571579 research-article2015
APHXXX10.1177/1010539515571579Asia-Pacific Journal of Public HealthTeng et al
Original Article
Health Status and Burden of Health Care Costs Among Urban Elderly in China
Asia-Pacific Journal of Public Health 2015, Vol. 27(2S) 61S–68S © 2015 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539515571579 aph.sagepub.com
Haiying Teng, MSc1, Zhizhong Cao, PhD1, Junlan Liu, MSc2, Pei Liu, MSc1, Wei Hua, MSc1, Yue Yang, MSc1, and Linping Xiong, PhD1
Abstract This study evaluates health status among elderly residents in urban China and medical insurance schemes for them. A total of 931 urban elderly individuals aged 60 years or above in 3 cities were interviewed. The survey gathered data on individual sociodemographic characteristics, self-reported health status, chronic disease diagnoses, use of and expenditure related to health care services, satisfaction with medical insurance, and so on. The prevalence of chronic disease was 79.1% among the respondents, and medical expenditure on chronic disease per patient was 4656 Yuan in half a year. Over the 2 earlier weeks, 27.4% of respondents had felt sick, and 63.5% of them had had outpatient visits; 29.5% of respondents had been hospitalized in the past year. Among different groups, the inpatient reimbursement rate ranged from 45.5% to 81.2%, and the outpatient reimbursement rate was between 4.1% and 100%. The health care demand had not been met for many elderly individuals because of the lack of general outpatient coverage in the basic medical insurance scheme. Keywords aging, chronic diseases, medical security, health care demand
Introduction The percentage of individuals >60 years old in China will increase from 10.5% in 2000 to 19.5% in 2025 and 29.9% by 2050.1 With an aging population, chronic diseases are increasingly becoming more and more common. According to the report of the Fourth National Health Service Survey (NHSS; 2008),2 the prevalence of chronic disease increased from 77.7% in 2003 to 85.2% in 2008 among individuals >65 years old in cities. China is facing many challenges in providing adequate health care. China has launched 2 different health insurance schemes for the urban population3,4: Basic Medical Insurance System for Urban Employees (BMISUE) and Basic Medical Insurance System for Urban Residents (BMISUR). The former expands coverage to urban residents who 1Second 2No.
Military Medical University, Shanghai, China 254 Hospital of the Chinese People’s Liberation Army, Tianjin, China
Corresponding Author: Linping Xiong, Department of Health Services Management, the Second Military Medical University, 800 Xiangyin Road, Shanghai 200433, China. Email: [email protected]
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have a job. The latter covers unemployed urban residents, including children, students, the elderly, and so on. In the BMISUE, the total insurance premiums are divided into 2 accounts: the Social Pool Fund (SPF) and Personal Savings Accounts (PSAs). The PSAs cover general outpatient expenditure, and the SPF covers medical costs incurred from hospitalization services, clinic services for serious illnesses, and clinic emergencies. Before the benefits from the SPF can be triggered, participants need to pay a certain amount of medical costs, called criteria payment. Compared with the BMISUE, the BMISUR has not set up the PSAs and has a lower reimbursement rate. On the basis of “high coverage but low level,” the basic health insurance schemes are established mainly to handle acute disease, and they do not give sufficient consideration to senior citizens. Though the inpatient reimbursement level has continuously improved in the past few years, general outpatient services have not been covered in most cities yet.5,6 Considering the fact that older people have a higher medical demand, the reimbursement rates are ruled higher for them than for young people in some cities. Whether the present schemes meet the health needs of older people and how much they should pay for their long-term medication are issues that few studies have looked at. This article tries to describe the health status and health demands of urban elderly in 3 cities, evaluate the medical economy burden of chronic diseases, and evaluate the reimbursement level of health insurance for old people.
Methods Sample The study was based on cluster random sampling. We randomly selected urban communities in 3 cities for detailed study, 2 communities in Yanta district of Xi’an (November to December 2011), 2 communities in Qinshan district of Wuhan (November to December 2012), and 5 communities in Pudong district of Shanghai (June to August 2012). These 3 cities are the most prosperous cities located in the western, middle, and eastern districts in China. Then, residents’ buildings were randomly selected according to a 10% sampling ratio, and all the eligible elderly dwelling in these buildings were interviewed face-to-face and asked to fill out questionnaires. With ethics committee approval, the trained investigators gave necessary explanations about this research and obtained informed consent from all participants. The inclusion criteria were as follows: (a) age 60 years and above, (b) registered local permanent urban residence, (c) participated in BMISUE or BMISUR. Those who could not understand the questionnaire or were unwilling to participate in the study were excluded.
Questionnaire Most parts of the questionnaire were directly based on the fourth NHSS and were divided into 4 sections: (a) sociodemographic characteristics, (b) self-rated health, (c) self-reported disability and chronic disease diagnoses, and (d) health care use. For an assessment of medical burden, we added the following items: (a) frequency and expenditures for the treatment of chronic diseases, (b) reimbursements of medical expenses, (c) payment capacity for hospitalization costs, and (d) satisfaction with medical insurance. Medical expenditure referred to the direct costs. Respondents were asked to show the service voucher if it had not been lost.
Data Collection In cooperation with community volunteers, 2 investigators, who were local medical professionals and had been trained in the use of objective methods as well as in the procedure of the investigation, read and explained the questionnaire to the participants. After removing questionnaires Downloaded from aph.sagepub.com at DALHOUSIE UNIV on May 19, 2015
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with incomplete answers and answers suspected to be untrue, 931 questionnaires (303 in Xi’an, 310 in Wuhan, and 318 in Shanghai) were collected, with a 97.3% effectiveness rate.
Data Analysis The data were entered into Epidata 3.1 software using the double-computer for double-person method, and the data quality was controlled by constructing logic constraining conditions and valid value ranges for the relevant variables. The data were analyzed by descriptive statistics. The χ2 test and a nonparametric test (MannWhitney U) were used to compare the sociodemographic characteristics between 2 different medical insurants in the same city. All statistical analyses were performed with SAS9.1, and P 60 years old in the fourth NHSS (53.2%). Also, 49.7% of respondents had multiple chronic health conditions. The prevalence of hypertension was about 52.4% and that of diabetes was 15.4%— both higher than that in urban elderly individuals >65 years old in the fourth NHSS (hypertension, 32.5%; diabetes, 8.4%). The prevalence of hyperlipidemia or heart disease in each group was more than 10%. Numerous respondents also suffered from chronic gastroenteritis, COPD, slipped discs, or arthritic joints.
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Table 1. Sociodemographic Characteristics and Self-reported Health Status Among Respondents.a Xi’an Age (year) Gender Female Education level No education Primary school Junior high school Senior high school+ Previous occupation State organizations Collective enterprises Monthly income (Yuan) Self-rated health Good or very good Walking ability Difficulty in climbing stairs Walk with crutch Confined to a wheelchair Bed ridden Eyesight problemsb Moderate difficult Extremely difficult Hearing difficulties Need voices to be louder Difficult in hearing Chronic disease Prevalence rate Multiple chronic conditions Hypertension Hyperlipidemia Diabetes Heart disease Muscles and joints problem Cerebrovascular disease Gastrointestinal problem Breathing problem
Wuhan
BMISUE (n = 260)
BMISUR (n = 43)
75.7 (76.0)
75.7 (76.0)
BMISUE (n = 289) 69.5 (69.0)
Shanghai
BMISUR (n = 21) BMISUE (n = 195) 69.3 (66.0)
69.2 (66.0)
BMISUR (n = 123) 68.9 (66.0)
55.4% (144)
100% (43)***
53.6% (155)
76.2% (16)*
46.2% (90)
66.7% (82)***
18.5% (48) 47.7% (124) 23.8% (62) 10% (26)
48.8% (21)*** 44.2% (19) 7.0% (3) 0 (0)
8% (23) 19.2% (55) 30.7% (88) 42.2% (121)
23.8% (5)* 28.6% (6) 28.6% (6) 19.0% (4)
7.7% (15) 25.1% (49) 34.9% (68) 32.3% (63)
20.3% (25)*** 46.3% (57) 30.9% (38) 2.4% (3)
86.9% (251) 11.4% (33) 2566 (2600)
42.9% (9)*** 23.8% (5) 1133 (1040)***
82.1% (160) 13.8% (27) 2341 (2200)
0 (0)*** 41.5% (51) 1372 (962)***
98.8% (257) 11.6% (5)*** 1.2% (3) 74.4% (32) 1845 (1800) 620 (680)*** 7.3% (19)
9.3% (4)
18.7% (54)
23.8% (5)
37.9% (74)
30.9% (38)
18.1% (47) 12.4% (32) 3.1% (8) 3.5% (9)
34.9% (15) 18.6% (8) 2.3% (1) 0 (0)
19.0% (55) 5.9% (17) 0.7% (2) 0 (0)
19.0% (4) 0 (0) 0 (0) 0 (0)
12.8% (25) 2.6% (5) 1.0% (2) 2.1% (4)
17.1% (21) 4.9% (6) 2.4% (3) 0 (0)
57.3% (149) 2.7% (7)
69.8% (30) 7.0% (3)
15.9% (46) 2.4% (7)
33.3% (7) 0 (0)
13.0% (19) 4.8% (7)
19.8% (34) 7.0% (12)
20.4% (53) 6.2% (16)
37.2% (16) 2.3% (1)
13.1% (38) 2.4% (7)
23.8% (5) 4.8% (1)
15.4% (30) 6.7% (13)
11.4% (14) 6.5% (8)
91.9% (239) 70.4% (183) 50.0% (130) 40.4% (105) 18.1% (47) 49.2% (128) 19.6% (51) 15.8% (41) 11.2% (29) 11.2% (29)
93.0% (40) 76.7% (43) 67.4% (29) 41.9% (18) 20.9% (9) 46.5% (20) 32.6% (14) 7.0% (3) 14.0% (6) 9.3% (4)
75.8% (219) 46.4% (134) 54.7% (158) 26.0% (75) 16.3% (47) 13.1% (38) 28.0% (81) 3.5% (10) 4.2% (12) 4.8% (14)
66.7% (14) 38.1% (8) 33.3% (7) 28.6% (6) 4.8% (1) 0 (0) 42.9% (9) 0 (0) 4.8% (1) 0 (0)
67.2% (131) 27.2% (53) 48.2% (94) 18.5% (36) 12.3% (24) 9.2% (18) 8.2% (16) 0.5% (1) 2.1% (4) 3.1% (6)
75.6% (93) 34.1% (42) 56.9% (70) 22.0% (27) 12.2% (15) 14.6% (18) 1.6% (2) 0.8% (1) 3.3% (4) 1.6% (2)
Abbreviations: BMISUE, Basic Medical Insurance System for Urban Employees; BMISUR, Basic Medical Insurance System for Urban Residents. aData are presented as mean values or proportions, with the median or frequency in parentheses. *P < .05; **.05 < P < .01; ***.01 < P < .001. The notability check was only used on sociodemographic characteristics. bThe ability to recognize an acquaintance 20 m away.
Use of and Expenditure Related to Health Services The 2-week prevalence among respondents ranged from 14.2% to 44.6% in the 3 cities, and the proportion of people who visited a doctor was between 8.2% and 31.0% (Table 2). In the past year, 42.2% of elderly people in Xi’an had been hospitalized, whereas the rates were 35.8% in Wuhan and 11.3% in Shanghai. The hospitalization rates of respondents (counted by number of cases) also far exceeded the result in the fourth NHSS (17.2%), especially in Xi’an and Wuhan. However, there were still many respondents (9.4% in BMISUE, 13.4% in BMISUR) who did not take doctors’ advice on hospitalization. This was mostly because of economic hardship (37.1% in BMISUE, 92.0% in BMISUR). Average outpatient costs over the past 2 weeks reported by those who got outpatient treatment varied from 375 to 1691 Yuan in different groups. According to the local medical insurance policies Downloaded from aph.sagepub.com at DALHOUSIE UNIV on May 19, 2015
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BMISUE (n = 260)
Two-week prevalence Prevalence rate 43.5% (113) Outpatient visit 30.4% (79) Outpatient cost (Yuan) 652 (370) Reimbursement rate 4.1% (0) Hospitalization Proportion of elderly 42.7% (111) Hospitalization rate 96.2% (250) Cost incurred the last 5830 (2700) time (Yuan) Reimbursement rate 66.0% (68.6%) Expenses paid by children Part of expense 27.5% (30) All of expense 29.4% (32) Not been hospitalized 10.4% (27) Reasons for not being hospitalized Economic hardship 70.4% (19) Not serious 0 (0) No effectual remedy 3.7% (1) Too old 7.4% (2) Chronic disease Total cost mean (Yuan) 5746 (3525) Reimbursement rates 8.1% (0) Long-term medication Hypertension Proportion 41.5% (108) Total cost (Yuan) 712 (600) Hyperlipidemia Proportion 21.5% (56) Total cost (Yuan) 632 (500) Diabetes Proportion 9.2% (24) Total cost (Yuan) 2968 (2700) Satisfied with insurance 6.5% (17)
Wuhan BMISUR (n = 43)
Shanghai
BMISUE (n = 289)
BMISUR (n = 21)
BMISUE (n = 195)
BMISUR (n = 123)
51.2% (22) 34.9% (15) 717 (350) 4.5% (0)
23.9% (69) 13.8% (40) 1691 (600) 78.4% (80.0%)
28.6% (6) 9.5% (2) 375 (375) 100% (100%)
11.8% (23) 5.6% (11) 1240 (350) 65.6% (75.0%)
17.9% (22) 12.2% (15) 792 (390) 30.3% (14.3%)
39.5% (17) 72.1% (31) 3548 (3000)
37.7% (109) 78.5% (227) 7875 (5000)
9.5% (2) 9.5% (2) 5554 (5554)
45.5% (46.7%)
81.2% (84.4%)
52.3% (52.3%)
10.8% (21) 19.0% (37) 16 360 (16 360) 69.3% (70.0%)
26.3% (5) 36.8% (7) 25.6% (11)
32.1% (34) 1.9% (2) 11.4% (33)
50.0% (1) 50.0% (1) 23.8% (5)
35.0% (7) 25.0% (5) 5.1% (10)
20.0% (3) 80.0% (12) 7.3% (9)
100% (11) 0 (0) 0 (0) 0 (0)
12.1% (4) 0 (0) 18.2% (6) 12.1% (4)
100% (5) 0 (0) 0 (0) 0 (0)
30.0% (3) 40.0% (4) 10.0% (1) 0 (0)
77.8% (7) 11.1% (1) 11.1% (1) 0 (0)
5315 (2875) 1.3% (0)
4169 (1000) 62.3% (73.2%)
1311 (415) 3.8% (0)
3642 (800) 67.9% (75.8%)
4652 (1000) 38.5% (42.9%)
43.6% (85) 1650 (600)
53.7% (66) 1388 (600)
12.2% (15) 17.1% (21) 15 967 (6000) 49.7% (50.0%)
58.1% (25) 845 (600)
49.1% (142) 1225 (602)
28.6% (6) 932 (385)
23.3% (10) 710 (800)
12.1% (35) 1174 (870)
14.3 (3) 115 (600)
8.2% (16) 2575 (1000)
8.9% (11) 1462 (800)
14.0% (6) 2287 (1200) 2.3% (1)
14.5 (42) 1167 (590) 53.0% (149)
4.8% (1) 300 (300) 30.0% (6)
8.7% (17) 2700 (1800) 36.9% (72)
10.6% (13) 3308 (1200) 13.8% (17)
Abbreviations: BMISUE, Basic Medical Insurance System for Urban Employees; BMISUR, Basic Medical Insurance System for Urban Residents. aValues are given as mean value or proportion, with median or frequency in parentheses.
during this survey period,7-10 in Shanghai, the general outpatient cost could be reimbursed by the SPF (60%-90% in BMISUE, 50%-65% in BMISUR) after participants had exhausted the funds in the PSAs for the current year and paid “criteria payment.” Perhaps because of the criteria payment or some self-paying medical services, the self-reported outpatient reimbursement rates (65.6% in BMISUE, 30.3% in BMISUR) were significantly below the policy standards. In Xi’an and Wuhan, the general outpatient cost only could be reimbursed by the PSAs for the BMISUE participants, and the SPF could reimburse 50% of the fees over criteria payment but under the maximum payment for the BMISUR participants—in fact, only 500 Yuan a year at most. However, the self-reported reimbursement rates were very different in the 2 cities—below 4.5% in Xi’an but more than 78.4% in Wuhan. The reason the reimbursement rate in Wuhan was so high is because most of the respondents were also covered by the enterprise subsidiary medical insurance and got extra reimbursement. It is also worth noting that only 27 patients in 3 cities used funds in the PSAs to pay outpatient costs.
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The average self-reported hospitalization costs during the last visit varied from 3548 to 16 360 Yuan in different groups. According to the local policies, the inpatient reimbursement rates were 86% to 97% in the BMISUE and 55% to 85% in the BMISUR, varying with level or size of hospitals and also with age in Shanghai. Similarly, the self-reported inpatient reimbursement rates (66.0%-81.2% in BMISUE, 45.5%-52.3% in BMISUR) were all below the policy standards. The rate in Wuhan was also the highest in the 3 cities. A large proportion of hospitalized respondents reported that their hospital costs had to be shared by their children, with the highest being 75.0% in Shanghai and the lowest 34.2% in Wuhan. In the past 6 months, the average expenditure on chronic diseases of respondents suffering from chronic illness was 4656 Yuan, and 60.1% of these costs were paid by patients themselves. The reimbursement rates were no more than 10% among respondents of Xi’an or BMISUR participants of Wuhan. The proportion who took long-term medication to control blood pressure, blood lipids, or blood glucose and the average amount spent on drugs over the prior 6 months are also presented in Table 2. About half of the respondents regularly took antihypertensive drugs. The costs for diabetes patients were relatively high—about 2167 Yuan per person.
Satisfaction Regarding Basic Medical Insurance The last row of Table 2 shows that the elderly individuals were not entirely satisfied with the reimbursement level of basic medical insurance. People in Wuhan had the highest rate of satisfaction among the 3 cities (50.0% satisfied), followed by Shanghai (28.0%) and Xi’an (5.9%). Elderly people in BMISUR were less satisfied than those in BMISUE.
Discussion This study shows that the general health status of the urban elderly was not good most likely because of poor physical function and high medical demand for chronic disease treatment. Many differences among the 3 cities could result from the following factors: sex and age structure, health care policy, personal income, local consumption levels, and so on. It is not surprising that chronic disease prevalence among respondents was higher than that in the fourth NHSS in 2008. We presume the chronic disease prevalence in China has risen further in the past 5 years. High chronic disease prevalence leads to high medical demand and economic burden. As many studies have reported, chronic disease is the most significant determinant of health care use in older people.11-13 In this survey, the main diagnosis for most outpatients or inpatients was chronic diseases. Medical expenditure for chronic disease per patient reached 4656 Yuan in the past 6 months, and more than 60% of it (about 23.8% of their income) was paid by the older people. There were many respondents who took long-term medication, and hypertensive patients already accounted for nearly half of total respondents. Underdiagnosis is pervasive and treatment is rare in China14; therefore, the potential medical demand is likely to be higher. By observing the payment capacity for hospitalization costs and satisfaction regarding medical insurance, we conclude that there were still many old people whose health care needs could not be met, especially those who participated in BMISUR. The low pensions and low savings are not adequate to handle the high medical expenses for elderly people. It was reported that the average pension of retired enterprise employees had been raised from 700 RMB in 2005 to 1900 RMB in 2013.15 Nevertheless, the pension has barely kept up with the rising prices over the past years. Medical insurance is crucial in later years. There is a structural deficiency in the basic medical insurance for old people—namely, the lack of general outpatient coverage. Based on the preceding analysis, we know that the general outpatient cost was only covered by the PSAs in the BMISUE in Xi’an and Wuhan, but there were only a few respondents who paid their outpatient costs by funds in the PSAs. The high self-paid ratio for chronic disease
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expenditure in half a year also showed that the funds in the PSAs were far from enough for most BMISUE participants. Take the BMISUE in Xi’an, for example; the premium allocated into the PSAs for retirees was only 5% of their pensions (about 1100 Yuan per year) in 2012. It might quickly be depleted by even routine health care demands, let alone long-term chronic medication. The situation of those who participated in BMISUR, no doubt, was much worse. Most patients with chronic diseases need long-term medication rather than hospitalization. But the current medical insurance scheme is less oriented to chronic illness. This is almost a fatal blow to the elderly. The lack of general outpatient coverage discouraged many patients from seeking medical care at an early stage. And in this survey, some patients complained that they had to select hospitalization instead of outpatient treatment in order to get medical reimbursement. Therefore, noting the significant increase in Xi’an and Wuhan, we postulate that this deficiency is likely to raise the hospitalization rate. Even basic medical insurance priorities such as the hospitalization cost and the actual inpatient reimbursement rates were much lower than the policy standards. In addition, we also notice that only 36.9% of BMISUE participants in Shanghai were satisfied with the basic medical insurance in spite of the higher outpatient reimbursement, but this proportion in Wuhan was relatively high. Probably, one reason is the higher medical costs because of higher prices in Shanghai; this can be surmised from the significantly higher hospitalization expenses in Shanghai. The other reason is the extra reimbursement by the enterprise subsidiary medical insurance for respondents in Wuhan. The supplementary medical insurance is an ideal complement to the basic medical insurance. But in China, most elderly solely rely on the basic medical insurance. Underdevelopment of the subsidiary medical insurance is also another defect in China’s health care system.
Conclusion Because most of the coverage for chronic illnesses is still not well established in China, the basic medical insurance policies, although favoring the older population, still cannot meet their needs. The findings of this study suggest various effective measures for reducing old people’s long-term medical care burden: for example, expanding coverage on outpatient treatments in the basic medical insurance, increasing allocation into the PSAs, and accelerating the development of subsidiary medical insurance. The high medical expenditure seen in this study is also a warning regarding the sustainability of the medical insurance fund. Facing a rapidly aging population at a low income level, the Chinese Government should reverse the tendency toward illness prevention rather than treatment and strengthen mass prophylaxis and community-based comprehensive management for chronic diseases, which is the most effective way to reduce medical costs and realize healthy ageing. Authors’ Note HT and ZC contributed equally to this work. The authors disclosed proof that this survey got approved by Changhai Hospital Ethics Committee in Shanghai, China.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the National Natural Science Foundation of China (Grant Number 71073171).
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References 1. Hou JW, Li KW. The aging of the Chinese population and the cost of health care. Soc Sci J. 2011;48: 514-526. 2. Centre for Health Statistics and Information–Ministry on Health. An Analysis Report of National Health Services Survey in 2008. Beijing, China: Chinese Academy Science & Peking Union Medical College; 2009. 3. State Council. Decisions of the state council on establishing the urban employee essential medical scheme. http://www.gov.cn/banshi/2005-08/04/content_20256.htm. Accessed January 24, 2015. 4. State Council Document No. 20. Instructions on establishing the urban resident essential medical scheme. http://www.gov.cn/zwgk/2007-07/24/content_695118.htm. Accessed January 24, 2015. 5. Lin WC, Liu GG, Chen G. The urban resident basic medical insurance: a landmark reform towards universal coverage in China. Health Econ. 2009;18:S83-S96. 6. Qian DF, Lucas H, Chen JY, et al. Determinants of the use of different types of health care provider in urban China: a tracer illness study of URTI. Health Policy. 2010;98:227-235. 7. Xi’an Municipal Human Resources and Social Security Bureau Document No.129. Notifications about adjusting the standards of urban employee basic medical insurance. http://www.xahrss.gov.cn/info/ iList.jsp?tm_id=60&cata_id=85&info_id=5640 8. Xi’an Municipal Human Resources and Social Security Bureau Document No.154. Notifications about specific implementing measures of reimbursement mode of out-patent service for the urban residents in Xian. http://www.xahrss.gov.cn/info/iList.jsp?tm_id=60&cata_id=90&info_id=5834 9. Wuhan Government Document No.165. Notifications of the Wuhan Government on increasing the level of the basic urban medical insurance in Wuhan. http://www.wh.gov.cn/fggwbgtwj/8772.jhtml. 10. Shanghai Municipal Human Resources and Social Security Bureau. Query system for the level of basic medical insurance. http://www.shyb.gov.cn/xxcx/yb02.html. 11. Chao JQ, Li YY, Xu H, Yu Q, Wang YM, Liu P. Health status and associated factors among the community-dwelling elderly in China. Arch Gerontol Geriatr. 2013;56:199-204. 12. Liu ZL, Albanese E, Li SR, et al. Chronic disease prevalence and care among the elderly in urban and rural Beijing, China: a 10/66 Dementia Research Group cross-sectional survey. BMC Public Health. 2009;9:394. 13. Zhang P, Zhang XZ, Brown J, et al. Global healthcare expenditure on diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87:293-301. 14. Lei XY, Yin NN, Zhao YH. Socioeconomic status and chronic disease: the case of hypertension in China. China Econ Rev. 2012;23:105-121. 15. Han YM. Pension of enterprise employees over the country rose 10%, 1900 RMB per capita per year. The Beijing News. http://news.qq.com/a/20130126/000039.htm. Accessed January 24, 2015.
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APHXXX10.1177/1010539515571579Asia-Pacific Journal of Public HealthTeng et al
Original Article
Health Status and Burden of Health Care Costs Among Urban Elderly in China
Asia-Pacific Journal of Public Health 2015, Vol. 27(2S) 61S–68S © 2015 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539515571579 aph.sagepub.com
Haiying Teng, MSc1, Zhizhong Cao, PhD1, Junlan Liu, MSc2, Pei Liu, MSc1, Wei Hua, MSc1, Yue Yang, MSc1, and Linping Xiong, PhD1
Abstract This study evaluates health status among elderly residents in urban China and medical insurance schemes for them. A total of 931 urban elderly individuals aged 60 years or above in 3 cities were interviewed. The survey gathered data on individual sociodemographic characteristics, self-reported health status, chronic disease diagnoses, use of and expenditure related to health care services, satisfaction with medical insurance, and so on. The prevalence of chronic disease was 79.1% among the respondents, and medical expenditure on chronic disease per patient was 4656 Yuan in half a year. Over the 2 earlier weeks, 27.4% of respondents had felt sick, and 63.5% of them had had outpatient visits; 29.5% of respondents had been hospitalized in the past year. Among different groups, the inpatient reimbursement rate ranged from 45.5% to 81.2%, and the outpatient reimbursement rate was between 4.1% and 100%. The health care demand had not been met for many elderly individuals because of the lack of general outpatient coverage in the basic medical insurance scheme. Keywords aging, chronic diseases, medical security, health care demand
Introduction The percentage of individuals >60 years old in China will increase from 10.5% in 2000 to 19.5% in 2025 and 29.9% by 2050.1 With an aging population, chronic diseases are increasingly becoming more and more common. According to the report of the Fourth National Health Service Survey (NHSS; 2008),2 the prevalence of chronic disease increased from 77.7% in 2003 to 85.2% in 2008 among individuals >65 years old in cities. China is facing many challenges in providing adequate health care. China has launched 2 different health insurance schemes for the urban population3,4: Basic Medical Insurance System for Urban Employees (BMISUE) and Basic Medical Insurance System for Urban Residents (BMISUR). The former expands coverage to urban residents who 1Second 2No.
Military Medical University, Shanghai, China 254 Hospital of the Chinese People’s Liberation Army, Tianjin, China
Corresponding Author: Linping Xiong, Department of Health Services Management, the Second Military Medical University, 800 Xiangyin Road, Shanghai 200433, China. Email: [email protected]
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have a job. The latter covers unemployed urban residents, including children, students, the elderly, and so on. In the BMISUE, the total insurance premiums are divided into 2 accounts: the Social Pool Fund (SPF) and Personal Savings Accounts (PSAs). The PSAs cover general outpatient expenditure, and the SPF covers medical costs incurred from hospitalization services, clinic services for serious illnesses, and clinic emergencies. Before the benefits from the SPF can be triggered, participants need to pay a certain amount of medical costs, called criteria payment. Compared with the BMISUE, the BMISUR has not set up the PSAs and has a lower reimbursement rate. On the basis of “high coverage but low level,” the basic health insurance schemes are established mainly to handle acute disease, and they do not give sufficient consideration to senior citizens. Though the inpatient reimbursement level has continuously improved in the past few years, general outpatient services have not been covered in most cities yet.5,6 Considering the fact that older people have a higher medical demand, the reimbursement rates are ruled higher for them than for young people in some cities. Whether the present schemes meet the health needs of older people and how much they should pay for their long-term medication are issues that few studies have looked at. This article tries to describe the health status and health demands of urban elderly in 3 cities, evaluate the medical economy burden of chronic diseases, and evaluate the reimbursement level of health insurance for old people.
Methods Sample The study was based on cluster random sampling. We randomly selected urban communities in 3 cities for detailed study, 2 communities in Yanta district of Xi’an (November to December 2011), 2 communities in Qinshan district of Wuhan (November to December 2012), and 5 communities in Pudong district of Shanghai (June to August 2012). These 3 cities are the most prosperous cities located in the western, middle, and eastern districts in China. Then, residents’ buildings were randomly selected according to a 10% sampling ratio, and all the eligible elderly dwelling in these buildings were interviewed face-to-face and asked to fill out questionnaires. With ethics committee approval, the trained investigators gave necessary explanations about this research and obtained informed consent from all participants. The inclusion criteria were as follows: (a) age 60 years and above, (b) registered local permanent urban residence, (c) participated in BMISUE or BMISUR. Those who could not understand the questionnaire or were unwilling to participate in the study were excluded.
Questionnaire Most parts of the questionnaire were directly based on the fourth NHSS and were divided into 4 sections: (a) sociodemographic characteristics, (b) self-rated health, (c) self-reported disability and chronic disease diagnoses, and (d) health care use. For an assessment of medical burden, we added the following items: (a) frequency and expenditures for the treatment of chronic diseases, (b) reimbursements of medical expenses, (c) payment capacity for hospitalization costs, and (d) satisfaction with medical insurance. Medical expenditure referred to the direct costs. Respondents were asked to show the service voucher if it had not been lost.
Data Collection In cooperation with community volunteers, 2 investigators, who were local medical professionals and had been trained in the use of objective methods as well as in the procedure of the investigation, read and explained the questionnaire to the participants. After removing questionnaires Downloaded from aph.sagepub.com at DALHOUSIE UNIV on May 19, 2015
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with incomplete answers and answers suspected to be untrue, 931 questionnaires (303 in Xi’an, 310 in Wuhan, and 318 in Shanghai) were collected, with a 97.3% effectiveness rate.
Data Analysis The data were entered into Epidata 3.1 software using the double-computer for double-person method, and the data quality was controlled by constructing logic constraining conditions and valid value ranges for the relevant variables. The data were analyzed by descriptive statistics. The χ2 test and a nonparametric test (MannWhitney U) were used to compare the sociodemographic characteristics between 2 different medical insurants in the same city. All statistical analyses were performed with SAS9.1, and P 60 years old in the fourth NHSS (53.2%). Also, 49.7% of respondents had multiple chronic health conditions. The prevalence of hypertension was about 52.4% and that of diabetes was 15.4%— both higher than that in urban elderly individuals >65 years old in the fourth NHSS (hypertension, 32.5%; diabetes, 8.4%). The prevalence of hyperlipidemia or heart disease in each group was more than 10%. Numerous respondents also suffered from chronic gastroenteritis, COPD, slipped discs, or arthritic joints.
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Table 1. Sociodemographic Characteristics and Self-reported Health Status Among Respondents.a Xi’an Age (year) Gender Female Education level No education Primary school Junior high school Senior high school+ Previous occupation State organizations Collective enterprises Monthly income (Yuan) Self-rated health Good or very good Walking ability Difficulty in climbing stairs Walk with crutch Confined to a wheelchair Bed ridden Eyesight problemsb Moderate difficult Extremely difficult Hearing difficulties Need voices to be louder Difficult in hearing Chronic disease Prevalence rate Multiple chronic conditions Hypertension Hyperlipidemia Diabetes Heart disease Muscles and joints problem Cerebrovascular disease Gastrointestinal problem Breathing problem
Wuhan
BMISUE (n = 260)
BMISUR (n = 43)
75.7 (76.0)
75.7 (76.0)
BMISUE (n = 289) 69.5 (69.0)
Shanghai
BMISUR (n = 21) BMISUE (n = 195) 69.3 (66.0)
69.2 (66.0)
BMISUR (n = 123) 68.9 (66.0)
55.4% (144)
100% (43)***
53.6% (155)
76.2% (16)*
46.2% (90)
66.7% (82)***
18.5% (48) 47.7% (124) 23.8% (62) 10% (26)
48.8% (21)*** 44.2% (19) 7.0% (3) 0 (0)
8% (23) 19.2% (55) 30.7% (88) 42.2% (121)
23.8% (5)* 28.6% (6) 28.6% (6) 19.0% (4)
7.7% (15) 25.1% (49) 34.9% (68) 32.3% (63)
20.3% (25)*** 46.3% (57) 30.9% (38) 2.4% (3)
86.9% (251) 11.4% (33) 2566 (2600)
42.9% (9)*** 23.8% (5) 1133 (1040)***
82.1% (160) 13.8% (27) 2341 (2200)
0 (0)*** 41.5% (51) 1372 (962)***
98.8% (257) 11.6% (5)*** 1.2% (3) 74.4% (32) 1845 (1800) 620 (680)*** 7.3% (19)
9.3% (4)
18.7% (54)
23.8% (5)
37.9% (74)
30.9% (38)
18.1% (47) 12.4% (32) 3.1% (8) 3.5% (9)
34.9% (15) 18.6% (8) 2.3% (1) 0 (0)
19.0% (55) 5.9% (17) 0.7% (2) 0 (0)
19.0% (4) 0 (0) 0 (0) 0 (0)
12.8% (25) 2.6% (5) 1.0% (2) 2.1% (4)
17.1% (21) 4.9% (6) 2.4% (3) 0 (0)
57.3% (149) 2.7% (7)
69.8% (30) 7.0% (3)
15.9% (46) 2.4% (7)
33.3% (7) 0 (0)
13.0% (19) 4.8% (7)
19.8% (34) 7.0% (12)
20.4% (53) 6.2% (16)
37.2% (16) 2.3% (1)
13.1% (38) 2.4% (7)
23.8% (5) 4.8% (1)
15.4% (30) 6.7% (13)
11.4% (14) 6.5% (8)
91.9% (239) 70.4% (183) 50.0% (130) 40.4% (105) 18.1% (47) 49.2% (128) 19.6% (51) 15.8% (41) 11.2% (29) 11.2% (29)
93.0% (40) 76.7% (43) 67.4% (29) 41.9% (18) 20.9% (9) 46.5% (20) 32.6% (14) 7.0% (3) 14.0% (6) 9.3% (4)
75.8% (219) 46.4% (134) 54.7% (158) 26.0% (75) 16.3% (47) 13.1% (38) 28.0% (81) 3.5% (10) 4.2% (12) 4.8% (14)
66.7% (14) 38.1% (8) 33.3% (7) 28.6% (6) 4.8% (1) 0 (0) 42.9% (9) 0 (0) 4.8% (1) 0 (0)
67.2% (131) 27.2% (53) 48.2% (94) 18.5% (36) 12.3% (24) 9.2% (18) 8.2% (16) 0.5% (1) 2.1% (4) 3.1% (6)
75.6% (93) 34.1% (42) 56.9% (70) 22.0% (27) 12.2% (15) 14.6% (18) 1.6% (2) 0.8% (1) 3.3% (4) 1.6% (2)
Abbreviations: BMISUE, Basic Medical Insurance System for Urban Employees; BMISUR, Basic Medical Insurance System for Urban Residents. aData are presented as mean values or proportions, with the median or frequency in parentheses. *P < .05; **.05 < P < .01; ***.01 < P < .001. The notability check was only used on sociodemographic characteristics. bThe ability to recognize an acquaintance 20 m away.
Use of and Expenditure Related to Health Services The 2-week prevalence among respondents ranged from 14.2% to 44.6% in the 3 cities, and the proportion of people who visited a doctor was between 8.2% and 31.0% (Table 2). In the past year, 42.2% of elderly people in Xi’an had been hospitalized, whereas the rates were 35.8% in Wuhan and 11.3% in Shanghai. The hospitalization rates of respondents (counted by number of cases) also far exceeded the result in the fourth NHSS (17.2%), especially in Xi’an and Wuhan. However, there were still many respondents (9.4% in BMISUE, 13.4% in BMISUR) who did not take doctors’ advice on hospitalization. This was mostly because of economic hardship (37.1% in BMISUE, 92.0% in BMISUR). Average outpatient costs over the past 2 weeks reported by those who got outpatient treatment varied from 375 to 1691 Yuan in different groups. According to the local medical insurance policies Downloaded from aph.sagepub.com at DALHOUSIE UNIV on May 19, 2015
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BMISUE (n = 260)
Two-week prevalence Prevalence rate 43.5% (113) Outpatient visit 30.4% (79) Outpatient cost (Yuan) 652 (370) Reimbursement rate 4.1% (0) Hospitalization Proportion of elderly 42.7% (111) Hospitalization rate 96.2% (250) Cost incurred the last 5830 (2700) time (Yuan) Reimbursement rate 66.0% (68.6%) Expenses paid by children Part of expense 27.5% (30) All of expense 29.4% (32) Not been hospitalized 10.4% (27) Reasons for not being hospitalized Economic hardship 70.4% (19) Not serious 0 (0) No effectual remedy 3.7% (1) Too old 7.4% (2) Chronic disease Total cost mean (Yuan) 5746 (3525) Reimbursement rates 8.1% (0) Long-term medication Hypertension Proportion 41.5% (108) Total cost (Yuan) 712 (600) Hyperlipidemia Proportion 21.5% (56) Total cost (Yuan) 632 (500) Diabetes Proportion 9.2% (24) Total cost (Yuan) 2968 (2700) Satisfied with insurance 6.5% (17)
Wuhan BMISUR (n = 43)
Shanghai
BMISUE (n = 289)
BMISUR (n = 21)
BMISUE (n = 195)
BMISUR (n = 123)
51.2% (22) 34.9% (15) 717 (350) 4.5% (0)
23.9% (69) 13.8% (40) 1691 (600) 78.4% (80.0%)
28.6% (6) 9.5% (2) 375 (375) 100% (100%)
11.8% (23) 5.6% (11) 1240 (350) 65.6% (75.0%)
17.9% (22) 12.2% (15) 792 (390) 30.3% (14.3%)
39.5% (17) 72.1% (31) 3548 (3000)
37.7% (109) 78.5% (227) 7875 (5000)
9.5% (2) 9.5% (2) 5554 (5554)
45.5% (46.7%)
81.2% (84.4%)
52.3% (52.3%)
10.8% (21) 19.0% (37) 16 360 (16 360) 69.3% (70.0%)
26.3% (5) 36.8% (7) 25.6% (11)
32.1% (34) 1.9% (2) 11.4% (33)
50.0% (1) 50.0% (1) 23.8% (5)
35.0% (7) 25.0% (5) 5.1% (10)
20.0% (3) 80.0% (12) 7.3% (9)
100% (11) 0 (0) 0 (0) 0 (0)
12.1% (4) 0 (0) 18.2% (6) 12.1% (4)
100% (5) 0 (0) 0 (0) 0 (0)
30.0% (3) 40.0% (4) 10.0% (1) 0 (0)
77.8% (7) 11.1% (1) 11.1% (1) 0 (0)
5315 (2875) 1.3% (0)
4169 (1000) 62.3% (73.2%)
1311 (415) 3.8% (0)
3642 (800) 67.9% (75.8%)
4652 (1000) 38.5% (42.9%)
43.6% (85) 1650 (600)
53.7% (66) 1388 (600)
12.2% (15) 17.1% (21) 15 967 (6000) 49.7% (50.0%)
58.1% (25) 845 (600)
49.1% (142) 1225 (602)
28.6% (6) 932 (385)
23.3% (10) 710 (800)
12.1% (35) 1174 (870)
14.3 (3) 115 (600)
8.2% (16) 2575 (1000)
8.9% (11) 1462 (800)
14.0% (6) 2287 (1200) 2.3% (1)
14.5 (42) 1167 (590) 53.0% (149)
4.8% (1) 300 (300) 30.0% (6)
8.7% (17) 2700 (1800) 36.9% (72)
10.6% (13) 3308 (1200) 13.8% (17)
Abbreviations: BMISUE, Basic Medical Insurance System for Urban Employees; BMISUR, Basic Medical Insurance System for Urban Residents. aValues are given as mean value or proportion, with median or frequency in parentheses.
during this survey period,7-10 in Shanghai, the general outpatient cost could be reimbursed by the SPF (60%-90% in BMISUE, 50%-65% in BMISUR) after participants had exhausted the funds in the PSAs for the current year and paid “criteria payment.” Perhaps because of the criteria payment or some self-paying medical services, the self-reported outpatient reimbursement rates (65.6% in BMISUE, 30.3% in BMISUR) were significantly below the policy standards. In Xi’an and Wuhan, the general outpatient cost only could be reimbursed by the PSAs for the BMISUE participants, and the SPF could reimburse 50% of the fees over criteria payment but under the maximum payment for the BMISUR participants—in fact, only 500 Yuan a year at most. However, the self-reported reimbursement rates were very different in the 2 cities—below 4.5% in Xi’an but more than 78.4% in Wuhan. The reason the reimbursement rate in Wuhan was so high is because most of the respondents were also covered by the enterprise subsidiary medical insurance and got extra reimbursement. It is also worth noting that only 27 patients in 3 cities used funds in the PSAs to pay outpatient costs.
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The average self-reported hospitalization costs during the last visit varied from 3548 to 16 360 Yuan in different groups. According to the local policies, the inpatient reimbursement rates were 86% to 97% in the BMISUE and 55% to 85% in the BMISUR, varying with level or size of hospitals and also with age in Shanghai. Similarly, the self-reported inpatient reimbursement rates (66.0%-81.2% in BMISUE, 45.5%-52.3% in BMISUR) were all below the policy standards. The rate in Wuhan was also the highest in the 3 cities. A large proportion of hospitalized respondents reported that their hospital costs had to be shared by their children, with the highest being 75.0% in Shanghai and the lowest 34.2% in Wuhan. In the past 6 months, the average expenditure on chronic diseases of respondents suffering from chronic illness was 4656 Yuan, and 60.1% of these costs were paid by patients themselves. The reimbursement rates were no more than 10% among respondents of Xi’an or BMISUR participants of Wuhan. The proportion who took long-term medication to control blood pressure, blood lipids, or blood glucose and the average amount spent on drugs over the prior 6 months are also presented in Table 2. About half of the respondents regularly took antihypertensive drugs. The costs for diabetes patients were relatively high—about 2167 Yuan per person.
Satisfaction Regarding Basic Medical Insurance The last row of Table 2 shows that the elderly individuals were not entirely satisfied with the reimbursement level of basic medical insurance. People in Wuhan had the highest rate of satisfaction among the 3 cities (50.0% satisfied), followed by Shanghai (28.0%) and Xi’an (5.9%). Elderly people in BMISUR were less satisfied than those in BMISUE.
Discussion This study shows that the general health status of the urban elderly was not good most likely because of poor physical function and high medical demand for chronic disease treatment. Many differences among the 3 cities could result from the following factors: sex and age structure, health care policy, personal income, local consumption levels, and so on. It is not surprising that chronic disease prevalence among respondents was higher than that in the fourth NHSS in 2008. We presume the chronic disease prevalence in China has risen further in the past 5 years. High chronic disease prevalence leads to high medical demand and economic burden. As many studies have reported, chronic disease is the most significant determinant of health care use in older people.11-13 In this survey, the main diagnosis for most outpatients or inpatients was chronic diseases. Medical expenditure for chronic disease per patient reached 4656 Yuan in the past 6 months, and more than 60% of it (about 23.8% of their income) was paid by the older people. There were many respondents who took long-term medication, and hypertensive patients already accounted for nearly half of total respondents. Underdiagnosis is pervasive and treatment is rare in China14; therefore, the potential medical demand is likely to be higher. By observing the payment capacity for hospitalization costs and satisfaction regarding medical insurance, we conclude that there were still many old people whose health care needs could not be met, especially those who participated in BMISUR. The low pensions and low savings are not adequate to handle the high medical expenses for elderly people. It was reported that the average pension of retired enterprise employees had been raised from 700 RMB in 2005 to 1900 RMB in 2013.15 Nevertheless, the pension has barely kept up with the rising prices over the past years. Medical insurance is crucial in later years. There is a structural deficiency in the basic medical insurance for old people—namely, the lack of general outpatient coverage. Based on the preceding analysis, we know that the general outpatient cost was only covered by the PSAs in the BMISUE in Xi’an and Wuhan, but there were only a few respondents who paid their outpatient costs by funds in the PSAs. The high self-paid ratio for chronic disease
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expenditure in half a year also showed that the funds in the PSAs were far from enough for most BMISUE participants. Take the BMISUE in Xi’an, for example; the premium allocated into the PSAs for retirees was only 5% of their pensions (about 1100 Yuan per year) in 2012. It might quickly be depleted by even routine health care demands, let alone long-term chronic medication. The situation of those who participated in BMISUR, no doubt, was much worse. Most patients with chronic diseases need long-term medication rather than hospitalization. But the current medical insurance scheme is less oriented to chronic illness. This is almost a fatal blow to the elderly. The lack of general outpatient coverage discouraged many patients from seeking medical care at an early stage. And in this survey, some patients complained that they had to select hospitalization instead of outpatient treatment in order to get medical reimbursement. Therefore, noting the significant increase in Xi’an and Wuhan, we postulate that this deficiency is likely to raise the hospitalization rate. Even basic medical insurance priorities such as the hospitalization cost and the actual inpatient reimbursement rates were much lower than the policy standards. In addition, we also notice that only 36.9% of BMISUE participants in Shanghai were satisfied with the basic medical insurance in spite of the higher outpatient reimbursement, but this proportion in Wuhan was relatively high. Probably, one reason is the higher medical costs because of higher prices in Shanghai; this can be surmised from the significantly higher hospitalization expenses in Shanghai. The other reason is the extra reimbursement by the enterprise subsidiary medical insurance for respondents in Wuhan. The supplementary medical insurance is an ideal complement to the basic medical insurance. But in China, most elderly solely rely on the basic medical insurance. Underdevelopment of the subsidiary medical insurance is also another defect in China’s health care system.
Conclusion Because most of the coverage for chronic illnesses is still not well established in China, the basic medical insurance policies, although favoring the older population, still cannot meet their needs. The findings of this study suggest various effective measures for reducing old people’s long-term medical care burden: for example, expanding coverage on outpatient treatments in the basic medical insurance, increasing allocation into the PSAs, and accelerating the development of subsidiary medical insurance. The high medical expenditure seen in this study is also a warning regarding the sustainability of the medical insurance fund. Facing a rapidly aging population at a low income level, the Chinese Government should reverse the tendency toward illness prevention rather than treatment and strengthen mass prophylaxis and community-based comprehensive management for chronic diseases, which is the most effective way to reduce medical costs and realize healthy ageing. Authors’ Note HT and ZC contributed equally to this work. The authors disclosed proof that this survey got approved by Changhai Hospital Ethics Committee in Shanghai, China.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the National Natural Science Foundation of China (Grant Number 71073171).
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