Evaluation of pay packages and components payment for the case of appendectomy in sonla provincial general hospital in 2012 – 2013 – Nguyen Duc Toan

Journal of military pharmaco-medicine n o 3-2018 122 EVALUATION OF PAY PACKAGES AND COMPONENTS PAYMENT FOR THE CASE OF APPENDECTOMY IN SONLA PROVINCIAL GENERAL HOSPITAL IN 2012 - 2013 Nguyen Duc Toan*; Pham Le Tuan**; Quach Thi Can*** SUMMARY Objectives: To evaluate the payment rates and treatment cost for case by case appendicitis at Sonla General Hospital. Subjects and methods: This was a study of hospital cost analysis, using qualitative methods to evaluate the treatment cost of acute appendicitis in 322 patients undergoing laparoscopic and open appendectomy in Sonla Provincial General Hospital from 01 - 2012 to 12 - 2013. The costs included the general expenses and payment receipts from the insurance agencies; the cost of the drug expenditure such as testing, material consumption. Data were collected and analyzed by STATA 14.0. Results and conclusion: The average cost of laparoscopic and open appendectomy according to case payment in 2012 (3,203.1 thousand VND and 2,819.9 thousand VND) lower than fee for services in 2013 (6,252.5 thousand VND and 5,238.0 thousand VND), the difference was statistically significant with p < 0.001. * Keywords: Appendicitis; Treatment costs; Pay packages and components. INTRODUCTION Currently, the insurance system (HEALTH INSURANCE) of the developed countries is gradually replacing treatment cost examination by service fees by more active methods: periodic payment and case-based payment [1, 4, 7]. The latter is a paying treatment cost according to predefined prices for each case. This payment level is built based on professional process accounting, including all the services provided for a specific disease cases from patient admission to discharge. Hospital is paid a predetermined fee for each illness, if the cost of treatment for patients is less than predetermined outlay, the hospital will be entitled to profit and vice versa, hospital can also must compensate [5, 6]. The Government's policy guidelines on health finance and actual activities of the hospital set out the requirements of research, the application of more advanced payment methods such as periodic payment and packages according to cases to supplement and replace the direct payment service. Derived from the above requirements, the study was conducted aiming to: Evaluate the cost of pay packages and components for the cases of appendectomy disease in Sonla Provincial General Hospital in 2012 - 2013. * Sonla Provincial Hospital ** Ministry of Health *** Otorhinolaryngological Central Hospital Corresponding author: Nguyen Duc Toan (nguyenductn29@gmail.com) Date received: 03/12/2017 Date accepted: 28/02/2018 Journal of military pharmaco-medicine n 0 3-2018 123 SUBJECTS AND RESEARCH METHODS 1. Subjects and sample size. The study consists of 322 patients treated by open appendectomy (OA) and laparoscopic appendectomy (LA) at Sonla Provincial General Hospital from 01 - 2012 to 12 - 2013. 2. Method. * Research design: Hospital cost was analyzed by the qualitative methods. * Viewpoint: Evaluate the payment rates and cost of components for each case of appendicitis at Sonla General Hospital. * Study variables: Age; time from illness to surgery (hour); time from house to hospital (minute); hospitalization stay length; the cost of OA/LA by components fee and total payment in 2012 - 2013 (number of days of treatment; cost of test/antibiotics/pain relief/infusion/drug others/surgery/total prescription/total payment by Health Insurance System and patient’s payment). Costs of this accounting cost perspective of hospital are taken from the accounting data of hospital with the charges and payment from the insurance agency/patients with drug costs, consumables, test... Total cost was calculated by components listed above, health insurance and patient’s payment. * Data collection and processing: Data on inpatient charges were extracted from hospital financial software during 2012, 2013. Data after cleaning were then entered, managed and analyzed using STATA 14.0 statistical software. RESULTS Table 1: Some characteristics of the study groups. General information OA (n = 149) LA (n = 173) p-values Age 45.8 ± 21.7 38.2 ± 13.8 0.016f Time from illness to surgery (hour) 28.1 ± 29.7 14.6 ± 13.7 0.000f Time from house to hospital (minute) 58.9 ± 53.0 46.0 ± 41.9 0.002f Hospitalization stay length 5.9 ± 3.3 4.0 ± 2.3 0.000f Male 78 (52.3%) 93 (53.8%) Gender Female 71 (47.7%) 80 (46.2%) 0.08a (a: Chi-squared test; f: Mann-Withney test) Some factors including age, time from illness to surgery, time from home to hospital, hospitalization stay length differed between the two study groups. Journal of military pharmaco-medicine n o 3-2018 124 Table 2: The cost of OA by components fee and total payment in 2012 - 2013. Index 2012 (n = 74) 2013 (n = 75) Total (n = 149) p-values No days to treat 4.8 ± 2.8 6.9 ± 3.3 5.9 ± 3.3 0.0001f HI-test 19.23 ± 18.6 442.2 ± 323.7 318.1 ± 291.9 0.0001f P-test 154.3 ± 153.9 166.9 ± 226.0 160.6 ± 193.0 0.918f HI-antibiotics 657.3 ± 903.0 1,256.9 ± 1.568.3 959.1 ± 1.312.4 0.002f P-antibiotics 396.5 ± 409.7 385.1 ± 506.6 390.7 ± 459.5 0.43f HI-pain relief 124.1 ± 120.3 258.3 ± 213.3 191.7 ± 188.5 0.0001f P-pain relief 106.3 ± 130.8 95.1 ± 136.7 100.7 ± 133.5 0.965f HI-infusion 172.6 ± 506.0 680.1 ± 1.357.7 429.9 ± 1.05.4 0.0001f P-infusion 79.2 ± 91.6 98.2 ± 151.6 88.8 ± 125.4 0.917f HI-drug other 40.5 ± 113.7 412.9 ± 1.058.1 227.9 ± 775.3 0.0001f P-drug other 25.6 ± 82.1 45.5 ± 172.4 35.6 ± 135.2 0.556f HI-surgery 640.7 ± 583.3 1,293.3 ± 777.8 969.2 ± 759.9 0.000f P-surgery 461.3 ± 520.3 559.7 ± 792.8 510.8 ± 671.0 0.864f HI-supplies 55.9 ± 63.0 72.1 ± 65.0 64.1 ± 64.3 0.08f P-supplies 36.4 ± 36.8 19.6 ± 25.4 28.0 ± 33.0 0.003f HI-other 37.4 ± 59.0 32.0 ± 24.5 179.8 ± 227.8 0.000f P-other 19.1 ± 26.2 146.4 ± 106.9 83.2 ± 100.7 0.000f HI-total prescription 998.1 ± 1.427.2 2,608.3 ± 3,186.7 1,808.6 ± 2,595.2 0.000f P-total prescription 607.6 ± 625.0 623.9 ± 828.7 615.8 ± 732.2 0.673f Total payment 3,203.1 ± 1,573 6,252.5 ± 3,722 4,738 ± 3,238.6 0.000f (Unit: thousand VND); f. Mann-Withney test; HI: Health Insurance; P: Patient) For OA, the cost covered by health insurance includes as ultrasound, test, analgesic, infusion, other prescription drugs, surgical costs, supplies for surgery and treatment in 2013 were higher and more significantly different from p < 0.05 compared to 2012. With the above components paid by the patient, there was hardly any difference with p > 0.05, among which supplies and other components were different with p < 0.05. The total cost of health insurance paid for an OA in 2013 was 2,608 million VND higher than that of 998.1 thousand VND in 2012; the total cost that patients paid for an OA in 2013 was 623.9 thousand and in 2012 was 607.6 thousand. The total cost for an OA in 2013 was 6,252 million VND, up from 3,203 million VND in 2012. The difference was statistically significant with p < 0.05. Journal of military pharmaco-medicine n 0 3-2018 125 Table 3: The cost of LAS by components fee and total payment in 2012 - 2013. Index 2012 (n = 92) 2013 (n = 81) Total (n = 173) p-values No days to treat 3.9 ± 2.5 4.2 ± 2.0 4.1 ± 2.3 0.012f HI-test 207.1 ± 198.6 358.1 ± 243.3 277.8 ± 232.6 0.000f P-test 173.3 ± 161.5 215.3 ± 244.7 193.0 ± 205.2 0.35f HI-antibiotic 495.0 ± 436.9 511.3 ± 466.4 502.6 ± 499.7 0.84f P-antibiotic 395.3 ± 392.5 275.5 ± 349.8 339.2 ± 376.9 0.004f HI-pain relief 124.0 ± 111.0 148.9 ± 142.6 135.7 ± 127.0 0.57f P-pain relief 101.4 ± 105.7 85.5 ± 112.7 93.9 ± 109 0.07f HI-infusion 185.4 ± 597.2 262.8 ± 588.5 221.6 ± 592.7 0.19f P-infusion 76.0 ± 97.0 68.2 ± 104.3 72.4 ± 100.3 0.09f HI-drug other 29.0 ± 108.6 67.8 ± 384.6 47.2 ± 274.6 0.17f P-drug other 17.0 ± 51.6 11.7 ± 22.2 14.5 ± 40.6 0.06f HI-surgery 492.0 ± 749.0 1,814.3 ± 1.201.2 1,111.1 ± 1.185.7 0.000f P-surgery 378.1 ± 629.5 1,069.8 ± 1.166.3 699.8 ± 979.3 0.000f HI-supplies 49.2 ± 63.7 31.0 ± 29.7 40.7 ± 51.4 0.014f P-supplies 32.3 ± 31.8 15.6 ± 19.7 24.5 ± 28.0 0.000f HI-other 38.0 ± 71.4 174.8 ± 150.5 102.1 ± 133.8 0.000f P-other 26.9 ± 46.6 140.6 ± 89.8 80.1 ± 90.2 0.000f HI-total prescription 833.4 ± 1.018.1 990.7 ± 1.120.5 907.1 ± 1.067.0 0.61f P-total prescription 589.6 ± 548.4 440.9 ± 515.5 520.0 ± 536.9 0.01f Total payment 2,819.9 ± 1.520.5 5,238 ± 1077.8 3,952.1 ± 1.796.7 0.000f (Unit: thousand VND) f. Mann-Withney test HI: Health Insurance; P: Patient) Costs for a LA case paid by Health Insurance include the following components: ultrasound, laboratory tests, surgical costs, materials consumed during surgery in 2013 was higher with statistically significant difference (p < 0.05) compared to 2012. Other components such as antibiotics, painkillers, fluids, prescription drugs, medical supplies for treatment and total treatment was not different between two years. The treatment cost, antibiotics, additional fees for surgery, supplies for surgery, other medical supplies, total treatment is significantly different with p < 0.05 between 2013 and 2012. The other components were not significantly different (p > 0.05). The total cost for an OA in 2013 was 5,538 million VND, down to 2,819.9 million VND in 2012. The difference was statistically significant with p < 0.05. Journal of military pharmaco-medicine n o 3-2018 126 Figure 1: Cost by LA and OA in 2012 - 2013. DISCUSSION The level of pay packages according to cases charged for a service package defined for each group of similarities: diagnosis, services needed and the costs required. This payment level is built on the basis of accounting that includes all the services provided for a specific disease cases from hospital admission to discharge [4, 5, 7]. In this study, the accounting is based on price components and calculated on a component-by-case basis and on all out- of-pocket payments. After computation, we found that the average cost per case for OA in 2012 and 2013 (3,203.1 thousand VND and 6,252.5 thousand VND) was higher than the cost per one LA case 2012 and 2013 (p < 0.001). Therefore, if conducted pay packages according to cases, the cost of the hospital and the cost of the patient must be taken into account. This result is also consistent with Duong Huy Lieu et al’s review [2] when applying the professional process for the disease group of acute appendicitis in Thanhnhan Hospital and Bavi, Hanoi. He saw the advantages of the method of case-based package payment, which enhances management improvement in hospital, reduces unreasonable costs and more transparency with the internal auditing 3203.1 2819.8 6252.5 5238 7000 6000 5000 4000 3000 2000 1000 0 N¨m 2012 CRTMM CRTNS N¨m 2013 Treatment cost (VND) Journal of military pharmaco-medicine n 0 3-2018 127 and independent auditing, improves operational efficiency, reduces the average time and the use of drugs and tests. In Sonla Provincial Hospital, this professional procedure has been applied and shows a significant cost reduction between both methods of surgery for patients with acute appendicitis in 2012 and 2013. After an analysis of data of the appendectomy patients before and after implementation of pay packages according to cases, Kim K.H et al (2016) [5] saw a decrease in postoperative period (2.8 ± 1.0 vs. 3.4 ± 1.9 days on, p < 0.001), but no reduction in the total cost of the hospital. The independent factors associated with the costs were patients of 70 years of age or more (OR = 3.214; 95%CI: 1.769 - 5.840; p < 0.001) and surgical time longer than 100 minutes (OR = 3.690; 95%CI: 6.599, p < 0.001 - 2.007). In addition, patients ≥ 70 years old had a risk of accompanied infections nearly as high as 10 times (95%CI: 20.214; p < 0.001, 5.141) and hospital risks were as high as 3.255 times (95%CI: 1.731, p < 0.001, 6.119). CONCLUSIONS The average cost for an OA case recorded in 2012 and 2013 (3,203.1 thousand VND and 6,252.5 thousand VND) was higher than the cost for one LA in 2012 and 2013 (2,819.9 thousand VND and 5,238 thousand VND). The difference was statistically significant with p < 0.01. REFERENCES 1. Tran Van Tien. Payment service fees, hidden risks. Journal of Medical Information. 2001, 10. 2. The Ministry of Health, Ministry of Finance. Circular No. 04/2012 of Ministry of Health and Ministry of Finance dated 29/02/2012 issued a maximum framing some examination and treatment in medical establishments. The Healing of the State. 2012. 3. Vu Van Le, Pham Tuan, Nguyen Thi Kim Tien. Some of the changes in clinical practice and patient costs in two pilot hospitals pay packages according to the patients. Journal of Practical Medicine. 2012, 5 (820), pp.2-5. 4. Edgar Hagenbichler. The Austrian DRG system. Federal Ministry of Health. 1st edition, 2010, July. 5. Kim K.H, Lee S.C, Lee S.K et al. Does Korea's current diagnosis-related group-based reimbursement system appropriately classify appendectomy patients? Ann Surg Treat Res. 2016, 91 (2), pp.66-73. 6. Kwon S. Payment system reform for health care providers in Korea. Health Policy and Planning. 2003, 18 (1), pp.84-92. 7. Song J.K, Kim C.Y. Participation determinants in the DRG payment system of obstetrics and gynecology clinics in South Korea. J. Prev. Med. Public Health. 2010, 43 (2), pp.117-124.