Impact of the New Cooperative Medical Scheme on the Rural Residents' Hospitalization Medical Expenses: A Five-Year Survey Study for the Jiangxi Province in China

The impact of medical insurance and old-age security on the utilization of medical services by the older population with disabilities

OBJECTIVE

In this study, the impact of medical insurance and old-age security on the use of medical services by the older population with disabilities is analyzed. A reference for decision makers is provided to improve medical and old-age security policies and enhance the use of medical services by the older population.

METHODS

Data were drawn from 3,737 older people with disabilities aged 65 years or above from the 2018 China Longitudinal Healthy Longevity Survey. A two-part model based on social ecological theory was used for both analysis and group prediction.

RESULTS

In terms of the use of outpatient medical services, old-age pension significantly increased the probability of outpatient visits for this population group (P < 0.05). Urban employee/resident medical insurance, the new rural cooperative medical insurance, and retirement pension significantly affected medical expenses. In terms of the use of inpatient medical services, the new rural cooperative medical insurance and retirement pension significantly influenced the choice of inpatient medical services; retirement pension increased inpatient medical expenditure (p < 0.01). The expected average probability of hospitalization, unconditional expected cost, and conditional expected cost for the older population with disabilities were 49.5%, RMB 6629.31, and RMB 3281.51, respectively. Both conditional and unconditional expected costs were significantly higher for older people with disabilities with the following attributes: male, married, no less than three chronic conditions, and unassisted daily care; costs were lower for older people with disabilities who are female, not married, had less than three chronic conditions, and had a spouse, child, or other caregiver.

CONCLUSION

Medical insurance and old-age security can significantly promote the utilization of medical services by the older population with disabilities. It is therefore recommended to focus on strengthening the support and health management of these people who are unattended to improve the effective use of health services and better meet their needs.

Primary malignant bone tumors incidence, mortality, and trends in China from 2000 to 2015

BACKGROUND

Primary malignant bone tumors are uncommon, and their epidemiological features are rarely reported. We aimed to study the incidence and death characteristics of bone tumors from 2000 to 2015.

METHODS

Population-based cancer registries submitted registry data to National Central Cancer Registry of China (NCCRC). The data collected from 501 local cancer registries in China were assessed using NCCRC screening methods and criteria. Incidence and mortality rates of primary bone tumor were stratified by age group, gender, and area. Age-standardized incidence and mortality rates were adjusted using the Chinese standard population in 2000 and Segi's world population. The annual percentage change (APC) in rate was calculated using the Joinpoint Regression Program.

RESULTS

Data from 368 registries met quality control criteria, of which 134 and 234 were from urban and rural areas, respectively. The data covered 309,553,499 persons. The crude incidence, age-standardized incidence, and crude mortality rates were 1.77, 1.35, and 1.31 per 100,000, respectively. Incidence and mortality rates were higher in males than those in females; they showed downward trends, with declines of 2.2% and 4.8% per year, respectively, and the rates in urban areas were lower than those in rural areas. Significant declining trends were observed in urban areas. Stable trends were seen in rural areas during 2000 to 2007, followed by downward trends. Age-specific incidence and mortality rates showed stable trends in the age group of 0 to 19 years, and downward trends in the age group elder than 19 years.

CONCLUSIONS

The incidence and mortality rates of primary malignant bone tumors in rural areas were higher compared to those in urban areas. Targeted prevention measures are required to monitor and control bone tumor incidence and improve the quality of life of affected patients. This research can provide a scientific basis for the prevention and control of bone tumors, as well as basic information for follow-up research.

Impact of Diagnosis-Related-Group (DRG) payment on variation in hospitalization expenditure: evidence from China

BACKGROUND

Diagnosis-Related-Group (DRG) payment is considered a crucial means of addressing the rapid increases of medical cost and variation in cost. This paper analyzes the impact of DRG payment on variation in hospitalization expenditure in China.

METHOD

Patients with chronic obstructive pulmonary disease (COPD), acute myocardial infarction (AMI) and cerebral infarction (CI) in a Chinese City Z were selected. Patients in the fee-for-service (FFS) payment group and the DRG payment group were used as the control group and intervention group, respectively, and propensity-score-matching (PSM) was conducted. Interquartile distance (IQR), standard deviation (SD) and concentration index were used to analyze variation and trends in terms of hospitalization expenditure across the different groups.

RESULTS

After DRG payment reform, the SD of hospitalization expenditure in respect of the COPD, AMI and CI patients in City Z decreased by 11,094, 4,833 and 4,987 CNY, respectively. The concentration indices of hospitalization expenditures for three diseases are all below 0 (statistically significant), with the absolute value tending to increase year by year.

CONCLUSION

DRG payment can be seen to guide medical service providers to provide effective treatment that can improve the consistency of medical care services, bringing the cost of medical care closer to its true clinical value.

Does direct settlement of intra-province medical reimbursements improve financial protection among middle-aged and elderly population in China? Evidence based on CHARLS data

In low- and middle-income countries, social health insurance schemes are the main focus of efforts to achieve universal health coverage (UHC) by promoting access to health care and financial protection. Problems with financial protection in China are caused mainly by health insurance fragmentation and a rapid rise in medical expenditure. In this context, China implemented a policy of direct settlement of intra-provincial medical reimbursement in 2014. We evaluated the impact of the policy on financial protection with a population aged 45 and above based on the China Health and Retirement Longitudinal Study from 2011 to 2018. We estimated the policy effects using the difference-in-differences method, based on coarsened exact matching. We found that the policy significantly reduced the catastrophic health expenditures (CHEs) rate by approximately 10% in the population, whether middle-aged or elderly. Subgroup analyses indicated that middle-aged and elderly people living in western China and with lower household incomes received greater protection from the policy. The CHEs rate for the two age groups in western China was reduced by 16.26% and 20.12%, respectively. The CHEs rate was reduced by 24.51% and 17.32% for middle-aged individuals in the lowest and second household income quartiles, respectively, and by 21.31% for older adults in the second household income quartile. The new rural cooperative medical scheme exerted a smaller protective effect than urban medical insurance among the participants aged 60 and older. We found that in addition to optimizing health insurance schemes, more health care reform measures, such as adopting more efficient payment methods and rationalizing medical expenditures, should be combined to help reduce health inequities and accelerate progress toward achieving UHC and the Sustainable Development Goals.

Effect of apparent temperature on hospitalization from a spectrum of cardiovascular diseases in rural residents in Fujian, China

Cardiovascular disease (CVD) is a leading threat to global public health. Although associations between temperature and CVD hospitalization have been suggested for developed countries, limited evidence is available for developing countries or rural residents. Moreover, the effect of apparent temperature (AT) on the spectrum of cause-specific CVDs remains unknown. Based on 2,024,147 CVD hospitalizations for rural residents from eight regions in Fujian Province, China, during 2010-2016, a quasi-Poisson regression with distributed lag non-linear model was fitted to estimate the AT effect on daily CVD hospitalization for each region, and then pooled in a meta-regression that included regional indicators related to rural residents. Stratified analyses were performed according to the cause of hospitalization, sex and age groups. Finally, we calculated the fraction of CVD hospitalizations attributable to AT, as a reflection of the burden associated with AT. The heat effect appeared at lag 0-1 days, with 19% (95% CI, 11-26%) increased risk of CVD hospitalization, which was worse for ischemic heart disease, heart failure, arrhythmias and ischemic stroke. The decreased AT was associated with increase of hemorrhagic stroke at lag 0-28 days. People aged 65 and above suffered more from the heat effect on cardiovascular and cerebrovascular diseases. Regions with a lower gross value of agricultural production, rural residents' per capita net income, number of air conditioners and water heaters were more susceptible. A large number of hospitalizations were attributable to heat for most subcategories. High AT level increased CVD hospitalization, and the subcategories had different susceptibilities. The effects were modified by individual and regional characteristics. These findings have important implications for the development of targeted interventions and for hospital service planning.

Public Medical Insurance and Healthcare Utilization and Expenditures of Older with Chronic Diseases in Rural China: Evidence from NRCMS

China's rural older are the threat from chronic diseases, making it important to evaluate the effect of public health insurance on the health care utilization and expenditures with chronic diseases. In 2003, China initiated a public health insurance, which was called the New Rural Cooperative Medical System (NRCMS). NRCMS is a voluntary program, targeting rural residents with government subsidies and individual contribution. Using the two-stage residual inclusion approach (2SRI), we analyzed the impact of NRCMS on health-care service utilization and expenditure of rural older with chronic diseases by using the 2011 and 2013 China Health and Retirement Survey (CHARLS) data. The results showed NRCMS did not play an effective role on improving the medical services utilization of rural older with chronic diseases. Although NRCMS immediate reimbursement significantly reduced the outpatient service fee, the actual outpatient reimbursement is the opposite. In addition, NRCMS did not significantly decrease their hospitalization expense. Policy makers should pay attention to health management about chronic diseases in rural China, and some measures should be taken to deepen the medical security system reform and improve the public health service system.

Activities of daily living, life orientation, and health-related quality of life among older people in nursing homes: a national cross-sectional study in China

PURPOSE

This study aimed to explore the current status of activities of daily living (ADLs), life orientation, and health-related quality of life (HRQoL) among older people in nursing homes and to further examine the mediating role of life orientation in the impact of ADLs on HRQoL.

METHODS

A national cross-sectional study was conducted among older people aged 60 and above in nursing homes by the randomly stratified cluster sampling method. The status of ADLs, life orientation and HRQoL were measured using an ADL scale, a life orientation scale and the SF-12v2 scale, respectively. Multiple linear regression models were used to identify explanatory factors associated with ADLs, life orientation, and HRQoL. The potential mediating role of life orientation in the relationship between ADL and HRQoL was explored by mediation analysis.

RESULTS

The overall prevalence of ADL disability was 52.67%, and 84.37% of older people in nursing homes had a negative life orientation. The mean scores of physical health and mental health among older people in nursing homes were 45.44 ± 6.46 and 42.67 ± 8.48, respectively. Some sociodemographic characteristics were associated with poor physical health and mental health. After adjustments were made for covariates, the life orientation score mediated 13.81% of the total effect of the ADL score on physical component score of HRQoL and mediated 45.33% of the mental component score of HRQoL.

CONCLUSION

A sizeable proportion of older people had ADL disability and negative life orientation, and HRQoL was poor among older Chinese people in nursing homes. Life orientation partially mediates the relationship between ADLs and HRQoL.

Measuring and decomposing the effort regarding the equity of inpatient benefits based on the adjustment of the new cooperative medical scheme in western rural China

BACKGROUND

The ultimate objective of rural health reform and development is to establish a mature healthcare service system that adapts to the socialist market economy and the developmental level of the Chinese economy and meets the health demands of the people. Reform of the payment system is one of the key elements. This article explores the effect of the system and the causes of benefit inequity, provides an objective evaluation of policy implementation and offers data support for policy adjustment.

METHODS

A two-stage stratified random sampling data collection method comprising a survey in 2009 (the sample size was 3832 families) and a follow-up survey in 2015 (the sample size was 3992 families) was used. Qualitative data are presented as rates or ratios and the χ2 test was used for descriptive statistics. Quantitative data were analysed using a t test. A generalized linear model (GLM) with gamma distribution of the log connection function was adopted to analyse the factors of the compensation benefit inequity. The degree of the compensation benefit inequity contribution was analysed using the concentration index (CI) decomposition method and the Oaxaca decomposition method.

RESULTS

Reimbursement refers to the reimbursement expense received by inpatients from the New Cooperative Medical System (NCMS). In the GLM, there were some positive factors for reimbursement in the NCMS, including economic level, level of health facility and deductibles. The CI decomposition analysis results show that the main factors that increased the compensation benefit inequity were economic levels and deductibles over the past 2 y. However, inpatient days (2009) and the actual reimbursement ratio (2015) decreased the inequity. The Oaxaca decomposition analysis results suggest that changes in compensation benefit inequity between 2009 and 2015 were more attributable to changes in economic status and variables related to policy compensation than to demographic variables. Conclusions: This study showed that inequity decreased from 2009 to 2015, which could be the result of adjustment of the compensation policy. However, we should remain vigilant lest the gap between the rich and the poor leads to an increase in inequity.

Cancer burden of major cancers in China: A need for sustainable actions

Cancer is still a major health problem in China although numerous efforts have been made for its prevention and control. Findings from this study showed that lung cancer remains the most common type of cancer diagnosed, and was attributed to nearly 30% of all cancer-related deaths. The incidence of the five most common cancers, in China, in 2015, including cancers of the lungs, stomach, colorectum, liver and breast, accounted for almost 60% of all cancers diagnosed. The high cancer burden in China highlights the need for further improvement in health education, professional training and the building up an anti-cancer network for introducing and implementing sustainable actions for cancer control.

Trend of disparity between coastland and inland in medical expenditure burden for rural inpatients with malignant tumor in southeast of China from 2007 to 2016

Background

New Rural Cooperative Medical Scheme (NRCMS) was developed to improve the health security for rural residents. This study aimed to assess the trend of disparity between coastland and inland in medical expenditure burden for rural inpatients with malignant tumor from 2007 to 2016 under the effect of NRCMS.

Methods

The data from medical records of 1,306,895 patients with malignant tumor who had NRCMS in 2932 hospitals was collected. The relative differences [95% confidence intervals (CIs)] between coastland and inland in four medical expense indicators were calculated using generalized linear models to assess the trend of disparity over time.

Results

In total, there were 769,484 (58.88%) coastland patients and 537,411 (41.12%) inland patients. Male and patients aged older than 44 years accounted for 56.87 and 80% of 1,306,895 patients, respectively. After adjusting for gender, age, tumor site and hospital level, coastland patients had higher hospitalization expenses which were all medical expenses incurred during the hospitalization, lower reimbursement ratio and ratio of out-of-pocket expenses to disposable income than inland patients in most years. The surgery expenses of coastland patients were lower than those of inland patients in 2016. The relative differences (95% CIs) between coastland and inland in medical expense indicators were moving closer to 1.0 from 2007 to 2010 among patients without surgery, implying that the disparity between two areas significantly narrowed. The range of change was similar between two areas from 2011 to 2016 whether among patients without or with surgery, implying that the disparity did not significantly change. The disparity between coastland and inland depended on the household income situation. For low-income patients, the differences between two areas in medical expense indicators were not statistically significance in most cases and the disparity between two areas did not significantly change over time.

Conclusions

Under the effect of NRCMS, the medical expenditure burden of rural inpatients reduced but suffering from malignant tumor was still catastrophic. As a whole, the inland patients had heavier medical expenditure burden than coastland patients. Because of economic factors and medical assistance policies, the medical expenditure burden was similar between coastland and inland low-income patients.

Study on the Utilization of Inpatient Services for Middle-Aged and Elderly Rural Females in Less Developed Regions of China

The aim of this study is to understand the utilization of inpatient services and its contributing factors among middle-aged and elderly females (MAEF) in less developed rural regions. Five surveys were conducted between 2006 and 2014 with rural residents of Jiangxi by stratified cluster random sampling. Participant females included only those who were aged 45 and above. Complex sampling logistics analysis was performed to analyze the effect of three factors on inpatient service. Complex sampling logistics regression analysis revealed that the probability of hospitalization for the divorced or widowed females was significantly lower than that of married ones (aOR = 0.177, p < 0.05). However, the probability of early discharge was significantly higher among divorced or widowed females than married ones (aOR = 3.237, p < 0.05). In addition, females with chronic diseases were more likely to be hospitalized (aOR = 3.682, p < 0.05). Also, early discharge (aOR = 7.689, p < 0.05) occurred among the participants who should be hospitalized but were not hospitalized occurred (aOR = 3.258, p < 0.05). The continuous improvement of the new rural cooperative medical policy has promoted the utilization of inpatient services for the MAEF. Findings from this study emphasize the need to strengthen the prevention and treatment of chronic diseases among middle-aged and elderly women.

China's New Cooperative Medical Scheme's Impact on the Medical Expenses of Elderly Rural Migrants

Background: With rapid urbanization in China, the scale of elderly migrants from rural areas to urban cities has increased rapidly from 5.03 million in 2000 to 13.4 million people in 2015. Methods: Based on the unbalanced panel data obtained from the Chinese Longitudinal Healthy Longevity Survey, this study investigates the impact of changes to the New Cooperative Medical Scheme (NCMS) on the medical expenditure of Chinese elderly rural migrants by using seemingly unrelated regression models. Results: NCMS coverage for elderly rural migrants rose from 11.83% in 2005 to 87.33% in 2014. The effective reimbursement rate increased significantly from 4.53% in 2005 to 36.44% in 2014, and out-of-pocket/income fell by 50% between 2005 and 2014. The NCMS significantly increased the effective reimbursement rate by 12.4% and out-of-pocket medical expenditure/income by 7.5% during this decade but played an insignificant role in reducing out-of-pocket payments. Conclusions: Policy makers need to promote a two-pronged strategy, which involves controlling the excessive growth of urban medical expenses and continuing to reform NCMS reimbursements for medical treatment, so non-urban resident elderly rural migrants can fully enjoy the welfare benefits of migration and urbanization.

Is There A Non-Essential Hospitalization Day In Inpatients With Diabetes Under Medical Insurance? Evidence From An Observational Study In China

PURPOSE

Non-essential hospitalization day of inpatient diabetes threatens health seriously and contributes to great economic burden on individuals and the society. Studying the essential utilization of hospitalization services is conducive to the reduction in the burden of diabetes. The purpose of this study is to identify the existence of non-essential hospitalization days during hospitalization in diabetic patients through exploring the use of health care in different types of insured patients.

PATIENTS AND METHODS

A sample of 6731 admission records from 5929 hospitalized patients was studied. Binary logistic regression was performed to estimate the adjusted effects of health insurance status on readmission. Multiple stepwise linear regression was performed to estimate the adjusted effects of health insurance status on length of stay (LOS), direct medical expenses (DME), out-of-pocket (OOP) expenditures, and percentage of individual payment after reimbursement (PIPAR). Adjusted odds ratios (with 95% CI) were reported as the results of logistic regression models and linear regression models, respectively.

RESULTS

Adjusted 7-day readmission rate and 30-day readmission rate were not significantly different between urban and rural resident basic medical insurance (URRBMI) and urban employee basic medical insurance (UEBMI). Compared with inpatients under URRBMI, the adjusted LOS and DME were significantly higher for UEBMI inpatients (adjusted OR of 2.6, 95% CI=1.9-3.2, adjusted OR of 1870.85, 95% CI=1370.97-2370.73, respectively). Adjusted OOP and PIPAR were significantly lower for UEBMI inpatients (adjusted OR of－970.86, 95% CI =-1111.63--830.10, adjusted OR of -0.19, 95% CI=-0.20--0.18, respectively).

CONCLUSION

There was a non-essential hospitalization day existing in the treatment of diabetes. Moral hazard has been found in UEBMI which would trigger overtreatment in hospitalization of diabetics, and the lower PIPAR of UEBMI was one of the main causes of moral hazard.

Institutional differences and geographical disparity: the impact of medical insurance on the equity of health services utilization by the floating elderly population - evidence from China

Background

The Chinese government has now achieved universal coverage of medical insurance through two systems: the Basic Medical Insurance System for Urban Employees (BMISUE) and the Basic Medical Insurance System for Urban and Rural Residents (BMISURR). This paper aims to identify the impact of China’s current medical insurance system on equity in the use of health services by the floating elderly population from two aspects: institutional differences and geographical disparity.

Methods

The data used in the study are from the China Migrants Dynamic Survey (CMDS) conducted by the National Health and Wellness Council of China. This study uses the Logit model to estimate the impact of the medical insurance system on the utilization of health services and the Propensity Score Matching (PSM) method to further test the robustness of the results.

Results

The study found that the type of medical insurance does not affect health services utilization by the floating elderly population in China. However, for those participating in the same medical insurance, participation in different regions will significantly affect the use of health service resources. For the BMISURR, when the place of the insurance is the same as the place of residence, the proportion of the floating elderly population that will see a doctor when they are sick will increase by 4.80%. For the BMISUE, when the place of the insurance is the same as the place of residence, the proportion of the floating elderly population that will see a doctor when they are sick will increase by 10.30%.

Conclusions

The difference between the place of insurance and the place of residence results in the unbalanced utilization of health services by the floating elderly population participating in the same medical insurance system.

The Impact of Health Insurance Policy on the Health of the Senior Floating Population-Evidence from China

The impact of health insurance on residents’ health is one of the focal points of academic research. Due to the fact that China’s medical insurance system is composed of a variety of programs and that the pooling districts are at the lower administrative level, enrollment in different medical insurance programs or at different places may have certain influences on the health of residents. This has mostly been neglected by previous studies. This paper uses data from the 2015 China Migrants Dynamic Survey (CMDS), focusing on the senior floating population and taking the difference in government subsidy proportions as an instrumental variable in order to identify the effects of health insurance programs and regional differences on the health of the senior floating population. Three effects were observed: First, participation in the health insurance system significantly improves floating seniors’ self-rated health. Second, the health status of floating seniors affects their choice of health insurance program: Less healthy persons tend to choose high-paying, wide-coverage basic medical insurance available for urban employees. Using an instrumental variable to control for the problem of endogeneity, it is discovered that compared with the basic medical insurance system for urban residents, the system for urban employees significantly enhances the health of the senior floating population. Third, “adverse selection” could be observed in the choice between enrolling in health insurance at the place of settlement or another place. Senior migrants with worse self-rated health tend to choose place of settlement in order to enjoy higher compensation and less complex reimbursement procedures. With an instrumental variable to control for the problem of endogeneity, it was found that compared with joining the medical insurance system at other places, joining at a place of settlement could improve the health of the floating senior population.