Appropriateness-based reimbursement of elective invasive coronary procedures in low- and middle-income countries: Preliminary assessment of feasibility in India

BACKGROUND: Elective coronary interventional procedures are often overused and sometimes inappropriately used. The incentives for overuse are greater in low- and middle-income countries, where much of healthcare is provided by poorly regulated, fee-for-service systems. Overuse and inappropriate use increase healthcare costs and are potentially harmful to patients. Linking appropriate use of elective procedures to their reimbursement might deter overuse.

METHODS: We explored the feasibility of introducing appropriateness criteria as a precondition to settling reimbursement claims in a publicly funded health insurance scheme in Maharashtra, India. Clinical algorithms were developed from the current best-practice criteria and used to determine appropriateness at the time of obtaining pre-authorization for elective percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgeries. The number of PCIs as a proportion of the total number of procedures reimbursed under the scheme was the primary outcome measure. This proportion was compared for 1-year periods before and after implementation of appropriateness-based reimbursement, using the chi-square test. Comparisons were also made separately for public and private hospitals. The change in the proportion of CABG surgeries over the same time periods was used as a comparator (as they are less subject to inappropriate use).

RESULTS: The insurance scheme provided cover to a population of 20 424 585 (18.2% of the population of Maharashtra) in 8 districts, through 106 hospitals (73 private and 33 public). There was a 12.3% (95% CI 8.9%-15.5%, p=0.0001) reduction in the proportion of PCIs performed in the 1-year period after the introduction of appropriateness-based reimbursement. The reduction was similar for public and private hospitals. There was no significant change in the proportion of CABG surgeries (2.3% v. 2.2%, p=0.20). At current rates, use of appropriateness-based reimbursement would result in approximately 783 (95% CI 483-1099) less PCIs with potential annual savings of about ₹ 57 million (US$ 0.93 million; 95% CI 0.57-1.3) to the government scheme.

CONCLUSIONS: It seems feasible to implement an appropriateness-based system for reimbursement of elective coronary interventional procedures in a government-funded health insurance scheme in a developing country. This potentially cost-saving approach may reduce inappropriate use.