| BackgroundThe New Rural Cooperative Medical Care System (NCMS) is an important part of rural social medical security in China, playing an important role in guaranteeing rural residents access to basic medical and health services, alleviating rural poverty due to illness and poverty reinstatement due to illness. It provides a template for developing countries to solve the universal problem. The new rural cooperative medical care system began to be piloted in some counties (cities) of China in 2003. After realized a basic coverage in 2008, the government introduced a new health care reform in 2009. The NCMS was also being adjusted and changed constantly in the next few years, covering almost all of the rural residents gradually by 2010, and its guarantee ability got improved continuously. But many experts and scholars at home and abroad put forward a large number of questions about its effects. For example, some people think that the coverage of NCMS was expanding, but it led to the waste of medical resources and the medical costs rising. So, the problem, "What is the effect on medical service needs and utilization and costs etc. after a complete coverage of NCMS", is worth for further academic discussion.Most literature from current research on NCMS was focused on evaluating the effect of NCMS and describing it. Majority of research data is cross section date or hybrid cross section data, and minority of research used the family or village level panel data to analyze, and only few studies used the same individual balance panel data to analyze. The research methods includes descriptive statistical analysis and econometric model analysis, such as the regression model, tend to match score method (PSM), times the difference method (DID), propensity matching score after the double difference method (DID-PSM) and two models, etc. At present, there are few research on systemic analysis of the key period before and after the new health care reform and after a complete coverage of NCMS. Most studies just analyze whether people participated in the NCMS affect medical service or not, and few studies put a specific policy of NCMS into a model to analyze. Summarizing the existing research found that the research on key elements of NCMS’compensation policy (such as, hospital outpatient compensation ratio, compensation limit compensation ratio, hospital compensation ratio, starting line, the top line, etc.) and how its change affect medical service needs, utilization and costs is still insufficient. The research about using the same individual balance panel data to analyze the policy of NCMS and the effect on the health service need and utilization and cost of residents by its changes is still relatively lack. The research about the effect on health care need, utilization and cost of residents with different income by key elements of NCMS’compensation is still insufficient too.The NCMS’compensation policy of three counties (Zhangqiu City, Changqing District, Pingyin county), Jinan was made great adjustments in the important period when the wide coverage of NCMS was completed before and after the new health care reform in 2008 and 2011. So, how about the implementation effect of NCMS as the policy of NCMS changing, especially after the new health care reform in 2009? Whether it raise the health level of the policyholders or not? Whether it promoted the medical service utilization of the policyholders and effectively solved the the difficulty of getting medical service or not? Whether it reduced the medical expenses paid by policyholders themselves and practically solve the problem of high cost of getting medical treatment or not? Whether it promoted the social justice or not as a kind of social pooling medical security system? What are the changes of implement effect, compared with the early period? The above questions are what this study concern about mostly. We used the same individual balance panel data in two years, based on the health and medical service demand theory of Grossman, the medical service using behavior theory of Andersen and the theory of medical insurance influencing medical consumer behavior and so on, to analyze the effect on medical service needs, utilization and cost burden of all residents and residents with different income by key elements of NCMS’ compensation policy and its changes, and provide useful reference for constantly perfecting the design of NCMS’compensation policy, improving the security capability of rural residents and promoting social equity.ObjectivesThe overall goal of this research is to provide useful references to policy-makers on constantly improving the compensation policy design of the new rural cooperative medical system (NCMS), enhancing the security offered by NCMS to rural residents and promoting social equity, by analyzing the influence of the key elements of NCMS compensation policy and its variation on the entire population and different income residents" need, utilization and expenses of medical service.The specific goals include:studying on the influence of the key elements(outpatient compensation ratio, compensation limits, hospital compensation ratio, deductible, limit line) of NCMS compensation policy and its variation on the entire population and different income residents’need of medical service,and revealing whether the NCMS compensation policy and its variation have improved the health level of rural residents or not; studying on the influence of the key elements of NCMS compensation policy and its variation on the entire population and different income residents’utilization of medical service, and clearly evaluating whether the NCMS compensation policy and its variation have released the medical service demand of rural residents and increased the utilization of medical service; studying on the influence of the key elements of NCMS compensation policy and its variation on the entire population and different income residents’expenses of medical service, and making it clear that whether the NCMS compensation policy and its variation have decreased rural residents’expenses of medical service and lightening the burden.MethodsIn this study, the data came from the household survey in three counties in Ji’nan city (Zhangqiu City, Changqing District, Pingyin county) in 2009 and 2012.The data consisted of 1454 households,5466 individual samples. And finally, we got the balance panel data of 2008 and 2011.We conduct descriptive statistics, univariate statistical inference, and multivariate statistical inference in the study. The main empirical models include:random effects of binary choice panel data model, random effects poisson regression model, generalized linear models (GLM) and difference in differences (DID) model. Random effects of binary choice panel data model is mainly used to analyze the influencing factors of residents’medical service needs(whether the individuals suffer from any diseases in the nearest four weeks or whether they suffer from chronic diseases), the influencing factors of residents’choices of using medical services or not, the influencing factors of whether residents would face catastrophic health expenditure or not; random effects poisson regression model is mainly used to analyze the influencing factors of how often residents use medical services; generalized linear models (GLM) is mainly used to analyze the influencing factors of expenses; difference in differences (DID) model is mainly used to analyze the influence of NCMS compensation policy and its variation on residents" need, utilization and expenses of medical service.Results1. The study found that among the total sample of 5466 rural cases, the four-week prevalence rate was 41.91% and the prevalence rate of chronic disease was 30.52%. Age, marital status, education, self-rated health status and alcohol factor have a significant impact on four-week prevalence rate and the prevalence rate of chronic disease.The new rural cooperative medical reimbursement rate was inversely proportional to four-week prevalence. The change of compensation ratio reduced the four-week prevalence rate. The four-week prevalence rate of residents who have deductible was higher than those who have no deductible. New rural cooperative medical outpatient and inpatient reimbursement policy only has an effect on the four-week prevalence of low-income people. The new rural cooperative medical Outpatient compensation limits were inversely proportional to the prevalence rate of chronic disease. The change of Outpatient compensation limits increased the prevalence rate of chronic disease.The inpatient reimbursement rate was inversely proportional to the prevalence rate of chronic disease. The change of compensation ratio reduced the prevalence rate of chronic disease. Outpatient compensation policy and its changes have a significant effect on chronic disease prevalence rate of low-income people.2. Compared to 2008, the four-week consultation rate in 2011 increased by 4.1%. The admission rate has increased by 0.48%. The analysis of the affecting factors of residents’health service utilization found that self-rated health status, life limited, the distance to the nearest medical institution have an influence on outpatient and inpatient service utilization. The analysis of the affecting factors of residents’ health service utilization frequency found that age, self-rated health status, suffering from chronic diseases have an effect on outpatient and inpatient service utilization frequency.The outpatient compensation ratio was directly proportional to the four-week consultation rate of rural residents. The change of compensation ratio reduced the four-week consultation rate. The new rural cooperative medical outpatient reimbursement policy has an effect on the four-week consultation rate of middle-income residents and high-income residents. The new rural cooperative medical inpatient compensation ratio, deductible and payment ceiling has no effect on the health service utilization. The new rural cooperative medical outpatient compensation ratio was directly proportional to the four-week consultation frequency. The change of outpatient compensation ratio reduced the four-week consultation frequency. The new rural cooperative medical outpatient reimbursement rate and its changes have an effect on the four-week consultation rate of middle-income residents and high-income residents. The new rural cooperative medical inpatient compensation ratio, deductible and payment ceiling has no effect on the inpatient service utilization frequency.3. The study found that age, occupation, income, self-rated health status, suffering from chronic diseases, outpatient institutions, family economic status and family scale have an influence on outpatient expenditure. Sex, education, life limited, inpatient institution, length of stay and year has an influence on hospitalization expenses. Family members≥60 years old, family scale, household incomes per capita, inpatient institutions, length of stay and year has an influence on the incidence of catastrophic health expenditure.The outpatient compensation ratio was inversely proportional to out-of-pocket expenses. The change of outpatient compensation ratio increased rural residents’ out-of-pocket expenses. The effect of the new rural cooperative medical inpatient reimbursement policy on the inpatient out-of-pocket expenses was not statistically significant. New rural cooperative medical outpatient reimbursement policy only has an effect on the outpatient out-of-pocket expenses and the proportion of out-of-pocket expenses of low-income people. The change of outpatient compensation ratio increased out-of-pocket expenses burden of low-income people. The higher the compensation rate, the incidence of catastrophic health expenditure is lower. The incidence of catastrophic health expenditure of residents who have deductible was higher than those who have no deductible. The change of deductible increased the incidence of catastrophic health expenditure of rural residents. The new rural cooperative medical inpatient reimbursement policy has a significant effect on the incidence of catastrophic health expenditure of low-income residents and middle-income residents.Conclusions and Policy Implications1. New rural cooperative medical reimbursement policy has a significant effect on the rural resident especially low-income people’medical service needs.The outpatient compensation ratio, inpatient compensation ratio and the deductible were important affecting factors of four-week prevalence; the outpatient compensation limits and the inpatient compensation ratio were important factors that influence the prevalence rate of chronic diseases. The compensation policies of the NCMS mainly affect the health status of low-income people. The changes of the outpatient compensation ratio, inpatient compensation ratio and the start line reduced the four-week prevalence rate, while the change of the outpatient compensation quota increased prevalence of the chronic diseases. We can see that perfect NCMS reimbursement policy is beneficial to improve the performance of the health of low-income people.2. The change of NCMS policy reduced rural resident especially middle-income people and high-income people’outpatient services utilization rate and frequency, while it has no significant effect the inpatient service utilization.NCMS outpatient compensation ratio and its changes have a significant influence on the four-week clinic visits of rural residents, especially middle-income people and high-income people. Thus, the NCMS compensation benefit major shift to middle and high income groups. The change of NCMS outpatient compensation ratio reduced four-week consultation rate and frequency. The change of the outpatient compensation quota reduced the four-week consultation rate of the high-income people, but increased four-week consultation rate of middle-income people. The NCMS inpatient compensation ratio, deductible and its changes have no significant effect on the inpatient service utilization and frequency.3. The change of NCMS policy increased the rural resident especially low-income people’outpatient out-of-pocket expenses burden, while it has no significant effect on the inpatient out-of-pocket expenses burden. The NCMS outpatient compensation ratio and its changes have a significant influence on the out-of-pocket expenses of the residents, especially low-income people. The change of the outpatient compensation ratio increased the rural resident especially low-income people’outpatient out-of-pocket expenses, increased the cost burden of residents. The NCMS policy tend to benefit middle-and high-income groups, low-income population’burden of medical expenses does not be relieved.The NCMS inpatient compensation ratio, the start line, the top line and its changes have no significant influence on the inpatient out-of-pocket expenses and the percentage of out-of-pocket expenses of the rural residents.4. The change of NCMS policy significantly increased the rural resident especially low-income people and middle-income people’incidence of the catastrophic healthy expenditure.The NCMS inpatient compensation ratio and the start line have a significant effect on the incidence of the catastrophic healthy expenditure of the rural residents, especially low-income people and middle-income people. The change of the start line increased the rural resident especially low-income people and middle-income people’incidence of the catastrophic healthy expenditure. Thus, the NCMS policy did not significantly improve the burden of medical expenses of people with low and middle income groups. Low and middle income residents did not benefit from the NCMS reimbursement policy.According the above conclusion, it was suggested that:(1)To improve the NCMS outpatient and inpatient compensation policy, increase the compensation ratio and compensation limits appropriately, decrease the inpatient deductible, improve the health performance of the new rural cooperative; (2)Increasing NCMS outpatient compensation level appropriately to promote the utilization of outpatient services and reduce the out-of-pocket expenses burden of the rural residents; (3)Increasing inpatient compensation level appropriately, improving inpatient compensation ratio, reducing inpatient deductible, reducing the incidence of catastrophic health expenditure of rural residents and reducing the " being into poverty by illness " phenomenon;(4)Strive to perfect medical assistance system, increase compensation level properly for low-income residents, and improve the ability to resist economic risk of disease in low income group. |
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