Department of Health Policy and Management, School of Public Health, Peking University Health Science Center, Beijing, China.
West China Research Center for Rural Health Development, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China.
BMC Health Serv Res. 2021 Dec 2;21(1):1296. doi: 10.1186/s12913-021-07338-8.
Provider payment system has a profound impact on health system performance. In 2016, a number of counties in rural Guizhou, China, implemented global budget (GB) for county hospitals with quality control measures. The aim of this study is to measure the impact of GB combined with pay-for-performance on the quality of care of inpatients in county-level hospitals in China.
Inpatient cases of four diseases, including pneumonia, chronic asthma, acute myocardial infarction and stroke, from 16 county-level hospitals in Guizhou province that implemented GB in 2016 were selected as the intervention group, and similar inpatient cases from 10 county-level hospitals that still implemented fee-for-services were used as the control group. Propensity matching score (PSM) was used for data matching to control for age factors, and difference-in-differences (DID) models were constructed using the matched samples to perform regression analysis on quality of care for the four diseases.
After the implementation of GB, rate of sputum culture in patients with pneumonia, rate of aspirin at discharge, rate of discharge with β-blocker and rate of smoking cessation advice in patients with acute myocardial infarction increased. Rate of oxygenation index assessment in patient with chronic asthma decreased 20.3%. There are no significant changes in other indicators of process quality.
The inclusion of pay-for-performance in the global budget payment system will help to reduce the quality risks associated with the reform of the payment system and improve the quality of care. Future reform should also consider the inclusion of the pay-for-performance mechanism.
支付制度对卫生系统绩效具有深远影响。2016 年，中国贵州省部分农村地区的县级医院实施了包含质量控制措施的总额预算制（GB）。本研究旨在衡量 GB 与按绩效付费相结合对中国县级医院住院患者医疗质量的影响。
从贵州省 2016 年实施 GB 的 16 所县级医院中选取了肺炎、慢性哮喘、急性心肌梗死和脑卒中这 4 种疾病的住院病例作为干预组，选取了仍采用按服务项目付费的 10 所县级医院的类似住院病例作为对照组。采用倾向评分匹配（PSM）对数据进行匹配，以控制年龄因素，并使用匹配样本构建差值-差异（DID）模型，对这 4 种疾病的医疗质量进行回归分析。
GB 实施后，肺炎患者痰培养率、急性心肌梗死患者出院时阿司匹林使用率、出院时β受体阻滞剂使用率、急性心肌梗死患者戒烟建议率均有所提高。慢性哮喘患者的氧合指数评估率下降了 20.3%。其他过程质量指标没有明显变化。
将按绩效付费纳入总额预算支付体系有助于降低支付制度改革带来的质量风险，提高医疗质量。未来的改革还应考虑纳入按绩效付费机制。
