We comprehensively analyzed curative care expenditure of 65 years and older based on SHA 2011, including distribution in age, disease, medical institution or reflected financing, origin and destination. Moreover, influencing factors were performed by multiple stepwise regression analysis.
The distribution of medical resources in medical institutions in the aged
From the result of SHA 2011, it is observed that the elderly spent a lot of CCE in the hospital rather than other medical institutions. For example, basic medical and health institutions (township hospital, community health service center) as well as ambulatory facility (village clinics, individual clinic), public health institutions (maternity and child health organ) all had a small percentage of curative care expenditure (Table
2). Furthermore, the other problems are the distribution of health resources is unreasonable, and health resources are deficient in the rural area [
11]. Medical resources prefer to the place where hospitals have huge purchasing power and high-level surgical treatment or high drug profit. Basic medical and health institutions, however, lack of medical workers, financial and other resources, which make the senile patients, more willing to go to a hospital. Peter’s analysis of Europe’s decades of medical reform thought to think promoting priority resources allocation ability should rely on evidence-based medicine reviews (EBMR), goalkeeper physicians (GP), performance reporting system (PRS) etc [
12].
The number of health institutions and health technicians in Liaoning province are in medium level in the China. However, in 2014, there were very few government health investments in Liaoning province (the government health expenditure made up 21.7% of the total health expenses), which the government health expenditure were 29.96% in the total health expenses in China [
8]. Changing the distribution of medical resources and solving problem of payment mechanism are necessary. If the new round of health care reform wants to achieve universal coverage of basic medical services in 2020, it requires us to consider the accessibility and affordability of medical service, and research on priority resources allocation is contributing to the sustainable development of our country’s medical system [
13].
We found that old patient’s hospitalization expenditure took the largest proportion in curative care expenditure. It is because the major part of disease for non-communicable diseases in the old population (Fig.
2). This kind of disease treatment is lengthy and difficult,which lead to high hospitalization expenditure. Moreover, some study shows that inpatient expenditure will be higher than outpatient expenditure with the same disease in the elderly patients [
14]. It is also related to the proportion of reimbursement in new medical reform. In China, taking Liaoning urban worker’s basic medical insurance for an example, the outpatient reimbursement ratio is lower than the inpatient ration and some special drug or examination fee are not reimbursed in outpatient but only in inpatient, which makes the aged patients try to transfer from outpatient to inpatient. Such phenomenon not only increased the hospitalization expense but also wasted the national health resources seriously [
15].
The burden of disease in the aged
The results of the study showed that the per capita curative care expenditure of the aged was much higher than that of other groups, which means the heavy burden is on old people. Not merely in China, but also in other developing and even developed countries, there is also heavy burden on the elderly.
The main cause of severe burden of disease on the old people was diseases of cardiovascular system (30.3%), malignant neoplasm (15.1%) etc. [
1] that is in accordance with our research. We can effectively control the cost of the disease if triple prevention is applied for elderly people. For the aged who has serious illness, the government, can provide a suitable prognostic measure to prevent further deterioration and improve the overall outcome for the individual. Priority is given to shelter the high-risk elderly, which could cut length of stay and hospitalization expenditure [
16]. Furthermore, Sonya Haw [
17] suggests that prevention and health care, especially in the early prevention, not only improve life quality but reduce greatly the burden on society, families and individuals. The demand of old people for prevention and health care is higher than that of young people, but the level of health care is not perfect in China where the health care institutions and workers are in deficiency [
18]. In conclusion, strengthening the construction of preventive health care team and institution is urgent, as well as giving appropriate compensation in purchase preventive health care serves.
Firstly, many studies of diseases of the old have illuminated the diseases of the circulatory system resulted in unpredictable costs. The WHO believes that the cardiovascular disease (CDV), the main circulation system disease, is one of the most popular and dangerous disease in the world. In China’s most prosperous cities, the health care expenditure per capita which is more than 25,000 RMB, and the medical cost for old population are much higher [
19]. As the risk factors of circulation disease continue to grow rapidly, such as obesity, high-fat-diet, high salt diet, etc., it will aggravate the current epidemics of diseases of the circulatory system and lead to high expense.
Secondly, we found that the CCE was also high in neoplasm for the aged which ranked second and was behind the diseases of the circulatory system. The standard incidence of malignant neoplasm is from 0.527% in 1990 to 0.750% in 2010 [
20]. But the accurate CCE is still unclear. In this research, the CCE of neoplasm is 13.43 billion RMB, much more than other populations. Elder cancer researchers focused on the incidence and the nursing that also shows the incidence of senile neoplasm higher than young people [
21]. However, there is dissimilarity in the country using different nurse methods. In developed countries, good care is the key to decrease neoplasm curative care expenditure. In China, the important reason of the costs of neoplasm at a high level all the time is improper nursing that would aggravate disease. The aged who has a malignant neoplasm, the rate of hospital infection among chemotherapy and radiotherapy can reach 44.36% [
22]. Those expenses caused by infection are also counted as a part of neoplasm’s curative care expenditure. Neoplasm treatment cycle is long and is also the important reason for the high curative care expenditure in neoplasm. In short, strengthening nursing care for senile neoplasm during hospitalization and treatment has become the crucial measure to reduce the expense.
Thirdly, the burden of respiratory system disease ranked third following circulation system and neoplasm diseases in Liaoning. That is because Liaoning, the heavy industry base in north China, has built a lot of polluting factories, which produce dirty air seriously. Furthermore, winter-time in Liaoning is long and very cold that has a six-month heating period each year. Some study showed that the concentration of PM 2.5 increased year by year and was significantly higher in the heating period (from November of the year to April of the next year) compared to that of other months. With the increased proportions of 11.6%,18.9%,and 35.8% for the year of 2009 to 20 l1 and the PM 2.5 concentration in the heating period of the 3 year was 44,35,and 60
μg/
m
3, respectively [
23]. And the 65 years and older people are extremely sensitive to air pollution [
24]. In the developed region, patients with respiratory diseases, the per capita expense could be up to 2878 RMB. In short, controlling the expenditure in respiratory system disease in the heating period is the key to lower the cost for the aged.
The CCE of diseases of the digestive system and endocrine, nutritional and metabolic diseases were heavy in elderly people too. That is related to traditional eating habits of the aged. Plenty of them prefer pickled foods and high-fat foods. Those bad eating habits lead to the morbidity of digestive disease and nutritional and metabolic diseases rising continuously, which brings high medical expense. Some study showed the direct cost of diabetic patients was four times than that of who did not have diabetes. Those expenses mainly were used to take care of the old and for hospital care [
25]. Not only expenditure of diabetes, as well as morbidity of digestive disease and nutritional and metabolic diseases all were heavy burdens.
These diseases have characteristics in a long cycle of treatment as well as in special treatment groups. We can establish comprehensive single payment disease system that could cover the high curative care expenditure of diseases of old people who have registered in the basic medical insurance system. The basic medical insurance system in Liaoning province has included single payment disease system this year. In addition, with the development of critical illness insurance in recent years, it is observed that many poor families can avoid catastrophic health expenditure because of critical illness insurance. In China, some areas have performed critical illness insurance system, but the same with single payment disease system, have not been universal.
The distribution of financing scheme in the aged
In this research, we analyzed simultaneously the distribution of the financing scheme in the elderly. We could best understand the distribution of financing in the aged.
The health financing calculation based on SHA 2011 has included all of the health subsidy and types of health insurance. The 65 yrs. and older have retired, so we did not include them. The social financing accounted for major curative care expenditure in all financing schemes. Family financing scheme, also called OOP, followed the social financing scheme. Moreover, there was a high proportion in OOP of the aged. The measurement results of OOP in Liaoning province by the method of health financing resource showed that OOP accounted for the total health expenditure was 36.04% [
26]. But in our research, OOP in the aged was 42.10%, which means expenditure burden was severe in the aged. From the distribution of outpatient and inpatient in health financing, we knew the elderly’s financing focused on inpatient. That was because long hospital stay and higher hospitalization expenditure led to high compensation cost.
Although health insurance in China can cover most of the old people, the outcome is not positive. Equity in health financing is set as a main objective by the global health policy. Many countries are trying to control the ever-increasing of public financing that make the OOP unceasingly increase. Rural and urban area’s patients in India have poverty health care financing are 40% and 60% respectively [
27]. The Portuguese scholars believed that the huge medical expenses were in urgent need to cut down that used to risk resistance in elderly people cannot afford [
28]. Our preliminary research showed that the government had increased the health investment from new medical reform, but individual was still the main undertaker of health expenditure [
13]. Hence the health financing structure should be adjusted immediately, dominated by public financing and concentrating on equity of China health financing among developed provinces and less developed provinces.
Almost all of the aged who are unable to work and lack of guaranteed by society, and they must be supported by their children, which makes the young family undergoes considerable stress. So, endowment insurance needs to be expanded. And designing specific type of insurance for the aged is to increase reimbursement when they experience disease. In our research, the proportion of commercial insurance financing is very low. The commercial insurance market of our country develops relatively late and far less than developed countries. What’s more, the reimbursement of commercial insurance is aimed at inpatient, rarely in outpatient. The government should introduce appropriate policies to encourage the development of commercial insurance particular for major medical expenditure, and not only in hospitalization, but in outpatient who needs medical insurance as well.
Control of the hospitalization curative care expenditure in the aged
The result of stepwise regression analysis showed that, the topic factors influencing hospitalization curative care expenditure included length of stay, operation, region, age, insurance and seasons. All factors were within the controllable range except age. The biggest impact factor was hospitalization days that maybe related to improvement of medical condition and enhance of elderly people’s health awareness, which led to admission number increased rapidly. The longer hospitalization days, the higher curative care expenditure would be. As this studied in many researchers, it was also accordant with our research [
29‐
31]. The operation is another key factor influencing hospitalization curative care expenditure [
32]. The cost of materials is the main composition of operation fee. The non-communicable diseases (NCD) need expensive imported surgical materials, and account for a very large proportion in disease among the aged. Thus surgeons tend to use imported surgical materials so that the risk of operation could be reduced, which ultimately makes the high medical expenses [
33]. In our study, we found that the influence of insurance for hospitalization curative care expenditure was not very big. The high proportion of elderly OOP caused a little effect of insurance in the process of seeking medical care. So, there is an urgent need for government to take competent measures to reduce the proportion of OOP in the aged. In addition, economic development level in China caused different hospitalization curative care expenditure level of individual old residents. However, this is the same as what happened in other countries [
34].
The research indicated that in the hospitalization curative care expenditure, the drugs’ income accounted for most of the total expenditure. As far as character in China medical system, expenses for medical have become a main factor for hospitalization expenditure. Medical worker’s value is ignored for a long time that brings about them taking rebate from prescription to make many illegal interests, which promote problem of “see a doctor expensively”. That showed the drugs addition policy in new medical reform need further improvement. Therefore, it needed to be transferred and controlled the drug expenditure, and the composition of hospitalization expenditure should be adjusted. The medical worker’s page is in urgent need of increasing as well [
35].
Shortening days of hospitalization is part of the most effective ways to control the medical expenses. To check the irrational increases of medical expenses, we must reinforce the administration of rational prescription and examination and farther consummate the reform of the medical care system. We could ultimately reduce the hospital costs of patients as well as the economic burden of patients and society, by strengthening the hospital management, shortening hospital stay, and rationally regulating drug use.