Effect of employment and social medical insurance on hospital admissions for people living with multimorbidity in China: analysis of a large community household survey

Abstract

BackgroundChina's comprehensive health-care reform was embarked on in 2009, targeting health-care financing, care delivery, drug supply, and hospital reform. The aim of this study was to explore the extent to which being people with multiple long-term disorders who are unemployed and uninsured are prevented from accessing hospital inpatient care. MethodsWe analysed data from a large community household survey of about 5% of the general resident population with household registry in three prefectures in southern China in 2011. Close-ended questions on demographics, socioeconomics, and lifestyle behaviours were derived from the National Health Services Survey (NHSS) 2008. Open-ended questions on chronic disorders (clinically diagnosed or being treated) and admissions to hospitals at the secondary level or above in the previous 12 months were designed by a research panel. The multistage sample designs and sampling weights were taken into account in the binary logistic regression analysis of the survey response. We cross-validated self-reported chronic disorders with paper-based medical reports obtained from previous health-care visits and annual check-ups. Multimorbidity was defined as having two or more chronic disorders from a validated list of 40 morbidities. Findings124 829 residents (aged ≥20 years) from 53 760 households participated in the survey. In the previous 12 months, 7211 (5·8%, 95% CI 5·7–5·9) residents had at least one admission to hospital, of whom 3002 (42%, 40·8–42·4) had multimorbidity. Admission to hospital was associated with the number of chronic disorders (≥4 disorders vs none: adjusted odds ratio 17·13 [95%CI 16·15–18·16]), having social medical insurance (1·41 [1·37–1·44]), household income per head (highest household income group vs the lowest household income group: 1·80 [1·74–1·85]), and unemployment (1·61 [1·55–1·66]). We found a statistically significant interaction between employment status and the presence of medical insurance on hospital admission, meaning that patients who were unemployed and not covered by a social medical insurance were least likely to be admitted to a hospital (0·50, 0·47–0·52). InterpretationThe ability to pay a medical bill seems to be significantly predictive of inpatient service use for multimorbidity. A better designed social medical insurance system with more government contribution would be of particular necessity to improve equitable access to health care, particularly for people with less affordability because of unemployment. FundingDepartment of Health, Guangdong province, China (C2009006/2009–2013), Department of Education, Guangdong province, China (BKZZ2011047/2010–2013), Medical Research Fund, Chinese Medical Association, China (2010-08-05), and Community Health Research Fund, Community Health Association of China, China (2012-2-91). HHXW was supported by a postdoctoral research fellowship in the Hong Kong-Scotland Partners in Post Doctoral Research programme, Research Grants Council of Hong Kong, and the Scottish Government, UK (S-CUHK402/12). JJW is supported by Guangdong Exemplary Centres for Exploratory Teaching in Higher Education Institutions – General Practice Exploratory Teaching Centre [GDJG-2010-N38-35, Guangdong Department of Education, China], and The Ninth Round of Guangdong Key Disciplines – General Practice [GDJY-2012-N13-85, Guangdong Department of Education, China], both of which he leads. The Scottish School of Primary Care partly supported SWM's post and the development of the National Research Programme on Multimorbidity, which he leads.