Benefit of China's Social Health Insurance Schemes: Trend Analysis and Associated Factors Since Health Reform

Trends in antidiabetic drug use and expenditure in public hospitals in Northwest China, 2012-21: a case study of Gansu Province

BACKGROUND

Since the twenty-first century, the prevalence of diabetes has risen globally year by year. In Gansu Province, an economically underdeveloped province in northwest China, the cost of drugs for diabetes patients accounted for one-third of their total drug costs. To fundamentally reduce national drug expenditures and the burden of medication on the population, the relevant departments of government have continued to reform and improve drug policies. This study aimed to analyse long-term trends in antidiabetic drug use and expenditure in Gansu Province from 2012 to 2021 and to explore the role of pharmaceutical policy.

METHODS

Data were obtained from the provincial centralised bidding and purchasing (CBP) platform. Drug use was quantified using the anatomical therapeutic chemistry/defined daily dose (ATC/DDD) method and standardised by DDD per 1000 inhabitants per day (DID), and drug expenditure was expressed in terms of the total amount and defined daily cost (DDC). Linear regression was used to analyse the trends and magnitude of drug use and expenditure.

RESULTS

The overall trend in the use and expenditure of antidiabetic drugs was on the rise, with the use increasing from 1.04 in 2012 to 16.02 DID in 2021 and the expenditure increasing from 48.36 in 2012 to 496.42 million yuan in 2021 (from 7.66 to 76.95 million USD). Some new and expensive drugs changed in the use pattern, and their use and expenditure shares (as the percentage of all antidiabetic drugs) increased from 0 to 11.17% and 11.37%, but insulins and analogues and biguanides remained the most used drug class. The DDC of oral drugs all showed a decreasing trend, but essential medicines (EMs) and medical insurance drugs DDC gradually decreased with increasing use. The price reduction of the bid-winning drugs was over 40%, and the top three drugs were glimepiride 2mg/30, acarbose 50mg/30 and acarbose 100mg/30.

CONCLUSIONS

The implementation of pharmaceutical policies has significantly increased drug use and expenditure while reducing drug prices, and the introduction of novel drugs and updated treatment guidelines has led to changes in use patterns.

Inequality in benefit distribution of reducing the outpatient cost-sharing: evidence from the outpatient pooling scheme in China

Objective

The implementation of the outpatient pooling scheme in China has substantially elevated the compensation levels for outpatient expenses. This study aims to assess whether socioeconomically disadvantaged enrollees benefit proportionally compared to their non-disadvantaged counterparts.

Method

A cohort comprising 14,581 Urban and Rural Resident Basic Medical Insurance (URRBMI) enrollees and 830 Urban Employee Basic Medical Insurance (UEBMI) enrollees was derived from the China Health and Retirement Longitudinal Study 2018. Outpatient pooling scheme benefits were evaluated based on two metrics: the probability of obtaining benefits and the magnitude of benefits (reimbursement amounts and ratios). Two-part models were employed to adjust outpatient benefits for healthcare needs. Inequality in benefit distribution was assessed using the concentration curve and concentration index (CI).

Results

Following adjustments for healthcare needs, the CI for the probability of receiving outpatient benefits for URRBMI and UEBMI enrollees were - 0.0760 and - 0.0514, respectively, indicating an evident pro-poor pattern under the outpatient pooling scheme. However, the CIs of reimbursement amounts (0.0708) and ratio (0.0761) for URRBMI recipients were positive, signifying a discernible pro-rich inequality in the degree of benefits. Conversely, socioeconomically disadvantaged UEBMI enrollees received higher reimbursement amounts and ratios.

Conclusion

Despite a higher likelihood of socioeconomically disadvantaged groups receiving outpatient benefits, a pro-rich inequality persists in the degree of benefits under the outpatient pooling scheme in China. Comprehensive strategies, including expanding outpatient financial benefits, adopting distinct reimbursement standards, and enhancing the accessibility of outpatient care, need to be implemented to achieve equity in benefits distribution.

The Experiences of Strategic Purchasing of Healthcare in Nine Middle-Income Countries: A Systematic Qualitative Review

BACKGROUND

Efforts to move towards universal health coverage (UHC) aim to rebalance health financing in ways that increase efficiency, equity, and quality. Resource constraints require a shift from passive to strategic purchasing (SP). In this paper, we report on the experiences of SP in public sector health insurance schemes in nine middle-income countries to understand what extent SP has been established, the challenges and facilitators, and how it is helping countries achieve their UHC goals.

METHODS

We conducted a systematic search to identify papers on SP. Nine countries were selected for case study analysis. We extracted data from 129 articles. We used a common framework to compare the purchasing arrangements and key features in the different schemes. The evidence was synthesised qualitatively.

RESULTS

Five countries had health technology assessment (HTA) units to research what services to buy. Most schemes had reimbursement mechanisms that enabled some degree of cost control. However, we found evidenced-based changes to the reimbursement mechanisms only in Thailand and China. All countries have some form of mechanism for accreditation of health facilities, although there was considerable variation in what is done. All countries had some strategy for monitoring claims, but they vary in complexity and the extent of implementation; three countries have implemented e-claim processing enabling a greater level of monitoring. Only four countries had independent governance structures to provide oversight. We found delayed reimbursement (six countries), failure to provide services in the benefits package (four countries), and high out-of-pocket (OOP) payments in all countries except Thailand and Indonesia, suggesting the schemes were failing their members.

CONCLUSION

We recommend investment in purchaser and research capacity and a focus on strong governance, including regular engagement between the purchaser, provider and citizens, to build trusting relationships to leverage the potential of SP more fully, and expand financial protection and progress towards UHC.

Gender Differences in Migrant Workers Health in China

Objectives: This study aimed to explore the distribution and differences in the health status of migrant workers in China by gender and age. In addition, it investigated the causes of health inequalities among them. Methods: This paper analyzes the differences in health status across age groups for migrant workers of different genders based on the data from the China Migrant Dynamic Survey in 2018. It also empirically assesses how education level and health insurance impact gender-related health inequalities. Results: The results suggest that female migrant workers in China have significantly lower health levels than males. Furthermore, these differences in health are exacerbated with age. This disparity may be attributed to lower participation in social insurance participation and less educational attainment among female migrant workers than their male counterparts. Conclusion: The government should take effective practical measures to increase the social insurance participation rate of female migrant workers. Moreover, investing in female education to reduce health inequality among migrant workers is essential.

Changes of equality of medical service utilization in China between 1993 and 2018: findings from six waves of nationwide household interview survey

BACKGROUND

Changes in China's health care system in the last three decades was remarkable. The current study aims on examine the change of equality of health care utilization in mainland China based on a nationwide household interview survey.

METHODS

We used household interview data extracted from six waves of National Health Service Survey between 1993 and 2018. Changes of health care utilization were descripted. Equality of the utilization were examined with univariate meta-regression across urban and rural areas, socioeconomic development regions and income groups.

RESULTS

The proportion of outpatient visits within last two weeks experienced a decrease from 17.0% in 1993 to 13.0% in 2013 and bounced back to 24.0% in 2018. The age-standardized trend remained unchanged. Hospitalization in the last 12 month increased from 2.6% in 1998 to 13.8% in 2018. The perceived unmet need of hospital admission fell from 35.9% in 1998 to 21.5% in 2018. The gaps in health care utilization between urban and rural areas, across regions and by income groups have been narrowed, implying improved equality of using medical services in the last two and a half decades.

CONCLUSION

China has experienced significant increases in health care utilization over the past 25 years. Meanwhile, the unmet needs for health care decreased remarkably and the equality of health care utilization improved significantly. These results imply significant achievements in health service accessibility in China.

The impact of China's zero markup drug policy on drug costs for managing Parkinson's disease and its complications: an interrupted time series analysis

Background

In April 2009, the Chinese government launched Zero Markup Drug Policy (ZMDP) to adjust medical institutions' revenue and expenditure structures.

Objective

This study evaluated the impact of implementing ZMDP (as an intervention) on the drug costs for managing Parkinson's disease (PD) and its complications from the healthcare providers' perspective.

Methods

The drug costs for managing PD and its complications per outpatient visit or inpatient stay were estimated using electronic health data from a tertiary hospital in China from January 2016 to August 2018. An interrupted time series analysis was conducted to evaluate the immediate change following the intervention (step change, β₁) and the change in slope, comparing post-intervention with the pre-intervention period (trend change, β₂). Subgroup analyses were conducted in outpatients within the strata of age, patients with or without health insurance, and whether drugs were listed in the national Essential Medicine List (EML).

Results

Overall, 18,158 outpatient visits and 366 inpatient stays were included. Outpatient (β₁ = -201.7, 95%CI: -285.4, -117.9) and inpatient (β₁ = -372.1, 95% CI: -643.6, -100.6) drug costs for managing PD significantly decreased when implementing ZMDP. However, for outpatients without health insurance, the trend change in drug costs for managing PD (β₂ = 16.8, 95% CI: 8.0, 25.6) or PD complications (β₂ = 12.6, 95% CI: 5.5, 19.7) significantly increased. Trend changes in outpatient drug costs for managing PD differed when stratifying drugs listed in EML (β₂ = -1.4, 95% CI: -2.6, -0.2) or not (β₂ = 6.3, 95%CI: 2.0, 10.7). Trend changes of outpatient drug costs for managing PD complications significantly increased in drugs listed in EML (β₂ = 14.7, 95% CI 9.2, 20.3), patients without health insurance (β₂ = 12.6, 95% CI 5.5, 19.7), and age under 65 (β₂ = 24.3, 95% CI 17.3, 31.4).

Conclusions

Drug costs for managing PD and its complications significantly decreased when implementing ZMDP. However, the trend in drug costs increased significantly in several subgroups, which may offset the decrease at the implementation.

Does self-medication reduce medical expenditure among the middle-aged and elderly population? A four-wave longitudinal study in China

Introduction

Self-medication has a high prevalence in the middle-aged and elderly population in China. Despite the published evidence demonstrating the economic benefits of self-medication, limited research has addressed the relationship between self-medication and individual medical expenditures, especially within the Chinese population. This study examined the effect of self-medication on individual medical expenditures in China and analyzed the heterogeneity between outpatient and inpatient cases.

Methods

We conducted a panel data analysis using data from four waves of the China Health and Retirement Longitudinal Study (CHARLS). Two-part mixed-effect models were implemented to estimate the effect of self-medication on total outpatient and inpatient expenses and out-of-pocket (OOP) costs, where mixed-effects logit regression was used as the first part, and generalized linear mixed models with log link and gamma distribution was used as the second part.

Results

We identified 72,041 responses representing 24,641 individuals, of which 13,185 responses incurred outpatient expenses and 9,003 responses incurred inpatient costs. Controlling for all covariates, we found that self-medication behaviors were significantly associated with a higher probability of outpatient service utilization (OR = 1.250, 95% CI = 0.179 to 0.269; P < 0.001), but displayed no significant association with outpatient expenses. Respondents who had taken self-medication were less likely to use inpatient services (OR = 0.865, 95% CI = -0.201 to -0.089; P < 0.001), and their inpatient expenses were significantly reduced by 9.4% (P < 0.001). Inpatient OOP costs were significantly reduced by 10.7% (P < 0.001), and outpatient OOP costs were significantly increased by 11.3% (P < 0.001) among respondents who had self-medicated.

Conclusions

This study allowed us to identify the economic value of self-medication among the middle-aged and elderly population in China. Future work should guide the middle-aged and elderly to take responsible self-medication to reduce their economic burden.

Utilization and out-of-pocket expenses of primary care among the multimorbid elderly in China: A two-part model with nationally representative data

Background

Multimorbidity has become an essential public health issue that threatens human health and leads to an increased disease burden. Primary care is the prevention and management of multimorbidity by providing continuous, comprehensive patient-centered services. Therefore, the study aimed to investigate the determinants of primary care utilization and out-of-pocket expenses (OOPE) among multimorbid elderly to promote rational utilization of primary care and reduce avoidable economic burdens.

Methods

The study used data from CHARLS 2015 and 2018, which included a total of 4,384 multimorbid elderly aged 60 and above. Guided by Grossman theory, determinants such as education, gender, marriage, household economy, and so on were included in this study. A two-part model was applied to evaluate primary care utilization and OOPE intensity in multimorbid populations. And the robustness testing was performed to verify research results.

Results

Primary care visits rate and OOPE indicated a decline from 2015 to 2018. Concerning primary outpatient care, the elderly who were female (OR = 1.51, P < 0.001), married (OR = 1.24, P < 0.05), living in rural areas (OR = 1.77, P < 0.001) and with poor self-rated health (OR = 2.23, P < 0.001) had a significantly higher probability of outpatient utilization, whereas those with middle school education (OR = 0.61, P < 0.001) and better household economy (OR = 0.96, P < 0.001) had a significantly less likelihood of using outpatient care. Rural patients (β = -0.72, P < 0.05) may have lower OOPE, while those with better household economy (β = 0.29, P < 0.05; β = 0.58, P < 0.05) and poor self-rated health (β = 0.62, P < 0.001) occurred higher OOPE. Regarding primary inpatient care, adults who were living in rural areas (OR = 1.48, P < 0.001), covered by Urban Employee Basic Medical Insurance (UEBMI) or Urban Rural Basic Medical Insurance (URBMI) (OR = 2.46, P < 0.001; OR = 1.81, P < 0.001) and with poor self-rated health (OR = 2.30, P < 0.001) had a significantly higher probability of using inpatient care, whereas individuals who were female (OR = 0.74, P < 0.001), with middle school education (OR = 0.40, P < 0.001) and better household economy (OR = 0.04, P < 0.001) had a significantly lower tendency to use inpatient care. Significantly, more OOPE occurred by individuals who were women (β = 0.18, P < 0.05) and with better household economy (β = 0.40, P < 0.001; β = 0.62, P < 0.001), whereas those who were covered by URBMI (β = -0.25, P < 0.05) and satisfied with their health (β = -0.21, P < 0.05) had less OOPE.

Conclusion

To prompt primary care visits and reduce economic burden among subgroups, more policy support is in need, such as tilting professional medical staff and funding to rural areas, enhancing awareness of disease prevention among vulnerable groups and so on.

Meaning in life and its relationship with family cohesion: A survey of patients with palliative care in China

OBJECTIVE

Meaning in life (MIL) and family cohesion are important concerns for the palliative care population; however, evidence of the relationship between MIL and family cohesion is scarce. Therefore, this study aimed to examine the relationship between MIL and family cohesion and explore the factors that influence MIL among the palliative care population.

METHODS

In this cross-sectional study, 205 patients with advanced cancer were recruited from two palliative care units in China. Data were collected using the meaning in life scale (MiLS), the family cohesion subscale of the Family Adaptability and Cohesion Scale, second edition, Chinese version, and the Karnofsky Performance Status Scale (KPS). Multivariate linear regression models were used to examine the relationship between family cohesion and perceived MIL and identify the potential factors of participants' MiLS score.

RESULTS

The mean MiLS score was 100.90 (SD ​= ​9.17). The results showed that family cohesion (r ​= ​0.313, P ​< ​0.001) and KPS scores (r ​= ​0.311, P ​< ​0.001) were positively correlated with MiLS scores. Multivariate linear regression revealed that MIL was significantly influenced by family cohesion, KPS score, sex, religiosity, whether participants lived alone, and their medical insurance payment method (Adjust R ² ​= ​28.4%, F ​= ​6.281, P ​= ​0.013).

CONCLUSIONS

Our findings indicate a positive relationship between family cohesion and MIL, suggesting that clinicians should consider increasing patients' family cohesion as an approach to enhance perceived MIL.

How does domestic migration pose a challenge in achieving equitable social health insurance benefits in China? A national cross-sectional study

OBJECTIVES

To evaluate the benefit distribution of social health insurance among domestic migrants in China.

DESIGN

A national cross-sectional survey.

SETTING

348 cities from 32 provincial units in China.

PARTICIPANTS

1165 domestic migrants who used inpatient care services in the city of a new residence and had social health insurance.

PRIMARY AND SECONDARY OUTCOME MEASURES

The probability of receiving reimbursements from social health insurance, the amounts and ratio of reimbursement received.

RESULTS

Among migrants who used inpatient care in 2013, only 67% received reimbursements from social health insurance, and the reimbursement amount only accounted for 47% of the inpatient care expenditure. The broader the geographical scope of migration, the lower the probability of receiving reimbursement and the reimbursement ratio, but the higher the reimbursement amount. Specifically, the probability of receiving reimbursements for those who migrated across cities or provinces was significantly lower by 14.7% or 26.0%, respectively, than those who migrated within a city. However, they received significantly higher reimbursement amounts by 33.4% or 27.2%, respectively, than those who migrated within a city. And those who migrated across provinces had the lowest reimbursement ratio, although not reaching significance level.

CONCLUSIONS

The unequal benefit distribution among domestic migrants may be attributed to the fragmented health insurance design that relies on localised administration, and later reimbursement approach that migrating patients pay for health services up-front and get reimbursement later from health insurance. To improve the equity in social health insurance benefits, China has been promoting the portability of social health insurance, immediate reimbursement for inpatient care used across regions, and a more integrated health insurance system. Efforts should also be made to control inflation of healthcare expenditures and prevent inverse government subsidies from out-migration regions to in-migration regions. This study has policy implications for China and other low/middle-income countries that experience rapid urbanisation and domestic migration.

An Empirical Study on the Inequality in Health and Healthcare in China’s Medical Reform

To make clear what role the Urban and Rural Residents Basic Medical Insurance (URRBMI) plays in the inequality in health and healthcare, this article combines the time-varying DID method with the concentration index to conduct an empirical study. We find that the URRBMI improves health but expands health inequality among different income groups, with its contribution growing over time. Besides, the URRBMI significantly promotes healthcare utilization, reduces the medical burden, and narrows the gap among different income groups, though this effect is generally downward. These findings help clarify what deserves more attention to enlarge benefits and reduce inequality in this medical reform and provide policy implications for policymakers. Increasing investment in medical resources and constructing the hierarchical medical system and medical treatment combination may make a difference.

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.