The medical insurance system's weakness to provide economic protection for vulnerable citizens in China: A five-year longitudinal study

Impact of frailty on mortality and healthcare costs and utilization among older adults in South Korea

Frailty has become increasingly relevant in a rapidly aging society, highlighting the need for its accurate identification and exploring associated clinical outcomes. Using a multidimensional framework to estimate frailty in a sample of community dwelling older adults, its effect on mortality, incurred healthcare costs and utilization were investigated. We obtained data from the 2008-2018 Korean Longitudinal Study of Aging (KLoSA). After excluding individuals aged < 65 years and those with missing data, a total of 3578 participants were included in our study. Cox proportional hazard analysis was conducted to investigate the impact of frailty on all-cause mortality by generating hazard ratios (HRs) and population attributable risks (PARs). Healthcare utilization and out-of-pocket costs incurred by frailty were examined using the Generalized Linear Mixed Model (GLMM). Subgroup analyses were conducted according to frailty components. Among 3578 older adults, 1052 individuals died during a 10-year follow up period. Compared to the low risk frailty group, the moderate risk group (HR: 1.52, 95% CI:1.37-1.69) and severe risk group (HR: 3.10, 95% CI: 2.55-3.77) had higher risks for all-cause mortality. 27.4% (95% CI: 19.0-35.3%) of all-cause mortality was attributable to frailty, and the PARs ranged from 0.5 to 22.6% for individual frailty components. Increasing frailty levels incurred higher total healthcare costs and cost per utilization, including inpatient and outpatient costs. Frailty also increased likelihood of inpatient use, longer length of stay and more frequent outpatient visits. Among the frailty components, Basic Activities of Daily Living (BADL) and Instrumental Activities of Daily Living (IADL) in particular were linked to elevated mortality, higher incurred healthcare costs and utilization. Frailty-tailored interventions are of utmost relevance to policy makers and primary caregivers as frailty threatens the ability to maintain independent living and increases risk of detrimental outcomes such as mortality and increased utilization and out-of-pocket costs of healthcare in older adults.

Exploring Older Adults' Perceived Affordability and Accessibility of the Healthcare System: Empirical Evidence from the Chinese Social Survey 2021

The difficulties in accessibility and affordability of healthcare services have posed persistent challenges to the Chinese government ever since the 1990s. This research aimed to explore the perceived accessibility and affordability of the healthcare system, which is also referred to as the social problem of Kan Bing Nan, Kan Bing Gui among older Chinese adults. The research, based on 2169 sample data points from the Chinese Social Survey (CSS) 2021 database, explored the objective and subjective factors in constructing the public perceptions of accessibility and affordability of the healthcare system among both older adult users and older adult non-users of healthcare services, including healthcare expenditure variables, patient experience variables, financial protection variables, and social evaluation variables. The study utilized binary logistic regression analysis to investigate how four different sets of independent variables impact the perceived affordability and accessibility of the healthcare system by older adults. The research found that Kan Bing Nan, Kan Bing Gui was considered the most pressing issue among the older adults in China. Self-reported medical burdens, the cost of healthcare services, and the perceived fairness of public healthcare services were significantly associated with older adults' perceived affordability and accessibility of the healthcare system.

Financial toxicity assessment and associated factors analysis of patients with cancer in China

PURPOSE

Cancer-related expenditures present a lasting economic burden on patients and their families and may exert long-term adverse effects on the patients' life and quality of life. In this study, the comprehensive score for financial toxicity (COST) was used to investigate the financial toxicity (FT) levels and related risk factors in Chinese patients with cancer.

METHODS

Quantitative data were collected through a questionnaire covering three aspects: sociodemographic information, economic and behavioral cost-coping strategies, and the COST scale. Univariate and multivariate analyses were performed to identify factors associated with FT.

RESULTS

According to 594 completed questionnaires, the COST score ranged 0-41, with a median of 18 (mean±SD, 17.98±7.978). Over 80% of patients with cancer reported at least moderate FT (COST score <26). A multivariate model showed that urban residents, coverage by other health insurance policies, and higher household income and consumption expenditures were significantly associated with higher COST scores, indicative of lower FT. The middle-aged (45-59 years old), higher out-of-pocket (OOP) medication expenditures and hospitalizations, borrowed money, and forgone treatment were all significantly associated with lower COST scores, indicating higher FT.

CONCLUSION

Severe FT was associated with sociodemographic factors among Chinese patients with cancer, family financial factors, and economic and behavioral cost-coping strategies. Government should identify and manage the patients with high-risk characteristics of FT and work out better health policies for them.

Poverty Reduction Effects of Medical Insurance on Middle-Aged and Elderly Families under the Goal of Common Prosperity in China

Eliminating poverty due to illness is an important way for China to pursue common prosperity. The high medical expenditure caused by the aging population has brought severe challenges to governments and families of all countries, especially in China, where the entire population has just been lifted out of poverty in 2020 and then hit by COVID-19. How to prevent the possible return of poor boundary families to poverty in China has become a difficult research topic. Based on the latest data from the China Health and Retirement Longitudinal Survey, this paper discusses the poverty reduction effect of medical insurance on middle-aged and elderly families from the absolute index and relative index. Medical insurance had a poverty reduction effect on middle-aged and elderly families, especially the poor boundary families. For example, people who participated in medical insurance reduced their financial burden by 2.36% for middle-aged and older families compared to people who did not participate in medical insurance. Furthermore, the poverty reduction effect had heterogeneity in gender and age. This research brings some policy implications. For example, the government should give more protection to vulnerable groups such as the elderly and low-income families and improve the fairness and effectiveness of the medical insurance system.

The impact of national comprehensive medical reform on residents' medical expenses: Evidence from China

Residents' high medical expenses is the core challenge that needs to be solved urgently in China's medical reform for a long time. Based on the panel data of 30 provinces in Chinese Mainland during 2011-2019, we evaluate the impact of China's national comprehensive medical reform pilot policy on residents' medical expenses by using the difference-in-differences model. The results show that the pilot policy was generally conducive to reducing residents' medical expenses, resulting in a reduction of 2.13% in per capita medical expenses for inpatients, but the effect on per capita medical expenses for outpatients was insignificant. Mechanism analysis shows that hospital competition and institutional environment played a moderating role in the effect of the pilot policy on residents' medical expenses reduction. The more intense the hospital competition and the better the institutional environment, the more significant of the reduction effect. In addition, the reduction effect of the pilot policy was greater in the central provinces, the provinces with poor medical infrastructure, and the provinces with strong financial strength. This study provides useful policy insights for deepening medical reform and reducing residents' medical expenses.

Cost-effectiveness analysis of sugemalimab vs. chemotherapy as first-line treatment of metastatic nonsquamous non-small cell lung cancer

Objective: Sugemalimab is approved in China as a first-line treatment in combination with chemotherapy for metastatic nonsquamous non-small cell lung cancer (NSCLC). This study aims to evaluate the cost-effectiveness of first-line additional sugemalimab in combination with chemotherapy vs. chemotherapy from the perspective of the Chinese healthcare system. Materials and methods: A three-state Markov model was designed to evaluate the costs and quality-adjusted life years (QALYs) of first-line sugemalimab combination with chemotherapy vs. chemotherapy over a 10-year period. Data on clinical outcomes were obtained from GEMSTONE-302 clinical trials. Costs and health utilities were collected from local databases and published literature. The uncertainty of the model parameters was explored through sensitivity analysis. Results: Compared to chemotherapy, sugemalimab treatment for NSCLC resulted in an extra 0.50 QALYs at an additional cost of $73627.99, with an incremental cost-effectiveness ratio (ICER) of 148354.07/QALY at the willingness-to-pay (WTP) threshold of $37663.26/QALY. One-way sensitivity analysis indicated that the primary motivator in this model was the cost of sugemalimab. However, none of the parameters significantly affected the model's results. Conclusion: Sugemalimab combination therapy is not economically advantageous for the first-line management of metastatic non-squamous NSCLC, according to the Chinese healthcare system.

Financial risk protection from out-of-pocket health spending in low- and middle-income countries: a scoping review of the literature

Background

Financial risk protection (FRP), defined as households’ access to needed healthcare services without experiencing undue financial hardship, is a critical health systems target, particularly in low- and middle-income countries (LMICs). Given the remarkable growth in FRP literature in recent times, we conducted a scoping review of the literature on FRP from out-of-pocket (OOP) health spending in LMICs. The objective was to review current knowledge, identify evidence gaps and propose future research directions.

Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to conduct this scoping review. We systematically searched PubMed, Scopus, ProQuest and Web of Science in July 2021 for literature published since 1 January 2015. We included empirical studies that used nationally representative data from household surveys to measure the incidence of at least one of the following indicators: catastrophic health expenditure (CHE), impoverishment, adoption of strategies to cope with OOP expenses, and forgone care for financial reasons. Our review covered 155 studies and analysed the geographical focus, data sources, methods and analytical rigour of the studies. We also examined the level of FRP by disease categories (all diseases, chronic illnesses, communicable diseases) and the effect of health insurance on FRP.

Results

The extant literature primarily focused on India and China as research settings. Notably, no FRP study was available on chronic illness in any low-income country (LIC) or on communicable diseases in an upper-middle-income country (UMIC). Only one study comprehensively measured FRP by examining all four indicators. Most studies assessed (lack of) FRP as CHE incidence alone (37.4%) or as CHE and impoverishment incidence (39.4%). However, the LMIC literature did not incorporate the recent methodological advances to measure CHE and impoverishment that address the limitations of conventional methods. There were also gaps in utilizing available panel data to determine the length of the lack of FRP (e.g. duration of poverty caused by OOP expenses). The current estimates of FRP varied substantially among the LMICs, with some of the poorest countries in the world experiencing similar or even lower rates of CHE and impoverishment compared with the UMICs. Also, health insurance in LMICs did not consistently offer a higher degree of FRP.

Conclusion

The literature to date is unable to provide a reliable representation of the actual level of protection enjoyed by the LMIC population because of the lack of comprehensive measurement of FRP indicators coupled with the use of dated methodologies. Future research in LMICs should address the shortcomings identified in this review.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00886-3.

A Task Allocation Approach of Multi-Heterogeneous Robot System for Elderly Care

Roboticized nursing technology is a significant means to implement efficient elderly care and improve their welfare. Introducing multi-heterogeneous robot systems (MHRS) and sensor networks into a smart home is a promising approach to improve the safety and acceptability of elderly care services in daily life. Among them, the energy consumption and task planning of MHRS determine nursing safety, which is particularly important in the real nursing process. Therefore, we established a novel smart home for elderly care based on seven heterogeneous nursing robots, and proposed a multi-robot task allocation (MRTA) algorithm, considering execution time and energy consumption. The whole system efficiency makes up for the functional limitations and service continuity of traditional MHRS. To realize efficiently conducted multitasks, we established an architecture with centralized task allocation center, robot alliance layer and distributed execution layer for the MHRS. The self-organizing architecture contributes to overall task allocation, communication and adaptive cooperative control between different robots. Then, to clearly describe the continuous nursing process with multiple simultaneous demands and emergency tasks, we modeled the whole nursing process with continuity, multi-priority, and interpretability. A novel MRTA algorithm with a dynamic bidding mechanism was proposed. Comprehensive experiments showed that the proposed algorithm could effectively solve the three key problems of multi-priority tasks, multi-robot safe and adaptive cooperation, and emergency task call in the scene of elderly care. The proposed architecture regarding the smart home could be applied in nursing centers, hospitals, and other places for elderly care.

Assessing the Long-Term Effects of Basic Medical Insurance on Catastrophic Health Spending in China

Many developing countries have implemented social health insurance programs to protect their citizens against the financial risks of seeking healthcare. While many studies have explored how individual insurance enrollments affect catastrophic health spending (CHS) in the short term, there is a lack of evidence on the long-term macro-level effects of social health insurance on CHS in low- and middle-income countries. This study examines the long-term effects of Basic Medical Insurance (BMI) on individual CHS in China, a middle-income country that has witnessed one of the highest worldwide increases in CHS rates despite its remarkable achievement of universal health insurance coverage. Specifically, we used existing longitudinal data from 1989 to 2015, therein assessing BMI policy effects by constructing two macro-level indicators, including the year of BMI presence at the prefectural level and number of years relative to BMI introduction. We employed a three-level difference-in-differences approach for the estimation. There were two main findings. First, BMI policy did not significantly reduce the probability of incurring CHS for BMI enrollees over time. Years after BMI was introduced, the policy even predicted a significant increase in the probability of incurring CHS for individuals who shifted their enrollments from traditional insurance to BMI. Second, BMI policy had spillover effects on the increase in the probability of incurring CHS for non-BMI individuals a few years after its inception. We believe there are three possible explanations for these findings: (1) shrinking BMI service coverage compared to pre-existing government-funded insurance schemes, (2) a profit-driven hospital reform that induces the overuse of expensive medicines and diagnostic tests, and (3) the absence of strategic purchasing among local BMI agencies. We also discuss how relevant policy interventions may alleviate insurance-driven financial risks.

The COVID-19 Run on Medical Resources in Wuhan China: Causes, Consequences and Lessons

The COVID-19 run on medical resources crashed Wuhan’s medical care system, a medical disaster duplicated in many countries facing the COVID-19 pandemic. In a novel approach to understanding the run on Wuhan’s medical resources, we draw from bank run theory to analyze the causes and consequences of the COVID-19 run on Wuhan’s medical resources and recommend policy changes and government actions to attenuate runs on medical resources in the future. Like bank runs, the cause of the COVID-19 medical resource run was rooted in China’s local medical resource context and a sudden realignment of expectations, reflecting shortages and misallocations of hospital resources (inadequate liquidity and portfolio composition); high level hospitals siphoning-off patients from lower level health providers (bank moral hazard and adverse selection problem); patients selecting high-level hospitals over lower-level health care (depositor moral hazard problem); inadequate government oversight and uncontrolled risky hospital behavior (inadequate bank regulatory control); biased medical insurance schemes (inadequate depositor insurance); and failure to provide medical resource reserves (failure as lender of last resort). From Wuhan’s COVID-19 run on medical resources, we recommend that control and reform by government enlarge medical resource supply, improve the capacity of primary medical care, ensure timely virus information, formulate principles for the allocation of medical resources that suit a country’s national conditions, optimize the medical insurance schemes and public health fund allocations and enhance the emergency support of medical resources.

Influence of the health status and other contributing factors on quality of life of the older people

Introduction/Aim: Aim of the study was to investigate influence of the health status as well as other contributing factors on perceived quality of life of the older people in Belgrade. Methods: The survey was conducted in October 2019 on a representative sample of 764 people aged between 65 and 79 years (X = 72.68 ? 7.11), (39.9% male and 60.1% female) living in Belgrade. The research used a questionnaire developed on the basis of the World Health Organization methodology for age friendly cities, aimed to explore 11 areas important for the elderly. Results: Factor of physical accessibility of community is highly significant [?2 (df = 3, n = 764) = 238.905; p < 0.001] and explained 39.4% of variance of perceived quality of life, while socio-economic factors show the same amount of variance, 35.0% [?2 (df = 3, n = 764) = 207.571; p < 0.001]. Social environment explains 24.6% of variance of perceived quality of life [?2 (df = 4, n = 764) = 140.242; p < 0.001]. Health status has greatest explanatory power regarding perceived quality of life and explain as much as 46.7% of variance [?2 (df = 8, n = 764) = 292.083; p < 0.001]. When unique impact of health status on quality of life is analyzed, when other variables are controlled, health status explains 21.6% of variance in addition to variance explained by physical accessibility, socio-economic status and social environment. Conclusion: Although health status has the greatest impact on perceived quality of life of older people, interventions on other life important domains such as physical accessibility, socio-economic status and social environment could have positive impact on perceived quality of life where health status alone could not be improved.