Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal.
J Health Serv Res Policy. 2011 Oct;16(4):197-202. doi: 10.1258/jhsrp.2011.010047.
The number of countries adopting per case hospital payment systems has been continuously increasing in recent years. Nonetheless, debates persist regarding their consequences for equity of access to services. This concern relates to the failure of diagnostic classifications properly to take into account patients' care requirements, raising the threat of case selection ('cream skimming'). We examine the heterogeneity of costs within diagnostic categories related to socioeconomic (SE) factors using length of stay (LOS) as a proxy measure of care needs and costs. We evaluate its consequences in terms of fairness in resource allocation between hospitals.
We employ data on all discharges in 2002-03 from a sample of 60 Belgian hospitals (617,275 observations), measuring the association between LOS and SE factors using generalized linear models. We design a resource allocation formula based on the Belgian financing scheme, where non-medical activity is paid based on a normative number of in-patient days, and measure financial penalties and rewards according to whether payment is adjusted for the SE characteristics of patients or not.
Both patients' SE status and hospitals' area SE profile have a significant impact on LOS, which persists after controlling for detailed diagnostic and hospital characteristics. Hospitals treating low income patients are financially penalized as a result.
SE factors are a predictor of in-patient LOS and should be taken into account in per case resource allocation among hospitals.
近年来，采用按病例支付医院费用的国家数量不断增加。然而，关于这些制度对服务获取公平性的影响仍存在争议。这种担忧源于诊断分类未能正确考虑患者的护理需求，从而导致病例选择的风险（“择优选择”）。我们使用住院时间（LOS）作为护理需求和成本的替代指标，来研究与社会经济（SE）因素相关的诊断类别内成本的异质性。我们评估了其在医院之间资源分配公平性方面的后果。
我们使用了 2002-03 年来自比利时 60 家医院的样本中的所有出院数据（617,275 例观察），使用广义线性模型来衡量 LOS 与 SE 因素之间的关联。我们基于比利时融资计划设计了一种资源分配公式，其中非医疗活动根据标准的住院天数进行支付，并根据是否根据患者的 SE 特征调整支付来衡量财务处罚和奖励。
患者的 SE 状况和医院所在地区的 SE 特征对 LOS 有显著影响，即使在控制了详细的诊断和医院特征后仍然存在。因此，治疗低收入患者的医院会受到财务处罚。
SE 因素是住院 LOS 的预测因素，应在医院之间按病例进行资源分配时加以考虑。
