Cost-effectiveness of medical migration for chronic kidney disease: a national cross-sectional study in China.

BACKGROUND: The phenomenon of medical migration is common in China. Due to the limited capacity and substantial geographical variation in medical practice, patients with chronic kidney disease (CKD) travel more frequently to seek medical care. We aimed to assess the cost-effectiveness of medical migration for CKD patients in China and provide real-world evidence for the allocation of CKD resources. METHODS: Records of patients with CKD between January 2014 and December 2018 were extracted from a large national database. A patient is defined as a medical migrant if she travelled across the provincial border to a non-residential province to be admitted for inpatient care. The propensity score matching method is used to estimate the effect of medical migration on medical expenditure, length of hospital stay, and in-hospital mortality. The cost-effectiveness is evaluated by comparing the estimated cost per life saved with contemporaneous estimates of the value of a statistical life. RESULTS: Among 4,392,650 hospitalizations with CKD, medical migrants accounted for 4.9% in 2018. Migrant patients were estimated to incur a 26.35% increase in total medical expenditure, experience a 0.24-percentage-points reduction in in-hospital mortality rates, and a 0.49-days reduction in length of hospital stay compared to non-migrant patients. Overall, medical migration among CKD patients incurred an average of 1 million yuan per life saved, which accounted for 20-40% of contemporaneous estimates of the value of a statistical life. Compared with migrant patients with self-payment and commercial insurance, migrant patients with public health insurance (urban basic medical insurance and new rural co-operative medical care) incurred lower cost per life saved. Cost per life saved for CKD patients was similar between female and male, lower among older population, and varied substantially across regions. CONCLUSIONS: The medical care seeking behaviors of CKD patients was prominent and medical resources of kidney care were unevenly allocated across regions. Medical migration led to a reduction in mortality, but was associated with higher medical expenditure. It is imperative to reduce the regional disparity of medical resources and improve the clinical capacity. Our study shows that it is imperative to prioritize resource allocation toward improving kidney health and regional health care planning.

Health insurance enrollment and vision health in rural China: an epidemiological survey.

BACKGROUND: Vision health is an important aspect of health worldwide. Visual impairment (VI) is associated with poor quality of life and is usually more prevalent in rural areas. To help rural populations obtain vision care, health insurance policies have emerged throughout the world. However, some existing literatures show that health insurance enrollment's impact on the overall physical health of rural population has been minimal. Focusing on vision health among adults in rural China, our study aims to investigates the impact of health insurance on vision health, heterogeneity of the effect, and the moderating effect of health insurance enrollment on the impact of chronic physical diseases and basic eye diseases on vision health. METHODS: Primary data were collected through a nation-wide epidemiological survey of vision health conducted in rural China in 2018, with a sample size of 28,787 used in our statistical analysis. Instrumental variables regression and Heckman selection models were conducted to examine the impact of health insurance enrollment and reimbursement ratio adults' vision health outcomes. Subsample regressions by sex, age, education level, and whether with eye diseases were further conducted to explore the heterogeneity in our results. We then examined whether health insurance enrollment moderates the impact of chronic physical diseases and basic eye diseases on vision health through the method of introducing interaction terms. RESULTS: Participating in health insurance reduced the probability of VI by 2.15 %. The reimbursement rate increasing by 1 % point may reduce the probability of worsening VI by 6.12 %. Men (-0.0235, P = 0.0002) benefit more from insurance enrollment than women (-0.0201, P = 0.0082) with respect to vision health. From the young adult group to the oldest group, the marginal effect of health insurance increased from - 0.0068 (P = 0.0394) to -0.0753 (P < 0.0001). The marginal effect on VI was most significant in people with lower education levels and weakened with increased education levels. People with basic eye diseases (-0.0496, P = 0.0033) benefit more from participating insurance than the people without basic eye diseases (-0.0196, P = 0.0001) with respect to vision health. The moderating effects of health insurance enrollment on the impacts of cerebral infarction (-0.1225, P < 0.0001), diabetes (-0.0398, P = 0.0245), hyperlipidemia (-0.1364, P = 0.0271), mental illness (-0.1873, P = 0.0010), glaucoma (-0.1369, P = 0.0073), diabetic retinopathy (-0.1560, P = 0.0043), and retinal vein obstruction (-0.2018, P = 0.0155) on vision health were significantly negative. CONCLUSIONS: The results suggest that participation in health insurance and higher health insurance reimbursement ratios reduced the risk of VI in the sampled adults. Health insurance has the most significant effect in in vulnerable groups. Heath insurance enrollment moderates the impacts of several chronic physical and basic eye conditions on vision health. Our findings have potential implications for reforming health insurance policies to improve vision health conditions in rural areas of developing countries.

Depression hurts, depression costs: The medical spending attributable to depression and depressive symptoms in China.

Due to its fast economic growth and lifestyle changes, China is experiencing a rapid epidemiological transition from communicable to noncommunicable diseases (NCDs). Mental disorder such as depression is an important yet often neglected NCD and is becoming a growing cause of disability, suicides, and disease burden. This paper provides the first nationally representative estimate of the medical cost attributable to depression and depressive symptoms among the adult population in China. On the basis of the 2012 China Family Panel Studies survey, our results indicate that these mental health conditions have significant impacts on the individual medical expenditure, and they jointly contribute to 14.7% of total personal expected medical spending in China, with depression and depressive symptoms accounting for 6.9% and 7.8%, respectively. Given that patients with mental illness face multiple psychological and institutional barriers in seeking appropriate treatment, the high depression-induced medical costs may be primarily driven by the cost-shifting effect from mental health care to general health care, as mental disorders often coexist with other NCDs such as diabetes and hypertension. As an implication, our study calls for an urgent reform of China's mental health and insurance systems to remove the policy-induced obstacles for the access to mental health care resources.

The Medical Cost Attributable to Obesity and Overweight in China: Estimation Based on Longitudinal Surveys.

With its rapid economic growth and fast changing lifestyle, China witnessed expansionary prevalence of obesity and overweight during the recent decades. This paper provides the first nationally representative estimate of the medical cost attributable to obesity and overweight in China. We improve upon the traditional estimation methodology (two-part model) by jointly adopting the instrumental variable approach and the panel data methods in order to correct for the potential endogeneity of body size and the individual heterogeneity in medical expenditure. Using longitudinal data from 2000-2009 China Health and Nutrition Surveys, we find that body size has a significant impact on the individual expected medical expenditure and the per capita medical cost attributable to obesity and overweight in a single medical event is estimated to be 6.18 Yuan, or 5.29% of the total personal medical expenditure. This translates to 24.35 billion Yuan annual cost on the national scale, accounting for 2.46% of China's national health care expenditure. The subsample analyses also show that such cost is higher for the urban, women, and better educated people and increases over time. Our results contribute to the literature on the economic impact of obesity in developing countries and bear policy implications on controlling the rising health care costs in China. Copyright © 2015 John Wiley & Sons, Ltd.

The Impact of Extreme Temperature Shocks on the Health Status of the Elderly in China.

With the accelerating process of climate change, long-term exposure to extreme temperatures could threaten individuals' physical health, especially for the vulnerable population. This paper aims to investigate the long-term effects of extreme temperature exposure on the health of the elderly in the context of climate change and aging. Different from most of the existing literature in environmental economics, we define the relative extreme temperature exposure based on the local temperature pattern. By combining a large national household survey and nationwide meteorologic historical data, this study provides empirical evidence that heat exposure days and cold exposure days during the past year both significantly affect the physical health of middle-aged and elderly groups, controlling for city, year, and individual fixed effects. The effect on individual physical health has certain seasonal characteristics and is heterogeneous across populations. Additionally, cooling and heating equipment are effective in alleviating the reverse impact of heat and cold exposure. The estimation is robust and consistent across a variety of temperature measurements and model modifications. Our findings provide evidence of the long-term and accumulative cost of extreme temperature to middle-aged and elderly human capital, contributing to helping the public to better understand the full impact of climate change.

Understanding and Addressing the Treatment Gap in Mental Healthcare: Economic Perspectives and Evidence From China.

A common challenge faced by the healthcare systems in many low- and middle-income countries is the substantial unmet mental healthcare needs, or the large gap between the need for and the provision of mental healthcare treatment. This paper investigates the potential causes of this treatment gap from the perspective of economics. Specifically, we hypothesize that people with mental illness face 4 major hurdles in obtaining appropriate healthcare, namely the high nonmonetary cost due to stigma, the high out-of-pocket payment due to insufficient public funds devoted to mental health, the high time costs due to low mental healthcare resource availability, and the low treatment benefit due to slow technology diffusion. We use China as a study setting to show country-specific evidence. Our analysis supports the above theoretical argument on the 4 barriers to access, which in turn sheds light on the effective approaches to mitigate the treatment gap. Four policy options are then discussed, including an information campaign for mental health awareness, increasing public investment in primary mental healthcare resources, transforming the healthcare system towards an integrated people-centered system and capitalizing on e-health technologies.

Tobacco use and E-cigarette regulation: Perspectives of University Students in the Asia-Pacific.

INTRODUCTION: The Asia-Pacific is home to 30% of the world's smokers. Additional efforts are needed to reduce negative health impacts of tobacco, including e-cigarettes. The study objectives were to 1. Investigate Asian-Pacific students' knowledge, attitudes, and use of tobacco products; 2. Determine the level of student support for tobacco control policies; and 3. Examine differences in students' attitudes by the strength of national tobacco control policies based on implementation of WHO's MPOWER package, and e-cigarette regulation in their countries. METHODS: A total of 1953 students from members of the Association of Pacific Rim Universities in 13 countries completed the online survey. We compared the results by the Fisher-Freeman-Halton test. RESULTS: While about 83% of students had heard of e-cigarettes; only 14.1% had tried them. Students in countries with e-cigarette bans were the least likely to report having experimented with e-cigarettes (8.1%). While the vast majority of students (87.9%) reported having seen health campaigns targeting combustible cigarettes, far fewer (42.5%) had seen any health campaigns targeting e-cigarettes. About 80% of students supported smoke-free campuses, with the most support coming from those in countries with the weakest adoption of MPOWER policies (88.7%) and no e-cigarette regulations (80.4%). Students in countries with the weakest MPOWER policies were also the most likely to support campus bans and government regulation of e-cigarettes. CONCLUSIONS: The adoption of tobacco control polices by government may have an impact on e-cigarette smoking behavior among students, and student support for tobacco control, including noncombustible products, is high. Universities should take action by adopting comprehensive tobacco control measures that include e-cigarette regulations.

Association of visual acuity with educational outcomes: a prospective cohort study.

BACKGROUND/AIM: To quantify the impact of baseline presenting visual acuity (VA), refractive error and spectacles wear on subsequent academic performance among Chinese middle school children. METHODS: A prospective, longitudinal, school-based study on grade 7 Chinese children (age, mean±SD, 12.7±0.5 years, range=11.1-15.9) at four randomly selected middle schools in Anyang, China. Comprehensive eye examinations including cycloplegic autorefraction were performed at baseline, and information on demographic characteristics, known risk factors for myopia and spectacle wear was collected. Academic test scores for all subjects in the curriculum were obtained from the local Bureau of Education. Main outcome measure was total test scores for five subjects at the end of grade 9, adjusted for total scored at the beginning of grade 7. RESULTS: Among 2363 eligible children, 73.1% (1728/2363) had seventh grade test scores available. 93.9% (1623/1728) completed eye examinations, and 98.5% (1599/1623) of these had ninth grade test scores. Adjusting only for baseline test score, the following were significantly associated with higher ninth grade scores: younger age, male sex, less time outdoors, better baseline presenting VA, higher parental education and income and parental myopia, but refractive error and spectacle wear were not. In the full multivariate model, baseline test score (p<0.001), presenting VA (p<0.01), age (p<0.001), quality of life (p<0.05) and parental education (p<0.001) and myopia (either: p<0.05; both: p<0.05) remained significantly associated with better ninth grade scores. CONCLUSIONS: In this longitudinal study, better presenting VA, but not cycloplegic refractive error or spectacle wear, was significantly associated with subsequent academic performance.

Is the pro-competition policy an effective solution for China's public hospital reform?

The new round of health care reforms in China achieved significant initial results. New and emerging problems coinciding with the deepening of the reforms, however, require further institutional changes to strengthen the competition mechanism and promote public hospital efficiency. This paper provides a conceptual framework and preliminary assessment of public hospital competition in China. Specifically, we distinguish between two closely related concepts - competition and privatization, and identify several critical conditions under which hospital competition can be used as a policy instrument to improve health care delivery in China. We also investigate the current performance and identify several unintended consequences of public hospital competition - mainly, medical arms race, drug over-prescription and the erosion of a trusting relationship between patients and physicians. Finally, we discuss the policy options for enhancing the internal competition in China's hospital market, and conclude that public investment on information provision is key to reaping the positive outcomes of pro-competition policies.

Transforming rural health care through information technology: an interventional study in China.

This article estimates the impacts of health information technology (HIT) on health-care delivery in the Wenchuan County of China, where the devastation of the 2008 Great Wenchuan Earthquake and the subsequent large-scale HIT implementation (the Healthy Wenchuan Program) offers a 'natural experiment' opportunity, enabling us to conduct a difference-in-difference evaluation of the potential benefits of HIT on accessibility, affordability and appropriateness of health-care services in the underdeveloped rural area. Based on data collected from two field surveys in township hospitals, we find that for both the inpatient and outpatient samples, the HIT system promotes access to medical care by increasing doctor referrals and encouraging within-county medical utilization, reduces patient financial burden in certain expenditure categories, and contributes to higher patient satisfaction on medical care quality. On the other hand, we also find that HIT leads to increased patient waiting time for hospital registration, reflecting the unique challenges in implementing HIT in the underdeveloped areas. Our study contributes to the growing body of literature on evaluating the impacts of HIT application in the developing regions, and provides implications on the potential role of HIT in China's national health system reforms.

Does the US health care safety net discourage private insurance coverage?

The large and growing uninsured population poses an alarming threat to the US health care system, and is a major target of the Obama health reform. This paper investigates analytically and empirically the degree to which the absence of health insurance in the US reflects the availability of the health care safety net, such as the guaranteed or charitable care provided by emergency rooms, community health centers and physicians. Our theoretical model demonstrates that the safety net can be a real alternative to health insurance, thus discouraging private insurance purchase in the market setting. In particular, when the community premium rate fails to reflect the value of such resources, not purchasing insurance becomes a rational decision for a sizeable portion of the population. The calibrated simulation based on US statistics indicates about 15.75% of the uninsured population, or 7.2 million people in US, are attributable to the existing safety net system. Further empirical analysis using nationally representative data shows consistently that the presence of local safety net resources may reduce the probability of individual insurance purchase by as much as 45.9%.

Disparity and convergence: Chinese provincial government health expenditures.

The huge regional disparity in government health expenditures (GHE) is a major policy concern in China. This paper addresses whether provincial GHE converges in China from 1997 to 2009 using the economic convergence framework based on neoclassical economic growth theory. Our empirical investigation provides compelling evidence of long-term convergence in provincial GHE within China, but not in short-term. Policy implications of these empirical results are discussed.