DOI: https://doi.org/10.21203/rs.2.21703/v3
After years of development, China's medical security system had gradually established a New Rural Cooperative Medical System(NRCMS), which was a system arrangement for rural residents[1]. The establishment of the NRCMS had alleviated the burden of medical expenses of rural residents in China, but the reimbursement for high medical expense was insufficient [2]. In order to further improve the reimbursement level of rural residents, China has established a Serious Illness Medical Insurance System(SIMIS) on the basis of NRCMS. There are two forms of payment: the first one is to pay for the high expense in proportion to the expenses exceeding the specified amount after the payment of NRCMS; the second one is to pay for some diseases in proportion after the payment of NRCMS. In this study, people who enjoy SIMIS were collectively referred to as serious illness patients.
There were few empirical studies on the reimbursement effect of China's SIMIS, which focused more on the payment of SIMIS and lack of analysis of patients' out of pocket costs. Based on the inpatient reimbursement data of NRCMS from 2013 to 2016 after the implementation of SIMIS provided by Jinzhai medical insurance management center of Anhui Province, this study analyzed the policy effect after the implementation of SIMIS and provided basis for policy adjustment.
Jinzhai County is located in the west of Anhui Province, China, with a registered population of 683,000 in 2017, including 572,000 in rural areas. There were about 40,000 poverty people in rural areas, of which about 20,000 were due to illness [3]. Therefore, it was very important to established medical security for rural residents to reduce poverty. Jinzhai County had gradually established a multi-level medical security system composed of NRCMS, SIMIS and other policies to prevent residents from poverty due to illness by improving the basic medical institutions [4]. Jinzhai County's SIMIS adopted the first form of payment for high expenses and the payment mode was as follows (Figure 1):
The total medical expense can be divided into two parts: Inside medical insurance part and outside medical insurance part.
1.Inside medical insurance: NRCMS payment and SIMIS payment.
2.Outside medical insurance: total self-payment which the medical insurance cannot be reimbursement.
This study intent to use two methods to analyze the reimbursement effect of SIMIS.
First, descriptive analysis was carried out on the inpatient situation of the serious illness patients, describing the different types of inpatient expenses and reimbursement situation in the year, and analyzing the reimbursement effect. In this paper, the hospitalization types could be divided into five categories: County hospitalization refers to the inpatient in Jinzhai County, City hospitalization refers to the inpatient outside Jinzhai County and in Lu'an City, Provincial hospitalization refers to the inpatient outside Lu'an City and in Anhui Province, and outside Anhui Province hospitalization refers to the inpatient outside Anhui Province, and cross regional hospitalization refers to the inpatient cross regional.
Second, the regression discontinuity (RD) method [5,6,7] was used to analyze the relief of medical expenses of rural residents after the implementation of SIMIS. RD method made use of the discontinuous characteristics of policy, that was, when the specific index of the research object was greater than the critical value specified by the policy, it would be treated by the policy, and the critical value was the breakpoint (C). As the policy of SIMIS in Jinzhai was to compensate the inpatients whose annual serious illness expenses were more than CNY 20,000, we could choose C = CNY 20,000 as the breakpoint in this study. The subjects whose annual serious illness expenses was more than CNY 20,000 would be included in the experimental group, and the subjects whose annual serious illness expenses was less than or equal to CNY 20,000 would be included in the control group. It could be considered that the basic situation of the objects near the breakpoint was similar. Whether they could enjoy the compensation treatment of SIMIS was the result of the random allocation of policies and systems. It could be regarded as a quasi-experiment. Because of the existence of random grouping, the average treatment effect of SIMIS near the breakpoint can be estimated.
In this study, STATA 15.0 RD statistical software package was used for data statistical analysis. The analysis process was as follows:
For the possibility of endogenous grouping, this study used the method proposed by McGrary (2008) [9]to test whether the density function of grouping variable was discontinuous at the breakpoint. First, the grouping variables were subdivided equidistantly on both sides of breakpoint C, the group distance was B, the center position of each group was noted as variable Xj, and then the standardization frequency of each group was calculated, which was noted as Yj. By using trigonometric kernel and local linear regression on both sides of breakpoint C, the estimated value and standard error of density function could be obtained according to the value of grouped variable. By comparing the estimated values of the density function at the breakpoint, we could judge whether the density function was continuous at the breakpoint.
In addition, if the conditional density function of covariates at breakpoint C also had a jump, it was not appropriate to attribute all policy effects to the implementation of policies. In fact, the implicit assumption of RD was that the conditional density of covariates was continuous at the breakpoint. In order to test this hypothesis, we took each covariate as the dependent variable and the serious illness expenses as the independent variable, and then carried out RD again to investigate whether there was a jump in its distribution at the breakpoint.
Table1 Basic information of variables
Variable |
Variable definition |
C≤20,000(n=5984) |
C>20,000(n=1370) |
||
Mean |
SD |
Mean |
SD |
||
Dependent variable (%) |
|||||
AMIPP |
Proportion of total medical insurance payment to total medical expenses |
48.16 |
13.52 |
51.93 |
11.47 |
IMIPP |
Proportion of total medical insurance payment to total inside medical insurance expenses |
59.48 |
13.19 |
61.39 |
11.93 |
IMSPP |
Proportion of inside medical insurance self-payment to total expenses |
32.69 |
11.96 |
32.81 |
11.14 |
OMISPP |
Proportion of outside medical insurance self-payment to total expenses |
19.15 |
10.99 |
15.26 |
10.71 |
Independent variable (grouping variable) |
|||||
Serious illness expenses |
Total of ceiling self-payment,Clinical Necessary treatment cost,self-payment under the NRCMS |
1.38 |
0.27 |
2.41 |
0.28 |
Covariates |
|||||
Age |
Age of inpatients |
49.82 |
18.39 |
50.45 |
17.15 |
Hospital stay |
Length of hospital stay |
23.26 |
29.38 |
26.46 |
36.34 |
Total expenses |
Total annual inpatient medical expenses |
4.78 |
2.42 |
7.49 |
3.27 |
Gender |
Female=1 |
0.58 |
0.49 |
0.57 |
0.49 |
Inpatient type |
Inpatient grade(1-5) |
4.06 |
1.06 |
4.24 |
1.16 |
Sample
The research data came from the medical insurance management center of Jinzhai County, Anhui Province, covering the individual annual hospitalization reimbursement data of NRCMS from 2013(n=73,042) to 2016 (n=73,571 in 2014, n=75330 in 2015, n=71928 in 2016), the use of data had been approved by Jinzhai County. Case information included: basic information of inpatients, hospitalization and medical expenses payment. In order to better analyze SIMIS reimbursement effect, we merged the four-year data (2013-2016, n=293871) for analysis.
According to the research idea, RD focused on the objects near both sides of the breakpoint. In order to ensure the same span on both sides of the breakpoint, we selected the patients from the merged data of 2013-2016 whose serious illness expenses was between CNY 10,000 and CNY 30,000 as the analysis objects (n=1553 in 2013, n=1797 in 2014, n=2147 in 2015, n=1856 in 2016, total n = 7353). And descriptive analysis of SIMIS reimbursement objects (n=468 in 2013, n=535 in 2014, n=831 in 2015, n=886 in 2016, total n = 2720) from the merged data of 2013-2016. Table 2 showed the distribution of serious illness expenses from 2013 to 2016.
Table 2 Distribution of serious illness expenses in Jinzhai County from 2013 to 2016
Expenses |
Frequency |
Frequency ratio(%) |
0.0 ~ |
285501 |
97.15 |
1.0~ |
5983 |
2.03 |
2.0 ~ |
1370 |
0.47 |
3.0 ~ |
493 |
0.17 |
4.0 ~ |
221 |
0.08 |
5.0 ~ |
303 |
0.10 |
SIMIS payment
Table 3 showed the descriptive statistics of serious illness patients in Jinzhai county.
The serious illness patients were often transferred to other hospitals in different regions. The average number of annul hospitalization was 3.64. The annual average medical expenses for serious illness patients were CNY 96,100, annual average NRCMS payment was CNY 48,000, annual average SIMIS payment was CNY 7,600, annual average inside medical insurance self-payment was CNY 26,200, annual average outside medical insurance self-payment was CNY 14300. The average annual expenses of inpatients at County was CNY 86,500,City was CNY 91,100, Province was CNY 90,500, Outside province was CNY 97,600, Cross regional was CNY 97,400. The proportion of NRCMS payment to the total medical expenses was 49.90%, proportion of SIMIS payment to the total medical expenses was 7.92%, inside medical insurance self-payment to the total medical expenses was 27.26%, outside medical insurance self-payment to the total medical expenses was 14.92%.
Table3 Annual average inpatients expenses of seriously illness patients in Jinzhai County from 2013 to 2016
Items |
Total |
County |
City
|
Province |
Outside province |
Cross regional |
Hospitalization |
||||||
proportion(%) |
100 |
2.08 |
5.61 |
12.23 |
27.57 |
52.51 |
Annual per capita hospital stays |
3.64(2.72) |
1.73(1.65) |
2.26(1.96) |
2.12(1.65) |
2.58(2.41) |
4.77(2.66) |
Medical expenses(CNY Ten thousand) |
||||||
NRCMS payment |
4.80(3.01) |
5.11(3.01) |
5.09(3.09) |
4.83(2.83) |
4.33(3.38) |
4.99(2.79) |
SIMIS payment |
0.76(0.11) |
0.55(1.40) |
0.60(0.83) |
0.57(0.63) |
0.87(1.50) |
0.76(0.96) |
Inside medical insurance self-payment |
2.62(1.17) |
2.33(1.16) |
2.35(0.90) |
2.36(0.72) |
2.78(1.28) |
2.61(1.01) |
Outside medical insurance self-payment |
1.43(1.37) |
0.66(0.57) |
1.07(0.42) |
1.31(1.19) |
1.77(2.36) |
1.37(1.98) |
Total |
9.61(5.77) |
8.65(4.58) |
9.11(4.67) |
9.05(4.62) |
9.76(7.59) |
9.74(4.97) |
Payment proportion (%) |
||||||
NRCMS payment |
49.90(10.46) |
59.08(16.25) |
55.89(9.09) |
53.34(9.37) |
44.41(10.86) |
51.30(9.21) |
SIMIS payment |
7.92(5.49) |
6.36(5.00) |
6.57(5.20) |
6.03(4.80) |
8.96(5.93) |
7.85(5.32) |
Inside medical insurance self-payment |
27.26(10.85) |
26.94(18.49) |
25.80(9.35) |
26.07(9.95) |
28.52(11.64) |
26.79(10.36) |
Outside medical insurance Self-payment |
14.92(11.06) |
7.63(7.76) |
11.73(9.22) |
14.56(10.76) |
18.11(11.50) |
14.06(10.92) |
Note: the values inside and outside the brackets represent the mean and standard deviation respectively.
Analysis of RD
SIMIS effect
Table 4 showed the estimated effect of policy treatment. In the absence of covariates, the lwald estimate of the actual medical insurance payment proportion (AMIPP) at the breakpoint was 0.025, which was significant at the level of 1%. Figure 2 showed that the reimbursement on the right side of the breakpoint was slightly higher than that on the left side, indicating that the implementation of SIMIS has improved the actual payment level, about 2.5%. The lwald estimate of the inside medical insurance payment proportion (IMIPP) was 0.020, Figure3 showed that the reimbursement on the right side of the breakpoint was slightly higher than that on the left side, indicating that the implementation of SIMIS had improved the actual payment level to some extent, about 2%, but slightly lower than the actual payment level of medical insurance. The lwald estimate of inside medical insurance self-payment proportion (IMSPP) was -0.006, and it's not significant, Figure 3 showed that the level of self-payment inside medical insurance was almost the same on the left and right sides of the breakpoint, indicating that the implementation of SIMIS has little impact on the level of self-payment inside medical insurance. The lwald estimate of outside medical insurance self-payment proportion (OMISPP) was -0.016, which was significant at the level of 5%, Figure 3 showed that the level of self-payment outside medical insurance on the right side of the breakpoint was slightly lower than that on the left side of the breakpoint, indicating that the implementation of SIMIS reduced the level of self-payment outside medical insurance to a certain extent, about 1.6%. After adding covariates, the results of RD were consistent.
Table 4 RD results of SIMIS
lwald |
AMIPP (H=0.6581) |
IMIPP (H=0.5345) |
IMSPP (H=0.5949) |
OMISPP (H=1.079) |
Not add Covariate |
0.025***(0.010) |
0.020*(0.011) |
-0.006(0.009) |
-0.016**(0.006) |
Add covariates |
0.022***(0.008) |
0.014**(0.006) |
-0.006(0.009) |
-0.011**(0.005) |
Note: * * * * represents significant at the level of 1%, * * represents significant at the level of 5%, and * represents significant at the level of 10%. H represents the optimal bandwidth. The value in brackets is SD of lwald.
Validity test
Independent variable continuity test
McGrary (2008) method was used to test whether the probability density function of independent variable was continuous at the breakpoint. The results showed θ=-0.054, standard error was 0.11, so the assumption of continuity of independent variable density function at the breakpoint could be accepted. Figure 5 showed that the confidence intervals of the estimated values of the independent variable probability density functions on both sides of the breakpoint were mostly overlapped, indicating that patients were randomly assigned on both sides of the breakpoint, and there was no endogenous grouping problem.
Table 5 showed that the estimated value lwald was not significant for Age, Gender, Hospital stay,
Total expenses, Gender and Inpatient type, which showed that the effect of SIMIS had no impact on covariates, and the policy effect could be attributed to the implementation of SIMIS.
Table 5 Covariate continuity test results
lwald |
AMIPR H=0.6581 |
IMIPR H=0.5345 |
IMSPR H=0.5949 |
OMISPR H=1.079 |
Age |
1.690(14.516) |
3.008(16.197) |
2.355(15.300) |
-2.93(11.38) |
Total expenses |
606.16(1971.54) |
1209.01(2135.78) |
968.03(2045.23) |
-907.36(1581.57.) |
Hospital stay |
0.943(2.897) |
2.082(3.241) |
1.433(3.058) |
2.176(2.225) |
Inpatient type |
-0.041(0.083) |
-0.033(0.094) |
-0.037(0.089) |
-0.052(0.066) |
Gender |
0.035(0.039) |
0.031(0.043) |
0.0358(0.041) |
0.035(0.030) |
Note: The dependent variables are age, total expenses, hospital stay, inpatient type and gender. The independent variables are serious illness expenses. The value outside the bracket is the estimated value of lwald, and the value inside the bracket is the estimated value of standard error.
The RD results showed that the SIMIS has improved the AMIPP and IMIPP. The treatment effect values(lwald) were 0.025 and 0.020 respectively, the proportion of payments increased by only 2.5% and 2%. It could also be seen from the figure that the gap between the two sides of the breakpoint was not very large after the implementation of SIMIS. Although the SIMIS reduced the actual out of pocket expenses of patients, the descriptive results showed that the reimbursement of serious illness patients was more from the NRCMS. The average annual NRCMS payment was CNY 48,000, and the SIMIS payment was CNY 7,600. The SIMIS reimbursement accounts for about 14% of the total reimbursement. The average annual actual out of pocket expenses were about CNY 40,500. In 2016, the average annual income of rural families in Anhui Province was about CNY 32,000[10], which meant that the annual income of serious illness patients’ families was lower than the actual self-paid medical expenses. And the SIMIS cannot play a role in preventing the catastrophic health expenditure of the people. In addition, the study found that the SIMIS reduced the OMISPR at the breakpoint, and the treatment effect value was - 0.0016, self-payment decreased by about 1.6%. It could be seen from the figure that the gap between the two sides of the breakpoint was very small, indicating that although the coverage of the SIMIS has been expanded compared with that of the NRCMS, but the range was small The per capita outside medical insurance for the serious illness patients was about CNY 14300, which was relatively high. This study also found that the inpatients who enjoy the compensation of SIMIS account for about 0.93% of the total inpatient population, with a narrow range of benefits.
The study found that about 45.41% of the serious illness patients in rural areas directly chose to be hospitalized outside Jinzhai County, about 52.51% of the patients chose to be transferred to hospitals outside the county. There were two explanations for the results. On the one hand, it may be related to the fact that the medical level in Jinzhai County cannot meet the medical needs of seriously illness patients; on the other hand, it may be related to the fact that there were more migrant workers in Jinzhai County. The study found that annual per capita hospital stays of serious illness patients was 3.64, and the annual per capita hospital stays across regions was 4.77. The results may be related to the fact that most of the serious illness patients were chronic and critically ill.
In addition, the study found that the NRCMS payment were related to the type of hospitalization. The result was related to the policy orientation of medical insurance, that was, the reimbursement for hospitalization in different places was lower than that of hospitalization in local areas, so as to guide patients to seek medical treatment in local areas. However, serious illness patients chose to go to hospital outside the county more, which showed that the guidance of NRCMS had little impact on patients with serious illness. It can be concluded that serious illness patients pay more attention to the level of medical technology rather than the economic condition. Some research results also showed that most of the rural patients who chose to go out to see a doctor have better economic condition, so they paid more attention to the level of hospital medical technology [11,12]. It was reported that about 22% of rural residents in Jinzhai County work across provinces all the year round [13]. Meanwhile, relevant research showed that the economic condition of migrant workers was relatively good, which may also lead to more patients choose to go to different places for medical treatment [14]. Therefore, it could be considered that people with better economic conditions were more likely to enjoy the SIMIS, while patients with poor economic conditions may choose not to see a doctor, which also causes unfairness to some extent [15,16].
Although this study analyzed the payment effect of SIMIS, there were still some limitations. RD only used part of the data on both sides of breakpoint to analyze the effect of SIMIS on relieving rural residents' economic burden, so it only reflected the policy effect near breakpoint. In addition, due to the fact that some of the poverty-stricken people determined by china have a serious illness expense higher than CNY 5000 could enjoy the SIMIS payment. It may affect the results of RD analysis, but the number of poverty people was very small, the impact on the results was limited.
As a further policy arrangement to alleviate the economic burden of patients with high medical expenses, the SIMIS has increased the reimbursement amount for some patients with high medical expenses. However, the local medical technology level of Jinzhai County cannot meet the needs of medical services for seriously ill patients, the range of beneficiaries of SIMIS was small, the ability to alleviate the economic burden o of rural residents was limited, and the high out of pocket medical expenses increased the possibility that people with better economic conditions can enjoy the reimbursement of SIMIS, resulting in inequity. Therefore, the policy of SIMIS should reduce the threshold payment, expand the scope of payment, improve the accuracy of payment, and promote the fairness of payment.
NRCMS: New Rural Cooperative Medical System
SIMIS: Serious Illness Medical Insurance System
AMIPP: Actual Medical Insurance Payment Proportion
IMIPP: Inside Medical Insurance Payment Proportion
IMSPP: Inside Medical Insurance Self-Payment Proportion
OMISPP: Outside medical insurance Self-Payment proportion
RD: Regression Discontinuity
Consent for publication
Not applicable
Ethics approval and consent to participate
This study did not involve personal data survey, and the analysis data which was related to reimbursement came from the medical insurance management center of Jinzhai county. The use of data had been approved by Jinzhai County. The data used in this study only uses the medical consumption of patients, and dose not include personal information.
Availability of data and materials
The data used in this study was authorized by Jinzhai medical insurance bureau and signed a confidentiality agreement with Jinzhai medical insurance bureau. The source data cannot be used publicly. All data generated or analyzed during this study are included in this published article [and its supplementary information files].
Competing interests
The authors declare that they have no competing interests.
Funding
This publication was funded by the National Natural Science Foundation of China (grant no. 71603270), Shanghai 3-Year Action Plan for Public Health System Construction (SCREENING STUDY GWIV-18) and Key projects of philosophy and social sciences of Education Ministry of China(16JZD022). The funder had no role in the study’s design, data collection, or analysis, the decision to publish or the preparation of the manuscript.
Authors’ Contributions
YL, FD contributed equally to this work. Obtained the funding: PX. Conceived and designed the experiments: YL, FD. Performed the experiments, analyzed the data, and contributed reagents/materials/analysis tools: YL , PX. Drafted the manuscript: YL. All authors participated in discussion, revision and approved of the final manuscript.
Acknowledgements
We are grateful for the enthusiastic cooperation of the insurance management center of Jinzhai County, Anhui Province.
Authors’ information
Yang Li, Department of Health Service, Second Military Medical University, Shanghai 200433, China
Guangfeng Duan, Department of Health Service, Second Military Medical University, Shanghai 200433, China
Linping Xiong, Department of Health Service, Second Military Medical University, Shanghai 200433, China