For households facing catastrophic health payments, the country’s health care system was emphasized as a key instrument in reducing the family burden and reliance on out-of-pocket payment against catastrophic health expenditure. One of the NRCMS’s key objectives is to secure the access to universal health care at an affordable price and to relieve impoverishment through protection for households under coverage health care systems effectively. The study indicated the following five significant factors.
1.Prices of drugs
Most NRCMS participants thought the price of drugs was much higher in the designated health institutions even after reimbursement under NRCMS than that in private drug stores, and the quality of provided service under NRCMS was not satisfying as well, leading to the phenomenon confirmed by the health managers and providers that individuals lose faith in the program and prefer to choose private drug stores. Table 5 introduces the relationship between the consumer price index (CPI) of rural population and the average medicine expense index for inpatients and outpatients. According to the table, from 2007 to 2015, average medicine expense index for inpatients increases 38.9% and average medicine expense index for outpatients increases 60.4%, both of the amplification greatly higher than CPI. Although in 2013 the medicine expense decreases for the first time, the increasing examination fees lead to a rise of total expense per capita, from CN¥ 4,729.4 to CN¥ 4,968.3.
Most members of NRCMS complained that the actual proportion of reimbursement was much lower than the publicized proportion of reimbursement when seeking hospitalization subsidies from the program. First, most of the enrollees are located within the home county and expected to seek medical services in the designated hospitals. Since the reimbursement rate is much lower in municipal medical institutions than that in rural areas, the phenomenon of criticizing NRCMS from the migrant workers is more obvious. This limits their NRCMS benefits. Secondly, as mentioned before, NRCMS policy mainly reimburses cost of hospitalization and medical expenses of inpatients rather than outpatient fees, surgical fees in medical care. According to most members who have ever enjoyed the hospitalization subsidies from NRCMS, the corresponding actual proportion of reimbursement is far less than the previously expected proportion of reimbursement. Thirdly, besides the low reimbursement rate of the program, the medical expenses are 2-3 times than the actual ones, indicating that it is necessary to standardize the doctors ’ behaviors on providing medical services and to improve the professional ethics of doctors by formulating relevant policies in the hospitals.
It was universally acknowledged by most NRCMS members, NRCMS managers and health providers that the reimbursement procedure of NRCMS was very complicated and inconvenient for vast majority of enrollees but it has been simplified in most designated health facilities[21, 22]. NRCMS reimbursement offices were set up in most designated health facilities. The members of the program can hold relevant certificates and then get reimbursement in these local health facilities immediately after they have paid for their health service, which tremendously leaves out many complicated intermediate procedures and saves a large amount of manpower and resources. But for migrant workers who move to other provinces, they have to return to their own local management center of new cooperative medical care units, bringing relevant certificates for examination and verification of reimbursement. The migrant workers can only get treatment elsewhere when it is approved by the local cooperative medical management center. Even worse, some outlanders have to bribe the staff in NRCMS office to get their medical expenditure reimbursed. What’s more, the reimbursement rate in other provinces is much lower than that in the local areas when seeing for medical services in their local healthcare facilities. We are hoping that in the near future, enrollees can just pay the corresponding copayment part without paying the full cost in advance and the medical circumstances can be further improved for migrant workers, thus can essentially remove the financial burden for the poor households, resolve the difficulties for enrollees to apply for reimbursement and improve the sustainability of the program.
4.The medical technology of the hospital
Obviously, the medical technology has a great influence on the overall satisfaction degree. It is common that patients are more willing to go to the top three hospitals, saying that they have more advanced equipment, more skilled doctors and more convincing diagnosis. While the medical technology depends on many aspects, such as personnel, management and equipment, personnel is taken as the main factor. Here is the contrast on the number of medical technical personnel, education attainment and professional title between rural and urban districts.
4.1 The number of medical technical personnel
By contrast with the city, the countryside has a great demand for medical technical personnel, but its number even doesn’t reach a half of the city’s. What’s worse, compared with the amplification of medical technological personnel per 1000 persons, licensed (assistant) doctors per 1000 persons and registered nurses per 1000 persons between 2003 and 2015, cities get a higher rate, which makes the original urban-rural gap much wider.
Since NRCMS was carried out in 2003, the outpatients and inpatients in township health centers increased significantly. This is because there’s no reimbursement policy in the past, so some sick farmers were unwilling to see a doctor. But now part of medical expenses can be reimbursed, surely they are more willing to go to the hospital. According to China health statistical yearbook 2016, the increase of rural medical technical personnel falls far behind the increase of outpatients and inpatients. From 2003 to 2015, the amplifications of medical technical personnel per 1000 persons, licensed (assistant) doctor per 1000 persons are 72.6%, 49.0% respectively, less than that of the inpatients in township health centers (128.6%).(Table 6)
4.2 Education attainment and professional title
In addition to the number of medical technical personnel, there’s also a big gap between rural areas and cities on the education attainment and professional title.
First, we take licensed (assistant) doctors as an example. The proportion of bachelor degree is the largest in the urban hospitals in 2015 (more than 50%). By contrast, graduates from college degree and special secondary school make up the largest proportion in township hospital (both over 40% and 82.8% in total). And as for the amplification, in urban hospital, master degree gets the first place and bachelor degree comes the second, while in township hospitals, bachelor degree is the largest and the following is college degree. Then, seen from the professional title in 2015, the proportion of the advanced and intermediate title in urban hospital is 56.5% altogether, compared with 24.7% in township hospital[25, 26].
A survey studying the reasons why people prefer urban hospitals showed that (multiple choices are permitted): good technology(29%), good service attitude(51%), good facilities (26%)[25, 26]. Therefore, no matter for patients and doctors, the better condition of urban hospitals is a main attraction. This is because the development of China is not in balance, and the urban-rural gap is wide, resulting in a much lower medical and sanitary condition in the rural areas. And undoubtedly cities are better in salary, education, social security and other countless advantages. So generally there’s a definite trend that experienced and better-trained medical personnel from rural health institutions keep migrating to cities for a better life.
To solve these problems, first, rural health institutions should offer more courses to train those rural medical technical personnel to improve their professional skill and medical technology level. Anyhow, people prefer skilled doctors, and trust is the basis of the patients’ choice. Second, various measures should be taken to attract skilled talents to work for the rural medical institutions. The government also needs to make some plans to lead more urban health workers to support those backward rural districts. Another feasible method is to raise the salary, or some other guarantee, especially for those with high degree and high title. And since many rural patients choose to go to the urban hospitals mainly for their advanced equipment, it is also vital for the township hospitals to get some fund from the government or some enterprises to update their equipment for a better diagnosis.
5.Ranges of drugs covered
In Liaoning province, the number of drugs can be reimbursed in NRCMS is lower than that in health care insurance (D-value is 1159). Now the rural residents in Liaoning Province follow NRCMS reimbursement catalog in township or lower medical institutions but follow health care insurance catalog in urban hospitals. In the NRCMS reimbursement catalog, about 800 kinds of drugs can be reimbursed in township or lower medical institutions, including national essential drugs and several local supplemental drugs, which can meet the peasants’ basic demand for the moment. However, with the diseases becoming various and more complex and the medical technology in urban hospitals enhancing unceasingly but township hospitals fall behind, more and more peasants choose urban hospitals for medical treatment, so the NRCMS reimbursement catalog can’t satisfy their actual needs, especially those cancer patients and chronic patients.
Drugs in the NRCMS reimbursement catalog are far less than those in the health care insurance catalog. As many essential medicines are not involved in the reimbursement list, there come up some new problems for both doctors and patients. For doctors, they have to prescribe within such a small scope of drugs that some more useful drugs may be ignored, and if they want to choose those uncovered drugs, they must get approval from the patient first, or they may be blamed by the patients. As for rural patients, they have to afford much higher medicine cost when choosing those uncovered drugs, and since they are not familiar with drugs, they are easy to mistake the doctor’s suggestion, thinking he is just cheating them to buy expensive drugs. This drawback may lead to a tense atmosphere among doctors and patients, which is a bad news for social harmony.
6.Suggestions to the NRCMS
The NRCMS policy mainly focuses on inpatient service rather than outpatients to achieve its principal goal of effectively reducing the hospitalization expenses of farmers participating in the NRCMS and providing high-quality, efficient and low-consumption medical services for the patients in the NRCMS[29, 30]. However, as an integral part of a comprehensive development of primary care, outpatient services should be incorporated into the future NRCMS policy in rural China. Expenses incurred for treating chronic illnesses are a major factor in medical impoverishment, especially for poor communities, in which the elderly and infirm are left behind with high prevalence rates of chronic conditions due to young and healthy workers migrating to rich areas. Without first considering distribution of health expenses of the population, Chinese policy makers did not realize the expensive outpatient services for chronic conditions and the importance of balance of outpatient and inpatient services to the health insurance systems. In addition, as outpatient services are more commonly used for effective and efficient interventions, the government’s ignorance of outpatient services in the NRCMS will lead to benefits produced from government subsidies and the farmers’ contributions not fully realized. Furthermore, a stronger strategy desperately needs to be developed to make NRCMS more quality and equity oriented, since the burden of chronic disease is expected to be much heavier in the near future.
As the core of the NRCMS policy, the reimbursement policy needs some improvement. First, as most NRCMS members reported they did not know all the detailed requirements and procedures, the universal information inquiry points can be established to publicize information about reimbursement procedures, the proportion of reimbursement and other basic information about the program. In addition, to make application for reimbursement further more convenient, we can establish the new rural cooperative medical care insurance outlets in healthcare facilities of various provinces and municipalities, which record what kinds of new rural cooperative medical care insurances are suitable to the various types of households in China with corresponding applicable proportion of reimbursement and other information. Third, as vast majorities of farmers, who may not be located at where their residence is registered, don’t know about the accurate premium-paying time, we suggest that relevant government officials can make sure to notify the time and place in detail to efficiently avoid situations like these. Finally, it is necessary to establish a monitoring mechanism and to carry out dynamic observation, thereby instantly finding and stopping the occurrence of unreasonable expenses; and it is necessary to link the performance with the performance assessment and to specify the system of rewards and penalties, thereby effectively managing the use of illegal projects.
According to the feedback from the enrollees, we have come up with the following suggestions to minimize the problem of low reimbursement rate. First, ensuring the maximum use of essential drugs and clinical projects within the range of the NRCMS policy is the foundation to enable the patients under the NRCMS gain maximum benefits, and to promote the healthy and balanced development on work of the NRCMS, thereby satisfying the government, hospitals, and the public. Second, since disposable income levels of rural and urban residents vary a lot, we highly recommend that the reimbursement rate standard should be set in accordance with enrollees’ net income and financial subsidies from the government shall be partially determined by the households’ financial conditions. Third, to strengthen the migrant workers’ cognition of the NRCMS, relevant reimbursement information should be transparent and open to the public by local medical institutions through consultation services provided by specialized inquiry points. To make sure each rural member knows about the specific reimbursement procedures and the proportion of reimbursement, the publicized points can be established where a large number of individuals cluster like local medical institutions and construction sites. Fourth, in the long run, setting up a stable fund-raising mechanism and establishing the unified social security system will bring more care and benefit to the farmers, thus greatly provide strong policy and legal guarantee for NRCMS enrollees.
The drug ranges and prices also need more improvement. More kinds of drugs should be added into the NRCMS reimbursement catalog, especially the drugs that can be reimbursed in the township hospitals. And as every province in China is not at the same development level, some provinces even has less drugs in its NRCMS reimbursement catalog than Liaoning, thus the central government should stress on those less developed provinces first. The number of ethnic drug is too little to be recognized. Ethnic drugs are traditional national drugs, which had saved a lot of people’s lives in ancient time. If more kinds of ethnic drug can be added into the catalog, it will give more effective choices to clinical medication. It is also important to expand the scope of disease covered in the catalog, such as cancer and chronic disease.
Furthermore, to increase the entire hospitalization expenses, some individual doctors recommend novel materials which they can receive a high “commission” from a range of drugs with the same efficacy. In addition, as the self-responsible payment amount of patients under the NRCMS is still a large part of the entire hospitalization expenses, relevant institutions operating for profit have not incorporate many new materials into the reimbursement list. In recent years, it is also taken as a vital measure to separate drug sales from medical services.