In this study, we comprehensively analyzed the CCE on neoplasms based on the SHA 2011 to answer the following questions: (i) How much was spent on the treatment of neoplasms? (ii) Where did these expenditures come from? (iii) Who provided the services and what services were provided? (iv) Who consumed these services? (i.e. the distribution of CCE of neoplasms according to age, gender and diseases category).(v) what were the key influencing factors of hospitalization expenditure?
So, how much was spent on treatment of neoplasms in one year in Gansu? The answer was 4442.269 million CNY. From the domestic perspective, this expenditure were huge and its’ proportion in CHE and GDP were high relatively in 2017, in which the share of malignant neoplasms was as high as 76.8%, equivalent to 3411.770 million CNY, accounting for 5.64% of CHE and 0.44% of GDP, whereas the CCE of malignant neoplasms only accounted for 0.23% of GDP in 2010 in the whole country[15], and in 2016 in Sichuan province, 0.29% of GDP [16], which indicated the heavier economic burden of neoplasm to society and government in underdeveloped region of China. Similarly, the economic burden of neoplasms was also heavy in the other countries of the word. In European Union, the health care expenditure on neoplasms amounted to 83.2 billion EUR representing 6.1% of total health expenditure in 2014 [4]. And the personal health care spending of neoplasms in the United States was about 115.4 billion dollars in 2013, ranking 11th among the aggregated condition categories [17].
In light of the above, it was urgent that the health system researcher and policy maker could have a sufficient comprehension on how the CCE of neoplasms varies, to help them identify which conditions, age and sex groups, services function and so on were the main composition of spending. This study found that the CCE of neoplasms did have obvious characteristics not only in the aspect of financing and provider but also beneficiaries.
The share of out-of-pocket payment in financing schemes was too high
OOP, a metrics of a countries’ financing performance, can directly exert an impact on poverty and household welfare particularly when there was a decline in healthcare financing [18]. Generally speaking, ideal goal of OOP share of should be below 30% at least [19]. In 2016, according to the Global Health Expenditure Database established by World Health Organization, the average OOP expenditure as percent of CHE was 33% in the world, and for the western developed countries, such as USA, UK and Germany, this value even was maintained below 15%, and in China in 2012, this was 44% reported by Peipei Chai, et al [20]. However, our study found that, the OOP’s percentage in CCE of neoplasm was as high as 54%, much higher than the proportion of personal OOP in CHE or CCE of China and other countries in the same period, which indicated that neoplasm patients in underdeveloped regions of China faced a heavier economic burden than patients in developed countries or regions, and simultaneously also exposed the unreasonable financing schemes for treatment of neoplasms in Gansu. Besides, neoplasm patients and their household were more susceptible to catastrophic health expenditure, and about more than 60% of patients with neoplasms in the research populations encountered the catastrophic health expenditure [21–23], and based on the hypothesis that social economic development level determined the extent of financial protection, the lack of adequate financial protection for neoplasm patients in Gansu caused by the underdeveloped economics would further increase the risk of catastrophic health expenditure [24]. What’s more, the heavy economic burden could affect health condition negatively, for the reason that this two aspects of patients were interactional - social disadvantage predisposed them and their households to illness-related poverty and economic hardship through loss of employment and out-of-pocket spending, which in turn can reduce quality of life and lead to non-adherence to, or the abandonment of, therapy [13, 14].
The reasons for the high proportion of OOP for neoplasm patients in China could be accounted from the following aspects. The drug expenditure were a key contributor to overall expenditure of neoplasms therapy [25, 26], however, up to now a number of anticancer drugs still were not enrolled in the National Essential Drug List (NEDL), which was a catalogue of drugs that are priced at a level far below the average market price and has higher reimbursement rates available under the national insurance systems than for other drugs [27], so patients had to cover the full cost of these expensive drugs, such as the innovative drug [25]. Additionally, under the national insurance systems, although anticancer drugs listed in the NEDL were easier procure and were more affordable, patients still needed to contribute to the cost of type B drug-an amount that varied between regions [25]. To this end, as government of China was doing now, negotiation on imported anticancer drugs with pharmaceutical company should be carried out further to decrease price of drugs that had been included the NEDL and to expand range of anticancer drugs on this list, and meanwhile, reimbursement rate in the national insurance systems should be increased further and for type B drug, proportion of cost that was covered by patient should be as low as possible especially for underdeveloped regions, where more social capital could be introduced instead of relying solely on revenue of local government.
The expenditures were mainly consumed in hospitals by hospitalized patients
Since the new health-care reform was initiated in China 2009 [28], many attempts aiming at reinforcing the Primary Health Care’ functions-a gate-keeping role of health inclusive of medical care, disease prevention, health promotion and education [29], were carried out by the ministry of health, such as an additional investment to grassroots medical networks, the implementation of hierarchical medical system as well as the groping for medical alliance [30, 31]. Although progresses in construction of primary health-care system were remarkable, the system still faced huge challenges in structural characteristics, quality of care and so on [30, 32], and the issue of “being unaffordable and difficult to access medical care services” still existed, especially for patients incurring serious illness inclusive of neoplasms. Similarly, we found that the treatment of neoplasms mainly centered in hospital, especially for general hospitals, which would lead to overcrowding of well-known hospital facilities while underuse of primary health care, prolong time to diagnosis and treatment, increase the likelihood of OOP spent for patients, and threaten to effectiveness and efficiency of health-care system further [25, 33]. For Chinese neoplasm patients, severity of neoplasm itself, limited drug variety and lack of advanced equipment for primary health-care providers, as well as perceived poor quality of primary health-care services, all determined their preference to large hospitals [33]. To tackle this issue, it was necessary not only to strengthen service capacities of primary health-care establishment but also to limit the uncontrolled expansion of hospitals, such as restricting or removing the general outpatient services in large general hospitals.
Apart from above-mentioned unreasonable distribution of CCE of neoplasm among health providers, its’ distribution in aspect of services function also showed significant features – nearly 90% of expenditure were spent on inpatient service, which was similar to the situation in neighboring province Sichuan 2016 [16] that is also one of the underdeveloped regions of China. However, in other regions of China, this expenditure gap between inpatient and outpatient was not so prominent [15, 20, 34]. About 60% of expenditures were consumed by inpatient service and 40% of expenditures were consumed by outpatient service (Fig. 8). Therefore, we conclude that neoplasm patients in underdeveloped regions of China were over-reliant on hospitalization and used less outpatient services, and this fact would in turn further contribute to high OOP of patients [5]. Under the current insurance system of China, patients had to rely on inpatient services to obtain more reimbursable drugs as the shallow coverage of insurance in outpatient[35]. Besides, the tradition of Chinese that they tended to conceal their sickness for fear of treatment[36], and the pretty low rate of early cancer detection for most of cancer in China[37], all led to the results that diagnosis of cancer was too late and patients can only choose to be hospitalized, which was more prevalent among neoplasm patients in underdeveloped regions of China. In response to above reasons, government can reduce the dependence of neoplasm patients on hospitalization by improving the coverage of outpatient services in national insurance system and vigorously promoting early diagnosis and treatment for common cancers.
Consumptions of CCE of neoplasm were concentrated on several specific types of neoplasms
Over the past decade, the age-standardized incidence rates (ASIR) and age-standardized mortality rates (ASMR) of digestive malignant neoplasm including stomach cancer, esophagus cancer and liver cancer in northwest were always highest among different regions of China [38]. And from the perspective of cancer’ pattern in northwest, disease burden of cancer were also mainly caused by digestive malignant neoplasm, and taking Gansu as an example, the top 4 cancer in terms of ASIR and ASMR were stomach cancer, lung cancer, esophagus cancer and liver cancer [39]. Consequently, as shown in this study, more than three quarters of CCE of neoplasm was consumed by patients with malignant neoplasm, nearly half of which was contributed by digestive organs inclusive of stomach cancer and colorectal cancer. Additionally, the high incidence and mortality rate of digestive malignant neoplasm in this region should be attributed to unhealthy diet of local inhabitants, lack of chemoprevention and screening for early detection, and so on [40], while all this motioned factors could be related to the relatively backward economic development level[41]. Hence, in northwest of China, a vicious circle inevitably occurred - backward economic could lead to high incidence and mortality of digestive malignant neoplasm to a certain extent, and the high incidence and mortality in turn would further aggravate the heavy economic burden of local inhabitants.
And what’s more, it was worthy to note that although the ASIR and ASMR of colorectal cancer in northwest was lowest in China[38], the expenditure consumptions of colorectal were second highest in this region preceded only by stomach cancer, the reasons of which remained to study further. Given the upward trend in western dietary pattern, increases in high-risk behaviors (e.g. smoking and excessive alcohol intake) and so on, colorectal cancer incidence had rapidly increased from 1990 to 2016 and would further increase in China over the next decade[42]. Consequently, colorectal cancer would inevitably bring a heavier economic burden to society in the future. Of course, as the leading cause of cancer death in all regions of China and the second most common cancer in northwest of China [39, 43], lung cancer also similarly consumed tremendous medical resource of Gansu province (8.8% of CCE of neoplasm), only 40 Million CNY lower than CCE of colorectal cancer.
Owing to the serious harm of malignant neoplasms to human health, previous researches in relevant fields tended to focus on malignant neoplasms and rarely paid attention to benign neoplasms [4, 25, 37, 41, 44]. However, at the present analysis, we found that uterine leiomyoma, as one of the most common benign tumors of female genital tract, consumed the most of curative expenditure on neoplasm for female (272.218 Million CNY), which was 10 Million CNY higher than breast cancer and 30 Million CNY higher than cervix uteri cancer. So far, despite the high prevalence, the pathogenesis, incidence and risk factors of uterine leiomyoma were far from being completely understood, and researches on its health expenditure were also rare [45]. Therefore, in this respect, our analysis could present preliminary data on future studies about benign neoplasm inclusive of uterine leiomyoma. Of course, the heavy economic burden of breast cancer and cervix uteri cancer for female also cannot be ignored. For female in Gansu [39], the most common cancer and the leading cause of cancer death were all stomach cancer while in our study the highest expenditure were consumed by the treatment of uterine leiomyoma, breast cancer and cervix uteri cancer, and further studies to assess possible reasons to this difference were warranted.
The age of female with the peak of CCE of neoplasm was 15 years younger than male
China was undergoing a rapid aging transition, which had substantially contributed to the rising number of new cancer. Additionally, given the complex management of elderly with cancer and the huge survival gap between younger and older cancer patients, the provision of clinical and health services that adequately met these needs must be facing severe economic challenges [46]. However, whether in China or abroad there were almost no researches on this respect. In 2017, as illustrated in this study, adults aged 65 and over consumed nearly 30% of total CCE of neoplasm for Gansu, and more than half of these expenditures were spent on the treatment of stomach cancer, colorectal cancer and lung cancer. Apart from elderly with neoplasm, the middle-aged adults (40–64 years old) with neoplasm were also worthy of attention from policy makers as for 57% of total CCE of neoplasm were consumed by them, which may be related to their huge population base and the rapid increase in cancer morbidity and mortality at this age [47]. What’s more, this study only accounted for the direct healthcare cost of neoplasms and did not draw indirect cost into analysis. The ages 40–64 years old were working age, and if indirect cost of neoplasms - a term referring to productivity losses related to neoplasm - were taken into account, the economic burden of middle-aged patients with neoplasm would be heavier in fact. Taken Australia as an example[48], in 2015, there were nearly half (46%) of patient with cancer aged 25–64 years old that were not in labor force, which resulted in a reduction of $1.7 billion to the GDP of Australia.
In this study, there was a significant difference in age-specific distribution of CCE of neoplasm for female and male - females’ expenditure mainly consumed by middle-aged women while for male it were elderly men, and the age of female with the peak of CCE of neoplasm was almost 15 years younger than male. As illustrated by result of this study, reasons for these disparities could be considered from disease spectrum aspect. Different from the top three neoplasms in male neoplasm expenditure, the incidence or mortality of top three neoplasms of female (uterine leiomyoma, breast cancer and cervix uteri cancer) increased rapidly since 40–49 years old [49–51], and took uterine leiomyoma as an example, Onchee Yu, MS analyzed the incidence rate of uterine fibroid among women aged 18–65 years by age in US from 2005 to 2014, and found that 45–49 years old was the age group with highest incidence rate in all years, followed by 40–44 years old [50]. By contrast, as for stomach cancer, lung cancer and colorectal cancer, most new cancer cases and cancer deaths occurred in the age range from 60 to 74 years[3]. In addition, it was worth noting that the bimodal phenomenon of age-specific CCE of neoplasm for whole population, male crowd or certain tumors inclusive stomach cancer, lung cancer as well as colorectal cancer (Fig. 3A and Fig. 5A), and the declined expenditure occurred in 55–59 age group, which was much similar to the results of Zhen Liu’s study[16]. The reasons for this phenomenon needed to be further explored in the future.
Hospitalization days is the key factor affecting the hospitalization expenditure of neoplasm patients
The results showed that 88.40% of the CCE for neoplasm was inpatient expenditure. Therefore, it is very necessary to analyze the hospitalization expenditure of neoplasm patients and its influencing factors. We found significant relationships between the independent variables and hospitalization expenditure, including the length of stay, institutional level, operation, proportion of drug, gender, serious condition, age, insurance, institutional type and neoplasms. Notably, these findings were consistent with those of other studies [52–54]. Besides, the top 5 influential factors in the ranking of importance were the length of stay, operation, proportion of drug, neoplasms and institution level.
The results of both the multiple linear regression and the random forest model indicated that the hospitalization days was the most influential factor among all variables. With the increase of hospitalization days, the bed fee, nursing fee and other related costs also increased, and the hospitalization expenditure increased accordingly. Reasonable shortening of invalid hospitalization days could not only improve the bed turnover rate and hospital economic benefit, but also reduce the economic burden of patients. Medical institutions should improve the quality of services, formulate scientific standard hospitalization scope for diseases and reasonable diagnosis and treatment procedures, and reduce unnecessary operations [55].Surgical patients incurred higher costs than non-surgical patients. Because the cost of treatment and materials for neoplasm patients undergoing surgery was higher than for non-surgical patients, and the length of stay was also longer. It was recommended that "day surgery" for Malignant neoplasms be introduced to reduce the length of hospital stay [53]. Drug proportion was also an important factor affecting the hospitalization expenditure of neoplasm patients.The cost of developing a new antineoplastic drug is high, and antineoplastic drugs are generally more expensive [54]. For some patients with malignant neoplasms, chemotherapy is the mainstay of treatment, which requires the use of expensive drugs for treatment[54]. The reasons for the high price of antineoplastic drugs in China include the research and development cost of antineoplastic drugs, patent fee, tariff and value-added tax, hospital markup, circulation cost, market factors and other factors[56].The policy of abolishing drug mark-ups, accelerating the implementation of the inclusion of antineoplastic drugs into the medical insurance reimbursement catalogue, ensuring the dynamic adjustment of the medical insurance catalogue, strictly implementing quantity-based procurement, improving the research and development capacity and quality of generic drugs, and improving the research and development capacity of independent innovation of drugs should be strictly implemented to reduce the economic and psychological burden of neoplasm patients and improve the accessibility of drugs for neoplasm patients. [56, 57]. There were also differences in medical expenditure for different types of tumors. These economic differences most likely reflected the differences in treatment, management patterns, survival times, and prognostic outcomes across different types of neoplasms[58]. The higher level of medical institution, the more expensive in the hospitalisation expenditure. The diagnosis and treatment of neoplasm requires a higher level of medical technology, and high-level hospitals can better meet the needs of patients. With the increase of the institution grade, the medical treatment is higher, whereas the financial burden on patients is heavier. Besides, patients have a preference for high-quality medical resources. No matter at the active treatment stage or conservative treatment, or even at the end of life, they will rush to high-level hospitals for treatment, resulting in a waste of medical resources [53].To address this phenomenon, we should promote and consolidate the hierarchical diagnosis and treatment system and the construction of medical association, rationally allocate resources and avoid the waste of medical resources. In fact, most common neoplasms are preventable. Primary and secondary prevention of neoplasm is very important, and community are the mainstay of this duty. Neoplasm prevention activities at the community must be strengthened[59].
To our knowledge,this study is the first article to decompose total CCE of neoplasm in a region to all types of neoplasms and whole crowds, overcoming the disadvantages of general Cost-of-illness studies, such as the risks double counting and the single disease. Compared with the general health cost indicators, such as THE, CCE used in this study can more accurately reflect the economic burden of diseases because it does not include investment in fixed facilities. As a powerful tool to describe financial flow, SHA 2011 allows this study to analyze the entire flow of funding for neoplasm treatment services, including financing scheme, medical institutions, population distribution, etc. However, it is undeniable that the study has its limitations in that there is data from only one province and few other similar studies, thus making it impossible to compare the cost of cancer treatment with other regions. The lack of data on household OOPs in the sample database prevents a study of households' catastrophic medical expenditures.