This study showed that cancer patients were 2.4 times more likely to use insurance to pay for medical costs after COVID-19. As we all known, China's medical insurance affordability is constantly improving. However, health-care funds in China are seriously insufficient, and that different medical payment modes are having certain stimulations and inducements toward doctors in their therapeutic behaviors. Afterall, China's medical insurance could only limit to some drugs and treatments prescribed by the government or the company. As we know, COVID-19 has led to substantial losses for the global economy as well as numerous indirect costs such as unemployment and loss of productivity and income owing to isolation measures[12]. Maybe unaffordability leads patients to prefer insurance payments. Future studies should explore why hospitalized patients take out insurance payments, whether it is related to the change of treatment, health insurance coverage, hospital level or COVID-19[13]. The use of unified disease diagnosis classification quota payment maybe helpful to further encourage hospitals to strengthen medical quality management, and take the initiative as shorten the number of days of hospitalization and decreasing non-essential medical expenses to reduce costs of cervical cancer. 51.3% of the inpatients had adopted the insurance payment, which was lower than that reported of 59.9% in Hungary for cervical cancer acute inpatients[14].
The median age of the 909 patients was 49 years, which was higher than the 42.03 years reported in a survey of the economic and human burden of cervical cancer in the United States from 2006 to 2015[15]. This study showed the average cost for every cervical cancer was 18,000 yuan, which was lower than that report in the Texas of the United Status[16] and domestic preliminary study[8]. There are too many factors affecting the total hospitalization cost, such as treatment mode, length of stay, concomitant disease, hospital grade, patient age or social environment. The proportion of services costs including costs of medical service, treatment operation, nursing and others decreased from 11.20% before COVID-19 to 10.89% during COVID-19 pandemic period of 2020–2021. General medical costs was accounting for 60.77% of the services costs and 6.71% of the total costs. Judging from the overall trend of changes in individual expenses of patients with cervical cancer, an average annual growth rate of the comprehensive medical services, consumables, drugs, diagnosis and treatment was − 3.82%, 23.53%, -5.83%, 4.51%, -1.12% respectively,which was all lower than that report in a city of China from 2007 to 2018, except the consumables costs average annual growth rate of 13.54%[17]. The implementation of the medical reform policy made the contribution proportion of services costs descend before COVID-19 but ascend during COVID-19. COVID-19 is impeding policy implementation[18]. Whether the lower growth rate of total hospitalization costs and the rapid growth rate of consumables costs are related to the COVID-19 epidemic is worth further investigation.
4.1 Influence of consumables costs on total medical expenditure among patients with cervical cancer
The proportion of consumables costs out of total costs increased from 2017 to 2021. Our research showed that consumables expenses had the largest average annual growth rate and had the lowest correlation degree of the five specific components. Similar to our results, a study in China showed that the average annual growth rate of consumables costs for patients hospitalized for cervical cancer was 16.56% and the weakest connection (0.7965) to the total cost of hospitalization [19]. The consumables costs was not observed decline in the lung cancer patients undergoing thoracoscopic surgery in China under the medical reform backgroud[20]. The DSV analysis showed that consumables costs fell the most from 2018 to 2019, when all public hospitals in Hunan Province were instructed to avoid any increase in consumption costs until December 31, 2019 to control unreasonable growth in expenditure on doctors and other medical expenses. Although the correlation between the consumables cost items and the total medical expenditure was the weakest, we still need to consider the cost of consumables in hospitals with the highest expenditure on disposable medical consumables and high value consumables because of the continuous development and introduction of medical technology. In other countries, doctors placed more consideration on the quality, after-sale and technical problems of medical consumables when supplying consumables for patients, but less attention to the price and cost of consumables[21]. At present, there is insufficient communication between hospital administrators, who manage hospital budgeting, and physicians, who are the end-users of hospital supplies and consumables. The costs of consumables were rarely posted or publicized within the hospital setting where they would be accessible to physicians, despite ample evidence that supplying physicians with cost information leads to more cost-efficient care[22]. In the future, we should focus on the management of consumables costs, not only taking consumption material addition, but also the introduction and use of domestic medical consumables to reduce the cost of medical consumables. At the same time, the government should establish the high value medical consumables proprietary system and reduce the high profit of its circulation ring.
4.2 Influence of diagnosis costs on total medical expenditure among patients with cervical cancer
Our research showed that diagnosis expenses had a fluctuating growth trend on the whole, with an average annual growth rate of 4.51%, and the proportion of diagnosis did not show a downward trend year by year. Relevant studies have confirmed that a zero drug markup policy will lead hospitals to compensate for the loss of drug income by increasing the costs of examinations and laboratory tests[23]. However, our study showed that the highest correlation was between diagnosis costs and the total hospitalization cost, indicating that there was excessive reliance on “high, fine, sharp” equipment for cervical cancer inspection at the hospital. This approach may lead to a decline in the medical skills of health technicians and may also lead to the blind pursuit of economic benefits by unnecessary and repetitive examination items. Therefore, medical service behavior should be strictly supervised and the synergistic driving mechanism between price and the medical security and supervision system should be monitored. The proportion of structural variation contribution of the diagnosis cost item toward total cervical cancer medical expenditure during 2017–2021 was the highest at 29.41%. The medical equipment and technical means of third grade hospitals are more advanced, and they provide more selective and high-quality services for patients leading to an increase in the diagnosis costs[7]. Thus, hospitals should pay attention to improving the technical skills of medical staff and reduce excessive dependence on equipment. For the hospital administrator, it is necessary to continuously optimize the performance assessment method and integrate the diagnosis costs, the average oerson average cost increase, and patient satisfaction degree into the performance examination plan for promoteing the medical staff to improve the main vision activity of controlling medical cost.
4.3 Influence of drug costs on total medical expenditure among patients with cervical cancer
In our study, the proportion of structural variation contribution of drug costs item toward total cervical cancer medical expenditure was the second highest of 28.06%. After the reform measures, the drug costs was not the most important factor in the changing trend of average inpatient cost for our studied hospital. However, the costs of drug are still the main factor affecting the costs of hospitalization. Drug costs including western medicine and Traditional Chinese medicine in a third class hospital in Yunnan Province was the highest structural variation (33.97%) for all hospitalized patients during 2018 to 2021[24]. Drug expenses showed a fluctuating falling trend on the whole, with an average annual decrease of 5.83%. The DSV analysis showed that drug costs fell from 2018 to 2019, when all public hospitals in Hunan Province implemented a zero additional drug costs at the end of 2017 to solve the “medicine costs to feed the doctor”. However, the proportion of structural variation contribution of the drug costs item toward total cervical cancer medical expenditure after the COVID-19 pandemic gradually increased. The COVID-19 pandemic, which was associated with acute negative economic events, may have exacerbated cancer-related financial toxicity[25]. The pandemic significantly reduced the dependence of cancer patients on treatment[26]. Therefore, more patients preferred conservative treatment to that with drugs. The government should actively promote the separation of medicine, cut off the profit chain of drug purchase and sale, regulate medical behavior and other acts to reduce drug costs.
The present study is the first to illustrate the impact of COVID-19 on inpatient health expenditure for cervical cancer. In this study, we analyzed the structure and the internal composition of cervical cancer patients’ hospitalization expenses using the gray correlation and the structural variation. We had elaborated the influence of consumables costs, diagnosis costs, and drug costs on the total medical expenditure to strengthen the management of hospital expenses, promote the reform of medical insurance payment system, and reduce medical costs and the economic burden of cervical cancer patients to provide a scientific basis for hospitals and health administrative departments during the COVID-19 epidemic.
There are some limitations to this study. First, our study was based on a single hospital, therefore, the results should be applied to other areas. Second, we selected three years to represent the pre-COVID-19 period, and two years to represent the post-COVID-19 period. However, this period is too short to fully explore the influence of COVID-19. Third, this study only listed five categories of costs as well as the unclassified the other costs, and does not break down the specific costs, such as the cost of testing for COVID-19 during hospitalization was included in the consumables costs. Non-transparent costing leads to the information bias.
In general, we observed the cancer inpatients were more likely to adopt the medical insurance payment after COVID-19. Diagnosis costs were the major factor influencing the hospitalization medical expenditure. Thus, we should pay attention to the rising cost of drugs after the COVID-19 pandemic and maintain a reasonable control over diagnosis costs to reduce the total expenditure for cervical cancer patients after the COVID-19 pandemic.