As this nationally representative study indicated, there was increasing trends in the prevalence of cancer, outpatient and inpatient service use among Chinese middle-aged and elderly adults between 2011 and 2015. About half of cancer patients utilized cancer treatment for their disease, with a higher proportion in the urban versus rural residents in 2015. Those patients with high socio-economic degree received a high proportion of surgery and chemotherapy compared with low SES patients in 2015. There was also a substantial increase in CHE among rural patients from 2011 to 2015 and a substantial decrease among urban patients in the same time period. Utilization of chemotherapy and surgery appeared to drive the CHE increase, regardless of SES.
There are likely several factors contributing to the observed urban-rural differences in cancer care that needs to be addressed to increase the equitable access to healthcare in future. First, cancer care is provided as specialized services, and generally secondary or higher levels hospitals have the capacity to provide such care. Rural residents have less geographic access to cancer care comparing with urban areas, and some patients need extended travel and additional expenses to urban cities to get specialized cancer services [37]. During the period of the Coronavirus Disease 2019 (COVID-19) pandemic, patients may face more challenges in accessing cancer care. COVID-19 pandemic could disrupt the access to essential healthcare and likely exacerbate existing disparities since rural residents are more likely to be negatively by travel restrictions for access to specialized health services [38–40]. Public health efforts will be needed to address the impact of delayed diagnosis and suboptimal care in these rural populations to minimize adverse health outcomes among patients with cancer.
Second, previous studies have documented the urban-rural disparity in availability of medical resources in China [41, 42]. Research has generally found that residents living in rural areas would be less likely to use healthcare services with same quality due to the unbalanced economic development [43, 44]. Consistent with other studies, people in rural areas are more likely to have a shortage of healthcare service providers and lack social supports [45–47]. Previous research suggested that the number of licensed doctors and nurses, medical-technical personnel as well as beds per 1000 population in urban communities increased more than the number in rural communities in China from 2005 to 2017. [48] Registered doctors per thousand populations in urban areas were 2.57 times more than in rural areas in China in 2015 [49]. For this reason, cancer patients in rural areas may prefer using the services from a nearby urban area, even at the cost of higher financial burden.
Third, patients in the rural areas face potentially more financial barrier to cancer care compared with patients in urban areas, likely due to more barriers in physical access to healthcare services, and high per-capita payment for cancer care. The social medical insurances likely contributes to urban-rural disparity in CHE through gaps in coverage and benefit packages [50]. While over 95% Chinese population are covered by basic medical insurances, the benefits packages can vary significantly across main social health insurances [5, 6, 23]. The per-capita fund of UEBMI is US$424.7, whereas only $61.2 for NCMS in 2015 [25]. The co-payment rates of NCMS (73.4%) was higher than UEBMI (36.8%) and URBMI (50.7%) in 2008 [51]. Herein, cancer patients in rural regions have lower reimbursement rates and lower annual maximum payment from insurance. Additionally, patients seek care from other county/prefectures usually have reduced reimbursement rates. In this case, if cancer patients from rural areas have to utilize cancer care from another city, they have to pay more proportion of their bill out-of-pocket. Such a heavy financial burden likely compels low SES and rural patients away from cancer treatment utilization, possibly explaining the large urban-rural disparity in inpatient care use than outpatient visits. Paying more attention to out of pocket expenses and financial implications of cancer treatment across health insurance schemes is need in future.
Finally, while the expenditures for cancer care are increasing in rural areas as well as urban areas, the uneven nature of economic development and low-level disposable income of rural residents may further contribute the urban-rural disparities in financial risk and treatment burden. The disposable income of urban citizens was 31,195 RMB per capita, which was three times higher than that of residents living in rural areas (11,422 RMB) in China in 2015 [52]. Medical expenditures due to cancer treatment, specifically surgery and chemotherapy, is likely to have significantly greater impact on rural patients, leading to increased risk of CHE and impoverishment [52]. In addition, since NCMS and URBMI were mainly financed by local county-level governments at the early stage of China new health system reform, the quality of benefit packages likely depends on local economic development [49].
We observed that those cancer patients with high socio-economic level were less likely to experience CH than low SES individuals, and by 2015, rural cancer patients had almost double the prevalence of CHE compared with urban cancer patients, suggesting that a potential unintended consequence of the health reform is widening of rural-urban disparities in CHE. The findings are consistent with previous research on trends in financial burden among residents with NCDs in China [25, 53]. Recent studies have documented a rapid rise in healthcare cost for cancer patients in China, however data on the population-level economic burden of cancers is limited and the reported expenditure per patient may be underestimated [54–60]. For example, a systematic review of the economic burden of liver cancer shows an increase in expenditure indicators (direct medical expenditure, annual expenditure per visit and annual expenditure per diem) from 1996 to 2015, with medication costs accounting for more than half of the overall expenditure (56. 6%) [57]. For colorectal cancer, the annual growth rate for medical expenditure per patient, per visit and per day increased from 6.9–7.8% from 1996 to 2015, respectively [58].
Policy Implications
The health insurance programs in China has had some positive impacts on healthcare utilization. For instance, we observed that outpatient visits and admissions in the past months increased between 2011 and 2015 in all socio-demographic groups examined. However, there are still challenges especially related to costs. Overall, the burden of cancer among Chinese adults is increasing and about one-fourth cancer patients experienced CHE. Yet disparities among urban-rural, and different SES still exist, even after the implementation of the national health insurance scheme.
To reduce financial burden of cancer and bridge the SES gaps, comprehensive changes to health insurance benefit packages and healthcare resource allocation are needed to ensure universal, affordable and patient-centered health coverage. First, the URBMI and the NCMS need to be further integrated in contribution, benefit package, as well as financial risk protection to accelerate the equitable access to health service in both urban and rural areas. Secondly, social health insurance benefit packages need to be further expanded. Health services, including medicines, with proved cost-effectiveness evidence can be added to the National Insurance Reimbursable List (NIRL). For instance, 17 and 22 anti-cancer medicines have been elected into the NIRL with significant price cut in 2018 and 2019, respectively, and have reduced the financial burden of cancer patients. [61, 62]. Thirdly, while the National Health Insurance is aiming at providing financial protection for essential care, the Critical Illness Medical Insurance (CIMI) should play an increasing role in providing financial support on catastrophic expenses, including cancer patients. In particular, the current CIMI in most regions followed the NIRL which prioritize the essential care [63]. To provide better protection on catastrophic expenses, CIMI should explore additional coverage on other therapies with proven health benefits. Furthermore, enhancing the capacity of the National Public Health Initiative can enhance cancer prevention strategies such as routine screening and case management. This might lead to early detection of cancer, reduced financial burden and improved cancer outcomes if diagnosed at early stages when cancer treatments are most effective. This approach might be especially critical given healthcare disruptions due to the COVID-19 pandemic.
Given unprecedented effects of the COVID-19 on global healthcare systems, it would be inevitable that the pandemic would substantially negatively influence the cancer patients, health practitioners, and healthcare systems [64, 65]. Due to the COVID-19 outbreak, several healthcare services have to be postponed and even cancelled in many countries, leaving patients without access to essential health services [66]. Globally, 42% countries have partially or completely disrupted services for cancer treatment/therapy [67]. During the COVID-19 period, the waiting time for surgery and days in hospital was longer, and total expenditures for inpatient care increased in China [68]. To cancer patients, this means delayed diagnosis or treatment and further lead to disease progression. In many countries, tele-consultations became an emerging form to provide essential healthcare while limit the spread of COVID-19 [69]. However, the capacity for providing telemedicine varied greatly, and there is limited coverage on telemedicine by China’s social health insurances, which may potentially make further disparities in health service use. In the post COVID-19 era, how to balance the health system emergency reaction with essential healthcare, how to best utilize new technology to improve access and equity will be emerging health policy issues.
Strengths and Limitations
This research utilized data from a China nationally representative study to investigate the trends and disparity in cancer treatments, healthcare service utilization and CHE from 2011 to 2015. Our study could contribute to a deeper understanding of socio-economic and rural-urban disparities in cancer treatment, health service utilization and expenditures. There are several significant limitations. This study used the measurements based on self-reported information of diagnosed cancer, treatment type and healthcare service use, which may lead to underestimate the prevalence of cancer and an under-reported utilization due to the recall bias [57]. Medical information regarding the severity of cancers had not been collected. The CHARLS survey only considered those middle-aged and elderly Chinese residents. Future research should also focus on the younger adults to explore the trends and disparities in cancer care and financial burden. Moreover, about 20% of total participants in CHARLS are with missing values of key dependent and independent variables during the survey conducted in 2011 and 2015.