Study on the equity of medical services utilization for elderly enrolled in different basic social medical insurance systems in an underdeveloped city of Southwest China

Over the last few decades, as China’s economic reform has sparked unprecedented economic growth, social resources have grown as well [1]. At the same time, concern for the equitable distribution of social benefits has also grown. As one of the most important social benefits, health resources have attracted considerable public attention. However, in recent years, as China’s health inequities have been increasing, public dissatisfaction has been growing [2, 3]. Health equity is the absence of systematic disparities in health between groups with different levels of underlying social advantage/disadvantage [4]. While health equity includes several important elements [5], medical services utilization, as one of these elements, was the focus of our study. The equity of medical services utilization does not mean that people with different incomes have the same rate of utilization. Instead, real equity means that utilization is not influenced by circumstances such as the ability to pay, but that people who need the services can utilize the services without financial burden [6].

Empirical evidence indicates that there is a strong correlation between income and the utilization of medical services [7, 8]. Furthermore, there is a growing income gap between rich and poor in China [9]. As a result, economic inequity is bound to cause inequity in medical services utilization [8]. To reduce inequity, the Chinese government has established a graded social medical insurance system to serves as the major source of healthcare financing and payment, which consists of three types of medical insurance. The major distinguishing features of these three schemes are that the availability of a specific medical insurance schemes depends on one’s employment status and/or residency status (urban vs. rural) [10]:Urban Employee Basic Medical Insurance (UEBMI) for the urban employed, Urban Resident Basic Medical Insurance (URBMI) for the urban unemployed resident, and the New Cooperative Medical Scheme (NCMS) for the rural population [11]. These three medical insurance schemes covered approximately 1.2 billion people (90% of the Chinese population), but each scheme operates independently, and contributions come from a variety of sources, including the central government, local governments, employers, employees, and residents [12]. For UEBMI, both employers and employees are required to contribute approximately 6 and 2%, respectively, of employees’ annual wages to the scheme. The source of the other two schemes are from individual premium contributions and subsides from central and local government. The government subsides in 2011 were 200 Yuan, individual premium contributions were varied by locations. So, the per-capita fund and annual maximum reimbursement cap were different in different schemes. In regard to the service package, compared with the comprehensive coverage of UEBMI, the other two schemes’ coverage focused on inpatient and catastrophic illness for outpatient services, while denying coverage for some basic outpatient services [10]. Table 1 contains basic information about the three social health insurance schemes in China [10, 13].

Many studies have concluded that the medical insurance system plays a vital role in the equity of medical services utilization [13‐16]. Additionally, they have shown that great disparities exist between people insured by different medical insurance schemes with regard to access to medical services. These disparities are part of the nature of the three systems in China, which base the level and type of insurance on individuals’ social attributes and function independently of each other, differing, for example, in aspects related to financing, reimbursement, and expansion as above [11]. Previous studies have attached great importance to comparing the three systems. For example, Meng et al. [13] and Lin et al. [17] noted that rural populations have more restricted access to medical services and show a larger financial burden than urban cohorts, mainly due to low funds for the NCMS. Furthermore, UEBMI has more comprehensive services coverage and financial protections than URBMI and the NCMS [18].

Recent years, populations are growing older in nearly all the countries of the world especially in China [19]. Ageing process could reflect some extent of socioeconomic development, for instance the health problems of the aging of population have been a great challenge to social development [20, 21]. Many studies have indicated that the elderly as a group are the greatest adult users of the health care system due to poor health [22‐24]. A number of scholars have begun to explore the health inequity among the elderly. For instance, Lu et al. [25] found that health equity was at a general level and that inequity in hospitalization was significant among the elderly in Fujian province. However, to date, there has been little research on the equity of medical services utilization among the elderly categorized according to the three categories of medical insurance in China.

This study was conducted in southwestern China, in Sichuan province, which is one of China’s relatively undeveloped provinces. The aging problem is serious in Sichuan province, where the proportion of people aged over 60 was 20.02% in 2016 [26]. With this background, we conducted this study to compare the utilization of outpatient and hospitalization services among elderly individuals enrolled in the three medical insurance schemes i.e. UEBMI, URBMI and NCMS, and to measure the inequity of the utilization due to household income in the different medical insurance schemes in a city of Sichuan province in southwest China. Our study provides possible explanations for the disparity in utilization of medical services among the elderly and provides some suggestions for formulating policy that could eliminate such inequity.

The present study showed that the coverage of medical insurance was 98.0%, which indicates that China has achieved much in the establishment of basic social medical insurance. However, there are still some people who remain uninsured among a large population base, which indicates a worthy goal to strive for.

In our investigation, there was no fundamental difference among the elderly under the three kinds of medical insurance in the utilization of outpatient services if they were ill. The treatment rates were approximately 78%, it could be because the expense was affordable for the elderly. Additionally, we found that members of the NCMS had lower outpatient costs than members of the two other systems. The reason may be that the members of NCMS prefer to seek medical services in primary health care institutions where the expense is lower [10, 29].When comparing the equity of the three medical insurances, we found that there was no significant difference in the utilization of outpatient service between different income levels in UEBMI and URBMI. However, in the NCMS, there was a tendency for the higher income group to utilize more services. This indicates that the equity of UEBMI and URBMI is better than NCMS. As we know, the NCMS are mainly targeted at hospitalization and the critical diseases of outpatient, and the benefit packages for medical services are not as munificent as those of UEBMI, and the enrolled have to pay for most outpatient fees personally [11, 30]. Although the expense of outpatient service was relative lower, but there were still some low-income population in NCMS who couldn’t easily afford it [31].

As far as hospitalization is concerned, the results indicated that the higher income group utilized hospitalization more, regardless of the insurance system. Thus, it can be speculated that inequity is widespread in the utilization of hospitalization. Additionally, we found that the range of hospitalization standardized rate among different income levels in the NCMS was between 13.30% and 16.38%, and the disparity was about 3%, which was significantly smaller than URBMI and UEBM (about 10%). Interestingly, this indicated that the NCMS was more equitable than URBMI and UEBMI in terms of hospitalization. This was verified by comparing the value of CI. And the CI of NCMS was smallest among the three systems. However it should be noted that the equity in NCMS was based on the overall low utilization of hospitalization regardless of income levels. This also suggested that the economic burden of hospitalization was considerable for NCMS cohort [31]. As mentioned in Table 5, the reimbursement ratio of the NCMS was lower than for the other two systems. Furthermore, we found that the hospitalization expenses of individuals in the NCMS were higher than those of participants with UEBMI, although the actual cost of the NCMS was lower.

The CI results clarify this inequity further. All the CI values we calculated were positive, which means that the richer participants had more utilization than poorer participants, whatever the medical system and the medical services. In addition, the CIs of hospitalization were larger than those of outpatient services. This result indicates that the inequity in hospitalization is more serious than for outpatient services, and the main reason is that the expenses of hospitalization are higher and thus income is crucial in deciding utilization.

We found that inequities still exist in all three health insurance systems, in particular, the inequities in utilization of hospitalization were more severe than outpatient services. When comparing the equity of the three medical insurances, UEBMI and URBMI were better than NCMS in the equity of outpatient services. NCMS was more equitable than URBMI and UEBMI in terms of hospitalization. However, the equity of hospitalization in NCMS was based on the “overall low utilization of hospitalization regardless of income levels”. Thus, basic social medical insurance can be further improved to make sure vulnerable groups utilize the medical services better. A comprehensive approach to reduce the inequity of the three basic social medical insurances should focus on the following factors: 1) Covering more basic outpatient services in the medical insurances, especially for NCMS; 2) raising the reimbursement rate of hospitalization for the three basic social medical insurance systems, especially for NCMS; 3) Eliminate the disparities of the three basic social medical insurance systems under the different health insurance plans. 4) For low-income residents, specific insurance policies including reducing deductible, covering more medical service and increasing reimbursement ratio could be considered.