The impact of medical insurance reimbursement on postoperative inflammation reaction in distinct cardiac surgery from a single center

Socioeconomic status is broadly defined from the sociological and economic characteristics which impacts on an individual’s position in the society, and takes into account various factors such as income level, education attainment, occupation status, as well as environment factors. Socioeconomic status is regarded as important predictor for cardiovascular disease prognosis [1]. Low socioeconomic status is associated with elevated risk of complications and death for people with cardiovascular disease [2]. Furthermore, low socioeconomic status was associated with some health problems such as depression and cognitive impairment, which are characteristic of higher levels of inflammatory markers [3].

Although it was unlikely that it is an index that can accurately reflect socioeconomic status, previous study referred government’s medical insurance premium as a reference indicator [4]. In China, most of all cardiac procedure centers are accumulated in the municipality and provincial capitals, the severely suffered patients having cardiac procedure needs with rural household registration have to be transferred to the tertiary hospitals. However, the urban–rural segmentation of the medical insurance system makes the rural population benefit less reimbursement percentage of the total expenses than the urban residents [5]. A study conducted in western rural China revealed that high out-of-pocket spending and low healthcare reimbursement led to medical impoverishment, which was an important poverty source [6]. Under the background, some commercial insurance companies promise additional medical coverage if it is in the list of the covered disease items under the terms of the contract. There are some exceptions such as congenital heart diseases like secundum atrial septum defect (ASD) and patent foramen ovale (PFO), the total expense of occlusion procedure is relatively low and the compensations are also consistently limited among all the patients. That is why the occlusion device for closing the defect is not in the reimbursement catalogue if done in the adult period whatever medical insurance types. Therefore, we used the classification of medical insurance coverage percentage as the indicator of the socioeconomic status, and then, aimed to investigate the relationships between medical insurance reimbursement and postoperative inflammatory markers in the two populations with different diseases of distinct typical therapeutic mode.

Our findings in the present study demonstrated that low versus high medical coverage percentage was associated with higher inflammation indexes and weaker intensive recovery among the population undergoing equivalent medical expenses for open mitral valve procedure. However, the phenomenon did not exist in the population undergoing transcatheter ASD occlusion procedure. To the best of our knowledge, the outcome added to the literature that negative correlation existed between medical insurance reimbursement and postoperative inflammation response undergoing cardiac procedure on cardiopulmonary bypass.

Psychosocial factors such as low socioeconomic status, acute or chronic stress and depression or anxiety are highly popular among the heart disease patients [10]. The patients with sepsis who live in the lowest median income populations had a higher risk of mortality and inflammation levels compared with the residents of the highest income [11]. Pro-inflammatory mechanism is regarded as a pivotal pathway translating socioeconomic inequalities into mental and physical health disparities [12]. Previous study showed that lower socioeconomic status independently predicted major adverse cardiac events via stress-associated neurobiological mechanism that includes heightened amygdalar activation, proinflammatory cytokine production from bone marrow immune cells, and atherosclerotic inflammation [13]. In the general child population, low socioeconomic status was associated with increased exposure to stressors like poverty and disadvantage, in turn associated with later inflammation [14]. Open mitral valve procedure need high medical expense, those who hold low medical insurance coverage were inclined to economic stress, reflected by psychological features such as anxiety and depression and concomitant higher inflammation indexes. In contrast, ASD interventional occlusion is exempt cardiopulmonary bypass and major surgical insult procedure. These patients enjoyed higher safety and only afforded less than a half of the total expenses which mitral valve procedure costs. Importantly, we did not observe remarked differences in baseline confounders of inflammation reaction in the recruited population like physical activities and adverse behavioral factors such as smoking, drinking, and obesity [15].

Inflammatory pathways provide important new intervention and prevention targets for cardiovascular and psychical disorders. There was robust evidence that easy-to-obtain blood-based inflammation biomarker indexed by hr-CRP significantly associated with sudden cardiovascular death risk in apparently low risk populations [16]. Higher level of systemic inflammatory markers such as CRP in the childhood was associated with an increased risk of developing depression and psychosis in young adulthood [17]. NLR is a non-specific, readily available blood-based biomarker of inflammation with potential scientific utility. Elevated NLR was associated with higher incidence, morbidity, and mortality in several systemic diseases, psychiatric, and age-related inflammatory conditions, including cardiovascular diseases and malignancies [18]. It was indicated in this study that medical reimbursement associated with postoperative inflammation response but not cardiac injury and energy metabolism indexed by TnI and lactate, respectively.

Low medical coverage usually indicated high out-of-pocket expenses during the cardiac procedure. In a cohort study, the individuals experiencing income volatility and drops were independently associated with a nearly twofold risk of cardiovascular disease and all-cause mortality [19]. In 2016, Chinese government launched healthcare reform including the new rural cooperative medical scheme, which the farmers, local finances, central government collectively raise the funds. The objective of this scheme enables the insured to enjoy the reimbursement benefit by paying a flat-rate premium. However, there is still a discrimination between the rural residents and urban employee in the present system of tiered medical services [20]. On account of no insurance coverage for occluder device which account for 75% of total hospital expenses, all of the insurance holders only shared with little reimbursement benefits from the rest part which was under the coverage. However, almost all of the expenses on open mitral valve procedure were included in the medical coverage. At last, the low medical coverage population could afford twofold expense of those that the high medical coverage population paid for. It indicated that economically affluent groups in the urban were more likely to receive advantageous finance reimbursements policy from independent insurance system, and meantime the reimbursements were also higher [21]. One study also showed that the implementation of essential medicines policies on primary healthcare institutions has certain positive but limited effects [22], which indicated that severe illness and impoverishment still occur like the twins in rural area [23]. Meanwhile, there were remarked difference in postoperative inflammation reaction among different medical insurance type only for mitral valve population but not for ASD occlusion population. Granted that the total expenses were relatively consistent for each cardiac procedure, the inflammation reaction was remarked elevated in serious cardiac procedure and reversely associated with practical medical payments.

Although there was no remarked difference on total hospital stay and expenses, weaker early intensive prognosis such as extended ICU stay and ventilation use predicts more negative emotions. Physical discomfort such as delayed chest tube removal will also trigger emotional abnormality that could result in compromised medical compliance [24]. Previous study showed that early sufficient physical excises is associated with a lower risk of death after cardiac valve procedure [25]. Moreover, over half of those who received ICU treatment were previously reported that significant symptoms like anxiety, depression or post-traumatic stress disorder appeared after discharge of hospital. Depression following critical illness is associated with an increased mortality risk in the first two years following discharge from ICU [26].

In previous studies, we investigated the series of the clinical conditions associated with the reduction of systemic inflammation reaction during cardiac procedure, such as remote ischaemic preconditioning [8], total thoracoscopic approach [27], and even high-altitude hypoxia environment [28]. In this study, we concentrated on the effect of medical insurance coverage in the specific population on inflammation reaction and clinical prognosis in the early period after heart surgery. The administration experiences on medicaid expansion remedies resulted in lower cardiovascular mortality in the middle-aged adults in United States [29]. Therefore, the equality on the benefits and compensations across diverse insurance coverage ranks in the population undergoing cardiac procedure with enormous expenditure should be prioritized on the basis of policy feasibility and equity. Meanwhile, more public and private sector efforts should be incorporated as part of a comprehensive strategy to alleviate medical coverage disparities. For the vulnerable populations, special policies such as covering the deficient medical insurance coverage on catastrophic procedure expenditure should also be considered. Implementation of the payment systems basedon Diagnosis-Related Group (DRG), which was established on the principle that same diagnoses and treatments require equal resource utilization, is also promising alternative [30].

The finding on the association between medical insurance coverage and postoperative inflammation response was limited due to the properties of observational study. The causality cannot be directly inferred from such retrospective study. Future studies focused on the validity of causality and mechanisms underlying the association between medical insurance coverage and postoperative inflammation are warranted. The attempt on completing the psychical stress questionnaire and commercial inflammatory cytokine detection should be considered in the future for further causality on the relationship.