Impact of medical insurance access negotiation on the utilization of innovative anticancer drugs in China: an interrupted time series analysis.

BACKGROUND: The high costs of innovative anticancer drugs hinder a number of cancer patients' access to these drugs in China. To address this problem, in 2018, the medical insurance access negotiation (MIAN) policy was implemented, when the prices of 17 innovative anticancer drugs were successfully negotiated and they were therefore included in the reimbursement list. This study aimed to explore the impact of the MIAN policy on the utilization of innovative anticancer drugs. METHODS: With monthly data on drug expenditures and defined daily doses (DDDs) of each innovative anticancer drug from January 2017 to December 2019, interrupted time series analysis was employed to estimate both the instant (change in the level of outcome) and long-term (change in trends of outcomes) impacts of the MIAN policy on drug utilization in terms of drug expenditures and DDDs. Our sample consists of 12 innovative anticancer drugs. RESULTS: From January 2017 to December 2019, the monthly drug expenditures and DDDs of 12 innovative anticancer drugs increased by about 573% (from US$8,931,809.30 to US$51,138,331.09) and 1400% (from 47,785 to 668,754), respectively. Overall, the implementation of the MIAN policy led to instant substantial increases of US$8,734,414 in drug expenditures and 158,192.5 in DDDs. Moreover, a sharper upward trend over time was reported, with increases of US$2,889,078 and 38,715.3 in the monthly growth rates of drug expenditures and DDDs, respectively. Regarding individual innovative anticancer drugs, the most prominent instant change and trend change in drug utilization were found for osimertinib, crizotinib, and ibrutinib. In contrast, the utilization of pegaspargase was barely affected by the MIAN policy. CONCLUSIONS: The MIAN policy has effectively promoted the utilization of innovative anticancer drugs. To ensure the continuity of the effects and eliminate differentiation, supplementary measures should be carried out, such as careful selection of drugs for medical insurance negotiations, a health technology assessment system and a multichannel financing mechanism.

Factors and key problems influencing insured's poor perceptions of convenience of basic medical insurance: a mixed methods research of a northern city in China.

BACKGROUND: This study aimed to explore the factors that affect insured's perceptions of convenience of the basic medical insurance (PCBMI) in Harbin, China and to diagnose the key problems to further propose corresponding measures. The findings provide evidence-based support for the reform of convenience of the basic medical insurance system (BMIS) and the cultivation of public literacy. METHODS: We adopted a mixed methods design composing a multivariate regression model using the data from a cross-sectional questionnaire survey (n = 1045) of residents who were enrolled for BMIS in Harbin to identify the factors influencing the PCBMI. A quota sampling method was further adopted. Semi-structured interviews were then conducted with 30 important information providers selected by convenience sampling. Interpretative phenomenological analysis was employed to summarize and analyze the key problems. RESULTS: Overall, approximately 51% of respondents reported poor PCBMI. The logistic regression model showed that insured without outpatient experience within two weeks (OR = 2.522, 95% CI = 1.267-5.024), had poorer levels of understanding of basic medical insurance information (OR = 2.336, 95% CI = 1.612-3.386), lived in rural areas (OR = 1.819, 95% CI = 1.036-3.195), had low levels of annual out-of-pocket medical expenses (OR = 1.488, 95% CI = 1.129-1.961), and were more likely to give the PCBMI a worse evaluation than their counterparts. The results of the qualitative analysis showed that the key problem areas of the PCBMI were the design of the BMIS, the cognitive biases of the insured, publicity information about the BMIS, and the health system environment. CONCLUSIONS: This study found that in addition to the design of BMIS, the cognition of the insured, the BMIS information publicity and the health system environment are also the key problems hindering PCBMI. While optimizing system design and implementation, Chinese policymakers need to focus on the insured with low PCBMI characteristics. Moreover, it is necessary to focus on exploring effective BMIS information publicity methods, supporting public policy literacy and improving the health system environment.

Perceptions of the benefits of the basic medical insurance system among the insured: a mixed methods research of a northern city in China.

Background: The perceptions of the benefits of the basic medical insurance system among the insured not only reflect the system's performance but also the public's basic medical insurance policy literacy, valuable information for countries that have entered the stage of deepening reform. This study aims to examine the factors that affect the perceptions of the benefits of the basic medical insurance system in China, diagnose the key problems, and propose corresponding measures for improvement. Methods: A mixed method design was used. Data for the quantitative study were obtained from a cross-sectional questionnaire survey (n = 1,045) of residents of Harbin who had enrolled for basic medical insurance system. A quota sampling method was further adopted. A multivariate logistic regression model was then employed to identify the factors influencing the perceptions of the benefits of the basic medical insurance system, followed by semi-structured interviews with 30 conveniently selected key informants. Interpretative phenomenological analysis was used to analyze the interview data. Results: Approximately 44% of insured persons reported low perceptions of benefits. The logistic regression model showed that low perceptions of the benefits of the basic medical insurance system was positively correlated with the experience of daily drug purchases (OR = 1.967), perceptions of recognition with basic medical insurance system (OR = 1.948), perceptions of the financial burden of participation costs (OR = 1.887), perceptions of the convenience of using basic medical insurance for medical treatment (OR = 1.770), perceptions of the financial burden of daily drug purchases costs (OR = 1.721), perceptions of the financial burden of hospitalization costs (OR = 1.570), and type of basic medical insurance system (OR = 1.456). The results of the qualitative analysis showed that the key problem areas of perceptions of the benefits of the basic medical insurance system were: (I) system design of basic medical insurance; (II) intuitive cognition of the insured; (III) rational cognition of the insured; and (IV) the system environment. Conclusions: Improving the perceptions of the benefits of the basic medical insurance system of the insured requires joint efforts in improving system design and implementation, exploring effective publicity methods of basic medical insurance system information, supporting public policy literacy, and promoting the health system environment.

Perspectives and evaluation on the effect of financial burden relief of medical insurance for people with catastrophic diseases and its influencing factors.

Background: Catastrophic disease sufferers face a heavy financial burden and are more likely to fall victim to the "illness-poverty-illness" cycle. Deeper reform of the medical insurance system is urgently required to alleviate the financial burden of individuals with catastrophic diseases. Methods: Data were obtained from a cross-sectional questionnaire survey conducted in Heilongjiang in 2021, and logistic regression and restricted cubic spline model was used to predict the core factors related to medical insurance that alleviate the financial burden of people with catastrophic diseases. Results: Overall, 997 (50.92%) medical insurance-related professionals negatively viewed financial burden relief for people with catastrophic diseases. Factors influencing its effectiveness in relieving the financial burden were: whether or not effective control of omissions from medical insurance coverage (OR = 4.04), fund supervision (OR = 2.47) and degree of participation of stakeholders (OR = 1.91). Besides, the reimbursement standards and the regional and population benefit package gap also played a role. The likelihood of financial burden relief increased by 21 percentage points for each unit increase in the level of stakeholder discourse power in reform. Conclusion: China's current medical insurance policies have not yet fully addressed the needs of vulnerable populations, especially the need to reduce their financial burden continuously. Future reform should focus on addressing core issues by reducing the uninsured, enhancing the width and depth of medical insurance coverage, improving the level and capacity of medical insurance governance that provides more discourse power for the vulnerable population, and building a more responsive and participatory medical insurance governance system.

Spatial effects of air pollution on the economic burden of disease: implications of health and environment crisis in a post-COVID-19 world.

BACKGROUND: Air pollution has been identified as related to the diseases of susceptible population, but the spatial heterogeneity of its economic burden and its determinants are rarely investigated. The issue is of great policy significance, especially after the epidemic of COVID-19, when human are facing the joint crisis of health and environment, and some areas is prone to falling into poverty. METHODS: The geographical detector was adopted to study the spatial distribution characteristics of the incidence of catastrophic health expenditure (ICHE) for older adults in 100 rural areas in China at the prefecture-city level. The health factors, sociological factors, policy factors and environmental factors and their interactions are identified. RESULTS: First, most health service factors had strong explanatory power for ICHE whether it interacts with air pollution. Second, 50 single-factor high-risk areas of ICHE were found in the study, but at the same time, there were 21 areas dominated by multiple factors. CONCLUSION: The different contributions and synergy among the factors constitute the complex mechanism of factors and catastrophic health expenditure. Moreover, during this process, air pollution aggravates the contribution of health service factors toward ICHE. In addition, the leading factors of ICHE are different among regions. At the end, this paper also puts forward some policy suggestions from the perspective of health and environment crisis in the post-COVID-19 world: environmental protection policies should be combined with the prevention of infectious diseases; advanced health investment is the most cost-effective policy for the inverse health sequences of air pollution and infectious diseases such as coronavirus disease 2019 (COVID-19); integrating environmental protection policy into healthy development policy, different regions take targeted measures to cope with the intertwined crisis.

Degree of protection provided by poverty alleviation policies for the middle-aged and older in China: evaluation of effectiveness of medical insurance system tools and vulnerable target recognition.

BACKGROUND: China's medical insurance schemes and poverty alleviation policy at this stage have achieved population-wide coverage and the system's universal function. At the late stage of the elimination of absolute poverty task, how to further exert the poverty alleviation function of the medical insurance schemes has become an important agenda for targeted poverty alleviation. To analyse the risk of catastrophic health expenditure (CHE) occurrence in middle-aged and older adults with vulnerability characteristics from the perspectives of social, regional, disease, health service utilization and medical insurance schemes. METHODS: We used data from the 2018 China Health and Retirement Longitudinal Study (CHARLS) database and came up with 9190 samples. The method for calculating the CHE was adopted from WHO. Logistic regression was used to determine the different characteristics of middle-aged and older adults with a high probability of incurring CHE. RESULTS: The overall regional poverty rate and incidence of CHE were similar in the east, central and west, but with significant differences among provinces. The population insured by the urban and rural integrated medical insurance (URRMI) had the highest incidence of CHE (21.17%) and health expenditure burden (22.77%) among the insured population. Integration of Medicare as a medical insurance scheme with broader benefit coverage did not have a significant effect on the incidence of CHE in middle-aged and older people with vulnerability characteristics. CONCLUSIONS: Based on the perspective of Medicare improvement, we conducted an in-depth exploration of the synergistic effect of medical insurance and the poverty alleviation system in reducing poverty, and we hope that through comprehensive strategic adjustments and multidimensional system cooperation, we can lift the vulnerable middle-aged and older adults out of poverty.

Factors that dynamically affect provincial incidences of catastrophic health expenditure among middle-aged and elderly Chinese population-transition of disease financial risk protection from global to local.

BACKGROUND: The high incidence of catastrophic health expenditure (ICHE) among middle-aged and elderly population is a major deterrent for reducing the financial risk of disease. Current research is predominantly based on the assumption of spatial homogeneity of nationwide population characteristics, ignoring the differences in regional characteristics. Thus, our study aimed to explore the impact of various influencing factors on the ICHE from a spatiotemporal perspective. METHODS: We used data from the China Health and Retirement Longitudinal Study (waves 1 to 4), to conduct a retrospective cohort study across 28 provinces, from 2011 to 2018. We measured regional incidences of catastrophic health expenditure using methods recommended by the World Health Organization. Ordinary least squares (OLS) and geographical and temporal weighted regression (GTWR) were used as the global and local estimation models, respectively. The Fortheringham method was used to test the spatiotemporal non-stationarity. RESULTS: National ICHE showed a gradual increase from 2011 to 2015, but suddenly decreased from 2015 to 2018, also showing the spatial heterogeneity. And the southwest area and Hebei showed persistently high ICHE (Qinghai even reached the highest value of 27.5% in 2015). Out-of-pocket payment, gross domestic product, PM2.5, ageing, incidence of non-communicable diseases and disabilities, number of nurses, and health insurance coverage in the global estimation passed the significance test, and the GTWR model showed a better model fit (0.769) than the OLS model (0.388). Furthermore, except for health insurance coverage, all seven variables had spatiotemporal non-stationarity among their impacts on ICHE. CONCLUSION: In this longitudinal study, we found spatiotemporal non-stationarity among the variable relationships, supporting regional governments' adoption of regional-target policies. First, after the completion of universal health insurance coverage, the spatiotemporal non-stationarity of the prevalence of non-communicable diseases and disability and ageing should be the focus of the next phase of health insurance design, where improvements to compensation coverage and benefit packages are possible policy instruments. Second, the governance and causes of catastrophic health expenditure need to be laid out from a macro perspective rather than only from the individual/household perspective, especially for the potential impact of economic development, air pollution and nursing resources.

What fragile factors hinder the pace of China's alleviation efforts of the poverty-stricken population? A study from the perspective of impoverishment caused by medical expenses.

OBJECTIVE: China has made remarkable achievements in poverty alleviation. However, with the change in economic development and age structure, the population stricken by poverty due to medical expenses and disability accounted for 42.3 and 14.4% of the total poverty-stricken population, respectively. Accordingly, it is crucial to accurately pinpoint the characteristics of people who are about to become poor due to illness. In this study, we analyzed the incidence of impoverishment by medical expense at the provincial, family, and different medical insurance scheme levels to identify the precise groups that are vulnerable to medical-related poverty. METHOD: Data were extracted from the Fifth National Health Service Survey in China in 2013 through a multi-stage, stratified, and random sampling method, leaving 93,570 households (273,626 people) for the final sample. The method recommended by World Health Organization (WHO) was adopted to calculate impoverishment by medical expense, and logistic regression was adopted to evaluate its determinants. RESULTS: The poverty and impoverishment rate in China were 16.2 and 6.3% respectively. The poverty rate in western region was much higher than that of central and eastern regions. The rate of impoverishment by medical expense (IME) was higher in the western region (7.2%) than that in the central (6.5%) and eastern (5.1%) regions. The New Cooperative Medical Scheme (NCMS) was associated with the highest rate (9.1%) of IME cases. The top three diseases associated with IME were malignant tumor, congenital heart disease, and mental disease. Households with non-communicable disease members or hospitalized members had a higher risk on IME. NCMS-enrolled, poorer households were more likely to suffer from IME. CONCLUSION: The joint roles of economic development, health service utilization, and welfare policies result in medical impoverishment for different regions. Poverty and health service utilization are indicative of households with high incidence of medical impoverishment. Chronic diseases lead to medical impoverishment. The inequity existing in different medical insurance schemes leads to different degrees of risk of IME. A combined strategy to precise target multiple vulnerabilities of poor population would be more effective.

The superposition effects of air pollution on government health expenditure in China- spatial evidence from GeoDetector.

BACKGROUND: As the fifth-largest global mortality risk factor, air pollution has caused nearly one-tenth of the world's deaths, with a death toll of 5 million. 21% of China's disease burden was related to environmental pollution, which is 8% higher than the US. Air pollution will increase the demand and utilisation of Chinese residents' health services, thereby placing a greater economic burden on the government. This study reveals the spatial impact of socioeconomic, health, policy and population factors combined with environmental factors on government health expenditure. METHODS: Spearman's correlation coefficient and GeoDetector were used to identify the determinants of government health expenditure. The GeoDetector consist of four detectors: factor detection, interaction detection, risk detection, and ecological detection. One hundred sixty-nine prefecture-level cities in China are studied. The data sources are the 2017 data from China's Economic and Social Big Data Research Platform and WorldPOP gridded population datasets. RESULTS: It is found that industrial sulfur dioxide attributed to government health expenditure, whose q value (explanatory power of X to Y) is 0.5283. The interaction between air pollution factors and other factors will increase the impact on government health expenditure, the interaction value (explanatory power of × 1âˆ©× 2 to Y) of GDP and industrial sulfur dioxide the largest, whose values is 0.9593. There are 96 simple high-risk areas in these 169 areas, but there are still high-risk areas affected by multiple factors. CONCLUSION: First, multiple factors influence the spatial heterogeneity of government health expenditure. Second, health and socio-economic factors are still the dominant factors leading to increased government health expenditure. Third, air pollution does have an important impact on government health expenditure. As a catalytic factor, combining with other factors, it will strengthen their impact on government health expenditure. Finally, an integrated approach should be adopted to synergisticly governance the high-risk areas with multi-risk factors.

Impact of the National Reimbursement Drug List Negotiation Policy on Accessibility of Anticancer Drugs in China: An Interrupted Time Series Study.

Objective: Since 2016, the Chinese government has been regularly implementing the National Reimbursement Drug List Negotiation (NRDLN) to improve the accessibility of drugs. In the second round of NRDLN in July 2017, 18 anticancer drugs were included. This study analyzed the impact of the NRDLN on the accessibility of these 18 anticancer drugs in China. Methods: National hospital procurement data were collected from 2015 to 2019. As measurements of drug accessibility, monthly average of drug availability or defined daily dose cost (DDDc) was calculated. Interrupted time series (ITS) analysis was employed to evaluate the impact of NRDLN on drug accessibility. Multilevel growth curve models were estimated for different drug categories, regions or levels of hospitals. Results: The overall availability of 18 anticancer drugs increased from about 10.5% in 2015 to slightly over 30% in 2019. The average DDDc dropped from 527.93 CNY in 2015 to 401.87 CNY in 2019, with a reduction of 23.88%. The implementation of NRDLN was associated with higher availability and lower costs for all 18 anticancer drugs. We found an increasing level in monthly drug availability (ß2 = 2.1126), which ascended more sharply after the implementation of NRDLN (ß3 = 0.3656). There was a decreasing level in DDDc before July 2017 (ß2 = -108.7213), together with a significant decline in the slope associated with the implementation of NRDLN (ß3 = -4.8332). Compared to Traditional Chinese Medicines, the availability of Western Medicines was higher and increased at a higher rate (ß3 = 0.4165 vs. 0.1108). Drug availability experienced a larger instant and slope increase in western China compared to other regions, and in secondary hospitals than tertiary hospitals. Nevertheless, regional and hospital-level difference in the effect of NRDLN on DDDc were less evident. Conclusion: The implementation of NRDLN improves the availability and reduces the cost of some anticancer drugs in China. It contributes to promoting accessibility of anticancer drugs, as well as relieving regional or hospital-level disparities. However, there are still challenges to benefit more patients sufficiently and equally. It requires more policy efforts and collaborative policy combination.

Multi-dimensional vulnerability analysis on catastrophic health expenditure among middle-aged and older adults with chronic diseases in China.

OBJECTIVE: Middle-aged and older adults are more likely to suffer from chronic diseases because of their particular health characteristics, which lead to a high incidence of catastrophic health expenditure (CHE). This study plans to analyse the different factors affecting CHE in middle-aged and older adults with chronic diseases, target the vulnerable characteristics, and suggest groups that medical insurance policies should pay more attention to. METHODS: The data used in this study came from the 2018 China Health and Retirement Longitudinal Study (CHARLS) database. The method of calculating the CHE was adopted from the World Health Organization (WHO). The logistic regression was used to determine the family characteristics of chronic disease in middle-aged and older adults with a high probability of incurring CHE. RESULTS: The incidence of CHE in middle-aged and older adults with chronic disease was highest in sub-poverty level families (26.20%) was lowest in wealthier level families (20.07%). Households with malignant tumours had the highest CHE incidence under any circumstances, especially if the householder had been using inpatient service in the past year. Among the comparison of CHE incidence in different types of medical insurance, the Urban and Rural Residents' Basic Medical Insurance (URRBMI) was the highest (27.46%). The incidence of CHE was 2.73 times (95% CI 2.30-3.24) and 2.16 times (95% CI 1.81-2.57) higher among people who had used inpatient services in the past year or outpatient services in the past month than those who had not used them. CONCLUSIONS: Relatively wealthy economic conditions cannot significantly reduce the financial burden of chronic diseases in middle-aged and older adults. For this particular group with multiple vulnerabilities, such as physical and social vulnerability, the high demand and utilization of health services are the main reasons for the high incidence of CHE. After achieving the goal of lowering the threshold of universal access to health services, the medical insurance system in the next stage should focus on multiple vulnerable groups and strengthen the financial protection for middle-aged and older adults with chronic diseases, especially for patients with malignant tumours.

Inequity in Health Services Utilization in Economically Underdeveloped Regions of Northeast China.

Background: The Chinese health system has long been committed to eliminating inequalities in health services utilization. However, few studies have analyzed or measured these inequalities in economically underdeveloped regions in China. Methods: A total of 6,627 respondents from 3,000 households in Heilongjiang Province were extracted from the Sixth National Health Services Survey. We measured horizontal inequity in both 2-week outpatient rate and annual inpatient rate, and then identified the factors contributing to inequality. Results: The horizontal inequity indices of the 2-week outpatient and annual impatient rates in Heilongjiang Province were 0.0586 and 0.1276, respectively. Household income, health status, place of residence, basic medical insurance, and commercial health insurance were found to be the main factors affecting inequality in health services utilization. The contributions of household income to these two indices were 184.03 and 253.47%, respectively. Health status factors, including suffering from chronic disease, limitations in daily activities, and poor self-rated health, played positive roles in reducing inequality in these two indices. The contributions of place of residence to these two indices were 27.21 and -28.45%, respectively. Urban Employee Basic Medical Insurance made a pro-rich contribution to these two indices: 56.25 and 81.48%, respectively. Urban and Rural Resident Basic Medical Insurance, Urban Resident Basic Medical Insurance, New Rural Cooperative Medical Scheme, and other basic medical insurance made a pro-poor contribution to these two indices: -73.51 and -54.87%, respectively. Commercial health insurance made a pro-rich contribution to these two indices: 20.79 and 7.40%, respectively. Meanwhile, critical illness insurance made a slightly pro-poor contribution to these two indices: -4.60 and -0.90%, respectively. Conclusions: The findings showed that the "equal treatment in equal need" principle was not met in the health services utilization context in Heilongjiang Province. To address this issue, the government could make policy changes to protect low-income populations from underused health services, and work to improve basic medical insurance, critical illness insurance, and social security systems.

Evolving Patterns of Nutritional Deficiencies Burden in Low- and Middle-Income Countries: Findings from the 2019 Global Burden of Disease Study.

Low- and middle-income countries (LMICs) suffered the most from nutritional deficiencies (NDs). Although decades of efforts have reduced it, little is known about the changing trajectory of ND burden in LMICs. By extracting data of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, we calculated indicators of incidence and disability-adjusted life years (DALYs) to measure the burden of NDs and its main subcategories in LMICs, including protein-energy malnutrition, iodine deficiency, vitamin A deficiency, dietary iron deficiency, and other nutritional deficiencies by sex, age and spatial patterns. In LMICs, ND incidence still increased in the age group 15+ born before 2005, especially in males. The effort of reducing the DALYs of NDs has generated a strong decline in per age group. In the main subcategories of NDs, protein-energy malnutrition incidence in males age 45+ born before 1970 still increased. Despite vitamin A deficiency incidence and dietary iron deficiency, DALYs strongly experienced decreases over three decades while still remaining at the heaviest level in 2019, especially in females and children under 5 years. The top largest tendency estimates occurred in Mali' females and Bhutan' males. Zimbabwe was the only country with increased DALYs rate tendency in both sexes.

Ten-Year Poverty Alleviation Effect of the Medical Insurance System on Families With Members Who Have a Non-communicable Disease: Evidence From Heilongjiang Province in China.

Aims: Non-communicable diseases (NCD) drag the NCD patients' families to the abyss of poverty. Medical insurance due to weak control over medical expenses and low benefits levels, may have actually contributed to a higher burden of out-of-pocket payments. By making a multi-dimensional calculation on catastrophic health expenditure (CHE) in Heilongjiang Province over 10 years, it is significant to find the weak links in the implementation of medical insurance to achieve poverty alleviation. Methods: A logistic regression was undertaken to predict the determinants of catastrophic health expenditure. Results: The average CHE of households dropped from 18.9% in 2003 to 14.9% in 2013. 33.2% of the households with three or more NCD members suffered CHE in 2013, which was 7.2 times higher than the households without it (4.6%). The uninsured households with cardiovascular disease had CHE of 12.0%, which were nearly 10% points lower than insured households (20.4-22.4%). For Medical Insurance for Urban Employees Scheme enrolled households, the increasing number of NCD members raised the risk of impoverishment from 3.4 to 20.0% in 2003, and from 0.3 to 3.1% in 2008. Households with hospital in-patient members were at higher risk of CHE (OR: 3.10-3.56). Conclusions: Healthcare needs and utilization are one of the most significant determinants of CHE. Households with NCD and in-patient members are most vulnerable groups of falling into a poverty trap. The targeting of the NCD groups, the poorest groups, uninsured groups need to be primary considerations in prioritizing services that are contained in medical insurance and poverty alleviation.

Economic burden and health related quality of life of ultra-rare Gaucher disease in China.

BACKGROUND: The diagnosis and health care of patients with rare diseases present a tremendous challenge worldwide. This study described the health care service utilization through participants' perspective and estimated the cost of illness (COI), and patients with Gaucher disease (GD)'s/caregivers' health-related quality of life in China. METHOD: An online retrospective survey of patients with GD and their caregivers was conducted during May-June 2018. Socio-demographic, health service utilization, disease-related expenses, social support, sleep quality (Pittsburgh Sleep Quality Index [PSQI]), and the Short Form Health Survey (SF-36) were investigated. Using self-reported information, we estimated the annual COI, including direct healthcare, direct non-healthcare, and indirect costs. RESULTS: Forty patients and their 49 caregivers were surveyed. The patients' onset age of GD was 9.3 ± 10.9; their disease course was 3.5 ± 3.1 years. 21 (42.9%) patients had ≥ 2 caregivers, but 35 (71.4%) caregivers reported have no experience as a caregiver. 79.6% caregivers have stopped working, and 87.8% changed weekly working schedule. Before final diagnosis, patients visited 3.9 ± 3.1 (max = 20) hospitals and took 1.2 ± 1.7 (max = 6.6) years for confirmed diagnosis. On average, 5.0 ± 9.6 misdiagnoses occurred, and the per-patient diagnoses cost was USD ($) 7576. After GD confirmation, 8 (16.3%) patients received no treatment, 40 (81.6%) received pharmacotherapy, 10 (20.4%) received surgery, 38 (77.6%) received outpatient service (8.8 ± 9.1 times/annually), and 37 (77.5%) received inpatient service (4.0 ± 3.5 times/annually). Annual per-patient COI was USD ($) 49,925 (95% confidence interval: 29,178, 70,672). Average direct healthcare cost was $41,816, including pharmaceutical ($29,908), inpatient ($7,451), and outpatient ($1,838). Productivity loss per-caregiver was $1,980, and their Zarit Burden Inventory score was moderate-severe (48.6 ± 19.6). Both patients/caregivers reported lower social support (32.4 ± 7.4, 34.9 ± 7.6), two times higher PSQI (7.9 ± 2.9, 8.7 ± 3.6), and half lower SF-36 (41.3 ± 18.6, 46.5 ± 19.3) than those reported for healthy Chinese individuals. CONCLUSIONS: The high misdiagnosis rate, together with delayed diagnosis, substantial costs, and deteriorated health-related quality of life of GD patients as well as their heavy care burden, calls for extreme attention from policymakers in China. Further efforts of government and society are urgently demanded, including pharmaceutical reimbursement, screening newborns, developing precise diagnostic tools, and training doctors.

Minimizing the Risk of Catastrophic Health Expenditure in China: A Multi-Dimensional Analysis of Vulnerable Groups.

Background: In moving toward universal health coverage in China, it is crucial to identify which populations should be prioritized for which interventions rather than blindly increasing welfare packages or capital investments. We identify the characteristics of vulnerable groups from multiple perspectives through estimating catastrophic health expenditure (CHE) and recommend intervention priorities. Methods: Data were from National Health Service Survey conducted in 2003, 2008, and 2013. According to the recommendation of WHO, this study adopted 40% as the CHE threshold. A binary regression was used to identify the determinants of CHE occurrence; a probit model was used to obtain CHE standardized incidence under the characteristics of single and two dimensions in 2013. Results: The total incidence of CHE in 2013 was 13.9%, which shows a general trend of growth from 2003 to 2013. Families in western and central regions and rural areas were more at risk. Factors related to social demography show that households with a female or an unmarried head of household or with a low socioeconomic status were more likely to experience CHE. Households with older adults aged 60 and above had 1,524 times higher likelihood of experiencing CHE. Among the health insurance schemes, the participants covered by the New Rural Cooperative Medical Scheme had the highest risk compared with the participants of all basic health insurance schemes. Households with several members seeking outpatient, inpatient care or with non-communicable diseases were more likely to experience CHE. Households with members not seeing a doctor or hospitalized despite the need for it were more likely to experience CHE. Characteristics such as a household head with characteristics related to low socioeconomic status, having more than two hospitalized family members, ranked high. Meanwhile, the combination of having illiterate household heads and with being covered by other health insurance plans or by none ranked the first place. Cancer notably caused a relatively high medical expenditure among households with CHE. Conclusion: In China, considering the vulnerability of the population across different dimensions is conducive to the alleviation of high CHE. Furthermore, people with multiple vulnerabilities should be prioritized for intervention. Identifying and targeting them to offer help and support will be an effective approach.

Does the medical insurance system play a real role in reducing catastrophic economic burden in elderly patients with cardiovascular disease in China? Implication for accurately targeting vulnerable characteristics.

BACKGROUND: The vulnerability of cardiovascular disease (CVD) patients' health abilities, combined with the severity of the disease and the overlapping risk factors, leads such people to bear the economic burden of the disease due to the medical services. We estimated the economic burden of CVD and identified the weak link in the design of the medical insurance. METHODS: Data from 5610 middle-aged and elderly with CVD were drawn from the 2015 wave of "China Health and Retirement Longitudinal Study" (CHARLS). The recommended method of the "World Health Organization" (WHO) was adopted to calculate "catastrophic health expenditure" (CHE), "impoverishment by medical expenses" (IME), and applied the treatment-effect model to analyze the determinants of CHE. RESULTS: The incidence of CHE was 19.9% for the elderly families with CVD members, which was 3.6% higher than for uninsured families (16.3%). Families with CVD combined with > 3 other chronic diseases (38.88%) were the riskiest factor for the high CHE in the new rural cooperative medical system (NCMS). Moreover, families with members > 75 years old (33.33%), having two chronic disease (30.74%), and families having disabled members (33.33%), hospitalization members (32.41%) were identified as the high risky determinants for the high CHE in NCMS. CONCLUSIONS: Elderly with physical vulnerabilities were more prone to CHE. The medical insurance only reduced barriers to accessing health resources for elderly with CVD; however it lacked the policy inclination for high-utilization populations, and had poorly accurate identification of the vulnerable characteristics of CVD, which in turn affects the economic protection ability of the medical insurance. The dispersion between the multiple medical security schemes leads to the existence of blind spots in the economic risk protection of individuals and families.

The medical insurance system's weakness to provide economic protection for vulnerable citizens in China: A five-year longitudinal study.

OBJECTIVES: Little is known about the magnitude of catastrophic health expenditure (CHE) attributable to critical disease, especially in the middle-aged and elderly population. This research aimed to exploring the key aspects of how the health insurance fails to protect the middle-aged and elderly against CHE in the past five years. And propose corresponding measures to improve. METHODS: Data were obtained from the 2011 to 2015 China Health and Retirement Longitudinal Study. The method was adapted from WHO to calculate the catastrophic health expenditure (CHE) and impoverishment by medical expense (IME), and use Generalized Linear Mixed Models (GLMMs) to comprehensively analyze the risk factors that cause middle-aged and elderly people to fall into CHE. RESULTS: The incidence of CHE of China's middle-aged and elderly population has been rose in the five years from 2011 (10.5 %) to 2013 (17.5 %) to 2015 (19.7 %). The CHE of richest families was almost 6 times from 2011 to 2015. Urban Employee Medical Insurance Scheme, the incidence of CHE was up 10 percentage from 2011 to 2015. According to the GLMMs, families have inpatient cares as the most important factor to CHE. The incidence of CHE increased by 2.25 times compared with those who did not use inpatient services. CONCLUSIONS: The health system needs to control the irrational growth of health expenses and reduce residents' overuse of health services. Government should take supplementary measures to comprehensively strengthen the advantages of health insurance. Raise residents' awareness of health care, enhance citizens' physical fitness, and avoid unnecessary waste of health resources.

Targeting vulnerable groups of health poverty alleviation in rural China- what is the role of the New Rural Cooperative Medical Scheme for the middle age and elderly population?

BACKGROUND: In light of the health poverty alleviation policy, we explore whether the New Rural Cooperative Medical System (NRCMS) has effectively reduced the economic burden of medical expenses on rural middle-aged and elderly people and other impoverished vulnerable groups. The study aims to provide evidence that can be used to improve the medical insurance system. METHODS: Data were obtained from the 2015 China Health and Retirement Longitudinal Study (CHARLS). The method of calculating the catastrophic health expenditure (CHE) and impoverishment by medical expense (IME) was adopted from the World Health Organization (WHO). The treatment effect model was used to identify the determinants of CHE for rural middle-aged and elderly people. RESULTS: The incidence of CHE in rural China for middle-aged and elderly people is 21.8%, and the IME is 8.0%. The households that had enrolled in the NRCMS suffered higher CHE (21.9%) and IME (8.0%), than those that had not enrolled (CHE: 20.6% and IME: 7.7%). The NRCMS did not provide sufficient economic protection from CHE for households with three or more chronic diseases, inpatients, or households with members aged over 65 years. Key risk factors for the CHE included education levels, households with inpatients, households with members aged over 65 years, and households with disabilities. CONCLUSIONS: Although the NRCMS has reduced barriers to the usage of household health services by reducing people's out-of-pocket payments, it has not effectively reduced the risk of these households falling into poverty. Our research identifies the characteristics of vulnerable groups that the NRCMS does not provide enough support for, and which puts them at a greater risk of falling into poverty due to health impoverishment.

Does the medical insurance system really achieved the effect of poverty alleviation for the middle-aged and elderly people in China? Characteristics of vulnerable groups and failure links.

BACKGROUND: We examined the physiological, household, and spatial agglomeration characteristics of the health poverty population in China. We identified weak links that affect the implementation of the medical insurance and further improve its effectiveness for health poverty alleviation. METHODS: A national representative sample from the China Health and Retirement Longitudinal Study (CHARLS) was analyzed. The WHO recommended method was adopted to calculate catastrophic health expenditure (CHE) and impoverishment by medical expenses (IME). We created a binary indicator for IME as the outcome variable and applied the treatment-effect model to analyze the determinants of IME. RESULTS: The incidence of IME was 7.2% of the overall population, compared to 20.3% of the sample households trapped in CHE. The incidence of IME enrolled in insurance schemes was 7.4% higher than that of uninsured families (4.8%). Economic level, living area, family size, age of household head, having hospitalized members, and participating in insurance were statistically significant for the occurrence of IME. CONCLUSIONS: The original poverty-promoting policies has not reached the maximum point of convergence with China's current demand for health. The overlapped health vulnerabilities exacerbated the risk of poverty among the elderly and households with high health needs and utilization. In addition, the medical insurance schemes have proven to be insufficient for protection against economic burden of poor households. So, special health needs, age, and household capacity to pay should be comprehensively considered while strengthening the connection between the disease insurance scheme with supplementary insurance.