgical inpatients, but not among other more expensive preoperative testing including preoperative echocardiogram and preoperative stress testing. During the first year of its implementation, inpatient prospective payment, Tw-DRGs, was associated with modest reductions in low-value preoperative testing services among surgical inpatients. However, such reduction did not persist in the following years. The Tw-DRG payment had only a short-term effect on reducing use of low-value preoperative testing. Financial incentives alone may not be sufficient in reducing low-value care and improving efficiency in health care.
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