Hypertension treatment expenditure is known to be associated with demographic factors such as age and gender. Our data confirms previous research that direct hypertension expenditure increases with age (Le et al. 2012). As hypertensive patients get older, severity of the disease and relative complications tend to increase, which can lead to concomitant rising expenditure. Moreover, the increasing trend of hypertension treatment cost applies to not only MI fund expenses, but also OOP expenses. Concerning the more vulnerable financial capacity of the elders, this result again emphasizes the need for inclining health insurance reimbursement for older hypertensive patients.
Results from our study show definite cost control effects of GBPS compared with traditional FFS, for total medical expense, MI fund expense and OOP expense. Except for those hypertensive patients above the age of 65 years old, the cost control effects of GBPS compared with OOP remain significant even after being stratified by age and gender. Qiu et al. also reported the cost control effects of GBPS for inpatient hospital expenditure from the analysis of 40 cerebral infarction patients in Tianjin (Qiu 2009). Total hospitalization cost per visit decreased by 8.7% from CNY10307.5 before the implementation of GBPS to CYN9411.0 after implementation. Along with total medical expense, drug use proportion and average length of hospital stay also decrease with GBPS. In this sense, by prospective payment, GBPS can be an effective method to curtail the fast rising medical expenditure and limit the incentive of health care providers to offer unnecessary service.
Moreover, GBPS shows robust cost control effects on the two components of total medical expense, meaning the MI fund expense and OOP expense. On one hand, MI fund expenses decrease significantly for GBPS compared with FFS, which can help minimize the risk of MI fund deficit and maximize the efficiency of insurance budget function. On the other hand, OOP expenses also decrease in the GBPS group to a similar extent of total medical expenses. Since the medical insurance system in China does not cover all expenses for patients, the affordability has always been a task of China’s health reform (Long et al. 2013). Increasing medical expenditure confers pressure not only for MI fund, but also for the financial vulnerability of low-income patients. Results from this study show enjoyable results that GBPS can also make hypertension treatment more affordable.
One interesting result from our study is that GBPS failed to decrease medical expenditure per capital for those above 65 years old. Concerning the fact that medical expenditure tends to increase with age, this result may imply the inability of GBPS to contain medical expenditure for those with an inherent high demand of medical service. The difference between GBPS and FFS for total medical expenses, MI fund expenses and OOP expenses also show a decreasing trends as patients get older. One possible explanation for this is that GBPS helps to restrain those unnecessary medical service, while the inherent demand of service due to severity of disease or relative complications can still amount to high level of expenditure. On the other hand, FFS has also set limitation on the maximum amount of reimbursement for a patient, and a negotiation between patients and health care providers may exist for reducing the volume of service as total expenses approaches the limitation. In this way FFS can also to some extent curtail the amount of service for those patients with high level of expenditure.
Though the cost control effects for inpatient expenses have been confirmed in initial studies (Song et al. 2014), the actual influence of GBPS on outpatient expenses is still not clear. Previous researches have predicted a shift of inpatient hospitalization to outpatient service by GBPS (Markovich 2012). However, our results prove a similar power of GBPS to limit unnecessary outpatient medical service in hypertension treatment, and this offers support for a wider implementation of GBPS.
Admittedly, GBPS may cause some adverse effects while reducing medical expenditure. For example, the average visits per capital for GBPS is a little bit more than that of FFS. The increasing times of visit may be a side effect of decreased medical service per visit, for a sense of health care providers to reduce expense for meeting the goal of the global budget may sometimes hypercorrect the former unnecessary expense by FFS. This hypercorrection, for example, reducing the amount of drugs prescribed per visit, can make the needs of some of the patients that indeed have a high demand of service unsatisfied, which will lead to increasing times of hospital visits. However, the average expense per visit for GBPS is smaller, which on the whole makes its total medical expense significantly lower.
There have been worries about quality of medical service and acceptance of health care providers since the introduction of GBPS. These concerns can be reasonable, for health care providers may reduce service quality to decline operating expenses, or shirk patients to other hospitals, so long as they can receive the same prepaid annual budget. Initial results from America show that GBPS can offer comparable quality of service and gain the acceptance of health care providers (Song et al. 2012, 2014). The key points in limiting the possible disadvantages of GBPS may lie in designing rational annual budget. A budget too high can decline the effects of cost control, while a budget too low may lead hospitals to reduce service quality. Moreover, there has been a recent trend for mixing prepaid payment method and FFS (Hsu 2014). With these in mind, HRSSB in Tianjin brings factors including service volume and capacity of a hospital into consideration when determining its annual budget, and reserves 6% of the annual budget for the year-end assessment, although further investigations are needed for better calculating the budget and evaluating the quality of service after implementation of GBPS.
A limitation of this study is that it is cross-sectional, which may neglect possible unbalance of base line characteristics between the GBPS group and FFS group. However, since it is a random selection of all patients to Tianjin’s primary hospital, this possibility of nonrandomization can be mitigated.
In conclusion, this study offers support for the cost control effects of GBPS, both for the MI fund expenses and OOP expenses, from the analysis of outpatient hypertension treatment data in Tianjin. The cost control effects of GBPS tend to decline for those with higher demand of medical service, and further studies are needed to analyze change of service quality after implementation of GBPS.