New Cooperative Medical System Research Articles

Which Matters for Medical Utilization Equity under Universal Coverage: Insurance System, Region or SES.

Background: China has achieved universal coverage, with a higher rate of 95% medical insurance. However, huge inequalities are concealed under universal coverage. This article aims to explore the medical insurance utilization disparities over different insurance schemes, regions, and socioeconomic statuses (SES). Methods: This study was based on an open-access dataset in 2010, 2012, 2014, and 2016. A longitudinal analysis and separate logistic models were performed. Results: Urban Employee Basic Medical Insurance (UEBMI) members had an outstanding advantage in specialist visiting over those on the Urban Resident Basic Medical Insurance Scheme (URBMI) (OR = 0.607, p < 0.001) and New Cooperative Medical System (NCMS) (OR = 0.262, p < 0.001). However, in terms of a doctor visiting if a person is sick, the odds of patients in the NCMS receiving a visit were 55.1% ((OR = 1.551; p < 0.05) higher than those on the UEBMI. Compared with west China, the odds of those in the north-east and east were 2.1% (p > 0.05) and 97.2% (OR = 1.972; p < 0.001) higher for seeking medical treatment if sick, and 10.8% (OR = 0.892; p < 0.01) and 42.7% lower (OR = 0.573; p < 0.001) for a specialist visiting. In terms of SES, for each unit of increase in the Standard International Occupational Prestige Scale (SIOPS), the odds of seeking medical treatment decreased by 4.3% (OR = 0.958; p < 0.05), and the odds of a specialist visiting increased by 17.1% (OR = 1.171; p < 0.001) for each unit of the annual income logarithm. Conclusions: NCMS members and residents in west China were in a disadvantage status in terms of access to specialists, though had a higher probability of medical care if sick. SES variables were positively correlated with a specialist visiting consistently. We suggest a further focus on healthcare quality in the west and rural areas.

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.

BackgroundThe 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.MethodsA 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.ResultsReimbursement 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.

Delivering universal health coverage for an aging population: An analysis of the Chinese rural health insurance program

There is now high level international commitment to the goal of universal health coverage. But how can countries make this a reality in the face of a limited budget and an aging population? Since 2008, China has been rolling out an ambitious reform program, which aims to achieve affordable health insurance coverage for all Chinese citizens. Under this reform program, Chinese living in rural areas are eligible to enroll in a subsidized scheme called the New Cooperative Medical System (NCMS). Using a three stage game model involving a government, a private fund manager and population, we explore the impact of population aging on NCMS. Our model highlights the role of government regulation and subsidy in ensuring operation efficiency of the system. We show that at optimality the government sets the operating framework for the fund manager to constrain the potential for monopoly profits. The Government subsidizes the scheme to prevent an adverse selection death spiral. However, the effectiveness of the subsidy in achieving this goal is moderated by the age structure of the population. Our model gives insights into the strengths of the NCMS framework and also can be used to support decisions about resource allocation and understand how scheme dynamics may unfold as the Chinese population ages further.

Analysis of Rural Residents’ Participation in New Cooperative Medical System: A Case of Yunnan Province, China

This research focuses on the problem of farmers’ unenthusiastic participation in the New Cooperative Medical System (NCMS) and took Yunnan Province as an example. We took the questionnaire approach to collect information of farmers’ participating action as well as participating willingness. Factor analysis and regression are used in this article to find the main factors affecting farmers’ willingness of participating NCMS. Solutions and suggestions to improve NCMS are also provided at the end based on previous analysis.

Effect of the new rural cooperative medical system on farmers' medical service needs and utilization in Ningbo, China.

BackgroundMany countries are developing health mechanisms to pursue the goal of universal coverage. In China, a rural health insurance system entitled New Cooperative Medical System (NCMS) has being developed since 2003. This paper aims to explore the changes in the health service needs and utilization among rural residents in Ningbo, China after the implementation of the new rural cooperative medical system (NCMS), and provide evidence to further improve the strategies of NCMS in China.MethodsStratified multistage cluster sampling was used to randomly select 10 villages from 5 townships in Yuyao and Fenghua counties of Ningbo Municipality. Eighty families were selected from each village, and face-to-face interviews were conducted by trained investigators to collect data using questionnaires.ResultsThe two-week visiting rate and prevalence of chronic diseases among the farmers included in the study was 25.40 and 22.50 %, respectively, which were higher than the levels in 2003 and 2008. The rate of not visiting the healthcare facility amongst those with illness, and the rate of non- hospitalization amongst those who required it were 32.36 and 0.60 %, respectively, which was lower than the levels in 2003 and 2008. Most of the outpatient visits were to the village clinics, while the hospitalizations were mainly to county hospitals.ConclusionNCMS greatly affected the utilization of healthcare services from outpatient clinics and improved the hospitalization rate in county hospitals. Financial difficulties are not the major causes of non-hospitalization and non-visiting any longer. These findings suggest that the NCMS policies alleviated the medical burdens of farmers in a certain degree.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1842-3) contains supplementary material, which is available to authorized users.

Does health insurance coverage lead to better health and educational outcomes? Evidence from rural China

Using the 2006 China Agricultural Census (CAC), we examine whether the introduction of the New Cooperative Medical System (NCMS) has affected child mortality, maternal mortality, and school enrollment of 6–16year olds. Our data cover 5.9 million people living in eight low-income rural counties, of which four adopted the NCMS by 2006 and four did not adopt it until 2007.Raw data suggest that enrolling in the NCMS is associated with better school enrollment and lower mortality of young children and pregnant women. However, using a difference-in-difference propensity score method, we find that most of the differences are driven by endogenous introduction and take-up of the NCMS, and our method overcomes classical propensity score matching's failure to address selection bias. While the NCMS does not affect child morality and maternal mortality, it does help improve the school enrollment of six-year-olds.

Exploring China’s western and central county systems performance measured by outcomes framework scores—A cross-sectional survey of routine healthcare data

This study was designed to measure the performance of county health systems in central and western China utilizing routine healthcare data. Drawing on a literature review and expert consultation, the study established a theoretical framework and an indicator system for performance review. Questionnaires were designed and disseminated to collect empirical data on health system performance in four counties of two central and western provinces. Quantitative data were subjected to descriptive statistical analysis through SPSS12.0. Three dimensions were introduced in the performance review framework-health outcomes, financial risk protection and consumer and provider satisfaction. Health outcomes were assessed from four secondary indicators: infant mortality rate; maternal mortality rate; under-5 child mortality rate; and the incidence of Class A and Class B notifiable diseases. Financial risk was assessed using two secondary indicators: the proportion of the cost of inpatient care that was reimbursed under the New Cooperative Medical System (NCMS) insurance scheme, and the rate of NCMS funds utilization. The assessment of satisfaction was made using two secondary indicators: the overall satisfaction of local residents with healthcare services, and the satisfaction of health practitioners at the township and village level. The study indicated better health system performance in the two counties in Chongqing than those in Shanxi. It was concluded that outcome framework scores can fairly reveal performance differences among county health systems in central and western China, and can provide practical evidence for optimizing the operation and inputs of county health systems. Caution needs to be exercised in generalizing such performance outcomes as many factors such as spending and organization that contribute to county health system performance were not included in the study.

WILLINGNESS TO PAY IN CHINA'S NEW COOPERATIVE MEDICAL SYSTEM

Household survey data from China is used to analyze the determinants of households' willingness to pay to participate in the New Cooperative Medical System (NCMS). Wealthier households, households with at least one member who has been treated as an inpatient, and households in counties where NCMS is already established are willing to pay more for the program. Households who carry other forms of insurance, however, have a lower willingness to pay for the NCMS. We also find that the participation fee could be increased substantially to increase the size of the risk pool while scarcely affecting participation rates. (JEL I1, O1, D1)

Utilisation, contents and costs of prenatal care under a rural health insurance (New Co-operative Medical System) in rural China: lessons from implementation

BackgroundIn China, the New Co-operative Medical System (NCMS), a rural health insurance system, has expanded nationwide since 2003. This study aims to describe prenatal care use, content and costs of care in one county where prenatal care is included in the NCMS and two counties where it is not. It also explores the perceptions of stakeholders of the prenatal care benefit package in order to understand the strengths and weaknesses of the approach in the context of rural China and to draw lessons from early implementation.MethodsThis study is based on the data from a cross-sectional survey and a qualitative investigation conducted in 2009. A survey recruited women giving birth in 2008, including 544 women in RC County (which covered prenatal care) and 619, and 1071 in other two counties (which did not). The qualitative investigation in RC included focus group discussions with women giving birth before or after 2007, individual interviews with local policy makers and health managers, NCMS managers and obstetric doctors in township hospitals.ResultsThere were no significant differences in prenatal care use between RC County (which covered prenatal care) and other two counties (which did not): over 70% of women started prenatal visits early and over 60% had five or more visits. In the three counties: a small proportion of women received the number of haemoglobin and urine tests recommended by the national guideline; 90% of women received more ultrasound tests than recommended; and the out-of-pocket expenditure for prenatal care consumed a high proportion of women's annual income in the low income group. In RC: only 20% of NCMS members claimed the reimbursement; the qualitative study found that the reimbursement for prenatal care was not well understood by women and had little influence on women's decisions to make prenatal visits; and several women indicated that doctors suggested them taking more expensive tests.ConclusionsWhether or not prenatal care was included in the NCMS, prenatal care use was high, but the contents of care were not provided following the national guideline and more expensive tests were recommended by doctors. Costs were substantial for the poor.

Utilisation of maternal health care in western rural China under a new rural health insurance system (New Co-operative Medical System)

To investigate factors influencing maternal health care utilisation in western rural China and its relation to income before (2002) and after (2007) introducing a new rural health insurance system (NCMS). Data from cross-sectional household-based health surveys carried out in ten western rural provinces of China in 2003 and 2008 were used in the study. The study population comprised women giving birth in 2002 or 2007, with 917 and 809 births, respectively. Correlations between outcomes and explanatory variables were studied by logistic regression models and a log-linear model. Between 2002 and 2007, having no any pre-natal visit decreased from 25% to 12% (difference 13%, 95% CI 10-17%); facility-based delivery increased from 45% to 80% (difference 35%, 95% CI 29-37%); and differences in using pre-natal and delivery care between the income groups narrowed. In a logistic regression analysis, women with lower education, from minority groups, or high parity were less likely to use pre-natal and delivery care in 2007. The expenditure for facility-based delivery increased over the period, but the out-of-pocket expenditure for delivery as a percentage of the annual household income decreased. In 2007, it was 14% in the low-income group. NCMS participation was found positively correlated with lower out-of-pocket expenditure for facility-based delivery (coefficient -1.14 P < 0.05) in 2007. Facility-based delivery greatly increased between 2002 and 2007, coinciding with the introduction of the NCMS. The rural poor were still facing substantial payment for facility-based delivery, although NCMS participation reduced the out-of-pocket expenditure on average.

A comparison of rural and urban healthcare consumption and health insurance

PurposeSince 1999, China has undergone reform of its healthcare system. City‐based social health insurance (SHI) is the primary form of current health insurance, supplemented by various commercial health insurance programs. The rural new cooperative medical system (NCMS) was introduced in 1993 and extended to cover the whole of rural China in 2003.Design/methodology/approachThe paper developed a theoretical model for consumer demand of medical services and health insurance based on an expected utility framework with a two‐stage decision under uncertainty. The model is then applied to current health insurance systems in China for urban citizens and rural residents separately. Least square and logistic regressions are employed.FindingsThe major results are that although the factors driving the decisions on health insurance participation are basically the same for rural and urban citizens, the participation levels are quite different. The major difference is that urban SHI has higher coverage and urban citizens have higher income, resulting in a much larger urban medical expenditure.Practical implicationsThe empirical analysis reveals that health insurance programs have played an important role in the healthcare expenditure for urban residents, while the NCMS has not made a significant impact towards increasing the ability of rural residents to seek more medical services, based on data at 2004.Originality/valueThis is the first paper employing a health production theory on China's new urban and rural healthcare programs.

Health insurance and catastrophic illness: a report on the New Cooperative Medical System in rural China

The overall goal of the paper is to understand the progress of the design and implementation of China's New Cooperative Medical System (NCMS) program between 2004 (the second year of the program) and 2007. In the paper we seek to assess some of the strengths and weaknesses of the program using a panel of national-representative, household survey data that were collected in 2005 and early 2008. According to our data, we confirm the recent reports by the Ministry of Health that there have been substantial improvements to the NCMS program in terms of coverage and participation. We also show that rural individuals also perceive an improvement in service by 2007. While the progress of the NCMS program is clear, there are still weaknesses. Most importantly, the program clearly does not meet one of its key goals of providing insurance against catastrophic illnesses. On average, individuals that required inpatient treatment in 2007 were reimbursed for 15% of their expenditures. Although this is higher than in 2004, on average, as the severity of the illness (in terms of expenditures on health care) rose, the real reimbursement rate (reimbursement amount/total expenditure on medical care) fell. The real reimbursement rate for illnesses that required expenditures between 4000 and 10,000 yuan (over 10,000 yuan) was only 11% (8%). Our analysis shows that one of the limiting factors is constrained funding.

Understanding Variation in the Design of China's New Co-operative Medical System

AbstractAlthough the New Co-operative Medical System (NCMS) was expected to operate in all rural Chinese counties by the end of 2008, county governments were given significant leeway in the design of the local programmes. As a result, fundamental characteristics of NCMS programmes vary dramatically between counties. Such heterogeneity in programme design may influence satisfaction with the NCMS in each county, and thus each programme's prospects for success. This article uses survey data collected by the authors to consider five distinct measures of success. We find that households respond favourably to making emigrants eligible for coverage and to lowering the spending threshold for reimbursement eligibility. However, households are less likely to have received reimbursement in counties that require referrals or limit treatment to approved hospitals. Finally, out-of-pocket expenditures associated with catastrophic health care may still be too high to facilitate treatment of the rural poor.

Application of Monte Carlo techniques in designing compensatory scheme of new cooperative medical system

To design a workable compensatory scheme of new cooperative medical system (NCMS) in rural China, 'Monte Carlo Simulation Techniques' is developed based on the data of a multistage random sampling survey. The total compensation rate, the decreased percentages of poverty caused by diseases and the deficit ratio of fund a 0.3782, 0.6540 and -0.0794 respectively, when the main strategy of inpatient reimbursement is recognized as 'serious illness'. The deficit ratios of funding appeared to be 0.4840, 0.4091 and -0.3789 when the main strategy of outpatient reimbursement is recognized on minor diseases. Compensation for minor diseases is more important than that of serious diseases. Considering the further impact of minor diseases on peasants, we should incorporate compensation for minor diseases into the compensatory scheme of NCMS.

Non-evidence-based policy: How effective is China's new cooperative medical scheme in reducing medical impoverishment?

In recent years, many lower to middle income countries have looked to insurance as a means to protect their populations from medical impoverishment. In 2003, the Chinese government initiated the New Cooperative Medical System (NCMS), a government-run voluntary insurance program for its rural population. The prevailing model of NCMS combines medical savings accounts with high-deductible catastrophic hospital insurance (MSA/Catastrophic). To assess the effectiveness of this approach in reducing medical impoverishment, we used household survey data from 2006 linked to claims records of health expenditures to simulate the effect of MSA/Catastrophic on reducing the share of individuals falling below the poverty line (headcount), and the amount by which household resources fall short of the poverty line (poverty gap) due to medical expenses. We compared the effects of MSA/Catastrophic to Rural Mutual Health Care (RMHC), an experimental model that provides first dollar coverage for primary care, hospital services and drugs with a similar premium but a lower ceiling. Our results show that RMHC is more effective at reducing medical impoverishment than NCMS. Under the internationally accepted poverty line of US$1.08 per person per day, the MSA/Catastrophic models would reduce the poverty headcount by 3.5–3.9% and the average poverty gap by 11.8–16.4%, compared with reductions of 6.1–6.8% and 15–18.5% under the RMHC model. The primary reason for this is that NCMS does not address a major cause of medical impoverishment: expensive outpatient services for chronic conditions. As such, health policymakers need first to examine the disease profile and health expenditure pattern of a population before they can direct resources to where they will be most effective. As chronic diseases impose a growing share of the burden on the population in developing countries, it is not necessarily true that insurance coverage focusing on expensive hospital care alone is the most effective at providing financial risk protection.