This study found that the median hospitalization expenditure of lung cancer patients was $1581.8, higher than the level of $1281.7per capita for all the hospitalized patients in China [11]. Compared with the national per capita disposable income, the lung cancer patients’ hospitalization expenditure occupied 32.4% of urban residents per capita disposable income, and 91.7% of the rural residents [12]. This shows that lung cancer will bring heavy burden to the entire society.
From the perspective of patients, the OOP decreased from $782.4 to $411.5 during the year of 2015 to 2017, which remarkably reduced the economic burden of lung cancer patients. However, it should be noted that among the study population, 61.8% of the patients were above 60 years old, retired with no income and subsisted on pension. In addition, the cost of treatment for malignant cancer is high. If complications like infection occurred during the course of treatment, patients’ conditions would be aggravated and additional economic burden be increased [13]. Thus, the risk of illness and poverty for these patients still exist.
From the constituents of the medical cost, treatment component was the main part of the total hospitalization expenditure, and drug cost occupied a large proportion, up to 41.6%. On one hand, high priced chemotherapy drugs and molecular target drugs are applied to lung cancer patients [14–15]. The high cost is also associated with lacking of domestic alternative medicines. On the other hand, China is entering a critical period of new round health care system reform, and compensation mechanism reform is an important part. The financial support to public hospitals by the government is relatively insufficient and public hospitals are running under pressure to a certain extent. Therefore, besides price factors, the compensation mechanism needs further improved. The problem of how to ensure all the medical institutions and physicians optimized the use of drugs is also needed to be solved. Currently, combined with other nations’ reform experience, the Chinese government is proceeding a series of measure of reform. Zero-tariff policy on imported anti-cancer drugs and government’s policy on pharmaceuticals purchase by public bidding are all included [16–17]. More anti-cancer drugs are brought into the medical insurance catalogue, as well as strengthening financial investment to health care institutions and implementing health technology assessment on drugs utilization.
The research showed that hospitalization expenditure was influenced by hospital length of stay, surgery, hospital type, hospital level and medical insurance situation. Hospital length of stay had the greatest impact on hospitalization expenditure and largest contribution to model R-Square. Since the severity of the disease, long time of observation and treatment for lung cancer hospitalized patients was needed, thereby the charges for beds, treatment and drugs increased accordingly. Moreover, for lacking of scientific and effective management on patients, some medical institutions increased the hospital stay and the cost in the process of treatment. The results of path analysis indicated that patients hospitalized cost was directly influenced by the stay length and indirectly by surgery, medical insurance situation and hospital type. The hospital length of stay was longer for those patients that had operations, medical insurance or having hospitalization in the special hospitals like oncology specialty hospitals. One reason was that compared with non-operative patients, the time for operative patients to recover was longer. For the patients with medical insurance, the usage of hospitalization service was increased to some extent compared with self-paid patients. The condition of lung cancer patients transferred from traditional Chinese medicine hospitals and general hospitals to specialized oncology hospitals was more severe.
Therefore, reducing the hospital length of stay was the prime way to lower down patients’ hospitalization expenditure. General control strategy should be established. Through clinical pathway management strategy, lung cancer patients could be scientifically and effectively treated and ineffective hospital length of stay be shortened, which had been demonstrated [18]. For various influencing factors, specific measures should be established to control the hospital length of stay. Through strict surgical indications and day surgery, hospital length of stay could be reduced [19]. By implementing diagnosis related groups-prospective payment system (DRGs-PPS) [20], the reform in UEBMI, URBMI and NCMS had been carried out. Meanwhile, hospitals’ ability in lung cancer patients’ diagnosis and treatment could be improved through coordination and cooperation.
In addition to hospital length of stay, patients whether or not taking operation was another direct influencing factor to hospitalized expenditure. The reason was that patients had to pay for the anesthesia drugs and the application of ECG monitoring and respirator cost, besides the operation cost. If complications like postoperative bleeding and atelectasis happened, additional cost would be paid. Therefore, physicians had to carefully choose the treatment plan. Currently, the treatment plan of lung cancer patients was based on pathological type and stage, chemotherapy, radiotherapy and operation were included [21]. Physicians had to select the most suitable treatment plan to patients based on their conditions.
Multiple linear regression showed that patients with medical insurance would pay higher hospitalized cost compared with the self-paid patients. Although the medical insurance system had provided more choices for patients, it should be aware that the moral hazard would appear and lead to overuse of medical resources between physicians and patients because of medical insurance [22]. Those with UEBMI had higher hospitalized cost than the patients with URBMI and NCMS. The reason was that China is still in the initial stage of developing basic medical insurance system. There was still a gap in financing level, the scope of insurance, the ratio of reimbursement among UEBMI, URBMI and NCMS. The lung cancer patients with UEBMI would have better medical guarantee and more choices of treatment plan. As to the self-paid patients, since the limitation of economy, some patients wouldn’t go to the hospital until the disease advanced, therefore missed the best time to treat. Meanwhile, they were also faced with limited options concerning the treatment cost. The results of survival analysis showed that the hospitalized cost of self-paid patients was spent quicker and the risk of catastrophic expenditure was easier to appear. It indicated that the supervision of self-paid patients’ hospitalized cost should be strengthened and more attentions should be paid from medical aid.
From the aspect of hospital type, lung cancer patients spent lower hospitalized cost in traditional Chinese medicine hospital. The reason was that traditional Chinese medicine and treatment could improve the physical function of the patients, prevent the recrudescence and reduce the post-operative complications. During the period of tumor chemotherapy and radiotherapy, traditional Chinese medicine could reduce its toxic side effects and enhance the therapeutic effect [23]. The introduction and combination of traditional Chinese medicine could make health care providers take patients as the foremost, focus on patients’ life quality. It could help patients to set up an accurate view of health and life, learn to weight the advantage and disadvantage of the treatment and avoid the pain brought by excessive medical treatment [24].
Judging from the hospital level, lung cancer patients’ hospitalization expenditure of district and county hospitals was obviously lower than the provincial and municipal hospitals. The charging rate and the complexity of patients’ condition from high level hospitals was one important reason for the high hospitalized cost. Compared with the patients of acute symptom and the critical patients in the ICU, the price elasticity of demand existed in chronic disease such as lung cancer [25]. Price lever was useful in patients flow and reducing the burden of lung cancer patients hospitalized cost. The family physician system and hierarchical medical treatment system should be enhanced for patients’ division. However, it required the lower level hospitals having strong support capacity and physicians meeting requirement of treatment. Strengthening the construction of regional medical center and hospital groups like the Britain’s hospital trust was the main way to upgrade the lower level hospitals capability.
There are two limitations in this study. First, more variables needed to be included. The data of this research was collected from sample medical institutions of Liaoning province, according to the framework of SHA 2011. Since the variables were limited, some variables like the patients’ income and education level were not included, which would be the influencing factors of patients’ hospitalization expenditure. Second, cross-sectional study was used in survival analysis and prospective research design was not included in the analysis of hospital length of stay for the patients reaching catastrophic expenditure rate. The patients whose self-paid cost reaching catastrophic expenditure rate but not discharge from hospitals were not included in the research and thereby reduced the sample size.