Cost burden of chemotherapy for Indonesian healthcare insurance and social security/Jaminan Kesehatan Nasional (JKN) patients with non-Hodgkin lymphoma.

BACKGROUND: Cancer is among the leading causes of death globally, posing a significant economic burden on the healthcare sector. Among other types of cancer in Indonesia, non-Hodgkin lymphoma (NHL) ranks fifth in terms of prevalence. Chemotherapy for NHL patients is funded by a national health insurance scheme through the National Healthcare Insurance and Social Security/Jaminan Kesehatan Nasional (JKN). OBJECTIVE: This study aimed to analyze cost burden of chemotherapy for JKN patients with NHL. DATA SOURCE: A retrospective cross-sectional observational study was conducted among NHL patients receiving chemotherapy at a hospital in East Java, Indonesia in 2021. Data were collected from medical record documents and a total of 44 patient visits were recorded in this study. DATA SUMMARY: The result showed that patient visits were dominated by females (55%), a significant proportion were aged 31 to 40 years (32%), and the majority were JKN participants in the Contribution Assistance Recipients/Penerima Bantuan Iuran (PBI) category (64%). The most chemotherapy regimen given was R-CHOP (68%) and the mean total cost for NHL patients was Indonesian Rupiah (IDR) 5,178,146. The highest mean cost burden was on chemotherapy drugs with a value of IDR 6,333,315. Based on the regimen, the highest cost burden was R-CHOP-Bleo with a mean cost of IDR 8,764,091. CONCLUSION: Based on the results, the highest cost burden for chemotherapy among JKN patients with NHL in Indonesia was attributed to R-CHOP-Bleo regimen with a mean of IDR 8,764,091.

Willingness to pay for private health insurance among workers with mandatory social health insurance in Mongolia.

BACKGROUND: High out-of-pocket health expenditure is a common problem in developing countries. The employed population, rather than the general population, can be considered the main contributor to healthcare financing in many developing countries. We investigated the feasibility of a parallel private health insurance package for the working population in Ulaanbaatar as a means toward universal health coverage in Mongolia. METHODS: This cross-sectional study used a purposive sampling method to collect primary data from workers in public and primary sectors in Ulaanbaatar. Willingness to pay (WTP) was evaluated using a contingent valuation method and a double-bounded dichotomous choice elicitation questionnaire. A final sample of 1657 workers was analyzed. Perceptions of current social health insurance were evaluated. To analyze WTP, we performed a 2-part model and computed the full marginal effects using both intensive and extensive margins. Disparities in WTP stratified by industry and gender were analyzed. RESULTS: Only < 40% of the participants were satisfied with the current mandatory social health insurance in Mongolia. Low quality of service was a major source of dissatisfaction. The predicted WTP for the parallel private health insurance for men and women was Mongolian Tugrik (₮)16,369 (p < 0.001) and ₮16,661 (p < 0.001), respectively, accounting for approximately 2.4% of the median or 1.7% of the average salary in the country. The highest predicted WTP was found for workers from the education industry (₮22,675, SE = 3346). Income and past or current medical expenditures were significantly associated with WTP. CONCLUSION: To reduce out-of-pocket health expenditure among the working population in Ulaanbaatar, Mongolia, supplementary parallel health insurance is feasible given the predicted WTP. However, given high variations among different industries and sectors, different incentives may be required for participation.

Protocol of a randomized controlled trial to test the effects of client-centered Representative Payee Services on antiretroviral therapy adherence among marginalized people living with HIV.

BACKGROUND: Client-Centered Representative Payee (CCRP) is an intervention modifying implementation of a current policy of the US Social Security Administration, which appoints organizations to serve as financial payees on behalf of vulnerable individuals receiving Social Security benefits. By ensuring beneficiaries' bills are paid while supporting their self-determination, this structural intervention may mitigate the effects of economic disadvantage to improve housing and financial stability, enabling self-efficacy for health outcomes and improved antiretroviral therapy adherence. This randomized controlled trial will test the impact of CCRP on marginalized people living with HIV (PLWH). We hypothesize that helping participants to pay their rent and other bills on time will improve housing stability and decrease financial stress. METHODS: PLWH (n = 160) receiving services at community-based organizations will be randomly assigned to the CCRP intervention or the standard of care for 12 months. Fifty additional participants will be enrolled into a non-randomized ("choice") study allowing participant selection of the CCRP intervention or control. The primary outcome is HIV medication adherence, assessed via the CASE adherence index, viral load, and CD4 counts. Self-assessment data for ART adherence, housing instability, self-efficacy for health behaviors, financial stress, and retention in care will be collected at baseline, 3, 6, and 12 months. Viral load, CD4, and appointment adherence data will be collected at baseline, 6, 12, 18, and 24 months from medical records. Outcomes will be compared by treatment group in the randomized trial, in the non-randomized cohort, and in the combined cohort. Qualitative data will be collected from study participants, eligible non-participants, and providers to explore underlying mechanisms of adherence, subjective responses to the intervention, and implementation barriers and facilitators. DISCUSSION: The aim of this study is to determine if CCRP improves health outcomes for vulnerable PLWH. Study outcomes may provide information about supports needed to help economically fragile PLWH improve health outcomes and ultimately improve HIV health disparities. In addition, findings may help to refine service delivery including the provision of representative payee to this often-marginalized population. This protocol was prospectively registered on May 22, 2018 with ClinicalTrials.gov (NCT03561103) .

Time trends and social security burden of temporary work disability due to chronic venous disease in Brazil.

BACKGROUND: Chronic venous disease (CVD) and disability are worldwide problems and have significant socioeconomic implications. This study aims to analyze the time trends and social security burden of temporary work disability due to CVD in Brazil. METHODS: An ecological time series study using the Brazilian Social Security System database was performed from 2005 to 2014. Data from all benefits granted to workers with temporary disability due to CVD were analyzed. The cases were identified using diagnosis codes I83-I83.9 of the International Classification of Diseases 10th Revision (ICD-10). The time trend analyses were performed by the Joinpoint Regression Model, with sex, age, regions, income, and category of affiliation as variables. Crude and age-standardized rates were calculated. RESULTS: A total of 429,438 benefits were granted for temporary work disability due to CVD from 2005 to 2014, with a growing trend and an age-standardized annual percent change (APC) of 3.4 (95% CI: 2.6-4.2) (p < 0.05). Social security expense increased 3.5-fold, and the number of days in benefit doubled from 2005 to 2014. In total, 27,017,818 working days were lost. The average duration of benefits was 55.3 days. The majority of workers were women (68.2%) (p < 0.001), between 30 and 59 years old, employed, had a monthly income ≤2 minimum wages (MW) (83.2%), and lived in the regions southeast (53.6%) and south (29.3%). Significantly higher APCs were observed for women than for men (APC: 4.9, 95% CI: 4.0-5.7 versus APC: 1.2, 95% CI: 0.1-2.4). All regions in Brazil had a significant growing trend, except in the north. No significant growth was observed in the age group of 60-69 years. A decreasing trend was observed in workers with monthly incomes above 2 MW (p < 0.05). CONCLUSIONS: Temporary work disability due to CVD and social security burden showed increasing trends with millions of working days lost, particularly among women and low-income workers. Preventing disability is challenging, and public policies are needed to reduce the social and economic impact of disability. Therefore, measures for promoting health at the workplace should be encouraged.

Cognitive Impairment and Social Security's Representative Payee Program.

Social Security's Representative Payee Program faces a difficult balance with respect to dementia: Many people living with dementia can conduct their finances without a payee if they have help from informal caregivers, but those without help are at risk. To date, it has been unclear what share of retirees with dementia use a payee, what share has help potentially available from another source, and what share has no observed means of assistance. This study finds that while fewer than 10% of retirees with dementia use a payee, only about 8% have no observed means of help.

Population-based analysis of the impact of trauma on longer-term functional outcomes.

BACKGROUND: Functional outcome measures are important as most patients survive trauma. The aim of this study was to describe the long-term impact of trauma within a healthcare region from a social perspective. METHODS: People active in work or education and admitted to hospitals in Central Norway in the interval 1 June 2007 to 31 May 2010 after sustaining trauma were included in the study. Clinical data were linked to Norwegian national registers of cause of death, sickness and disability benefits, employment and education. Primary outcome measures were receipt of medical benefits and time to return to preinjury work level. Secondary outcome measures were mortality within 30 days or during follow-up. RESULTS: Some 1191 patients were included in the study, of whom 193 (16·2 per cent) were severely injured (Injury Severity Score greater than 15). Five years after injury, the prevalence of medical benefits was 15·6 per cent among workers with minor injuries, 22·3 per cent in those with moderate injuries and 40·5 per cent among workers with severe injuries. The median time after injury until return to work was 1, 4 and 11 months for patients with minor, moderate and severe injuries respectively. Twelve patients died within 30 days and an additional 17 (1·4 per cent) during follow-up. CONCLUSION: Patients experiencing minor or major trauma received high levels of medical benefits; however, most recovered within the first year and resumed preinjury work activity. Patients with severe trauma were more likely to receive medical benefits and have a delayed return to work. Registration number: NCT02602405 (http://www.clinicaltrials.gov).

Indirect costs and incidence of caregivers' short-term absenteeism in Poland, 2006-2016.

BACKGROUND: There is a growing interest in the costs of informal care; however, the results of previous studies mostly rely on self-reported data, which is subject to numerous biases. The aim of this study is to contribute to the topic by estimating the indirect costs of short-term absenteeism associated with informal caregiving in Poland with the use of social insurance data on care absence incidence. METHODS: The human capital method was used to estimate the indirect costs of caregiving from a societal perspective. The incidence of caregiving was identified based on the Social Insurance Institution's data on absence days attributable to care provided to children and other family members. Gross domestic product (GDP) per worker was used as a proxy of labour productivity. Deterministic one-way sensitivity analysis was performed. RESULTS: The indirect costs of short-term caregivers' absenteeism in Poland was €306.2 million (0.116% of GDP) in 2006 and increased to €824.0 million in 2016 (0.180% of GDP). The number of care absence days grew from 5.9 million (0.45 days per worker) in 2006 to 10.6 million (0.70 days per worker) in 2016. Approximately 85% of the total costs were attributable to child care. The results of the sensitivity analysis show that the indirect costs varied from the base scenario by - 30.8 to + 15.8%. CONCLUSION: Informal short-term caregiving leads to substantial productivity losses in the Polish economy, and the dynamic upward trend of care absence incidence suggests that the costs of caregiving are expected to rise in the future.

Collective constructions of 'waste': epistemic practices for disinvestment in the context of Dutch social health insurance.

BACKGROUND: Faced with growing budget pressure, policymakers worldwide recognize the necessity of strategic disinvestment from ineffective, inefficient or harmful medical practices. However, disinvestment programs face substantial social, political and cultural challenges: mistrust, struggles for clinical autonomy or stakeholders' reluctance to engage in what can be perceived as 'rationing'. Academic literature says little about effective strategies to address these challenges. This paper provides insights on this matter. We analyzed the epistemic work of a group of policymakers at the National Health Care Institute on what was initially a disinvestment initiative within the context of the Dutch basic benefits package: the 'Appropriate Care' program. The Institute developed a strategy using national administrative data to identify and tackle low-value care covered from public funds as well as potential underuse, and achieve savings through improved organization of efficiency and quality in health care delivery. How did the Institute deal with the socio-political sensitivities associated with disinvestment by means of their epistemic work? METHOD: We conducted ethnographic research into the National Health Care Institute's epistemic practices. Research entailed document analysis, non-participant observation, in-depth conversations, and interviews with key-informants. RESULTS: The Institute dealt with the socio-political sensitivities associated with disinvestment by democratizing the epistemic practices to identify low-value care, by warranting data analysis by clinical experts, by creating an epistemic safe space for health care professionals who were the object of research into low-value care, and by de-emphasizing the economization measure. Ultimately, this epistemic work facilitated a collaborative construction of problems relating to low-value care practices and their solutions. CONCLUSIONS: This case shows that - apart from the right data and adequate expertise - disinvestment requires clinical leadership and political will on the part of stakeholders. Our analysis of the Institute's Appropriate Care program shows how the epistemic effort to identify low-value care became a co-construction between policymakers, care providers, patients and insurers of problems of 'waste' in Dutch social health insurance. This collective epistemic work gave cognitive, moral and political standing to the idea of 'waste' in public health expenditure.

Impact of frailty status on the cost of drugs and dietary supplements prescribed to nursing home residents: the SENIOR cohort.

BACKGROUND: The financial impact associated with drug consumption has been poorly investigated among frail subjects and, specifically, in nursing home settings. AIMS: To determine the association of the average monthly cost of the drugs and dietary supplements consumed by nursing home residents with their frailty status. METHODS: This is an analysis of the first follow-up year of the SENIOR cohort. All participants were classified into "frail" or "non-frail" categories according to Fried's criteria at baseline. Monthly bills from the pharmacy were analysed to determine the association between the average monthly cost of the drugs and dietary supplements consumed and frailty status. RESULTS: A sample of 87 residents (83.8 ± 9.33 years and 75.9% women) from the SENIOR cohort was included. The prevalence of frailty was 28%. The median number of medications consumed each day was 9 (6-12) (no difference between frail and non-frail subjects; p = 0.15). The overall median monthly cost was € 109.6, of which 49% was covered by Belgian social security and the remaining balance was paid by the patient. When comparing the drug expenses of the frail subjects and the non-frail subjects, the overall average monthly cost did not differ between the 2 groups (p = 0.057). Nevertheless, the expenditure remaining to be paid by the residents, after the Belgian social security intervention, was significantly higher among the frail residents (€ 65.7) than among the non-frail residents (€ 47.6; p = 0.017). CONCLUSIONS: Frailty status has an impact on the expenditures related to the consumption of drugs.

[Out of pocket expenditure on health during the last year of life of Mexican elderly: analysis of the Enasem]. / Gasto de bolsillo en salud durante el último año de vida de adultos mayores mexicanos: análisis del Enasem.

OBJECTIVE: To estimate the out-of-pocket expenses (OOPE) during the last year of life in Mexican older adults (OA). MATERIALS AND METHODS: Estimation of the OOPE corresponding to the last year of life of OA, adjusting by type of management, affiliation and cause of death. Data from the National Health and Aging Study in Mexico (2012) were used. To calculate the total OOPE, the expenses in the last year were used in: medications, medical consultations and hospitalization. The OOPE was adjusted for inflation and is reported in US dollars 2018. RESULTS: The mean OOPE was $6 255.3±18 500. In the ambulatory care group, the OOPE was $4 134.9±13 631.3. The OOPE in hospitalization was $7 050.6±19 971.0. CONCLUSIONS: The probability of incurre in OOPE is lower when hospitalization is not required. With hospitalization, affiliation to social security and attending to public hospitals plays a protective role.

OBJECTIVE: Estimar el gasto de bolsillo (GB) durante el último año de vida en adultos mayores (AM) mexicanos. MATERIALS AND METHODS: Estimación del GB del último año de vida de AM, ajustando por tipo de manejo, afiliación y causa de muerte. Se emplearon datos del Estudio Nacional de Salud y Envejecimiento en México (2012). Los gastos en medicamentos, consultas médicas y hospitalización durante el año previo a la muerte conforman el GB. El GB se ajustó por inflación y se reporta en dólares americanos 2018. RESULTS: La media de GB fue $6 255.3±18 500. En el grupo de atención ambulatoria el GB fue $4 134.9±13 631.3. El GB en hospitalización fue $7 050.6±19 971.0. CONCLUSIONS: La probabilidad de incurrir en GB es menor cuando no se requiere hospitalización. Con hospitalización, la afiliación a la seguridad social y atenderse en hospitales públicos juega un papel protector.

Evaluation of a Placement Coaching Program for Recipients of Disability Insurance Benefits in Switzerland.

Purpose During 2009‒2013 a pilot project was carried out in Zurich which aimed to increase the income of disability insurance (DI) benefit recipients in order to reduce their entitlement to DI benefits. The project consisted of placement coaching carried out by a private company that specialized in this field. It was exceptional with respect to three aspects: firstly, it did not include any formal training and/or medical aid; secondly, the coaches did not have the possibility of providing additional financial incentives or sanctioning lack of effort; and thirdly due to performance bonuses, the company not only had incentives to bring the participants into (higher paid) work, but also to keep them there for 52 weeks. This paper estimates the medium-run effects of the pilot project and assesses the net benefit from the Swiss social security system. Methods Different propensity score matching estimators are applied to administrative longitudinal data in order to construct suitable control groups. Results The estimates indicate a reduction in DI benefits and an increase in income even in the medium-run. A simple cost-benefit analysis suggests that the pilot project was a profitable investment for the social security system. Conclusion Given a healthy labor market, it seems possible to enhance the employment prospects of disabled persons with a relatively inexpensive intervention, which does not include any explicit investments in human capital.

Social Health Insurance in Europe: Basic Concepts and New Principles.

This article discusses recent developments in and new principles of European social health insurance (SHI). It analyses how privatization policies and competition have altered social insurance and whether financial difficulties are caused by social insurance features not evident in other types of health care systems. There is little if any evidence that SHI causes higher cost increases than other types of systems. The comparison of five European SHI systems demonstrates that despite cost containment policies these countries do not experience a trust crisis in health care or loss in support among the public. The author shows that SHI has moved toward universal health care and that the traditional values of solidarity and social security have even been strengthened over the past decades.

How strong is the Social Security safety net? Using the Elder Index to assess gaps in economic security.

Older Americans rely heavily on Social Security benefits (SSBs) to support independent lifestyles, and many have few or no additional sources of income. We establish the extent to which SSBs adequately support economic security, benchmarked by the Elder Economic Security Standard Index. We document variability across U.S. counties in the adequacy levels of SSBs among older adults. We find that the average SSBs fall short of what is required for economic security in every county in the United States, but the level of shortfall varies considerably by location. Policy implications relating to strengthening Social Security and other forms of retirement income are discussed.

Temporal Trends in Healthcare Costs and Outcome Following ICU Admission After Traumatic Brain Injury.

OBJECTIVE: To assess temporal trends in 1-year healthcare costs and outcome of intensive care for traumatic brain injury in Finland. DESIGN: Retrospective observational cohort study. SETTING: Multicenter study including four tertiary ICUs. PATIENTS: Three thousand fifty-one adult patients (≥ 18 yr) with significant traumatic brain injury treated in a tertiary ICU during 2003-2013. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Total 1-year healthcare costs included the index hospitalization costs, rehabilitation unit costs, and social security reimbursements. All costs are reported as 2013 U.S. dollars ($). Outcomes were 1-year mortality and permanent disability. Multivariate regression models, adjusting for case-mix, were used to assess temporal trends in costs and outcome in predefined Glasgow Coma Scale (3-8, 9-12, and 13-15) and age (18-40, 41-64, and ≥ 65 yr) subgroups. Overall 1-year survival was 76% (n = 2,304), and of 1-year survivors, 37% (n = 850) were permanently disabled. Mean unadjusted 1-year healthcare cost was $39,809 (95% CI, $38,144-$41,473) per patient. Adjusted healthcare costs decreased only in the Glasgow Coma Scale 13-15 and 65 years and older subgroups, due to lower rehabilitation costs. Adjusted 1-year mortality did not change in any subgroup (p < 0.05 for all subgroups). Adjusted risk of permanent disability decreased significantly in all subgroups (p < 0.05). CONCLUSION: During the last decade, healthcare costs of ICU-admitted traumatic brain injury patients have remained largely the same in Finland. No change in mortality was noted, but the risk for permanent disability decreased significantly. Thus, our results suggest that cost-effectiveness of traumatic brain injury care has improved during the past decade in Finland.

Mental health and retirement savings: Confounding issues with compounding interest.

The questionable ability of the U.S. pension system to provide for the growing elderly population combined with the rising number of people affected by depression and other mental health issues magnifies the need to understand how these household characteristics affect retirement. Mental health problems have a large and significant negative effect on retirement savings. Specifically, psychological distress is associated with decreasing the probability of holding retirement accounts by as much as 24 percentage points and decreasing retirement savings as a share of financial assets by as much as 67 percentage points. The magnitude of these effects underscores the importance of employer management policy and government regulation of these accounts to help ensure households have adequate retirement savings.

The Welfare Cost of Perceived Policy Uncertainty: Evidence from Social Security.

Policy uncertainty reduces individual welfare when individuals have limited opportunities to mitigate or insure against the resulting consumption fluctuations. We field an original survey to measure the degree of perceived policy uncertainty in Social Security benefits and to estimate the impact of this uncertainty on individual welfare. Our central estimates show that on average individuals are willing to forgo 6 percent of the benefits they are supposed to get under current law to remove the policy uncertainty associated with their future Social Security benefits. This translates to a risk premium from policy uncertainty equal to 10 percent of expected benefits.

Indirect costs and public finance consequences of heart failure in Poland, 2012-2015.

BACKGROUND: As a consequence of unfavourable epidemiological trends and the development of disease management, the economic aspects of heart failure (HF) have become more and more important. The costs of treatment (direct costs) appear to be the most frequently addressed topic in the economic research on HF; however, less is known about productivity losses (indirect costs) and the public finance burden attributable to the disease. Therefore, the aim of this study was to estimate the indirect costs and public finance consequences of HF in Poland in the period 2012-2015. METHODS: The study uses a societal perspective and a prevalence-based top-down approach to estimate the following components of HF indirect costs: absenteeism of the sick and their caregivers, presenteeism of the sick, disability, and premature mortality. The human capital method has been chosen to identify the value of productivity losses attributable to HF and the public finance consequences of the disease. Deterministic sensitivity analysis was performed to assess the robustness of the results. RESULTS: The total indirect costs of HF in Poland were €871.9 million in 2012, and they increased to €945.3 million in 2015. In the period investigated, these costs accounted for 0.212-0.224% of GDP, an equivalent of 22.63€-24.59€ per capita. Mortality proved to be the main driver of productivity losses, with 59.3-63.4% of the total costs depending on year, followed by presenteeism (21.1-22.5%), disability (11.1-14.2%) and the sick's absenteeism (3.3-4.0%). The cost of caregivers' absenteeism was unimportant. The social insurance expenditure for benefits associated with HF accounted for €40.7 million in 2012 and €45.6 million in 2015 (0.56-0.59% expenditure for all diseases). The potential public revenue losses associated with HF were €262.7-€287.9 million. Sensitivity analysis showed that the costs varied by - 12.1% to + 28.8% depending on the model parameter values. CONCLUSION: HF is a substantial burden on the economy and public finance in Poland. By confronting the disease more effectively, the length and quality of life for those affected by HF could be improved, but society as a whole could also benefit from the increased economic output.

Trump and the GOP agenda: implications for retirement policy.

This commentary provides background on the current state of American retirement, highlights recent efforts to reform retirement policy, and predicts what to expect under President Donald Trump. Retirement has not been a major focus of national policy makers in recent years. Early actions during the Trump administration to undo Obama administration policies may make it more difficult for individuals to save for retirement. While it is impossible to predict the future with any certainty, long-standing trends and recent political developments suggest that major action will not be taken during the Trump presidency to boost retirement security.

Do beneficiaries' views matter in healthcare purchasing decisions? Experiences from the Nigerian tax-funded health system and the formal sector social health insurance program of the National Health Insurance Scheme.

BACKGROUND: Purchasing is a health financing function that involves the transfer of pooled resources to providers on behalf of a covered population. Little attention has been paid to the extent to which the views of that population  are reflected in purchasing decisions. This article explores how purchasers in two financing mechanisms: the Formal Sector Social Health Insurance Programme (FSSHIP) operating under the Nigerian National Health Insurance Scheme (NHIS), and the tax-funded health system perform their roles in light of their responsibilities to the populations. METHODS: A case study approach was adopted in which each financing mechanism is a case. Sixteen (16) in-depth interviews with purchasers and eight (8) focus group discussions with beneficiaries were held. Agency and organizational behavioural theories were used to characterise the purchaser-citizen relationships. A deductive framework approach was used to assess whether actions identified in a model of 'ideal' strategic purchasing actions were undertaken in each case. RESULTS: For both cases, mechanisms exist to reflect people's health needs in purchasing decisions, including quantitative and qualitative needs assessment, mechanisms to raise awareness of benefit entitlements and allow choice. However, purchasers do not use the mechanisms to effectively engage with and hold themselves accountable to the people. In the tax-funded system, weak information systems and unclear communication channels between the purchaser and citizens constrain assessment of needs; while timeliness of health information and poor engagement practices of Health Maintenance Organisations (HMOs) are the main constraints in FSSHIP. Inadequate information sharing in both mechanisms limits beneficiaries' awareness of entitlements. Although beneficiaries of FSSHIP can choose providers, lack of information on the quality of services offered by providers constrains rational decision-making and the inability to change HMOs reduces HMO responsiveness to beneficiary needs. CONCLUSIONS: Responsiveness and accountability to beneficiaries are undervalued by purchasers in both financing mechanisms. In the tax-funded system, civil society organisations can facilitate engagement and accountability of purchasers and the people. In FSSHIP, NHIS needs to provide stronger stewardship of HMOs to promote effective engagement with members. Furthermore, the NHIS should introduce mechanisms that allow FSSHIP members to choose their own HMO, which could encourage HMOs to be more responsive to members.

Is the medical financial assistance program an effective supplement to social health insurance for low-income households in China? A cross-sectional study.

BACKGROUND: China uses both social health insurance (SHI) programs and a medical financial assistance (MFA) program to protect the poor from illness-induced financial risks. The MFA provides a dual benefit package targeting low-income families: subsidizing these families' participation in SHI programs, and providing cash aid to protect them from catastrophic health expenditure (CHE). This study aims to investigate: (1) the association between MFA subvention for SHI enrollment and SHI enrollment; (2) the association between MFA cash aid and CHE; and (3) the association between SHI enrollment and CHE in low-income households in China. METHODS: Using nationally representative data from a comprehensive survey of low-income households in 2014, we construct an estimate of CHE based on out-of-pocket health spending data. Controlling for other covariates, we estimate the three associations using a three-level logistic model. RESULTS: The MFA program subsidizes 50.1% of low-income households to aid their enrollment in SHI programs and provides cash aid to 24.1% of these households. Multilevel logistic analysis reveals that MFA subvention has no significant association with low-income households' SHI enrollment, that MFA cash aid has no significant association with CHE, and that full SHI enrollment is inversely associated with CHE status. CONCLUSIONS: The MFA program is currently not an effective supplement to SHI programs in China in terms of promoting SHI enrollment and providing financial risk protection. The Chinese government needs to invest more funds to expand further low-income household enrollment in SHI programs and to widen the benefit package of MFA cash aid.