managing urban stroke health expenditures in china: role of payment method and hospital level

Background: stroke is one of the leading public health issues in china and imposes a heavy financial burden on patients and the healthcare system. this study assess which payment method provides the lowest hospital costs for china’s healthcare system and the lowest out-of-pocket (oop) expense for insured patients. methods: this is a 4-year cross-sectional study. from the china health insurance research association (chira) database, a 5% random sample of urban health insurance claims was obtained. descriptive analysis was conducted and a generalized linear model (glm) with a gamma distribution and a log link was estimated. results: for outpatients, capitation payment had the lowest hospital cost (rmb180.9/us$28.8) and lowest oop expenses (rmb75.6/us$12.0) per patient visit in primary hospitals compared with fee-for-service (ffs) payments. the global budget (gb) displayed the lowest total hospital costs (rmb344.7/us$54.8) in secondary hospitals, and was 27.4% (95% ci = -0.32, -0.29) lower than ffs. ffs had the lowest oop expenses (rmb123.4/us$19.6 vs. rmb151.8/us$24.1) in secondary and tertiary hospitals. for inpatients, ffs had the lowest total hospital costs (rmb5918.7/us$941.1) per visit and capitation payments had the lowest oop expenses (rmb876.5/us$139.4, 40.1% lower than ffs, 95% ci = -0.58, -0.15) in primary hospitals. capitation payment had both the lowest hospital costs (rmb7342.9/us$1167.5 vs. rmb17 711.7/us$2816.2) and the lowest oop expenses (rmb1664.2/us$264.6 vs. rmb3276.3/us$520.9) for both secondary and tertiary hospitals. conclusion: for outpatients in primary hospitals and inpatients in secondary and tertiary hospitals, the capitation payment was the most money-saving payment method delivering both the lowest oop expenses for patients and the lowest hospital total costs for hospitals. we recommend that health policymakers prioritize the implementation of the payment method with the lowest oop expenses when the payment method does not deliver both the lowest hospital costs for the health system and lowest oop expenses for patients.