Study On The Equity Of Urban-rural Residents Basic Medical Insurance Scheme In Shandong Province

BackgroundOwing to the dual socioeconomic structure of urban and rural areas and other historical reasons,there existed three basic social health insurance systems in China,including the Urban Employees' Basic Medical Insurance Scheme,New Rural Cooperative Medical Scheme and Urban Residents' Basic Medical Insurance Scheme.The three health insurance schemes were decentralized and operated locally.There were also big gaps in the financing,level of fund pooling,benefit package and copayment rates among different health insurance systems.The fragmentation of health insurance system has led to inequitable access and financial protection and inefficiency in operations.Equity and justice is the basic objective and core value of social insurance systems,and it is also the key index of performance evaluation.With the deepening of health system reform,the problem of the inequality caused by the "fragmentation" of health insurance system has been paid more and more attention.Fragmentation has affected the equity and sustainable development of the basic medical insurance system.In order to realize the equity of the medical insurance system and improve the equity in coverage,financing,health service utilization and benefits,it is necessary to consolidate the fragmented medical insurance system and establish an "integration and multi-level"basic health insurance system.There are some similarities in the population coverage,financing level and copayment policy between New Rural Cooperative Medical Scheme and Urban Residents' Basic Medical Insurance Scheme.Thus integrating them is considered as the first step to establish the integrative basic health insurance system.Integration of Urban Residents' Basic Medical Insurance and New Rural Cooperative Medical Scheme was carried out in Shandong province in 2014.Urban-rural Residents'Basic Medical Insurance was established to cover both urban unemployed residents and rural residents.However,it is unclear about whether the integration improves the equity of health insurance system.Thus,it is necessary to study the following questions:what is the concept of equity of Urban-rural Residents' Basic Medical Insurance,how to evaluate its equity,what is the equity of Urban-rural Residents' Basic Medical Insurance in Shandong province,what are the main factors that affect the equity in health insurance coverage,equity in financing and premium,equity in the medical service utilization and equity in benefit,and how the policy of Urban-rural Residents'Basic Medical Insurance affect its equity?The previous studies were mainly focused on importance and significance of the integration of medical insurance system and discussed the effect of integration on equality in access to health care and financial protection,based on theory of health equity and overall planning of the urban and rural developments.There were few empirical research on equity of Urban-rural Residents' Basic Medical Insurance.There was not reasonable framework to analyze equity of medical insurance system.Although there were several research on the inequity of medical insurance system abroad,there was little systematic research on the inequity of Urban-rural Residents' Basic Medical Insurance and its factors.ObjectivesThe general objectives of this study are to assess the equity of Urban-rural Residents'Basic Medical Insurance systemically.including the equity in health insurance coverage,financing,health care utilization and benefit.The research also aims to examine the impact factor on equity of Urban-rural Residents' Basic Medical Insurance and provide scientific policy implication to improve the equity and the Urban-rural Residents' Basic Medical Insurance schemes.The specific aims include:(1)to develop a framework for analyzing the equity of Urban-rural Residents' Basic Medical Insurance.(2)to evaluate the equity of Urban-rural Residents' Basic Medical Insurance coverage,financing,health care utilization and the benefit,respectively.(3)to examine the factor which impacts on the equity using quantitative method,especially the effect of Urban-rural Residents' Basic Medical Insurance policy design on equity.(4)to make reasonable and scientific recommendations for the design of Urban-rural Residents' Basic Medical Insurance.MethodsIn this study,five cities in Shandong Province,which had completed the integration of Urban-rural Residents,Basic Medical Insurance,were selected as the research objects.The data were mainly derived from the statistical reports on socioeconomic development and the development of health system in the sample cities;the household survey of the insured families;medical insurance policy documents for Urban-rural Residents' Basic Medical Insurance and the statistical data of the system operation process;questionnaire survey and semi-structured interview on the medical insurance managing staff.Multistage stratified random sampling method was employed in the research.Five cities were selected in Shandong Province,and one district and one county were randomly selected in each city.Next,three communities/townships were randomly designated from each district/county,and two neighborhood committees/villages were randomly identified from each community/township.Then,20 households were randomly selected in each neighborhood committee/village.Finally,a total of 2431 household members in 1044 households and 67 staff members in medical insurance managing entity were investigated,and 40 managers and administrators were interviewed in the medical insurance managing entity.On the basis of literature review and Delphi Method,the analytical framework were constructed,including indicators of the equity of medical insurance systems,as well as the policy elements of medical insurance system.Descriptive statistical analysis,univariate statistical analysis and generalized linear regression analysis were conductedto analyze quantitative data.The Girni coefficient,the concentration curve and the concentration index,the Kakwani index and the redistributive effect index were used to measure the equity of financing.The concentration curve and concentration index,as well as horizontal inequity index were employed to measure the inequity in health care service and the equity of the benefit.The nonlinear decomposition method was used to decompose the concentration index and distinguish the factors that contributed to inequality of health care utilization and benefit.A thematic framework analysis was used to analyze qualitative interview data.Results1.98%of the urban unemployed population and rural population in the five cities were covered by Urban-rural Residents' Basic Medical Insurance in 2015.The immigrant population still lacked health insurance coverage under the context of universal health insurance coverage.94.71%of the household heads said they were willing to continue to participate in Urban-rural Residents' Basic Medical Insurance,and about 5%of households were unwilling or hesitated to enroll Urban-rural Residents'Basic Medical Insurance in the next year.2.The premium of Urban-rural Residents' Basic Medical Insurance for urban and rural residents was regressive.The Kakwani index for personal contributions was-0.3184,which was significantly negative.The premium was vertical inequity which was significantly regressive.The premium in rural area was more regressively than that in urban area.The patter of unified premium was more regressive than the patter of difference premium.The redistributive effect of individual contribution was 0.0054.The Gini index after contribution payment was higher than that before the contribution payment.The contribution payment expanded the gap between the poor and the rich.The decomposition analysis of redistributive effect found that vertical inequity was the main source of the pro-rich redistribution.About 90%of the insured families thought that the burden of Urban-rural Residents' Basic Medical Insurance premium was low or moderate.The region of residence(urban and rural areas),the total amount of premium of households and the number of households' members had significant effects on the assessment of the burden of Urban-rural Residents' Basic Medical Insurance premium.Household consumption expenditure had no significant impact on the assessment of the burden of premium.3.There was no significant inequity in outpatient care utilization among enrolls of Urban-rural Residents' Basic Medical Insurance.The probability of outpatient care utilization in previous two weeks was 9.87%.The concentration index for probability of outpatient service utilization was-0.0451(p>0.05),which was insignificant.The horizontal inequity index for probability of outpatient service utilization was-0.0665(p<0.05).The economic status,region of residence(urban and rural areas)and the outpatient reimbursement policy under Urban-rural Residents' Basic Medical Insurance had no significant effect on the probability of outpatient care utilization in previous two weeks.4.The probability of inpatient care utilization during the previous year was 11.64%.The concentration index for probability of inpatient visit was 0.3037(p<0.01)and the horizontal inequity index was 0.2252(p<0.01),after indirect standardization of need variables.The mean of conditional number of inpatient visits was 1.32 and the median was 1.The concentration index for conditional number of inpatient visits was 0.0502(p<0.01)and the horizontal inequity index was 0.0360(p<0.05).All the indices were significantly positive.Socioeconomic status was the main factor that led to the inequality in inpatient service utilization.It made 65%?98%positive contribution to inequality in inpatient care utilization,which widened the pro-rich inequality in inpatient care utilization.The region of residence(urban and rural areas)had no significant effect on inpatient service utilization.The dummy variables of Urban-rural Residents' Basic Medical Insurance policy had significant effects on the probability and conditional number of inpatient service visits.In particular,pattern of different financing-reimbursement policies had reduced the probability and frequency of inpatient services utilization,which showed a positive contribution to the concentration index for inpatient service utilization.The high deductible reduced the utilization of inpatient services,which had positive contribution to the concentration index for inpatient service utilization.High reimbursement rates enhanced the probability of inpatient service utilization of the insured.However,it decreased the conditional number of inpatient visits.Overall,high reimbursement rates showed negative contribution and reduced pro-rich inequality in inpatient service utilization.However,owing to the small variation of inpatient reimbursement policy of Urban-rural Residents' Basic Medical Insurance in the sample area,the effect on the inpatient care utilization and its equity was low.5.The probability of outpatient benefit among the insured residents was 42.41%.The concentration index for probability of benefit was-0.0003(p>0.05)and the horizontal inequity index was 0.0006(p>0.05).The mean of outpatient reimbursement amount was 236.60 yuan.The concentration index for outpatient reimbursement amount was 0.1612(p<0.01)and the horizontal inequity index was-0.0534(P<0.05).The socioeconomic status,region of residence(urban and rural areas)and the outpatient reimbursement policy under Urban-rural Residents' Basic Medical Insurance had no significant effects on the probability of outpatient benefit.The reimbursement policy of chronic disease had positive influence on the reimbursement amount,which decreased the inequality of outpatient benefit degree.6.The probability of inpatient benefit among the insured residents was 10.2%.The concentration index for probability of inpatient benefit was 0.3015(p<0.01)and horizontal inequity index was 0.2246(p<0.01).The mean amount of inpatient reimbursement was 6367.05 yuan.The concentration index for amount of inpatient reimbursement was 0.3207(p<0.01)and horizontal inequity index was 0.2380(p<0.01).The disparity of' socioeconomic status sho-wed high positive contribution to inequality in inpatient reimbursement,which got up to about 56%-65%.The region of residence(urban and rural areas)had no significant effect on the inpatient reimbursement.The contribution of Urban-rural Residents' Basic Medical Insurance policy was small.The pattern of different financing-reimbursement policies had positive contribution to inequality in probability of inpatient benefit,and had a negative contribution to inequality in degree of inpatient benefit.Finally,the contribution of high deductible to inequality in probability and degree of inpatient benefit was negative and high reimbursement rate had a negative contribution.But when the inpatient reimbursement rate reached 75%,the contribution to the inequality in inpatient benefit had turned to positive.Conclusions and policy implicationsThe main conclusions of this study are as follows:(1)Urban-rural Residents' Basic Medical Insurance basically realizes its equality in coverage;(2)there is vertical inequity in financing and premium;(3)the utilization and benefit of outpatient service is equally distributed among the enrollees;(4)there exists inequality in utilization and benefit of inpatient service which is concentrated among the better-off;(5)socioeconomic status is still the main source of pro-rich inequality in inpatient service(6)reasonable financing and reimbursement policy design is helpful to improve the equality in Urban-rural Residents' Basic Medical Insurance.According the above conclusion,the flowing recommendations is proposed:(1)expand the medical insurance coverage to the migrant population;(2)direct targeted specific subsidy to the disadvantaged and low-income groups;(3)develop the financing-reimbursement policy pattern according to local socil-economic context;(4)provide more subsidy to chronic patients with outpatient care utilization;(5)design reasonable deductible and reimbursement rate for inpatient care utilization.