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.

How do moral hazard behaviors lead to the waste of medical insurance funds? An empirical study from China.

Objective: The huge loss of health insurance funds has been a topic of concern around the world. This study aims to explore the network of moral hazard activities and the attribution mechanisms that lead to the loss of medical insurance funds. Methods: Data were derived from 314 typical cases of medical insurance moral hazards reported on Chinese government official websites. Social network analysis (SNA) was utilized to visualize the network structure of the moral hazard activities, and crisp-set qualitative comparative analysis (cs/QCA) was conducted to identify conditional configurations leading to funding loss in cases. Results: In the moral hazard activity network of medical insurance funds, more than 50% of immoral behaviors mainly occur in medical service institutions. Designated private hospitals (degree centrality = 33, closeness centrality = 0.851) and primary medical institutions (degree centrality = 30, closeness centrality = 0.857) are the main offenders that lead to the core problem of medical insurance fraud (degree centrality = 50, eigenvector centrality = 1). Designated public hospitals (degree centrality = 27, closeness centrality = 0.865) are main contributor to another important problem that illegal medical charges (degree centrality = 26, closeness centrality = 0.593). Non-medical insurance items swap medical insurance items (degree centrality = 28), forged medical records (degree centrality = 25), false hospitalization (degree centrality = 24), and overtreatment (degree centrality = 23) are important immoral nodes. According to the results of cs/QCA, low-economic pressure, low informatization, insufficient policy intervention, and organization such as public medical institutions, were the high-risk conditional configuration of opportunism; and high-economic pressure, insufficient policy intervention, and organizations, such as public medical institutions and high violation rates, were the high-risk conditional configuration of risky adventurism (solution coverage = 31.03%, solution consistency = 90%). Conclusion: There are various types of moral hazard activities in medical insurance, which constitute a complex network of behaviors. Most moral hazard activities happen in medical institutions. Opportunism lack of regulatory technology and risky adventurism with economic pressure are two types causing high loss of funds, and the cases of high loss mainly occur before the government implemented intervention. The government should strengthen the regulatory intervention and improve the level of informatization for monitoring the moral hazard of medical insurance funds, especially in areas with low economic development and high incident rates, and focus on monitoring the behaviors of major medical services providers.