Urban Resident Basic Medical Insurance Research Articles

Chinese residents’ educational disparity and social insurance coverage

PurposeThe Chinese society has embraced rapid social reforms since the late twentieth century, including educational and healthcare systems. The Chinese Central Government launched an ambitious health reform program in 2009 to improve service quality and provide affordable health services, regardless of individual socio-economic status. Currently, the Chinese social health insurance includes Urban Employee Basic Medical Insurance, Urban Resident Basic Medical Insurance, and New Cooperative Medical Insurance for rural residents. The purpose of this paper is to measure the association between individual education level and China’s social health insurance scheme following the reform.Design/methodology/approachUsing the latest (2011) China Health and Nutrition Survey (CHNS) data and multivariable logistic regression models with cross-sectional design (n=11,960), the odds ratios (OR) and 95% confidence intervals (95% CI) are reported.FindingsThe authors found that education is associated with all social health insurance schemes in China after the reform (p<0.001). Residents with higher educational attainments, such as technical school (OR: 6.64, 95% CI: 5.44–8.13) or university and above (OR: 9.86, 95% CI: 8.14–11.96), are associated with UEBMI, compared with lower-educated individuals.Practical implicationsThe Chinese Central Government announced a plan to combine all social health insurance schemes by 2020, except UEBMI, a plan with the most comprehensive financial package. Further research is needed to investigate potential disparities after unification. Policy makers should continue to evaluate China’s universal health coverage and social disparity.Originality/valueThis study is the first to investigate the association between residents’ educational attainment and three social health insurance schemes following the 2009 health reform. The authors suggest that educational attainment is still associated with each social health insurance coverage after the ambitious health reform.

Reducing the medical economic burden of health insurance in China: Achievements and challenges.

The aims of this study were to describe health insurance reforms initiated by the Chinese government over the past two decades, to review their achievements in reducing the medical economic burden, and to summarize the challenges that still exist regarding a further reduction in out-of-pocket expenditures in this country. China has successfully attained the goal of providing health insurance coverage to almost the entire population by developing a mixed health insurance system, which consists of Urban Employees Basic Medical Insurance (UEBMI), Urban Resident Basic Medical Insurance (URBMI), New Rural Cooperative Medical Scheme (NCMS), and supplementary Catastrophic Health Insurance. Despite this achievement, China is still facing the challenges of a disparity in the medical economic burden by region and by health insurance scheme, relatively little protection from financial risk compared to developed countries, as well as low efficiency and quality of care under current payment systems. To further reduce the disparity in the medical economic burden and to increase the overall protection from financial risk in China, the Government should increase central government transfers to NCMS and URBMI enrollees in poor regions and increase the total amount of government subsidies to NCMS. In addition, China should improve the efficiency and quality of health insurance by further reforming the payment system.

Equity of outpatient service utilization for hypertensive patients in community

To analyze the equity of outpatient service utilization for hypertensive patients (HPs) under 3 kinds of social medical insurance, and to explore its influential factors. Methods: A total of 8 670 HPs (aged at 15 years old from 28 sub-centers) in 14 provinces were selected. Indirectly standardized method and concentration index were used to analyze the equity of outpatient utilization in HPs, and decomposition analysis was used to explore the impact factors of outpatient treatment among the whole sample population, population with urban employees' basic medical insurance (UEBMI), and population with urban residents' basic medical insurance (URBMI) and new rural cooperative medical systems (NCMS). Results: The overall concentration index (CI) for the whole sample population was 0.2378. After the standardizing "need" variable, horizontal inequity (HI) was 0.2360, indicating that the outpatient service of HPs was inequity and that the higher economic level, the more outpatient services received. The decomposition of overall CI results showed that the positive factors for contribution were gross domestic product (GDP) level, retired, UEBMI and URBMI, and the negative factors for contribution were NCMS. The CI of UEBMI, URBMI and NCMS was 0.2017, 0.1208 and 0.0288, respectively; the HI was 0.1889, 0.1215 and 0.0219, respectively. The inequity in UEBMI is the most serious, followed by NRCMS and URBMI. The economic level was the main factor that caused inequity in the outpatient services utilization in three social medical insurance. In addition to the economic level, a common positive factor for the contribution to UEBMI and URBMI was district of residence, and the age was the positive factor to UEBMI as well. Conclusion: There are different levels of inequity in the HPs covered by 3 kinds of social medical insurance, and the inequity of UEBMI is the highest one among 3 kinds social medical insurance. The economic level is the main factor that affects the equity of outpatient in the HPs under 3 kinds of social medical insurance.

Study on the equity of medical services utilization for elderly enrolled in different basic social medical insurance systems in an underdeveloped city of Southwest China

BackgroundThe equity of medical services utilization for elderly individuals enrolled in different basic social medical insurance systems holds significant meaning for social harmony against a background of demographic aging and a growing wealth gap in China. This study is to explore the equity of the three medical insurance systems in southwest China with the aim of providing recommendations for relevant policy.MethodsA total of 9600 elderly people insured through basic social medical insurance were selected and interviewed with a questionnaire. This study used a binary logistic regression model to investigate the effect of household income for medical services utilization and adopted a concentration index to measure the inequity of medical services utilization among elderly participants enrolled in different medical insurance categories.ResultsOutpatient services utilization was almost identical in the different insurance systems (78.5%, 77.7% and 78.6%). There were no statistically significant differences according to income level in the Urban Employee Basic Medical Insurance (UEBMI) and Urban Resident Basic Medical Insurance (URBMI) programs, but in the New Cooperative Medical Scheme (NCMS), higher-income groups tended to utilize more services. The corresponding concentration index (CI) values were 0.0162, 0.0173 and 0.0179 respectively. The NCMS showed a lower hospitalization rate than UEBMI and URBMI (17.7% vs 24.2% and 24.9%). The higher income group utilized hospitalization more, regardless of the insurance system. The corresponding CI values were 0.0817, 0.0605 and 0.0319 respectively.ConclusionThe equity of medical services utilization for elderly exist in all three health insurance systems, in particular, the inequities in utilization of hospitalization were more severe than outpatient services. UEBMI and URBMI were better than NCMS in the equity of outpatient services. Although NCMS was more equitable than URBMI and UEBMI in terms of hospitalization, this was based on “overall low utilization of hospitalization regardless of income levels” in NCMS compared with URBMI and UEBMI. The disparities of the three basic social medical insurance systems should be eliminated. For low-income residents, specific insurance policies including reducing deductible, covering more medical service and increasing reimbursement ratio could be considered.

Reimbursement for injury-induced medical expenses in Chinese social medical insurance schemes: A systematic analysis of legislative documents

Social medical insurance schemes are crucial for realizing universal health coverage and health equity. The aim of this study was to investigate whether and how reimbursement for injury-induced medical expenses is addressed in Chinese legislative documents relevant to social medical insurance. We retrieved legislative documents from the China National Knowledge Infrastructure and the Lawyee databases. Four types of social medical insurance schemes were included: urban employee basic medical insurance, urban resident basic medical insurance, new rural cooperative medical system, and urban and rural resident medical insurance. Text analyses were conducted on all identified legislative documents. As a result, one national law and 1,037 local legislative documents were identified. 1,012 of the 1,038 documents provided for reimbursement. Of the 1,012 documents, 828 (82%) provided reimbursement only for injuries without a legally responsible person/party or not caused by self-harm, alcohol use, drug use, or other law violations, and 162 (16%) did not include any details concerning implementation. Furthermore, 760 (92%) of the 828 did not provide an exception clause applying to injuries when a responsible person/party could not be contacted or for situations when the injured person cannot obtain reimbursement from the responsible person/party. Thus, most Chinese legislative documents related to social medical insurance do not provide reimbursement for medical expenses from injuries having a legally responsible person/party or those caused by illegal behaviors. We argue that all injury-induced medical expenses should be covered by legislative documents related to social medical insurance in China, no matter what the cause of the injury. Further research is needed to explore the acceptability and feasibility of such policy changes.

Comparing the effects of China\u2019s three basic health insurance schemes on the equity of health-related quality of life: using the method of coarsened exact matching

BackgroundChina has three basic health insurance schemes: Urban Employee Basic Medical Insurance (UEBMI), Urban Resident Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NRCMS). This study aimed to compare the equity of health-related quality of life (HRQoL) of residents under any two of the schemes.MethodsUsing data from the 5th National Health Services Survey of Shaanxi Province, China, coarsened exact matching method was employed to control confounding factors. We included a matched sample of 6802 respondents between UEBMI and URBMI, 34,169 respondents between UEBMI and NRCMS, and 36,928 respondents between URBMI and NRCMS. HRQoL was measured by EQ-5D-3L based on the Chinese-specific value set. Concentration index was adopted to assess health inequality and was decomposed into its contributing factors to explain health inequality.ResultsAfter matching, the horizontal inequity indexes were 0.0036 and 0.0045 in UEBMI and URBMI, 0.0035 and 0.0058 in UEBMI and NRCMS, and 0.0053 and 0.0052 in URBMI and NRCMS respectively, which were mainly explained by age, educational and economic statuses. The findings demonstrated the pro-rich health inequity was much higher for the rural scheme than that for the urban ones.ConclusionThis study highlights the need to consolidate all three schemes by administrating uniformly, merging funds pooling and benefit packages. Based on the contributing factors, strategies aim to facilitate health conditions of the elderly, narrow economic gap, and reduce educational inequity, are essential. This study will provide evidence-based strategies on consolidating the fragmented health schemes towards reducing health inequity in both China and other developing countries.

Geographic variation in health insurance benefits in Qianjiang District, China: a cross-sectional study

BackgroundHealth insurance contributes to reducing the economic burden of disease and improving access to healthcare. In 2016, the Chinese government announced the integration of the New Cooperative Medical Scheme (NCMS) and Urban Resident Basic Medical Insurance (URBMI) to reduce system segmentation. Nevertheless, it was unclear whether there would be any geographic variation in health insurance benefits if the two types of insurance were integrated. The aim of this study was to identify the potential geographic variation in health insurance benefits and the related contributing factors.MethodsThis cross-sectional study was carried out in Qianjiang District, where the NCMS and URBMI were integrated into Urban and Rural Resident Basic Medical Insurance Scheme (URRBMI) in 2010. All beneficiaries under the URRBMI were hospitalized at least once in 2013, totaling 445,254 persons and 65,877 person-times, were included in this study. Town-level data on health insurance benefits, healthcare utilization, and socioeconomic and geographical characteristics were collected through health insurance system, self-report questionnaires, and the 2014 Statistical Yearbook of Qianjiang District. A simplified Theil index at town level was calculated to measure geographic variation in health insurance benefits. Colored maps were created to visualize the variation in geographic distribution of benefits. The effects of healthcare utilization and socioeconomic and geographical characteristics on geographic variation in health insurance benefits were estimated with a multiple linear regression analysis.ResultsDifferent Theil index values were calculated for different towns, and the Theil index values for compensation by person-times and amount were 2.5028 and 1.8394 in primary healthcare institutions and 1.1466 and 0.9204 in secondary healthcare institutions. Healthcare-seeking behavior and economic factors were positively associated with health insurance benefits in compensation by person-times significantly, meanwhile, geographical accessibility and economic factors had positive effects (p < 0.05).ConclusionsThe geographic variation in health insurance benefits widely existed in Qianjiang District and the distribution of health insurance benefits for insured inpatients in primary healthcare institutions was distinctly different from that in secondary healthcare institutions. When combining the NRCM and URMIS in China, the geographical accessibility, healthcare-seeking behavior and economic factors required significant attention.

The effects of China's three basic health insurance schemes on the equity of health-related quality of life: a cross-sectional survey using coarsened exact matching

BackgroundFragmentation in health insurance schemes adversely affects health equity. To achieve universal health coverage by 2020, China has implemented comprehensive reforms to improve health insurance. China has three basic health insurance schemes: Urban Employee Basic Medical Insurance (UEBMI), Urban Resident Basic Medical Insurance (URBMI), and the New Rural Cooperative Medical Scheme (NRCMS). However, little research has compared the effects of different health insurance schemes on the equity of health-related quality of life. This study aimed to compare the equity of health-related quality of life of residents under any two of the schemes. MethodsOur analysis used cross-sectional survey data from the 5th National Health Services Survey of Shaanxi Province, China, with a coarsened exact matching method to control for confounding factors. We included a matched sample of 6802 respondents between UEBMI and URBMI, 34 169 respondents between UEBMI and NRCMS, and 36 928 respondents between URBMI and NRCMS. Health-related quality of life was measured by three-level EuroQol five-dimensions (EQ-5D-3L) based on the Chinese-specific value set. We adopted a concentration index to assess health equity and its contributing factors. In this study, the horizontal inequity index of health-related quality of life was obtained by removing the contributions of unavoidable variables (such as gender and age) from the overall concentration index of health-related quality of life. A positive (or negative) horizontal inequity index of health-related quality of life indicated pro-rich (or pro-poor) inequity. FindingsAfter matching, the mean EQ-5D utility scores were 0·9589 (SD 0·0036) and 0·9449 (0·0062) in UEBMI and URBMI, 0·9579 (0·0036) and 0·9473 (0·0016) in UEBMI and NRCMS, and 0·9505 (0·0055) and 0·9605 (0·0013) in URBMI and NRCMS, respectively. Horizontal inequity indexes were 0·0036 and 0·0045 in UEBMI and URBMI, 0·0035 and 0·0058 in UEBMI and NRCMS, and 0·0053 and 0·0052 in URBMI and NRCMS, respectively, which were mainly explained by age, educational and economic statuses. For example, between UEBMI and NRCMS, we found that age (52·15%), educational status (19·88%), and economic status (19·78%) made the largest contributions to explain the inequality of health-related quality of life for the insured residents of UEBMI. InterpretationOur findings highlight the need to consolidate all three schemes with uniform administration, merged funding pools, and matched benefit packages. Strategies to reduce the factors that contribute to health inequity (eg, to facilitate health conditions of elderly people, narrow the economic gap, and reduce educational inequity) are essential. This study will provide evidence-based strategies on consolidating the fragmented health schemes towards reducing health inequity in both China and other developing countries. FundingResearch Program of Shaanxi Soft Science (2015KRM117), National High-Level Talents Special Support Plan (“Thousands of People Plan”), Shaanxi Provincial Youth Star of Science and Technology in 2016, and the Basic Scientific Research Funding of Xi'an Jiaotong University (SK2015007).

Who benefits the most from basic health insurances? Income-related equity analysis for patients with chronic diseases in China

BackgroundTo relieve patients' financial burden, China has established three basic health insurances: Urban Employee Basic Medical Insurance (UEBMI), Urban Resident Basic Medical Insurance (URBMI), and the New Rural Cooperative Medical Scheme (NRCMS). However, because the insured rich have more opportunity to access health care, more subsidies might be paid to them rather than the poor. We analysed the income-related benefit equity of health insurance for patients with chronic diseases to investigate who benefits most from government health insurance in China. MethodsWe used data from the second phase of the China Health and Retirement Longitudinal Study (CHARLS), collected in 2013. Benefit incidence (use of inpatient care or not), benefit degree 1 (measured by subsidy paid by the basic health insurances for inpatients), and benefit degree 2 (measured by reimbursement paid by health insurances for all patients with chronic diseases, such as cancer, hypertension, and diabetes) were deployed to indicate the benefits from the health insurances. We used the decomposition of the concentration index to analyse income-related horizontal inequity of benefit incidence and benefit degree. FindingsThere were 9728 patients identified for the analysis. The benefit incidence for patients with chronic diseases were 15·42% for those covered by UEBMI, 11·99% for those covered by URBMI, and 12·73% for those covered by NRCMS, while the subsidies paid by the three health insurances for inpatients (benefit degree 1) were ¥6457, ¥3127, and ¥2718, respectively, and for patients with chronic diseases (benefit degree 2) were ¥860, ¥307, and ¥279, respectively. By decomposing the concentration index, the income-related horizontal inequities of benefit incidence were 0·0868 for UEBMI, 0·1904 for URBMI, and 0·1495 for NRCMS. The horizontal inequities of benefit degree 1 and benefit degree 2 were 0·1880 and 0·4194 for UEBMI, 0·1186 and 0·3764 for URBMI, and 0·0900 and 0·2862 for NRCMS. InterpretationWith same health-care needs, high-income patients with chronic diseases benefit more than low-income patients in each of China's basic health insurances. Improvement of benefit equity should be a concern of health insurance policy development. FundingResearch Program of Shaanxi Soft Science (2015KRM117), Shaanxi Provincial Youth Star of Science and Technology in 2016, Basic Scientific Research Funding of Xi'an Jiaotong University (SK2015007), National Program for Support of Top-Notch Young Professionals, China Medical Board (15-227).

Differences exist across insurance schemes in China post-consolidation.

BackgroundIn China, the basic insurance system consists of three schemes: the UEBMI (Urban Employee Basic Medical Insurance), URBMI (Urban Resident Basic Medical Insurance), and NCMS (New Cooperative Medical Scheme), across which significant differences have been observed. Since 2009, the central government has been experimenting with consolidating these schemes in selected areas. This study examines whether differences still exist across schemes after the consolidation.MethodsA survey was conducted in the city of Suzhou, collecting data on subjects 45 years old and above with at least one inpatient or outpatient treatment during a period of twelve months. Analysis on 583 subjects was performed comparing subjects’ characteristics across insurance schemes. A resampling-based method was applied to compute the predicted gross medical cost, OOP (out-of-pocket) cost, and insurance reimbursement rate.ResultsSubjects under different insurance schemes differ in multiple aspects. For inpatient treatments, subjects under the URBMI have the highest observed and predicted gross and OOP costs, while those under the UEBMI have the lowest. For outpatient treatments, subjects under the UEBMI and URBMI have comparable costs, while those under the NCMS have much lower costs. Subjects under the NCMS also have a much lower reimbursement rate.ConclusionsDifferences still exist across schemes in medical costs and insurance reimbursement rate post-consolidation. Further investigations are needed to identify the causes, and interventions are needed to eliminate such differences.

The quality of invasive breast cancer care for low reimbursement rate patients: A retrospective study

Though evidence-based treatments have been recommended for breast cancer, underuse of the treatments was still observed. To certain extent, patients’ access to care, which can be enhanced by increasing the coverage of health insurance, could account for the current underuse in recommended care. This study aimed to examine the association between different proportions of reimbursement and quality of recommended breast cancer care, as well as length of hospital stay. In this retrospective study, 3669 patients diagnosed with invasive breast cancer between 1 June, 2011 and 30 June, 2013 were recruited. Seven quality indicators from preoperative diagnosis procedures to adjuvant therapy and one composite indicator were selected as dependent variables. Logistic regression and generalized linear models were used to explore the association between quality of care and length of hospital stay with different reimbursement rates. Compared with UEBMI (urban employment basic medical insurance), which represented high level reimbursement rate, patients with lower rates of reimbursement were less likely to receive core biopsy, HER-2 (human epidermal growth factor receptor-2) testing, BCS (breast conserving surgery), SLNB (sentinel lymph nodes biopsy), adjuvant therapy and hormonal treatment. No significant difference in preoperative length of hospital stay was observed among the three insurance schemes, however URBMI (urban resident basic medical insurance) insured patients stayed longer for total length of hospital stay. Significant disparities in utilization of evidence-based breast cancer care among patients with different proportions of reimbursement were observed. Patients with lower rate of reimbursement were less likely to receive recommended care. Our findings could provide important support for further healthcare reform and quality improvement in breast cancer care.

Development and enrolee satisfaction with basic medical insurance in China: A systematic review and stratified cluster sampling survey.

Basic Medical Insurance (BMI) has changed remarkably over time in China because of health reforms that aim to achieve universal coverage and better health care with adequate efforts by increasing subsidies, reimbursement, and benefits. In this paper, we present the development of BMI, including financing and operation, with a systematic review. Meanwhile, Pudong New Area in Shanghai was chosen as a typical BMI sample for its coverage and management; a stratified cluster sampling survey together with an ordinary logistic regression model was used for the analysis. Enrolee satisfaction and the factors associated with enrolee satisfaction with BMI were analysed. We found that the reenrolling rate superficially improved the BMI coverage and nearly achieved universal coverage. However, BMI funds still faced dual contradictions of fund deficit and insured under compensation, and a long-term strategy is needed to realize the integration of BMI schemes with more homogeneous coverage and benefits. Moreover, Urban Resident Basic Medical Insurance participants reported a higher rate of dissatisfaction than other participants. The key predictors of the enrolees' satisfaction were awareness of the premium and compensation, affordability of out-of-pocket costs, and the proportion of reimbursement. These results highlight the importance that the Chinese government takes measures, such as strengthening BMI fund management, exploring mixed payment methods, and regulating sequential medical orders, to develop an integrated medical insurance system of universal coverage and vertical equity while simultaneously improving enrolee satisfaction.

Rural\u2013urban difference in the use of annual physical examination among seniors in Shandong, China: a cross-sectional study

BackgroundRegular physical examination contributes to early detection and timely treatment, which is helpful in promoting healthy behaviors and preventing diseases. The objective of this study is to compare the annual physical examination (APE) use between rural and urban elderly in China.MethodsA total of 3,922 participants (60+) were randomly selected from three urban districts and three rural counties in Shandong Province, China, and were interviewed using a standardized questionnaire. We performed unadjusted and adjusted logistic regression models to examine the difference in the utilization of APE between rural and urban elderly. Two adjusted logistic regression models were employed to identify the factors associated with APE use in rural and urban seniors respectively.ResultsThe utilization rates of APE in rural and urban elderly are 37.4% and 76.2% respectively. Factors including education level, exercise, watching TV, and number of non-communicable chronic conditions, are associated with APE use both in rural and urban elderly. Hospitalization, self-reported economic status, and health insurance are found to be significant (p < 0.05) predictors for APE use in rural elderly. Elderly covered by Urban Resident Basic Medical Insurance (URBMI) (p < 0.05, OR = 1.874) are more likely to use APE in urban areas.ConclusionsThere is a big difference in APE utilization between rural and urban elderly. Interventions targeting identified at-risk subgroups, especially for those rural elderly, are essential to reduce such a gap. To improve health literacy might be helpful to increase the utilization rate of APE among the elderly.

Does non-employment based health insurance promote entrepreneurship? Evidence from a policy experiment in China

Previous researchers have shown that employment-based health insurance lowers job mobility and deters entrepreneurship. The Urban Resident Basic Medical Insurance (URBMI) program, piloted in 2007 in China and fully established in 2009, offers health insurance to about 271 million urban residents without formal employment. Before the implementation of URBMI, most urban residents obtained health insurance through their employers, and therefore a large number of unemployed and self-employed individuals were uninsured. Thus, URBMI creates a new insurance option that does not depend on formal employment and may promote entrepreneurship. We take advantage of this policy change to evaluate the effect of URBMI on self-employment. Using 2000–2011 data from the China Health and Nutrition Survey and a difference-in-differences approach with propensity score weighting, we found that URBMI increased self-employment rate by at least 8.73% for the overall population. The result was mainly driven by the URBMI’s impact on unhealthy workers, individuals with 12 years of schooling or less, and workers above 30 years old.

Demand and Signing of General Practitioner Contract Service among the Urban Elderly: A Population-Based Analysis in Zhejiang Province, China.

This study aims to examine whether the urban elderly in the Zhejiang Province of China signed contracts with their general practitioner (GP) based on their health service needs, and to further identify the determinants of their demand and signing decisions. A community-based cross-sectional study was conducted in 16 community health service (CHS) institutions in Zhejiang Province, China. The urban elderly over 60 years of age were enrolled when visiting the sampled CHS. Baseline characteristics were compared between participants using Chi-Square tests for categorical variables. Univariate and multivariable logistic regression analyses were used to identify determinants of the GP contract service demand and signing decisions, respectively. Among the 1440 urban elderly, 56.67% had signed contracts with their GP, and 55.35% had a demand of the GP contract service. The influencing factors of demand were a history of diabetes or cardiovascular disease (OR = 1.33, 95% CI, 1.05–1.68); urban resident basic medical insurance (URBMI) vs. urban employee basic medical insurance (UEBMI) (OR = 1.96, 95% CI, 1.46–2.61); and middle-income vs. low-income (OR = 0.67, 95% CI, 0.50–0.90 for RMB 1001–3000; OR = 0.59, 95% CI, 0.39–0.90 for RMB 3001–5000). Having a demand for the GP contract service was the strongest determinant of signing decisions (OR = 13.20, 95% CI, 10.09–17.27). Other factors also contributed to these decisions, including gender, caregiver, and income. The urban elderly who had signed contracts with GPs were mainly based on their health care needs. Elderly people with a history of diabetes or cardiovascular disease, as well as those with URBMI, were found to have stronger needs of a GP contract service. It is believed that the high-income elderly should be given equal priority to those of low-income.

Chinese health care system and clinical epidemiology.

China has gone through a comprehensive health care insurance reform since 2003 and achieved universal health insurance coverage in 2011. The new health care insurance system provides China with a huge opportunity for the development of health care and medical research when its rich medical resources are fully unfolded. In this study, we review the Chinese health care system and its implication for medical research, especially within clinical epidemiology. First, we briefly review the population register system, the distribution of the urban and rural population in China, and the development of the Chinese health care system after 1949. In the following sections, we describe the current Chinese health care delivery system and the current health insurance system. We then focus on the construction of the Chinese health information system as well as several existing registers and research projects on health data. Finally, we discuss the opportunities and challenges of the health care system in regard to clinical epidemiology research. China now has three main insurance schemes. The Urban Employee Basic Medical Insurance (UEBMI) covers urban employees and retired employees. The Urban Residence Basic Medical Insurance (URBMI) covers urban residents, including children, students, elderly people without previous employment, and unemployed people. The New Rural Cooperative Medical Scheme (NRCMS) covers rural residents. The Chinese Government has made efforts to build up health information data, including electronic medical records. The establishment of universal health care insurance with linkage to medical records will provide potentially huge research opportunities in the future. However, constructing a complete register system at a nationwide level is challenging. In the future, China will demand increased capacity of researchers and data managers, in particular within clinical epidemiology, to explore the rich resources.

Undiagnosed and Uncontrolled Chronic Conditions in China: Could Social Health Insurance Consolidation Make a Change?

Policy makers in China are considering consolidating the country's fragmented health insurance programs. This system consists of three components. The Urban Employee Basic Medical Insurance (UEBMI) covers formal employees, the New Cooperative Medical Scheme (NCMS) covers rural residents, and the Urban Resident Basic Medical Insurance (URBMI) covers urban residents. Consolidation could, in theory, create a more efficient health system that is better able to address noncommunicable diseases. Using national survey data during 2011 to 2013, I found that 44% to 76% cases of hypertension, diabetes, and dyslipidemia went undiagnosed among Chinese adults aged 45 and older. I found that the UEBMI enrollees had a greater number of health checks and 10% higher rates of diagnosis. Assuming that this level of efficiency would be possible under an integrated system, I conducted microsimulation analyses to project future benefits. Such consolidation could result in 46.2 million new diagnoses, and 30.0 million of these cases would be controlled.

Analysis of inpatient payments of breast cancer patients with different medical insurance coverages in China (mainland) in 2011-2015.

An understanding of the levels and trends of medical cost is made for breast cancer patients with different medical insurance coverages in China (mainland), in an attempt to offer a clue to further control the costs. The inpatient payments of 9,716,180 breast cancer patients spent in medical institutions of different types and grades during 2011-2015 were collected from the inpatient medical record home page (IMRHP) dataset. The data were then processed with SAS (Version 9.3; SAS Institute, Cary, NC, USA). Indicators like means, increase (decrease) percentages were used to descriptively analyze the average hospitalization expense of each time (AHEET) and its trends of breast cancer patients with different medical insurance coverages treated in medical institutions of different types and grades. In 2011-2015, the AHEET borne by breast cancer patients in China had been constantly increasing. Specifically, the self-pay inpatients had the largest increase, inpatients covered by Urban Employee Basic Medical Insurance (UEBMI) and Urban Resident Basic Medical Insurance (URBMI) were the next, and those covered by New Rural Cooperative Medical System (NRCMS) had the least increase. Breast cancer inpatient treated in public hospitals had quite greater increase and higher expenditure level than those in private hospitals. The AHEET borne by the inpatients in Grade 3 hospitals had greater increase and higher cost than those in Grade 2 hospitals. The inpatient payments of breast cancer patients will be wisely controlled by reducing the number of self-pay inpatients, taking advantage of restriction mechanism of the medical insurances, and promoting healthy competition between private hospitals and public hospitals. The economic burden imposed on the society by breast cancer can be relieved through further control of inpatient payments of UEBMI- and URBMI-covered breast cancer patients and of Grade 3 hospitals.

Age or health status: which influences medical insurance enrollment greater?

BackgroundThe New Cooperative Medical Scheme (NCMS) for peasantries implemented in 2003 and the Urban Resident Basic Medical Insurance (URBMI) for the urban unemployed implemented in 2007 have many similarities. They both apply the financing mode of individual premiums plus government’s subsidies, and the voluntary enrollment. The Chinese government plans to integrate these two systems and build a unified basic medical insurance system for the unemployed in order to achieve the medical equity and increase the general health level. Thus, to analyze the main influencing factors of the enrollment of the urban unemployed and rural residents is very important for improving the system and securing the stability of the system during the transition.MethodsThe study uses data from the China Health and Nutrition Survey (CHNS) and adopts logistic regression models to test which factors influence the enrollment of the URBMI and the NCMS under the background of rather high enrollment rate of Chinese basic medical insurances and strong fiscal support of the Chinese government, especially whether health status or age influences enrollment of these two insurances greater.ResultsThere is indeed some adverse selection in the URBMI and the NCMS. Whether the individual has chronic diseases have significant influence on enrollments of both the urban unemployed and rural residents, while whether the individual got ill in last four weeks just influences enrollments of the urban unemployed. Age influences enrollment greater than health status. The older the insured are, the larger the enrollment rates are.ConclusionBecause of the active support for basic medical insurances of the Chinese government, the enrollment performance of the urban unemployed and rural residents has already changed. When implementing the new policy, the government should pay attention to the willingness to enroll in and the change of enrollment performance of the insured. Therefore, under the policy of voluntary enrollment, every coordinated province and city should enlarge the proportion of young people to insuring group, optimizing the age structure, and the financing proportion of governments and individuals should be measured properly. With the increasing of governments’ subsidies, the proportion of individual’s premiums should also be increased.

Health insurance and quality and efficiency of medical care for patients with acute myocardial infraction in tertiary hospitals in Shanxi, China: a retrospective study

BackgroundPrevious studies have shown that health insurance type affects patient outcomes, but empirical research on the effect of health insurance on quality and efficiency of care in China is scarce. This study aimed to determine whether there are health insurance-related differences in hospital care for acute myocardial infraction. MethodsPatients with a principal diagnosis of acute myocardial infraction were identified from inpatient discharge records of 27 tertiary hospitals in Shanxi, China from September 1, 2013, to October 31, 2014. Patients were classified into four health insurance categories: Urban Employee Basic Medical Insurance (UEBMI), Urban Residents Basic Medical Insurance (URBMI), the New Rural Cooperative Medical Scheme (NCMS), or uninsured (out-of-pocket). The outcomes of interest were in-hospital mortality, length of stay, and total cost. Multilevel logistic regression was applied for in-hospital mortality, and multilevel linear regression for log transformed LOS and total cost. All models were adjusted for patient and hospital characteristics. Limited information from patient medical records was extracted from a database and all records were anonymised. As such, no ethical approval was required for this study. FindingsWe analysed records for 9075 patients. Compared with UEBMI group, in-hospital mortality was significantly lower for NCMS group (OR 0·613 [95% CI 0·438–0·859]) and uninsured group (0·477 [0·281–0·810]). Excluding patients who died during hospitalisation, compared with UEBMI group length of stay was shorter in the URBMI (coefficient of variable, −0·074 [95% CI −0·115 to −0·034]), NCMS (−0·116 [–0·139 to −0·093]) and uninsured (−0·146 [–0·177 to −0·114]) groups and total cost was lower in the URBMI (−0·067 [–0·130 to −0·004]), NCMS (−0·118 [–0·154 to −0·082]) and uninsured (−0·115 [–0·165 to −0·066]) groups. InterpretationFor patients hospitalized for acute myocardial infarction, health insurance type is significantly associated with quality and efficiency of care under current health policies in Shanxi, China. The underlying mechanism justifying this association should be explored further. FundingNone.