This study retrospectively analyzed the trends and influencing factors of hospitalization expenses for GC patients in Shanghai, using ITSA and the new GRA. The findings revealed a rising trend in hospitalization expenses for GC patients from 2014 to 2021, with the increase primarily driven by the growing costs of drugs and consumables both before and after the implementation of UZMDP. Additionally, demographic characteristics, disease severity, and hospital-level factors collectively influence hospitalization expenses for GC patients.
Trends in hospitalization expenses and the impact of the UZMDP
Our study indicated that a general upward trend in hospitalization expenses before and after the implementation of the UZMDP. The varying growth rates of hospitalization expense during the pre- and post- UZMDP periods were linked to changes in the components of these expenses. Specifically, drug expenses, which were the primary contributor to hospitalization costs, decreased before the UZMDP, potentially contributing to the slower overall growth in hospitalization expenses during that period.
Meanwhile, expenses for medical consumables, healthcare services, and diagnostic tests continued to rise, ultimately contributing to the overall increase in hospitalization expenses, consistent with previous studies [12, 13]. This phenomenon reflects the complex influence of provider-induced demand (PID), which occurs when healthcare providers influence patients’ demand for care in ways that may not align with their best interests [14]. The implementation of the UZMDP did not reduce hospitalization expenses, as it may have reduced drug expenses driven by PID but instead shifted its effects to other revenue sources, such as consumables and examinations, to compensate for the revenue loss [14]. This suggests that reducing hospitalization expenses requires not only adjusting drug prices but also monitoring the prices of other healthcare services, such as consumables and examinations, while establishing effective incentive mechanisms for healthcare providers.
Trends in components of hospitalization expenses and the impact of the UZMDP
Our study indicated that drug expenses were a key component contributing to the increasing trends in hospitalization expenses from 2014 to 2021. Although drug expenses initially decreased in Shanghai, the ITSA revealed a steady increase over time after the full implementation of the UZMDP. On the one hand, this may be attributed to a decrease in drug prices, which could lead patients to purchase larger quantities or opt for more expensive drugs within a fixed budget [16]. Additionally, the increase in the annual number of patients could also explain this trend [14]. On the other hand, healthcare providers remain incentivized to adjust their strategies to maximize profits, which could potentially result in increased drug expenses after the implementation of the UZMDP. For example, doctors may still be incentivized to overprescribe drugs or prescribe more expensive drugs to patients in exchange for rebates and higher profits [16]. In the future, there is still a need to further regulate prescribing practices so as to reduce the burden of medication on patients.
Since the full implementation of the UZMDP in 2017, other healthcare expenses in hospitals have continued to rise due to insufficient subsidies and cost-effectiveness motives [17]. Our study showed that the impact of consumables expenses on hospitalization expenses for GC patients is almost equivalent to that of drug expenses. The trend in consumable expenses increased both before and after the implementation of the UZMDP. This may be due to the fact that consumables account for a relatively large portion of hospitalization expenses for GC patients [18]. After the implementation of the UZMDP, healthcare providers compensated for the reduction in drug revenues by increasing the provision of other services or products, leading to increases in consumable expenses [19]. To reduce consumables expenses, China implemented the universal consumables markup policy in 2019 [20]. However, this study found that only a 2.7% decrease in consumables expenses for GC patients in 2020 compared to 2019, followed by a continued upward trend thereafter. The main reason may be that there were more elderly GC patients who used more high-value consumables in this study, which made the change in consumables expenses less noticeable [18]. Further research is needed to focus on establishing and improving the medical consumables management system based on patient’s characteristics, as well as regulating the consumables use behavior of medical personnel to reduce patient’s consumables expenditure [18].
It is also noteworthy that the study identified an upward trend in healthcare services expenses from 2014 to 2021. This trend may be linked to China’s public hospital reforms launched in 2015, which aimed to increase remuneration for professional services provided by healthcare workers, improve performance-based salaries for medical staff, and establish a contemporary hospital management system [17]. These reforms sought to reduce instances of PID by aligning incentives with professional services, rather than excessive treatments or prescriptions. However, the continued increase in drug, consumables, and examination expenses suggests that further research and policy efforts are necessary to refine pricing strategies for medical services and reduce PID incentives driven by unreasonable salaries.
Factors influencing hospitalization expenses
Regarding the demographic characteristics of patients, this study found that elderly GC patients incurred higher total hospitalization expenses, consistent with previous studies. On one hand, this is due to the higher incidence of GC among the elderly [21]. Elderly GC patients undergo complex treatments, leading to increased use of high-value consumables and adjuvant items, thereby increasing their hospitalization expenses [18]. Through univariate analysis, our study found that male GC patients incurred higher treatment costs than female ones. In multiple regression analysis, however, we found that male GC patients would have fewer costs, which is inconsistent with previous studies [22]. The inconsistency between results may be due to the unequal distribution of key factors, such as disease severity and LOS, between male and female GC patients. After adjusting for these variables in the multivariable model, the independent effect of gender reversed. This suggests that further research should include subgroup analyses and carefully select appropriate covariates to better understand these relationships [23, 24].
Regarding illness severity, our study indicated that patients with more severe conditions have higher hospitalization expenses than those with milder illnesses. Specifically, patients diagnosed with GC who undergo prolonged hospital stays and surgical interventions tend to accumulate elevated hospitalization expenses due to increased healthcare resource utilization, resulting in higher medical costs [22]. However, it has been found that inpatients have unnecessary hospitalization days, that is, patients need to stay in the hospital for observation even if they do not receive any treatment, which leads to an increase in their costs [25]. This not only increases the economic burden on patients but also leads to the waste of healthcare resources, suggesting the need to improve the efficiency of technical services while ensuring the quality of healthcare services in the future [25].
In terms of hospital characteristics, in line with prior research, our study indicates that patients incur the highest hospitalization expenses when receiving care at tertiary hospitals. This association is likely due to the higher concentration of patients with severe gastric cancer in tertiary care settings [16].
Implications for policy reforms and implementation
Our study suggests that a comprehensive policy framework is needed to collectively regulate the irrational growth of medical expenses and establish a fair remuneration system for medical services, aiming to reduce PID driven by unreasonable salaries in future policy reforms. Specifically, policymakers should focus on implementing performance-based payment mechanisms that align doctors’ incentives with quality care, rather than the quantity of services. This could involve balancing remuneration between medical services and consumables, ensuring that doctors are adequately compensated for delivering high-value care. Secondly, transparent procurement systems for consumables and standardized pricing models for examinations could help control excessive costs, while maintaining resource efficiency. Additionally, considering the characteristics of GC patients, it is essential to enhance awareness campaigns targeting older adults to improve early diagnosis rates.
Strengths and limitations
Our study is the first to investigate trends in hospitalization expenses and the impact of the UZMDP on GC patients in Shanghai. It provides valuable insights into the rational control of hospitalization expenses for GC patients and the advancement of healthcare system reforms.
The study has several limitations. First, the unavailability of other variables, such as patients’ income and history of other diseases, introduces potential confounding effects on the results. For instance, patients with higher incomes often have greater access to advanced medical treatments and high-quality healthcare services, which may lead to higher hospitalization expenses. These increased expenses are not solely attributable to drug, consumable, and examination costs, but could also be driven by the selection of more intensive or specialized care options. Addressing these confounding variables in future research, including subgroup analyses, would enhance the accuracy and reliability of the findings. Second, the absence of specific GC classifications hinder a detailed analysis of the influencing factors of hospitalization expenses among patients with diverse GC classifications. Without categorizing patients based on these subtypes, it becomes challenging to determine which factors are driving hospitalization expenses for specific groups. Future studies should incorporate specific GC classifications, such as early-stage and advanced-stage, into their analysis. Third, the intricate policy environment, marked by the concurrent implementation of multiple healthcare reform measures, complicates the measurement of the net effect of the UZMDP. The results of the ITSA and the new GRA may be influenced by various policies [12], potentially distorting the observed outcomes. Future studies could conduct sensitivity analyses to isolate the specific impact of the UZMDP. Additionally, since ITSA assumes linear relationships and clear interruption points, it may not fully capture non-linear effects, while GRA is sensitive to data scaling and does not establish causality, which could lead to biased or incomplete conclusions. To address this limitation, future research could use a more comprehensive model to explore the trends before and after the implementation of the UZMDP. Moreover, we did not account for the potential impact of inflation on the observed increase in hospitalization expenses over the years. Future studies could adjust for inflation to better isolate the effects of policy reforms and provide a more accurate representation of changes in hospitalization expenses. Furthermore, it is important to consider the potential impact of a large-scale outbreak of COVID −19 in 2020 on the hospitalization expenses of GC patients, as it could have contributed to an increase in medical across various categories.
link