| BackgroundThe Chinese New Rural Cooperative Medical System (NCMS) was carried out from2003. It has a great process with the support of governments at all levels since the pilot was initiated. With the development of New Rural Cooperative Medical System, the policy was also adjusted and changed constantly. The basic coverage was realized in2008and the new healthcare reform was carried out in2009. Although the effect of NCMS has got a certain degree of recognition, but there are still some different voices about the actual effect of the NCMS. One of the main different opinions is although the medical coverage was expanded, the medical costs increased faster. The utilization of hospitalization service can generate higher medical costs, it can induce the households into poverty to a certain extent, although the actual hospitalization reimbursement ratio reached41.5%in2009, but the increasing coverage of NCMS did not decrease the economic risk of disease.There are many studies about NCMS, from the view of study content, some focused on the description of NCMS, some focused on the evaluation of implementation effects of NCMS; about the analysis methods, some used the descriptive analysis, some adopted more strict methods, such as propensity score matching (PSM), logistic regression, difference in difference method (DID), about the analysis of the fairness, most literatures used Concentration Index (CI), Lorenz curve, slope index of inequity (SII) and other methods, there still exist deficiencies by applying Oaxaca decomposition method to analyze changes of equity; about the study period, there still lack system analysis during the wide coverage period after the implementation of NCMS and the period before and after the healthcare reform; about the variables, the variables about NCMS were whether to participate the NCMS, some literatures also incorporate the NCMS policies into the analysis model, there still lack system analysis on the changes of reimbursement rate, deductible and ceiling; about the type of data, most of the studies used cross-sectional data or pooled cross-sectional data, there are only a little studies used household level or village level panel data, there is still lack of study using individual level(same individual) panel data.In2006,2008and2011, the hospitalization reimbursement rate of the three counties (Zhangqiu City, Changqing District, and Pingyin County) showed an increasing trend, and the reimbursement rate decreased with the increase of hospital level. The ceiling also showed a great increasing trend. Pingyin and Changqing didn’t set up deductible in2006and2008, but all medical institutions set up deductible in2011, ZhangQiu reduced deductible of county and municipal hospital and set up deductible in township level hospital in2011. From the wide coverage period before2008, to the period that after the first stage of the healthcare reform in2011, whether the improvement of hospitalization reimbursement rate, the increase of ceiling and the set of deductible have increased the accessibility of inpatient service? Whether improved equity? These are the main concerns of the study.This study used individual level panel data, based on the health needs theory, starting from income effect of the insurance, price effect and risk aversion effect, analyzing whether the improvement of the compensation level and ceiling, and the set of deductible has increased the accessibility of inpatient services (including the overall level of accessibility and affordability), and whether improved the equity, to provide the policy basis of improving accessibility and equity of inpatient service.ObjectivesThe objective of this study is to analyze the effect of the evolution of NCMS compensation policies including increasing reimbursement rate and the ceiling, and setting the deductibles on the accessibility and equality of inpatient services, to reveal the related influencing factors, and to provide policy support to improve the accessibility of inpatient services and reduce inequity and economic burden. The specific objectives are as follows:to analyze the impact of the evolution of NCMS policies (increasing compensation rate and the ceiling, setting the deductibles) on the accessibility of inpatient services; to analyze the impact of the evolution of NCMS policie on the equality of inpatient servers, and explore the contribution of policy changes to the inequality; to clarify the longitudinal trends of inequality, the contribution of policies on the inequality, further reveal whether the changes of equality are due to the contribution of the elasticity or the contribution of concentration index, and provide basis for policy improvement.MethodsThis research mainly studied the inpatient services over the last year, using the household survey data which from three counties or districts of Jinan city (Zhangqiu county, Changqing district, Pingyin county) in the year2006,2008and2011, including a total sample of9020individuals from2600households. The unbalanced panel data of three years based on the year2008at individual level was selected as the study sample; the data ensured that the same individual was investigated at least twice in the three-year investigation.Analysis methods that were used in this research mainly included descriptive statistical analysis, single factor statistical inference and multivariate statistical inference. Multivariate statistical inference included the following five parts:(1) Using random effects of binary choice panel data model to analyze whether new rural cooperative medical system compensation policies affect the use of inpatient services or not.(2) Using negative binomial random effects model to analyze the impact of new rural cooperative medical system on the number of hospitalizations.(3) Using generalized linear models to analyze the impact of new rural cooperative medical system on hospitalization out of pocket expenses and reimbursement costs.(4)Using concentration index to measure the equity and using decomposition of concentration index to analyze the contribution of new rural cooperative medical system policy variables to equity.(5) Using Oaxaca decomposition method to analyze the time variation of equity, and then the time variation is decomposed into changes of concentration index and elasticity.Results(1) This study found that the hospitalization rates (in terms of the number of visitors) in2006,2008and2011were4.77%,4.40%and4.79%respectively, and there was no significant difference. The reimbursement level was positive proportional to utilization of hospitalization and frequency of hospitalization. County-level hospitals had deductible and township hospitals did not have deductible, which is inversely proportional to the frequency of hospitalization. There was no significant in the effect of payment ceiling on utilization of hospitalization and frequency of hospitalization. Economic status was a significant factor affecting the utilization of hospitalization.Concentration index of the utilization of hospital services was0.255,0.326and0.244in the three years respectively, indicating that the utilization of hospitalization of high income group was higher than low income group. Increasing reimbursement rate of NCMS prompted high income group to get more inpatient services, but the contribution was smaller. In the year of2006and2008, township hospitals did not have deductible, but county-level hospitals had deductible, which reduced the inequality of utilization of hospital services and prompted low income group to use more hospital services. The change of concentration index between2006and2008was0.071. The change of concentration index between2008and2011was-0.082. The contribution of reimbursement rate and deductible make high income group using more inpatient services in2006and2008. The contribution of new rural cooperative reimbursement rate is in opposite direction to the overall change, indicating that reimbursement rate was not the reason to make low income population use more hospital services in2008and2011. The main reason was the improvement of economic conditions.(2) In the year of2006,2008and2011, actual inpatient reimbursement rate was12.15%,12.46%and33.40%respectively. Nominal reimbursement rate and actual reimbursement rate was inversely proportional to inpatient out of pocket expense and was proportional to reimbursement cost. Setting deductible can significantly improve the patients’out of pocket payment. Choosing county level and above hospitals and two weeks or above length of stay can increase the out of pocket payment and reimbursement costs significantly.In the year of2006,2008and2011, Concentration index of reimbursement cost was0.035,0.020and0.033respectively. The contribution of real inpatient reimbursement rate on concentration index was negative in2006and2008. Contribution of reimbursement rate and deductible was positive in2011.The change of concentration index between2006and2008was-0.015.The change of concentration index between2008and2011was0.013. The contribution of NCMS policies of reimbursement rate, deductible and ceiling prompted concentration index of NCMS beneficial degree favoring low income group during2006and2008, accounting for11.33%of total change. The improvement of reimbursement rate and ceiling prompted concentration index of NCMS beneficial degree favoring high income group during2008and2011, accounting for32%and17%of the change of concentration index in the two years.(3) The incidence, mean gap and positive gap of catastrophic health expenditure after reimbursement of New Rural Cooperative Medical System were obviously lower than that before; the rate has showed a decreasing tendency after reimbursement of NCMS in three years; the scale of decrease was increased almostly. As we can see from the results of the model, the actual reimbursement rate was inversely proportional to the occurrence of catastrophic health expenditure, and staying in hospital for more than two weeks and visiting higher level hospital can significantly increase the catastrophic health expenditure, but the families which self-evaluate health status and economic status were better have a lower incidence of catastrophic health expenditure. Households that have members above65years old faced with catastrophic health expenditure more easily.At40%threshold, after the reimbursement of NCMS, the concentration index of incidence of catastrophic health expenditure were0.155,0.096and0.034respectively in the three years. The contribution of reimbursement rate leads to high income group occurred more catastrophic health expenditure. The change concentration index was-0.019during2006and2008, during2008and2011concentration index change was-0.062. Although the occurrence of catastrophic health expenditure for three years concentrates in high income households, it has a tendency to favoring low-income population. The rising reimbursement rate and ceiling induced the occurrence of catastrophic health expenditure in low income households in2008higher than2006. The reimbursement rate was mainly attributed to the change of elasticity, and ceiling was mainly attributed to the change of concentration index. The contribution of the reimbursement rate and ceiling in2008and2011induces the occurrence of catastrophic health expenditure in high income households in2011higher than2006and that is mainly attributed to the co-effect of elasticity and the concentration index.Conclusions and Policy ImplicationsAccording to the research results, the main conclusion of this research is:(1) The increase of NCMS reimbursement rate can increase the accessibility of inpatient service.The increase of NCMS reimbursement rate can increase the utilization and the number of hospital service, reduce out-of-pocket payments, increase benefit, and with the improvement of reimbursement rate and ceiling, the ability of new rural cooperative medical system in risk aversion is improving; the setting of the deductible will improve the patients’ out-of-pocket payments.(2) There exist inequality in hospital service utilization and reimbursement costs, favoring rich; catastrophic health expenditure was mainly concentrated in the high income households.Inequality of hospital service utilization was mainly due to income inequality; the increase of reimbursement rate contributed a little to the inequality, the need of hospital service is still not satisfied for low-income people relative to the high-income people in the three years.In2006and2008, reimbursement rate improved the beneficial degree in low-income group; reimbursement rate and ceiling contribute to high income group getting more reimbursement in2011. The economic status, length of stay, hospitalization institution, and reimbursement rate were the main factors to increase inequality of reimbursement costs. Length of stay, high level of hospitalization institution were the leading causes for catastrophic health expenditure happened in rich households; the household size and high reimbursement rate were the protection factors of catastrophic health expenditure in poor households group.(3) The improvement of reimbursement rate can prompt the rich group to use more hospital service during the period of2006-2011, but the orientation of influence on equality of beneficial degree and catastrophic health expenditure were opposite in2006-2008and2008-2011.During the broad coverage period of NCMS between2006and2008, the increased reimbursement rate improved the rich group using more inpatient services. The improvement of reimbursement rate and ceiling, and the setting of deductible induced beneficial degree favoring poor group. Although the reimbursement of low-income group has been improved, the length of hospitalization stay and high level of hospital institution have relatively increased the occurrence of catastrophic health expenditure in low-income households. During the new healthcare reform period between2008and2011, the increased reimbursement rate induces high income people to get more inpatient service. In2011, reimbursement rate and ceiling of high income household has improved, which benefit more high income group. Although the new healthcare reform increased the security intensity of new rural cooperative medical system, it compensated more for the high income groups and did not improve the benefit level of low-income group. But because of the increasing of hospitalization length of stay and hospitalization institution level, the incidence of catastrophic health expenditure of high-income households was increased relatively.Based on the above conclusions, this study has the following policy implications:1) improve appropriate compensation level, raise the overall level of accessibility, and improve the affordability, to prevent rural residents bearing high economic burden of disease due to the increase level of hospitalization expense exceeding the increase level of reimbursement;2) reduce the deductible in township hospitals, improve the deductible in county hospitals, guide patients to choose hospital reasonably, and reduce the equality of hospital service utilization;3) shorten hospitalization length of stay, improve service quality, reduce unnecessary medical expenditure and reduce the risk of catastrophic health expenditure;4) continue to improve medical assistance system, increase subsidies properly, and improve inpatient service utilization and the ability to resist economic risk of disease in low income group. |
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