Payment systems and hospital length of stay: a bunching-based evidence

Abstract

Despite the huge attention on the long average hospital length of stay (LOS) in Japan, there are limited empirical studies on the impacts of the payment systems on LOS. In order to shed new light on this issue, we focus on the fact that reimbursement for hospital care is linked to the number of patient bed-days, where a "day" is defined as the period from one midnight to the next. This "midnight-to-midnight" definition may incentivize health care providers to manipulate hospital acceptance times in emergency patients, as patients admitted before midnight would have an additional day for reimbursement when compared with those admitted after midnight. We test this hypothesis using administrative data of emergency transportations in Japan from 2008 to 2011 (N = 2,146,498). The results indicate that there is a significant bunching in the number of acceptances at the emergency hospital around midnight; the number heaps a few minutes before midnight, but suddenly drops just after midnight. Given that the occurrence of emergency episode is random and the density is smooth during nighttime, bunching in the number of hospital acceptances around midnight suggests that hospital care providers shift the hospital acceptance times forward by hurrying-up to accept the patients. This manipulation clearly leads to longer LOS by one bed-day. In addition, the manipulation is observed in the prefectures where private hospitals mainly provide emergency medical services, suggesting hospital ownership is associated with the manipulation of hospital acceptance time.

Examining organisational responses to performance-based financial incentive systems: a case study using NHS staff influenza vaccination rates from 2012/2013 to 2019/2020

“…Takaku et al also identify bunching of recorded admissions just before midnight, especially in private hospitals, presumably to obtain an extra day of inpatient payment. 33 We are also aware of another study in the public health field. 6 Our study seems novel insofar as it identifies the threshold effect and studies both how the phenomenon tracks a moving threshold level and the relationship of the threshold effect to the approaching target date.…”

Impact of increased reimbursement for ambulance transportation on hospital acceptance in Japan: a difference-in-difference study

“…This study analysed the national ambulance records of the FDMA in Japan from 1 April 2015 to 31 December 2016. These data include all ambulance transports throughout Japan except those for Tokyo prefecture, because fire stations in Tokyo are managed by an organisation independent of the national government and are not included in the FDMA database 12. This study included all patients referred to an ambulance and transported to a hospital.…”

Factors associated with difficulty of hospital acceptance of patients suspected to have cerebrovascular diseases: A nationwide population-based observational study

“…This study analyzed the national ambulance records of the FDMA in Japan from 1 January 2016 to 31 December 2016. These data include all emergency transports throughout Japan except for Tokyo prefecture because fire stations in Tokyo are managed by an organization independent of the national government, and are not included in the FDMA database [13]. The data were collected by EMS personnel, in cooperation with the physicians overseeing the patient's care.…”

“…Demographic factors (age and gender), chronological factors (date and time), severity, location, and prefecture were extracted from available data. The severity is classified into 4 categories: dead, severe, moderate and mild [13]. Severe patients are those expected to be hospitalized for over 3 weeks, and moderate patients are those expected to be hospitalized for 3 weeks or less.…”