study on effects of capitation payment method on cost and indicators of health insurance services at four district hospitals inthanh hoa province

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY TRAN QUANG THONG STUDY ON EFFECTS OF CAPITATION PAYMENT METHOD ON COSTS AND INDICA

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY

TRAN QUANG THONG

STUDY ON EFFECTS OF CAPITATION PAYMENT METHOD ON COSTS AND INDICATORS OF HEALTH INSURANCE SERVICES AT FOUR DISTRICT HOSPITALS IN THANH HOA PROVINCE

Major: Public health Code: 62.72 03.01

A SUMMARY OF THE PHD THESIS IN PUBLIC HEALTH

Ha Noi - 2012

THIS THESIS HAS BEEN COMPLETED AT THE

NATIONAL INSTITUTE OF HYGIENE END EPIDEMIOLYGY

Supervisors:

1 Professor Truong Viet Dung

2 Associate Professor Nguyen Thi Hong Hanh

This thesis is available at:

1 The National Library

2 The National Institute of Hygiene end Epidemiology

LIST OF PUBLISHED RESEARCHES

1 Trần Quang Thông, Trương Việt Dũng, Nguyễn Thị Hồng Hạnh (2011), “Nghiên cứu ảnh hưởng của phương thức thanh toán theo định suất đến chi phí và chất lượng khám chữa bệnh Bảo hiểm Y tế tại

Bệnh viện Đa khoa Mường Lát – Thanh Hóa”, Tạp chí Y học dự phòng,

XXI, No 7 (125), pp.194-200

2 Trần Quang Thông, Trương Việt Dũng, Nguyễn Thị Hồng Hạnh (2011), “Nghiên cứu ảnh hưởng của phương thức thanh toán theo định suất đến chi phí và chất lượng khám chữa bệnh Bảo hiểm Y tế tại

Bệnh viện Đa khoa Hà Trung – Thanh Hóa”, Tạp chí Y – Dược học Quân

sự, No 9-2011, pp 52-58

for the implementation of health insurance policies

The primary method of payment in Vietnam is FFS method, which is the

administrative costs, leading to an imbalance between revenues and expenditures of health insurance For the past few years (2005-2009), Vietnam has over-spent thousands of billion VND of health insurance, which has resulted from the FFS method

Some countries have step by step replaced FFS method with more efficient methods of package payment and prepayment such as capitation, payment based on specific cases or diagnosis-related groups  (DRG) of inpatients

In accordance with the scheme of implementing the Law on Health Insurance, all initially registered agencies will have started applying capitation

by 2015 However, there has not been any intensive study on capitation so far With an aim to contribute evidence to establishing and completing capitation to make it applicable in a wider scope as well as guarantee its scientifically and practicality, the study was conducted with following objectives:

1 To evaluate the effects of capitation on the healthcare costs under health insurance cover in four district hospitals of Thanh Hoa province

2 To evaluate the effects of capitation on some healthcare indicators under health insurance cover in four district hospitals of Thanh Hoa province

NEW CONTRIBUTIONS OF THIS STUDY

1 The study statistically proved that: the application of capitation decreased the rise of cost, most of which was for tests, imaging diagnosis, medicine, infusion and sending patients to the upper-level hospitals;

2 Compared to FFS method, capitation in the area of research was not seen affecting several indicators of healthcare quality indicators and benefits as well as patients’ satisfaction

Besides, the findings of this study proved the suitability and practicality

of capitation in the area, which has provided a foundation for the expansion

of this payment scheme as proposed in the Law on Health Insurance

ORGANIZATION OF THE STUDY This thesis is comprised of 123 pages (excluding references and appendices), among which there are 2 pages for problem statement , 2 pages for conclusion, 1 page for recommendations, 37 pages for chapter one, 17 pages for chapter two, 36 pages for chapter three and 29 pages for chapter 4 There are a total of 44 tables, 4 charts and 154 reference materials, among which there are 89 ones in Vietnamese and 65 in English, being used in this thesis

Chapter 1 OVERVIEW 1.1 Healthcare costs

1.1.1 Direct costs under health insurance cover

The basic costs covered by health insurance include the ones for: medicine, chemicals, infusion, blood, medical procedures , tests, imaging diagnosis, medical facilities, etc in the scope of benefits of health insurance regulated by the Ministry of Health

1.1.2 Factors affecting healthcare costs

There are a number of factors affecting healthcare costs: scale of healthcare taken by people; frequency of using medicine as well as medical facilities and technologies; costs of medical services; method of payment; average costs for each phase of inpatient and outpatient treatment, etc During the development of health insurance, there were several noteworthy trends as follows:

- An increase in the scale of using healthcare services: In the period from

2002 to 2006, there were annually about 9 out of 100 people on average going

to public hospitals By early 2009, the figure increased to 12 out of 100 This rate was relatively high compared to many countries in the world, including such developed countries as the United States (11.7), Canada (7.8) and Singapore (9.39)

- An increase in the average costs for the number of outpatient care and phases of inpatient treatments: In the period from 2003 to 2009, the costs for

inpatient and outpatient treatments under health insurance cover increased in hospitals of all levels

- A remarkable trend of increase in the investment in medical facilities as well as equipment for testing and imaging: The statistics of healthcare costs

under health insurance cover demonstrated a quick increase in the proportion of expenditures on tests and imaging diagnosis in the healthcare costs under health insurance cover, especially in central and provincial hospitals

- A great proportion of expenditures on medicine in total medical expenditure: According to the annual Health Statistics Yearbooks, the average

expenditures on medicine swiftly increased and reached almost 17 USD per capita in 2008 Besides, medicine accounted for 61% of total healthcare costs under health insurance cover in 2009

- A quick increase in healthcare costs resulting from the increase of noncommunicable diseases: The treament costs for noncommunicable diseases

was many times higher than that for other communicable diseases because they required advanced techniques, expensive specifics, long periods of treatments and high vulnerability to complications

The per capita medical cost of Vietnamese people was 1.1 million VND

in 2008, which was 4.6 times higher than factual costs in 1998 (or 2.3 times if they are adjusted based on inflation indices) That was a good signal reflecting

an increase of medical investment However, this high level of increase compared to total medical expenditures could become a big concern if there was any increase in the cost for inappropriate services

* Factors in organizing healthcare networks:

The popularity of transfering patients to upper-level hospitals: Due to

this phenomenon, a number of people used healthcare services in provicial or even central hospitals for just normal healthcare, which led to a considerable waste of financial resources as well as other unexpected consequences

1.2 Healthcare indicators:

The indicators evaluating the operation process and outputs enable the measurement of quality of provided services This evaluation is conducted by establishing indicators evaluating the process and outputs of specific kinds of

diseases, based on which it be known whether the provided services for patients have met the requirements of quality and appropriateness

1.2.1 Definition of healthcare quality

1.2.2 An evaluation on healthcare quality

1.2.2.1 An evaluation on healthcare quality

The objective of the evaluation is to improve the efficiency of healthcare process in the coming periods The evaluation is to be based on the objectives, indicators and evidences The evaluation is usually based on theory and the evaluation of findings is based on processes and input mechanism The input here signifies a resource for the healthcare system, including human resource, material, capacity and medical technology

Regarding the evaluation on healthcare quality, it is important to specify requirements and standards which adequately reflect the mechanism, processes and findings In reality, information from medical records is usually insufficient and lacks important factors to assess their techniques and communication However, utilization of medical records is still one of the primary methods of evaluation

In healthcare, the expectations of patients on the quantity and quality of provided services from health agencies are regarded as their satisfaction, which may involve many things such as time of waiting, time of treatments, provider’s attitude, the result of the treatments, etc

1.2.2.2 Indicators to evaluate healthcare quality

- Input indicators: human resource; equipment; finance; technical procedures; medicine availability; medical supplies; objectives in healthcare quality; etc

- Process indicators: working environment; direction and management of the implementation (progress, quality, level of implementation, etc.); evaluation

of the process; support for promotion, etc

- Output indicators: compliance with treatments procedures; health results; indicators of improved health; patients’ satisfaction; improvement of staff professionalism; enhancement of equipment, etc

Chapter 2 RESEARCH SUBJECTS AND METHODS 2.1 Subjects

Senior executives of Vietnam’s Department of Health Insurance – Ministry of Health - and Social Security; senior executives of Department of Health and Social Security of Thanh Hoa province; senior executives of district hospitals and social security; senior executives of communes’ medical stations and owners of health insurance taking inpatient care in hospitals; medical records and reports of balance for the healthcare costs on a quarterly basis

2.2 Study sites

The research was carried out at four district hospitals of Thanh Hoa province In the plain area, Ha Trung Hospital piloted capitation with the control of Dong Son Hospital whose payment was based on FFS method In the mountainous area, Muong Lat Hospital piloted capitation with the control of Quan Son Hospital whose payment was based on FFS method

2.3 Time

- From January 1st to December 31st, 2008: FFS method;

- From January 1st to December 31st, 2009: pilot capitation

2.4.2 Sample size and sampling methods

- Outpatients: all collective sheets of outpatients’ costs and common prescriptions (03 cases) for those diagnosed with acute bronchitis, acute gastritis – duodenitis, primary hypertension In reality, 3.073 sheets were collected

- Inpatients: all collective sheets of costs and common medical records (5 cases) for those diagnosed with acute bronchitis; acute gastritis – duodenitis; primary hypertension; appendicitis (classical operating); and Caesarean section

In reality, 2.080 sheets were collected

- Satisfaction of patients taking inpatient care: 50 patients in each hospital were randomly selected for interviewing

2.4.3 Method of data collection

Qualitative method

- Six direct interviews with senior executives of Department of Health Insurance, board of implementing health insurance policies, senior executives

of Ha Trung and Muong Lat hospitals, senior executives of social security of

Ha Trung and Muong Lat districts Six discussions among staff and senior executives of Department of Health; staff and senior executives of social security in Thanh Hoa province; staff and senior executives of faculties, departments as well as doctors directly treating patients possessing health insurance and heads of commune medical stations

Quantitative method

- Calculate healthcare costs gained from the recordes on healthcare costs

in the two years of 2008 and 2009

- Direct interviews with patients taking inpatient care and having discharged from hospitals, using structured questionnaires (50 patients in each hospital) Direct interviews with senior executives from deputy chiefs of departments (faculties) upwards, using structured questionnaires at two hospitals piloting capitation (17 senior executives from Ha Trung Hospital and

20 ones from Muong Lat Hospital)

2.4.4 Contents

Evaluative indicators in the research

¾ Objective 1 To evaluate the effects of capitation on the healthcare costs

under health insurance cover in four district hospitals

- The growth rate of average costs per number of medical visits in commune, district inpatient and outpatient, provincial and central hospitals;

- The growth rate of total cost in commune; district inpatient and outpatient; provincial and central hospitals;

- The average growth rate per card per year based on health insurance subjects;

- The growth rate of medical costs, tests and imaging diagnosis per number of medical visits in outpatient district hospitals;

- The growth rate of medical costs, tests and imaging diagnosis per number of medical visits in inpatient district hospitals;

- The growth rate of total medical costs, tests and imaging diagnosis in outpatient district hospitals;

- The growth rate of average medical costs per number of medical visits in inpatient district hospitals;

- The growth rate in average testing costs per number of medical visits in inpatient district hospitals;

- The growth rate of average costs for imaging diagnosis per number of medical visits in inpatient district hospitals;

- The growth rate of total medical costs, tests and imaging diagnosis in inpatient district hospitals;

- Indicators affecting the costs at hospitals adopting capitation, etc

¾ Objective 2 To evaluate the effects of capitation on some healthcare

indicators under health insurance cover

- To compare the degree of compliance with disease-based treatments;

- To compare the degree of treatment results/outcomes;

- To compare the degree of patients’ satisfaction;

- Frequency of medical visits;

- Average number of days of inpatient treatments per course of treatment;

- Several factors of capitation affecting healthcare quality as well as hospital activities

2.4.5 Research variables and several definitions used in the research

- The formula to calculate the average cost:

X=

n

xi

∑

In which: X: The average cost;

xi: The expenditures (for treatment phases, medicine, blood, etc.) in each treatment phase (or each medical /episode);

n: The number of treatment phases or medical visits/episode on

a yearly basis

- The formula to calculate the cost growth rate in 2009 compared to 2008: The cost growth rate (%) = {(in 2009 – in 2008)/in 2008}*100

2.4.6 Data processing: The data were collected from reports and sets of tools

Excel software was used to input data whereas SPSS to process and analyze data Costs in 2008 were adjusted in terms of value whereas in 2009 Consumer Price Index (CPI) was adopted (gso.org.vn) The CPI was 100 in 2008 and 106.9 in 2009 Statistical analysis using Z test (Prtesti n1 p1 n2 p2) identified difference of statistical significance between two rates Value p {p(Ztest)}

verified the difference and with p<0,05 the difference was of statistical significance

2.5 Research ethics: not to be considered

Chapter 3 FINDINGS 3.1 Effects of capitation on the growth of healthcare costs under health insurance cover

3.1.1 Effects of capitation on the growth of healthcare costs under health insurance cover

Table 3.1 Average costs/ number of visits under health insurance based on

Capitation(2009)

Increase

(%)

FFS (2008)

FFS (2009)

Increase (%)

In the mountainous area

in both plain and mountainous areas in commune, district inpatient and outpatient as well as provincial hospitals The cost growth rate in commune and district inpatient hospitals of plain area together with commune and district outpatient hospitals of mountainous area even decreased Particularly the

growth rate in central hospitals rose to 377.4% in a hospital piloting capitation

in Muong Lat Besides, the difference between the growth of average cost per number of medical visits in the inpatient hospital of Muong Lat district and that

of Quan Son district was not of statistical significance The obvious difference lay in commune, district outpatient and general hospitals in both plain and mountainous areas

Table 3.2 Total expenditures for health insurance based on levels of

Capitation (2009)

Increase

(%)

FFS (2008)

FFS (2009)

Increase

(%) Commune 490 429 -12,4 608 806 32,8 <0,05

District

outpatient 2.506 3.176 26,9 3.505 4.312 23,1 <0,05District

inpatient 4.669 5.907 26,6 3.587 4.768 33,0 <0,05

Provincial 1.736 2.457 41,7 7.709 11.780 53,0 <0,05

Central 2.237 2.484 11,1 2.614 3.371 29,1 <0,05

General 11.639 14.454 24,3 18.023 25.037 39,1 <0,05

In the mountainous area

District

outpatient 1.487 1.196 -19,5 1.210 1.395 15,4 <0,05District

inpatient 1.684 1.694 0,6 1.098 1.802 64,4 <0,05

Provincial 429 563 31,0 778 1.438 84,9 <0,05

General 3.723 3.665 -1,5 3.745 5.428 45,1 <0,05

Table 3.2 shows that the growth rate of total expenditures based on levels

of hospitals in 2009 compared to 2008 in hospitals piloting capitation was lower than those adopting FFS method That difference was of statistical significance

in both plain and mountainous areas as well as all commune, district outpatient and inpatient, provincial and central hospitals Like table 3.1, the growth rate of total expenditures in commune hospitals of plain area together with district outpatient and general hospitals of mountainous area even decreased The growth rate of total expenditures of patients transferred from Muong Lat to

central hospitals was 327.2% The difference in total expenditures of district inpatient hospitals had a statistical significance

Table 3.3 Average costs/card/year based on subjects

In the plain area Unit: 1000 VND

Subject

P

FFS (2008)

Capitation 2009)

Increase (%)

FFS 2008)

FFS (2009)

Increase (%)

In the mountainous area

3.1.3 Healthcare costs in district hospitals

Table 3.8 Total healthcare expenditures in district inpatient and outpatient

Capitation(2009)

Increase (%)

FFS (2008)

FFS (2009)

Increase (%) Outpatient 2.504 3.176 26,9 3.502 4.312 23,1 <0,05

Inpatient 4.665 5.907 26,6 3.584 4.768 33,0 <0,05

In the mountainous area

Outpatient 1.485 1.196 -19,5 1.209 1.395 15,4 <0,05

Inpatient 1.683 1.604 -4,7 1.097 1.803 64,4 <0,05

Total 3.168 2.799 -11,6 2.306 3.198 38,7 <0,05