The impact of the new cooperative medical scheme on financial burden of tuberculosis patients: evidence from six counties in China.

BACKGROUND: Tuberculosis (TB) patients in China encounter heavy financial burdens throughout the course of their treatment and it is unclear how China's health insurance systems affect the alleviation of this burden under the integrated approach. This study aimed to measure reimbursement for TB services under the New Cooperative Medical Scheme (NCMS) in rural China and to evaluate changes in catastrophic health expenditure (CHE) caused by the reimbursement policies. METHODS: Reimbursement data were obtained from routine data systems for the NCMS in Yichang (YC) and Hanzhong (HZ). 1884 TB inpatients reimbursed by NCMS from 2010 to 2012 were included. Household surveys were conducted. A total of 494 TB patients under the NCMS were selected in this paper. 12 Focus Group Discussions (FGDs) were held. We measured the impact of the NCMS by counterfactual analysis, which analyzed the financial burden alleviation. Equity was assessed by Concentration Index (CI), and disaggregated by project sites. RESULTS: TB inpatients were reimbursed with an effective reimbursement rate of 57.3 %. Average out-of-pocket (OOP) payments for outpatient and inpatient services after diagnosis were 1413 yuan and 430 yuan, and 3572 yuan and 3013 yuan in YC and HZ, respectively. The reimbursement level for TB outpatient care after diagnosis was very low due to a limited outpatient quota. TB patients in HZ incurred higher effective reimbursement rates, but the incidence of CHE remained higher. The reduction of CHE incidence after the NCMS showed no difference statistically (P > 0.05). The severity of CHE was alleviated slightly. CIs after reimbursement were all below zero and their absolute values were higher than those before reimbursement. CONCLUSIONS: Low reimbursement for TB patients could lead to heavy financial burden. Poor TB patients incurred high rates of CHE. The NCMS was found to be a protective factor for CHE, but the impact was modest and the equity of CHE did not improve. The NCMS reimbursement policies should be improved in the future to include a more comprehensive coverage of care. Supplemental programs may be necessary to expand coverage for TB care.

Non-medical financial burden in tuberculosis care: a cross-sectional survey in rural China.

BACKGROUND: Treatment of tuberculosis (TB) in China is partially covered by national programs and health insurance schemes, though TB patients often face considerable medical expenditures. For some, especially those from poorer households, non-medical costs, such as transport, accommodation, and nutritional supplementation may be a substantial additional burden. In this article we aim to evaluate these non-medical costs induced by seeking TB care using data from a large scale cross-sectional survey. METHODS: A total of 797 TB cases from three cities were randomly selected using a stratified cluster sampling design. Inpatient medical costs, outpatient medical costs, and direct non-medical costs related to TB treatment were collected using in-person interviews by trained interviewers. Mean and median non-medical costs for different sub-groups were calculated and compared using Kruskal-Wallis and Mann-Whitney U tests. Regression analysis was conducted to assess the influence of different patient characteristics on total non-medical cost. RESULTS: The median non-medical cost was RMB 1429, with interquartile range RMB 424-2793. The median non-medical costs relating to inpatient treatment, outpatient treatment, and additional nutrition supplementation were RMB 540, 91, and 900, respectively. Of the 797 cases, 20 % reported catastrophic expenditure on non-medical costs. Statistically significant differences were detected between different cities, age groups, geographical locations, inpatient/outpatient care, education levels and family income groups. CONCLUSIONS: Non-medical costs relating to TB treatment are a serious financial burden for many TB patients. Financial assistance that can limit this burden is urgently needed during the treatment period, especially for the poor.

Factors that associated with TB patient admission rate and TB inpatient service cost: a cross-sectional study in China.

BACKGROUND: China has recently adopted the "TB designated hospital model" to improve the quality of tuberculosis (TB) treatment and patient management. Considering that inpatient service often results in high patient financial burden, and therefore influences patient adherence to treatment, it is critical to better understand the TB patient admission rate and TB inpatient service cost, as well as their influential factors in this new model. METHODS: Quantitative and qualitative studies were conducted in two cities, Hanzhong in Shaanxi Province and Zhenjiang in Jiangsu Province, in China. Quantitative data were obtained from a sample survey of 533 TB patients and TB inpatient records from 2010-2012 in six county designated hospitals. Qualitative information was obtained through interviews with key stakeholders (40 key informant interviews, 14 focus group discussions) and reviews of health policy documents in study areas. Both univariate and multivariate statistical analyses were applied for the quantitative analysis, and the thematic framework approach was applied for the qualitative analysis. RESULTS: The TB patient admission rates in Zhenjiang and Hanzhong were 54.8 and 55.9 %, respectively. Qualitative analyses revealed that financial incentives, misunderstanding of infectious disease control and failure of health insurance regulations were the key factors associated with the admission rates and medical costs. Quantitative analyses found differences in hospitalization rate existed among patients with different health insurance and patients from different counties. Average medical costs for TB inpatients in Jurong and Zhenba were 7,215 CNY and 4,644 CNY, which was higher than the 5,500 CNY and 3,800 CNY limits set by the New Rural Cooperative Medical System. No differences in medical cost or length of stay were found between patients with and without comorbidities in county-level hospitals. CONCLUSIONS: TB patient admission rates and inpatient service costs were relatively high. Studies of related factors indicated that a package of interventions, including health education programs, reform of health insurance regulations and improvement of TB treatment guidelines, are urgently required to ensure that TB patients receive appropriate care.

Use of anti-tuberculosis drugs among newly diagnosed pulmonary tuberculosis inpatients in China: a retrospective study.

BACKGROUND: China's national tuberculosis control program (NTP) provides free, first-line anti-tuberculosis (TB) drugs to pulmonary TB patients. This treatment regimen follows the World Health Organization's (WHO) guideline. The objective of this paper is to evaluate the current status of anti-TB drug use for newly diagnosed pulmonary TB inpatients treated in prefecture- and county-level designated hospitals. METHODS: Three prefecture-level hospitals and nine county-level hospitals were selected for the study. All newly diagnosed pulmonary TB inpatient medical records from 2012 were reviewed and doubly examined by two national senior physicians. The rational use of anti-TB drugs was evaluated based on criteria in line with WHO's guideline. RESULTS: Of the 2,060 total treatment regimens for TB, 53.1 % were found to be rational (1093/2060). The percentages in prefecture-level and county-level hospitals were 50.3 % (761/1513) and 60.7 % (332/547), respectively. The difference between the two levels of hospitals was statistically significant (Chi-square value = 17.44, P < 0.01). The percentages of rational treatment regimens for first-time hospitalizations and for two or more hospitalizations were 59.5 % (983/1653) and 27.0 % (110/407), respectively, with a statistically significant difference (Chi-square value = 138.00, P < 0.01). The overall use of second-line drugs (SLD) was 54.9 % (1131/2060). The percentages for prefecture-level and county-level hospitals were 50.6 % (766/1513) and 66.7 % (365/547), respectively. A statistically significant difference was found (Chi-square value = 42.06, P < 0.01). The use of SLD for inpatients hospitalized once and inpatients hospitalized twice or more was 58.4 % (966/1653) and 40.5 % (165/407), respectively, with a statistically significant difference (Chi-square value = 42.26, P < 0.01). CONCLUSIONS: Half of inpatients might be treated with irrational regimens, and the use of SLD was more appropriately dispensed in city-level hospitals than in county-level hospitals. Trainings and guidelines for health personnel, supervision led by health authorities and increased investment to designated hospitals may help to improve the rational use of anti-TB drugs.