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Table 3 Summary of financial interventions for reducing the caesarean section rate

From: The effectiveness of financial intervention strategies for reducing caesarean section rates: a systematic review

Author, Year Intervention (effect) Details of Intervention Strategies Sample Size Outcome Measure Certainty (GARDE)
Keeler and Fok, 1996 [29] Provider intervention: fee equalization for hospitals (No significant effect) Fees for vaginal deliveries were increased by 3%, and fees for CS were reduced to the amount charged for vaginal deliveries (an average reduction of 18%). 11,767 CS rate (%) Before intervention 25.3 Post intervention 24.6 P > 0.05 MODERATE
Lo, 2008 [30] Provider intervention: fee equalization for hospitals (No significant effect) Fees for vaginal birth after caesarean section were raised to the level of caesarean section in April 2003; Fees for vaginal deliveries were also raised to the level of caesarean section in May 2005. 1,084,686 OR (95%CI) for CS Post-VBAC fee rose 1.05 (1.00–1.09) Post-fee equivalence 1.03 (0.97–1.09) HIGH
Hong and Linn, 2012 [32] Provider intervention: fee equalization for hospitals (No significant effect) The payment to hospitals for vaginal deliveries was raised in May 2005. Before this intervention, the payment for caesarean section with medical indications was $911 to $1132 but the payment for vaginal deliveries was only $506 to $609. After this intervention, the payment for deliveries was $911 to $1132 regardless of delivery mode. 51,085 OR (95%CI) for CS aUnplanned CS 0.978 (0.90–1.07) aPlanned CS 0.995 (0.09–1.06) CDMR 0.862 (0.69–1.07) MODERATE
Patient intervention: co-payment for CDMR for patients (No significant effect) Between May 2005 and May 2006, the payment for CDMR was equal to that for vaginal deliveries ($911 to $1132). After the co-payment policy applied, the payment for CDMR was $506 and the co-payment for that was increased from $0 to $475–697. OR (95%CI) for CS aUnplanned CS 0.960 (0.88–1.05) aPlanned CS 0.942 (0.88–1.00) CDMR 1.083 (0.87–1.35)
Liu et al., 2013 [33] Provider intervention: bthe global budget system for hospitals (No significant effect) Fees for services plan were replaced by the global budgeting system at this tertiary hospital in July 2002 for controlling CS rates. The global budget system is prospective payment system, which aiming at allocating resource and controlling cost. 35,616 CS rate (%) Before GBS 35.1 After GBS 36.7 P = 0.0525 LOW
Chen et al., 2014 [34] Provider intervention: fee equalization for hospitals (No significant effect) A global fee ($905–1132) was set for obstetric services at different levels of medical institutions, regardless of the mode of delivery in May 2005. 1,003,412 OR for CS 20–1.033 25–1.009 30–0.987 35–0.966 40–0.944 45–0.923 HIGH
Patient intervention: co-payment for CDMR for patients (No significant effect) After May 2006, the Bureau of National Health Insurance (BNHI) took partial reimbursement for where mothers had to pay a co-payment. With this intervention, physicians still received the same total payments for CDMR, but their payments came from two components. For instance, in medical centers, physicians obtain payments of $1132 for CDMR, which included the reimbursement of $609 for vaginal delivery and the copayment of $523, paid by the BNHI and mothers, respectively. OR for CS 20–1.037 25–1.021 30–1.007 35–0.992 40–0.977 45–0.961
Liu et al., 2018 [36] Provider intervention: ccase payment for hospitals (Significant increase) Insurance agencies took a payment reform in 2009 and completed in 2011, the traditional fee-for-service payment was transformed into case payment for caesarean sections. The case compensation standard for CS is higher than that of vaginal deliveries ($493.47 for CS without complications, $197.39 for vaginal deliveries without complications). 28,314 CS rate (%) Pre-CPR:26.124% Post-CPR:32.475% P < 0.001 MODERATE
Misra, 2008 [31] Provider intervention: drisk-adjusted capitation for hospitals (Limited its increase) In 1997, the Maryland Department of Health and Mental Hygiene replaced the mixed model of fee-for-service and voluntary managed care enrollment for a majority of Medicaid enrollees with a mandatory managed care system called HealthChoice. HealthChoice capitation rates are risk-adjusted. The monthly payments to a managed care organization for providing all necessary services to a particular enrollee are based on the individual’s documented health status. Managed care organizations receive a higher payment when the more severe the patients’ clinical conditions. 128,743 OR (95%CI) for CS Primary CS 0.67 (0.573~0.774) Repeat CS 0.71 (0.623~0.804) HIGH
Kim et al., 2016 [35] Provider intervention: e the diagnosis-related group payment for hospitals (Significant decrease) Vaginal deliveries followed the fee-for-service system and the cost for CS followed the diagnosis-related group payment system. In 2002, the diagnosis-related group payment system for caesarean section only in voluntary health sectors. From July 2012, he diagnosis-related group payment system became mandatory in hospital and clinics, the it was also applied to general hospitals and tertiary hospitals since July 2013. 1,289,989 OR (95%CI) for CS Mandatory adoption of DRG system 0.823 (0.816–0.830) A longer length of the DRG system adoption period 0.997 (0.996–0.998) HIGH
Kozhimannil, 2018 [37] Provider intervention: fee equalization for hospitals and clinicians (Significant decrease) Before this intervention, facility fees were $3144 and $5266 for uncomplicated vaginal and cesarean births, respectively. After intervention, the policy changed the rate to $3528 for uncomplicated births regardless of the mode of delivery. Professional services fees also changed because of the policy, from $776.62 and $1147.42 for prenatal, delivery, and postpartum care for uncomplicated vaginal and cesarean births, respectively, to a single blended rate of $867.37. 671,177 CS rate (%) Intervention-group: decrease 3.24% Control-group: increase 0.6% HIGH
  1. Note:
  2. a Unplanned caesarean sections and planned caesarean sections are types of caesarean section with medical indications
  3. b Global Budget System is one of prospective reimbursement for healthcare providers and government set a target on the amount of overall cost for health providers
  4. c Case payment means that healthcare provider will get a fixed price per admission irrespective of the actual health cost incurred
  5. d Risk-adjustment capitation was charged monthly according to the applicants’ health status, and managed care organizations receive a higher payment, the more severe the patients’ clinical conditions
  6. e Diagnostic-related group payments means groups of patients with similar clinical conditions and these patients would incur comparable health costs