Does health insurance matter to the use of health services for the elderly in China? A multiyear, nationwide, cross-sectional study

Abstract

BackgroundChina has a population that is rapidly ageing. This rapid growth raises many challenges such as financing and delivery of health care. The Urban Residents Basic Medical Insurance (URBMI) has provided financial protection for the urban elderly not covered by other health insurance schemes since 2007. We therefore aimed to do a national level assessment on the changes in perceived health needs and use of health services of the elderly enrolled in URBMI. MethodsWe extracted data from two waves (2008 and 2013) of the National Health Service Surveys. We included eligible individuals aged 60 years or over and enrolled in URBMI for analysis. Our primary measures were self-reported diagnosis of non-communicable diseases (NCDs), outpatient visits in the past 2 weeks, hospital admissions within the past year, and proportion of forgone necessary admissions referred, which were analysed by age groups (60–69 years, 70–79 years, and ≥80 years) and income levels (low, middle, and high). We used multivariate regression models to estimate associations of socioeconomic factors (age and income groups) and perceived health demand to the use of health services with control of demographic characters (sex, household size, marriage status, and education) and year of survey (2008 as base). The National Health Services Surveys were reviewed and approved by National Statistics Bureau and all participants gave oral consent to participate in the study. FindingsFrom June 1, 2008, to Sep 30, 2013, 7634 individuals were eligible for analysis, in whom self-reported prevalence rates of NCDs increased from 67·9% (553 of 815) to 77·8% (5305 of 6819). 89·1% (1792 of 2012) of individuals aged 70–79 years reported with NCDs in 2013, which is 9·0% higher than those aged 80 years or over and 17·6% higher in those aged 60–69 years. 80·1% (1821 of 2273) of the elderly from the middle-income group reported having NCDs, whereas 78·9% (1793 of 2273) from the high-income group and 75·4% (1714 of 2273) from the low-income group reported having NCDs in 2013. Between 2008 and 2013, outpatient visits increased from 23·7% (193 of 815) to 27·0% (1841 of 6819) and hospital admissions increased from 13·3% (108 of 815) to 16·6% (1132 of 6819). Outpatient visits increased from 24·8% to 32·1% for those aged 70–79 years and 19·7% to 26·7% for those aged 80 years or over, but remained at 24·5% for individuals aged 60–69 years. The high-income group had the highest increase from 23·0% to 31·1% whereas the low-income group had a decrease from 26·3% to 22·2%. Hospital admissions increased among all groups, with the 70–79 years' age group and the middle-income group having the largest increase. Proportion of forgone necessary admission reduced from 29·4% to 17·7%, and both low-income and middle-income groups had more than 20% reduction between 2008 and 2013. Age, income, and survey year significantly influenced outpatient visits whereas education, age, income, self-reported NCDs, and survey year were significant influential factors for hospital admission. InterpretationThe use of overall services increased and forgone necessary admission decreased after the implementation of URBMI, indicating the improvement of access to health services. However, outpatient use favoured those in the high-income group and calls for further attention on equity. Additionally, the prevalence rate of NCDs among the elderly in urban regions increased sustainably and action plans on health promotion and primary prevention of NCDs should be implemented. The benefit package of insurance should also support the care of NCDs. FundingNone.