Does the approved tariff cover the actual cost of global surgical procedures?

Abstract

Background: Following the implementation of the health transformation plan in Iran and the significant increase in medical tariffs, it seems there is still a considerable gap between the actual cost of the Global Surgical procedures (GSPs) and the approved tariffs. The aim of this study was to compare the actual costs of GSPs with approved tariffs in hospitals affiliated to Qazvin University of Medical Sciences in 2016. Methods: In this cross-sectional study, data of 6,126 GSPs performed in three hospitals were extracted from Hospital Information System and approved tariffs were also obtained from the Supreme Council of Health Insurance. The difference between the average actual costs of a GSP and its tariff was considered as the tariff-actual cost gap. Regression test was used to determine the factors affecting the tariff-actual cost gap using SPSS.21. Results: The average actual cost of GPSs was 503 USD while the average tariff was 361 USD, indicating a significant negative gap between the approved tariffs and the actual cost of GPSs. In fact, for each procedure, the hospital suffered an average of 142 USD losses. In 54 of 63 GSPs, the average actual cost was 0.3% to 307.4% higher than the tariff. The highest negative gap was related to the “femoral fracture fixation" with -307.4%. The gap was higher in older patients, females, and patients with a longer stay, orthopedic specialty, and full-time surgeons (p<0.05). Conclusions: The findings of this study showed that tariffs covered only 71.8% of actual costs. It is suggested that in the tariff setting of GSPs, factors such as inflation rate, patient's age, comorbidity, disease severity, and hospital function (teaching or referral center) be considered. In addition, hospital management can also reduce the gap by modifying processes and managing resource consumption, especially medicines and consumables items.