Determinants of Hospital Cost Containment Under Universal Health Coverage: A Systematic Review
Keywords:
DRG, hospital cost containment, hospital efficiency, payment reform, universal health coverageAbstract
Universal Health Coverage (UHC) requires effective cost control to ensure the sustainability of health systems. Hospitals account for a large share of healthcare expenditure, and rising costs are driven by increasing service utilization, technological advancement, and inefficiencies in care delivery. Although prospective payment systems such as Diagnosis-Related Groups (DRGs) are widely implemented, their effectiveness in controlling costs remains mixed. This study aims to systematically review empirical evidence on hospital cost containment under UHC, focusing on payment reforms, operational efficiency, and system-level determinants. A systematic review was conducted following PRISMA guidelines. Literature searches were performed in Scopus, PubMed, and Google Scholar for studies published between 2015 and 2025. Primary empirical studies examining hospital cost containment strategies were included. Of the 355 articles obtained at the start of the search, further filtering was carried out according to the criteria so that the final result was 10 suitable articles met the inclusion criteria. Data were extracted and synthesized using a narrative approach. Findings indicate that cost containment is influenced by multiple interrelated factors. DRG-based payment systems were associated with reduced length of stay and, in some cases, lower hospital costs. However, evidence also shows increased service volume and inconsistent effects on quality of care. Operational efficiency, particularly shorter length of stay, emerged as a key driver. System-level factors such as governance, strategic purchasing, and blended payment models further influence cost outcomes. Hospital cost containment under UHC is multidimensional and context-dependent. DRG systems alone are insufficient; effective strategies require integrated approaches combining payment reform, efficiency improvements, and strong governance.
References
Al-khalil, O., Valeri, F., Senn, O., Rosemann, T., & Gangi, S. Di. (2020). Effects of a DRG-based hospital reimbursement on the health care utilization and costs in Swiss primary care : A retrospective “ quasi-experimental ” analysis. PLOS ONE , 1–14. https://doi.org/10.1371/journal.pone.0241179
Aragón, M. J., Chalkley, M., & Kreif, N. (2022). The long-run effects of diagnosis related group payments on hospital lengths of stay in a publicly funded health care system : Evidence from 15 years of micro data. Health Economics , June 2021 , 956–972. https://doi.org/10.1002/hec.4479
Cao, Z., Liu, X., Wang, X., Guo, M., & Guan, Z. (2024a). Impacts of DRG-Based Prepayment Reform on the Cost and Quality of Patients with Neurologic Disorders : Evidence from a Quasi-Experimental Analysis in Beijing, China. Risk Management and Healthcare Policy , May , 1547–1560.
Cao, Z., Liu, X., Wang, X., Guo, M., & Guan, Z. (2024b). Impacts of DRG-Based Prepayment Reform on the Cost and Quality of Patients with Neurologic Disorders : Evidence from a Quasi-Experimental Analysis in Beijing, China Impacts of DRG-Based Prepayment Reform on the Cost and Quality of Patients with Neurology. Risk Management and Healthcare Policy , 1594 . https://doi.org/10.2147/RMHP.S458005
Chen, M., Pan, D., Pan, T., & others. (2025). Impact analysis of DRG payment reform on hospitalization expenses and length of stay for lung cancer inpatients. Frontiers in Health Services . https://doi.org/10.3389/frhs.2025.1661995
Chen, Y., Zhang, X., Tang, X., Yan, J., Qian, M., & Ying, X. (2023). How do inpatients' costs, length of stay, and quality of care vary across age groups after a new case‑based payment reform in China? An interrupted time series analysis. BMC Health Services Research , 1–10. https://doi.org/10.1186/s12913-023-09109-z
Jian, W., Lu, M., Liu, G., & others. (2019). Beijing's diagnosis-related group payment reform pilot: Impact on quality of acute myocardial infarction care. Social Science & Medicine , 243 , 112590. https://doi.org/10.1016/j.socscimed.2019.112590
José, M., Martin, A., & Noémi, C. (2022). The long-run effects of diagnosis related group payments on hospital lengths of stay in a publicly funded health care system : Evidence from 15 years of micro data. Health Economics , June 2021 , 956–972. https://doi.org/10.1002/hec.4479
Liu, Z., Zhou, L., Zhang, L., Hu, C., Huang, The impact of DRG payment reform on hospitalization costs and length of stay: A multicenter study across different hospital levels and departments. Public Health , 253 , 106206. https://doi.org/https://doi.org/10.1016/j.puhe.2026.106206
Mathauer, I., Dale, E., Meessen, B., & Kutzin, J. (2017). Strategic purchasing for universal health coverage: Key policy issues and questions . World Health Organization.
Messerle, R., & Schreyögg, J. (2024). Country ‑ level effects of diagnosis ‑ related groups : evidence from Germany's comprehensive reform of hospital payments. The European Journal of Health Economics , 25 (6), 1013–1030. https://doi.org/10.1007/s10198-023-01645-z
Methley, A.M., Campbell, S., Chew-Graham, C., McNally, R., & Cheraghi-Sohi, S. (2014). PICO, PICOS and SPIDER: a comparative study of specificity and sensitivity in pictorial communication interventions systematic reviews. BMC Health Services Research , 14 (1), 1–10. https://doi.org/10.1186/1472-6963-14-272
Milstein, R., & Schrey, J. (2024). Health policy The end of an era? Activity-based funding based on diagnosis-related groups : A review of payment reforms in the inpatient sector in 10 high-income countries. Health Policy , 141 (December 2023). https://doi.org/10.1016/j.healthpol.2023.104990
Moreno-Serra, R., & Wagstaff, A. (2010). System-wide impacts of hospital payment reforms: Evidence from Central and Eastern Europe and Central Asia. Journal of Health Economics , 29 (4), 585–602. https://doi.org/10.1016/j.jhealeco.2010.05.007
Palmer, K.S., Agoritsas, T., Martin, D., Scott, T., Mulla, S.M., Miller, A.P., & others. (2014). Activity-based funding of hospitals and its impact on mortality, readmission, and volume of care: A systematic review. PLOS ONE , 9 (10), e109975. https://doi.org/10.1371/journal.pone.0109975
Peng, Z., Chen, X., Lu, X., Coyte, P. C., & Sha, X. (2026). The trade-off between cost containment and quality enhancement under the DRG payment model. BMC Health Services Research , 26 (1), 188. https://doi.org/10.1186/s12913-026-14006-2
Skarayadi, O., Endarti, D., & Mukti, AG (2025). Discrepancies in Hospital Cost and Indonesia's Case-Based Groups (INA-CBG): A Literature Review. Journal of Pharmaceutical Management and Services , 15 (4), 233–245.
Zhang, H., Fu, X., Wu, Y., Tang, Y., Jin, H., & Xie, B. (2025a). The Impact of DRG-Based Payment Reform on Inpatient Healthcare Utilization : Evidence from a Natural Experiment in China. Healthcare , 13 , 1–21. https://doi.org/https://doi.org/10.3390/healthcare13192424
Zhang, H., Fu, X., Wu, Y., Tang, Y., Jin, H., & Xie, B. (2025b). The Impact of DRG-Based Payment Reform on Inpatient Healthcare Utilization: Evidence from a Natural Experiment in China. Healthcare , 13 (19). https://doi.org/10.3390/healthcare13192424
Zhang, X., Tang, S., Wang, R., & others. (2024). Hospital response to a new case-based payment system in China: the patient selection effect. Health Policy and Planning . https://doi.org/10.1093/heapol/czae034
Zhenyu, S., Feng, L., Ping, H., & Dawei, Z. (2024). Effect of DRG Reform and Its Impact on Different Hospital Departments. Medical Journal of Peking Union Medical College Hospital . https://doi.org/10.12290/xhyxzz.2024-0458
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