The Comparison of Various Types of Health Insurance in the Healthcare Utilization, Costs and Catastrophic Health Expenditures among Middle-Aged and Older Chinese Adults

Healthcare utilization and its association with socioeconomic status in China: Evidence from the 2011-2018 China Health and Retirement Longitudinal Study

INTRODUCTION

Healthcare utilization often favors the higher-socioeconomic status (SES) and having chronic diseases may exacerbate this inequality. This study aims to examine the trends in health service use over time, the effect of SES on healthcare utilization, and the role of chronic diseases in this association.

METHODS

Data used in this study were from the China Health and Retirement Longitudinal Study (CHARLS) in 2011, 2013, 2015, and 2018, which is the first nationally representative survey of the middle-aged and older. The sample included people aged 45 years and older who responded to all the waves. A total of 10,922 adults were included in this study. Healthcare utilization was categorized into outpatient and inpatient service use and SES was measured by per-capita household expenditure. A multilevel zero-inflated negative binomial regression model was performed to analyze outpatient and inpatient service use, separately.

RESULTS

The rates of outpatient service use in 2011, 2013, 2015, and 2018 were 19.11%, 21.45%, 20.12%, and 16.32%, respectively, while the rates of inpatient service use were 8.40%, 13.04%, 14.17%, and 18.79%, respectively. Compared to individuals in the lowest quintile of per-capita household expenditure, those in higher quintiles had higher odds of outpatient service use (Q2: odds ratio = 1.233, p < 0.0001; Q3: 1.416, p < 0.0001; Q4: 1.408, p < 0.0001; or Q5: 1.439, p < 0.0001) and higher rates of inpatient service use (Q2: incidence rate ratio = 1.273, p < 0.0001; Q3: 1.773, p < 0.0001; Q4: 2.071, p < 0.0001; or Q5: 1.992, p < 0.0001). Additionally, having morbidity generally increased healthcare utilization, but did not play a significant role in moderating the relationship between SES and healthcare utilization.

CONCLUSIONS

Healthcare utilization rates were overall low in China, but relatively high for people in higher quintiles of per-capita household expenditure or those with morbidity, compared to their counterparts. Policy actions are required to provide more health education to the public, to further optimize health insurance schemes targeting outpatient services, especially for the low-SES, and to establish new health delivery models for NCD management in the primary health care setting.

Effects of Urban and Rural Resident Basic Medical Insurance on Healthcare Utilization Inequality in China

Objectives: This study aims to evaluate the effects of Urban and Rural Resident Basic Medical Insurance (URRBMI) integration on healthcare utilization and explore the contribution of URRBMI to healthcare utilization inequality among middle-aged and older adults. Methods: Using data from the China Health and Retirement Longitudinal Study (CHARLS) 2011-2018. The difference-in-difference model, concentration index (CI), and decomposition method were adopted. Results: The results suggested that the probability of outpatient visits and the number of outpatient visits had decreased by 18.2% and 10.0% respectively, and the number of inpatient visits had increased by 3.6%. However, URRBMI had an insignificant effect on the probability of inpatient visits. A pro-poor inequality for the treatment group was observed. The decomposition revealed that the URRBMI contributed to the pro-poor inequality in healthcare utilization. Conclusion: The findings suggest that URRBMI integration has decreased outpatient care utilization and improved the number of inpatient visits. While the URRBMI has improved healthcare utilization inequality, some challenges still exist. Comprehensive measures should be taken in the future.

Individual-Level Health Care Costs Attributable to Noncommunicable Diseases: A Longitudinal Study Based on the Older Adults in China

Noncommunicable chronic diseases among the elderly population represent a significant economic burden in China. However, previous disease-related health cost studies lacked representation of older adults and comparability of the burden of multiple chronic diseases. The objective of this study was to determine the fraction of health care costs attributable to the 6 most prevalent chronic diseases and comorbidities in the sample of older adults. This study employed data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), with 3 waves in 2011, 2014, and 2018, and included 18 349 observations in total. Outpatient costs, inpatient costs, and total health care costs were included in this study. Based on a 2-part random effects model, the effect of chronic disease on health service utilization was first explored by constructing a dummy variable for whether or not to utilize health care, followed by estimation of attributable costs in the population with health care utilization. Among the older adults in the sample, hypertension, heart disease, cataracts, arthritis, stroke or Cerebrovascular disease (CVD) and chronic lung disease are the 6 most prevalent chronic conditions. The costs attributable to the 6 chronic diseases mentioned above were 36.00% of outpatient costs, 55.92% of inpatient costs, and 45.05% of total health care costs for older adults. Of these, heart disease, stroke or CVD, and chronic lung disease accounted for 22.11%, 13.24%, and 10.56% of total health care costs, respectively. Moreover, the proportion of health care costs attributable to chronic diseases was higher for older adults who were male, lived in urban areas, and had a lower level of education. The proportion of health care costs attributable to chronic diseases is substantial among older adults in China. Health care costs associated with chronic diseases can be decreased with well-targeted interventions and comprehensive access to health services.

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.

Changes in health care utilization and financial protection after integration of the rural and urban social health insurance schemes in Beijing, China

BACKGROUND

China expanded health coverage to residents in informal economic sectors by the rural new cooperative medical scheme (NCMS) for rural population and urban resident basic medical insurance scheme (URBMI) for non-working urban residents. Fragmentation of resident social health insurance schemes exacerbated the health inequity and China started the integration of urban and rural resident medical insurance schemes since 2016. Beijing finished the insurance integration in 2017 and has been implementing a unified urban and rural resident basic medical insurance scheme (URRBMI) since the beginning of 2018. This study aims to examine changes in health care utilization and financial protection after integration of the rural and urban social health insurance schemes.

METHODS

We used household survey data from Beijing Health Services Survey in 2013 and 2018. Respondents who were 15 or older and covered by URBMI, NCMS or URRBMI were included in this study. Our study finally included 8,554 individuals in 2013 and 6,973 individuals in 2018, about 70% of which were rural residents in each year. Descriptive analysis was used to compare the healthcare utilization, healthcare expenditure and incidence of catastrophic health expenditure between different groups. A series of two-part regression models were used to analyze the changes of healthcare utilization, healthcare expenditure and incidence of catastrophic health expenditure.

RESULTS

From 2013 to 2018, urban-rural disparity in outpatient care utilization seemed widened because urban residents' utilization of outpatient care increased 131% while rural residents' utilization only increased 72%; both rural and urban residents' spending on outpatient care increased about 50%. Utilization of inpatient care changed little and poor residents still used significantly less inpatient care compared with the rich residents. Poor residents still suffered heavily catastrophic health expenditures.

CONCLUSION

From 2013 to 2018, residents' utilization of healthcare, especially outpatient care, increased in Beijing. Health insurance reforms increased residents' utilization of healthcare but failed to reduce their healthcare financial burden, especially for poor people. Our study advocates more pro-poor insurance policies and more efforts on the efficiency of health system.