New Cooperative Medical Scheme Research Articles

How hospital autonomy affects provider payment reform effectiveness.

Provider payment reforms (PPRs) have demonstrated mixed results for improving health system efficiency. Since PPRs require health care organisations to interpret and implement policies, the organizational characteristics of hospitals may affect the effectiveness of PPRs. Hospitals with more autonomy have the flexibility to respond to PPRs more efficiently, but they may not if the autonomy previously facilitated behaviours that counter the PPR's objective. This study examines whether hospitals with higher autonomy responds to PPRs more effectively. We used data from a matched-pair, cluster randomized controlled PPR intervention in a resource-limited Chinese province between 2014 and 2018. The intervention reformed the reimbursement method from the publicly administered New Cooperative Medical Scheme (NCMS) from fee-for-service to global budget. We interacted measures of hospital autonomy over surplus, hiring, and procurement (drugs, consumables, equipment, and overall index) with the difference-in-difference estimator to examine how autonomy moderated the intervention's effect. Autonomy over surplus (p<0.01) and procurement of equipment (p<0.01) were associated with relatively faster NCMS expenditure growth, demonstrating worse PPR response. They were also associated with higher expenditure shifting to out-of-pocket expenditures (p>0.05). Post hoc analysis suggests that hospitals with surplus autonomy had higher OOP per admission (p<0.01), suggesting profiteering tendencies. Other dimensions of autonomy demonstrated imprecise association. Hospitals with more autonomy may not necessarily respond more effectively to PPRs that incentivise efficiency when they had previously been encouraged to maximise profit. Policymakers should assess the extent of perverse incentives before granting autonomy and adjust the incentives accordingly.

The effect of the new cooperative medical scheme on rural labor supply in China

In 2003, China launched the New Cooperative Medical Scheme (NCMS), a public healthcare plan targeting rural households. While the literature mostly considers the impact of NCMS coverage on health outcomes, we investigate potential impacts on labor supply and household savings levels. To mitigate endogeneity bias driven by households self-sorting into NCMS coverage, we use panel data spanning two decades to estimate difference-in-differences and instrumental variables (2SLS) models. We find NCMS coverage reduced aggregate labor supply by roughly 8%. Consistent with Borjas (2003), we find the NCMS impacts are larger for higher income households.

The largest insurance program in history: Saving one million lives per year in China

The New Cooperative Medical Scheme (NCMS), rolled out in China from 2003–2008, provided insurance to 800 million rural Chinese. We combine aggregate mortality data with individual survey data, and identify the impact of the NCMS from program rollout and heterogeneity across areas in their rural share. We find that there was a significant decline in aggregate mortality, with the program saving more than one million lives per year at its peak, and explaining 78% of the entire increase in life expectancy in China over this period. We confirm these mortality effects using micro-data on mortality, other health outcomes, and utilization.

Can rural health insurance coverage improve educational attainment? Evidence from new cooperative medical scheme in China

This paper bridges health policy with education outcomes through eight waves of a nationally-representative health survey in China. We construct an index of health poverty with CHNS (1991–2011) data, and find health poverty in period (t-1) is significantly detrimental to education outcomes in period t. We further treat the expansion of New Cooperative Medical Scheme (NCMS) in rural China as a quasi-natural experiment and evaluate the effect of the publicly provided health insurance on education attainment. We find that NCMS participation can increase individual's schooling by 0.54, 0.75 and 0.83 years in east, central and west regions, respectively. The effect is larger for those at lower education levels, i.e. for individuals at 15% percentile schooling level, the schooling increases by 1.12, 1.43 and 1.72 years in the east, central and west. The effect is larger for women than men, for the unhealthy, risk-avoiding group relative to healthy group, and sustains longer in the central than other regions. Among different insurance clauses in NCMS, the outpatient medical service compensation generates stronger effect on education outcomes.

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

BackgroundChina 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.MethodsWe 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.ResultsFrom 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.ConclusionFrom 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.

What fragile factors hinder the pace of China’s alleviation efforts of the poverty-stricken population? A study from the perspective of impoverishment caused by medical expenses

ObjectiveChina has made remarkable achievements in poverty alleviation. However, with the change in economic development and age structure, the population stricken by poverty due to medical expenses and disability accounted for 42.3 and 14.4% of the total poverty-stricken population, respectively. Accordingly, it is crucial to accurately pinpoint the characteristics of people who are about to become poor due to illness. In this study, we analyzed the incidence of impoverishment by medical expense at the provincial, family, and different medical insurance scheme levels to identify the precise groups that are vulnerable to medical-related poverty.MethodData were extracted from the Fifth National Health Service Survey in China in 2013 through a multi-stage, stratified, and random sampling method, leaving 93,570 households (273,626 people) for the final sample. The method recommended by World Health Organization (WHO) was adopted to calculate impoverishment by medical expense, and logistic regression was adopted to evaluate its determinants.ResultsThe poverty and impoverishment rate in China were 16.2 and 6.3% respectively. The poverty rate in western region was much higher than that of central and eastern regions. The rate of impoverishment by medical expense (IME) was higher in the western region (7.2%) than that in the central (6.5%) and eastern (5.1%) regions. The New Cooperative Medical Scheme (NCMS) was associated with the highest rate (9.1%) of IME cases. The top three diseases associated with IME were malignant tumor, congenital heart disease, and mental disease. Households with non-communicable disease members or hospitalized members had a higher risk on IME. NCMS-enrolled, poorer households were more likely to suffer from IME.ConclusionThe joint roles of economic development, health service utilization, and welfare policies result in medical impoverishment for different regions. Poverty and health service utilization are indicative of households with high incidence of medical impoverishment. Chronic diseases lead to medical impoverishment. The inequity existing in different medical insurance schemes leads to different degrees of risk of IME. A combined strategy to precise target multiple vulnerabilities of poor population would be more effective.

Early childhood exposure to health insurance and adolescent outcomes: Evidence from rural China

This paper examines the impact of exposure to public health insurance in early life on outcomes in adolescence in rural China. Exploiting the variation in the county-by-county rollout of the New Cooperative Medical Scheme (NCMS) between 2003 and 2008, we find that exposure to the NCMS during ages 0–5 significantly improves health, cognitive, and educational outcomes during adolescence. In contrast, exposure after age five has no significant effects. Our further investigation provides evidence for several underlying mechanisms, such as improved prenatal care and birth outcomes, better preventive medical protection against childhood diseases, and lower risk in medical expenditure. (JEL Classification I13; I21; D04).

Public health insurance and enrollees’ diet structure in rural China

This study examines the consumption-stimulation function of public health insurance (PHI) programs from the perspective of food consumption. We estimate the impact of enrollment in rural China's PHI program, the New Cooperative Medical Scheme (NCMS), on the insured's diet diversity and diet balance using panel data from the China Health and Nutrition Survey. Exploiting temporal and spatial variations in the program's local implementation, our difference-in-differences estimation (combined with propensity score matching in some analyses) reveals significant increases in the insured's diet diversity, overall diet balance, and nutrition intakes. However, the program's consumption-stimulation function is not entirely beneficial. While NCMS enrollment reduced the incidence of under-consumption of animal products and fruits, it raised that of over-consumption of grains, imposing potential health risks on the insured.

Empirical Study on the Impact of Urban and Rural Resident Basic Medical Insurance on Children's Educational Outcomes.

This paper employs data from the 2016 and 2018 China Family Panel Studies (CFPS) to study the impact of participation in Urban and Rural Resident Basic Medical Insurance (URRBMI) on children's educational outcomes by using the logit model, double selection Lasso model, and propensity score matching. It is found that participating in URRBMI has no significant effect on children's Chinese performance, but has a significant negative effect on children's mathematics performance. The negative effect is more obvious for children who participating in the New Cooperative Medical Scheme (NCMS). The paper also studies the channel effects of participation in URRBMI on children's educational outcomes trough two different ways. It is noticed that both channel effects are not significant, that is, participation in URRBMI neither improves children's health nor changes household education expenditures.

Urban-rural differences in healthcare utilization among beneficiaries in China\u2019s new cooperative medical scheme

BackgroundThe New Cooperative Medical Scheme (NCMS) is a voluntary social health insurance program launched in 2002 for rural Chinese residents where 80% of people were without health insurance of any kind. Over time, several concerns about this program have been raised related to healthcare utilization disparities for NCMS participants in urban versus rural regions. Our study uses 2015 national survey data to evaluate the extent of these urban and rural disparities among NCMS beneficiaries.MethodsData for our study are based on the Chinese Health and Retirement Longitudinal Study (CHARLS) for 2015. Our 12,190-patient sample are urban and rural patients insured by NCMS. We use logistic regression analyses to compare the extent of disparities for urban and rural residence of NCMS beneficiaries in (1) whether individuals received any inpatient or outpatient care during 2015 and (2) for those individuals that did receive care, the extent of the variation in the number of inpatient and outpatient visits among each group.ResultsOur regression results reveal that for urban and rural NCMS patients in 2015, there were no significant differences in inpatient or outpatient utilization for either of the dependent variables – 1) whether or not the patient had a visit during the last year, or 2) for those that had a visit, the number of visits they had. Patient characteristics: age, sex, employment, health status, chronic conditions, and per capita annual expenditures – all had significant impacts on whether or not there was an inpatient or outpatient visit but less influence on the number of inpatient or outpatient visits.ConclusionsFor both access to inpatient and outpatient facilities and the level of utilization of these facilities, our results reveal that both urban and rural NCMS patients have similar levels of resource utilization. These results from 2015 indicate that utilization angst about urban and rural disparities in NCMS patients do not appear to be a significant concern.

Who will drop out of voluntary social health insurance? Evidence from the New Cooperative Medical Scheme in China.

Although public voluntary health insurance (VHI) has been adopted in many low- and middle-income countries to improve access to care for the population, a common issue with VHI is its high dropout rate. Using the New Cooperative Medical Scheme (NCMS)—a public VHI in China—as a case study, this article employs a fixed-effects negative binomial regression model combining the difference-in-difference-in-differences approach and multivariate distance matching to examine the factors associated with dropping out and the impact of dropout on outpatient care utilization among middle-aged and older people in rural China. Drawing data from the China Health and Retirement Longitudinal Study, our results showed that healthy people, vulnerable people and people who use less healthcare tended to drop out. Dropout had a significant negative impact on outpatient care utilization, especially for those with worse health statuses and those living in poorer provinces. We also found that the impact of dropout on outpatient utilization was more pronounced at secondary and tertiary hospitals than at primary care clinics. We urge policymakers to rethink the design of the NCMS by waiving premiums for the most vulnerable people.

Ten-year impacts of China’s rural health scheme: lessons for universal health coverage

China has made profound progress in advancing universal health coverage (UHC) over the past two decades. New Cooperative Medical Scheme (NCMS) was initiated in 2003 to provide health insurance coverage...

Childhood Nutrition in Rural China: What Impact Does Public Health Insurance Have?

ObjectivesTo investigate the impact of public health insurance coverage, specifically the New Cooperative Medical Scheme (NCMS), on childhood nutrition in poor rural households in China, and to identify the mechanisms through which health insurance coverage affects nutritional intake. MethodsLongitudinal data on 3291 children were taken from four time periods (2004, 2006, 2009, and 2011) from the China Health and Nutrition Survey (CHNS). Panel data analysis was performed with the fixed-effect model and the propensity score matching with difference-in-differences (PSM-DID) approach. ResultsThe introduction of the NCMS was associated with a decline in calories, fat, and protein intake, and an increase in the intake of carbohydrates. The NCMS had the greatest negative effect on children aged 0 to 5 years, particularly girls. Out-of-pocket medical expenses were identified as the main channel through which the NCMS affected the nutritional intake of children. ConclusionsThe study showed that the NCMS neither significantly improved the nutritional status of children nor enhanced intake of high-quality nutrients among rural poor households. These findings were attributed to the way in which health-seeking behavior was modified in the light of NCMS coverage. Specifically, NCMS coverage tended to increase healthcare utilization, which in turn increased out-of-pocket medical expenditures. This encouraged savings to aid financial risk protection and resulted in less disposable income for food consumption.

The impact of health insurance on healthcare service use and costs: evidence from rural China

PurposeThe purpose of this paper is to study the effects of introducing a health insurance program in rural China between 2004 and 2006, the New Cooperative Medical Scheme (NCMS).Design/methodology/approachThe authors apply difference in difference and propensity score matching methods (PSM-DID) to a widely used panel dataset, the China Health and Nutrition Survey (CHNS). Findings are robust across several treatment and comparison groups used in previous NCMS studies.FindingsHouseholds who participated in NCMS increased the use of preventive services and western medicine, while lowering the use of traditional Chinese medicine. NCMS also reduced hospital use, out of pocket payments, travel time to healthcare facilities and waiting time to see doctors. The authors estimate that reductions in travel and waiting time saved roughly 52m U.S. dollars in 2006.Research limitations/implicationsPreviously divergent findings on health insurance effects may be due to researchers studying health insurance across different healthcare delivery systems. In addition, in estimating how health insurance access affects healthcare costs, the authors should consider economic costs related to the time needed to access health services.Originality/valueThe authors study how health insurance access affects patients' choice of providers and economic costs to accessing health care services, outcomes that have not received much attention previously. The authors depart from previous NCMS studies by comparing several different approaches to identifying treatment and control groups when applying PSM-DID.

Health system reforms in China a half century apart: Continuity but adaptation.

Well-functioning governance arrangements are an essential, but often overlooked or poorly understood contributor to high quality health systems. Yet governance systems are embedded in institutional structures and shaped by cultural norms that can be difficult to change. We look at a country that has implemented two major health system reforms separated by half a century during which it has undergone remarkable political, economic, and social change. These are the Chinese Patriotic Health Campaign (PHC), beginning in the 1950s, and the New Cooperative Medical Scheme (NCMS), in the 2000s. We use these as case studies to explore how governance arrangements supported the design and implementation of policies implemented on a large scale in these quite different contexts. Drawing on review of archival documents, published literature, and semi-structured interviews with key policy makers, we conclude that few aspects of governance underwent fundamental changes. In both periods, the policy design stage included encouragement of sub-national tiers of government to pilot policy options, accumulate evidence, and disseminate it to others facing similar challenges, all facilitated by clear lines of accountability and a willingness by those at the top of the hierarchy to learn lessons from lower levels. At the implementation stage, rapid scaling up benefitted from leadership by national institutions that could enact regulations and set policy goals and targets for lower tiers of government, evaluating the performance of local government officers in terms of their ability to implement policy, while encouraging local government to pilot innovative measures. These findings highlight the importance of a detailed understanding of governance and how it is shaped by context, demonstrating continuity over long periods even at times of major social, political, and economic change. This understanding can inform future policy development in China and measures to strengthen governance aspects of reforms elsewhere.

Locked out? China’s health insurance scheme and internal migration

Providing health insurance with certain geographical restrictions may lead to misallocations in the labour market by hindering migration. This paper tests whether the rural health insurance first introduced in 2003, the New Cooperative Medical Scheme (NCMS), had unintended and negative effects on rural-to-urban migration mobility in China. The NCMS offers health insurance only to people with rural household registration, and they can benefit from the NCMS only when visiting the hospitals near their registered location in the household registration system. An event-study approach to a new dataset collected from provincial yearbooks in China reveals at the county level that the NCMS reduces the percentage and rate of growth of the percentage of rural residents who are rural-to-urban migrants and who work outside their home county. Using the China Health and Nutrition Survey (CHNS), my instrumental variable (IV) results show that being enrolled in the NCMS reduces the probability of individual-level migrating. The IV is a time-variant dummy indicating the counties that have relative early NCMS implementations. I also use the CHNS to construct a county-level dataset and replicate the county-level results. Together, the results suggest that the NCMS “locks” the rural labour force into rural areas and further hinders geographical job mobility in China.

Do Chinese Older Adults Rely on Social Insurance Schemes? Primary Coverage on out-of-Pocket Medical Expenses for Outpatient and Inpatient Treatments

This study assesses the associations between primary sources of insurance coverage and out-of-pocket outpatient and inpatient medical expenses among Chinese older adults. The 2012 and 2014 waves of the Chinese Longitudinal Healthy Longevity Survey (n = 6,924) were analyzed. Sources of coverage for survey participants were recorded as the: New Cooperative Medical Scheme (NCMS), Urban Employment Basic Medical Insurance (UEBMI), and the Urban Residence Basic Medical Insurance (URBMI). Self-payment, “other” financial sources and unaffordability were also recorded. The Heckman two-step procedure was employed to control selection bias. The outcomes in the first step of the Heckman model determined whether or not the participants had any outpatient or inpatient expenses in the past year. The outcomes in the second step were out-of-pocket expenses for outpatient or inpatient treatments. Majority of older participants still claimed self-payment as the primary financial source to cover medical expenses. Having UEBMI coverage was associated with more outpatient and inpatient out-of-pocket expenses, compared to the NCMS scheme (all p < 0.01). Self-payment was positively associated with outpatient and inpatient medical expenses (all p < 0.01). However, URBMI coverage was not associated with either outcome, compared to NCMS. Further policy implications and research directions are discussed.

Comparison of inpatient distribution amongst different medical alliances in a county: a longitudinal study on a healthcare reform in rural China

BackgroundChina has launched the medical alliances (MAs) reform to drive the development of primary medical institutions and decrease health inequality in rural areas. Three different types of MAs were built to promote township hospitals in Y County. This study aims to evaluate the actual effect of China’s MAs reform in rural areas on inpatient distribution especially amongst different types of MAs.MethodsWe obtain 2008–2015 claims data from the New Cooperative Medical Scheme (NCMS) in Y County, Hubei Province of China. We consider January 2008–December 2010 as the pre-reform period and January 2011–December 2015 as the post-reform period.We use independent sample t-test and single-group interrupted time series analysis (ITSA) to compare the number of inpatients per month in the three MAs, including three county and 10 township hospitals before and after the reform. We use paired t-test and multiple-group ITSA between seven township hospitals within MAs and seven township hospitals outside MAs.ResultsThe MAs reform in Y County increased the number of inpatients in county and township hospitals within MAs. After the reform, the number of inpatients per month in county hospitals had an upward trend, with a slope of 31.01 person/month (P < 0.000). Approximately 19.99 new inpatients were admitted to township hospitals monthly after the reform (P < 0.000). Furthermore, township hospitals within MAs had a substantial increase in the number of inpatients (10.45 new inpatients monthly) compared with those outside MAs.ConclusionThe MAs reform in Y County significantly improved the capability of medical institutions within MAs. After the reform, township hospitals within MAs had greater development advantages than those outside MAs. However, it also caused further imbalance in the county region, which contained the new health inequality risk.

Do Health Insurance Schemes Heterogeneously Affect Income and Income Distribution? Evidence from Chinese Agricultural Migrants Survey.

Currently, the particularity of Chinese agricultural migrants groups determines that they can participate in various types of public health insurance schemes, i.e., the New Cooperative Medical Scheme (NCMS), Urban Residents Basic Medical Insurance (URBMI), and Urban Employees Basic Medical Insurance (UEBMI). The goal of this paper is to shed light on whether and how these health insurance schemes affect the agricultural migrants’ income and income distribution. A dataset of 86,660 individuals is obtained from China Migrants Dynamic Survey implemented by the National Health Commission. The study uses the basic ordinary least squares regression to assess association between health insurance schemes and income and uses the propensity score matching method to estimate the income effect. In addition, we further use the quantile regression method to explore heterogeneous effects of health insurance schemes on income distribution. We find that UEBMI and URBMI have significant increased monthly net income of agricultural migrants, while NCMS does not. The income-increasing effect of UEBMI is greater than that of URBMI. The income-increasing effect of UEBMI is most obvious in the low-income group. While URBMI has a significant role in increasing income with its income-increasing effect being obvious for the lowest and highest income groups. We suggest that China’s health insurance system needs further reforms in order to reduce income inequality of agricultural migrants.

SAT-294 The relationship between peritoneal dialysis mortality and the Chinese medical insurance

There are two major medical insurance models in China: the Urban Basic Medical Insurance (UBMI) and the New Cooperative Medical Scheme (NCMS). We have observed that Chinese medical insurance type may affect the outcomes of patients treated with hemodialysis. The aim of the present study was to evaluate the association of the medical insurance type of patients undergoing peritoneal dialysis (PD) with their survival. We retrospectively analyzed the end-stage renal disease (ESRD) adult patients initiating PD between January 2008 and December 2016 in Zhejiang province, followed up through December 31, 2017. Patients had received continuous ambulatory PD for over 3 months, whom were divided into two groups according to their medical insurance type. Demographic, education level, clinical data, biochemical parameters and primary clinical outcomes including all-cause mortality, switch to hemodialysis and kidney transplant were analyzed. The survival rates were calculated by using the Kaplan-Meier method. A total of 8065 patients were enrolled, which is the largest cohort in China so far. There were 3523 patients (2090 males(59.3%)) with UBMI and 4542 (2317 males (51.0%)) with NCMS enrolled from 92 peritoneal dialysis units. Compared with UBMI, patients with NCMS were older (50 (IQR: 41-62) years old vs. 53 (IQR: 44-64)years old, P<0.001), had lower education level, smaller proportion of diabetic nephropathy and malignancy, more severe anemia, and more frequent hypoalbuminemia and hypocalcemia. The 1-, 3- and 5-year overall survival rates were 97.5%, 88.9%, and 81.5% in UBMI group, 95.9%, 85.9%, and 76.7% in NCMS group, respectively. Patients with NCMS showed higher all-cause mortality compared with UBMI (P<0.001). In multivariate Cox proportional hazards model, NCMS was independently associated with higher mortality (AHR=1.288; 95% CI 1.110,1.494). The medical insurance model was independently associated with PD patient survival, NCMS was associated with increased mortality among patients undergoing maintenance peritoneal dialysis in China.