The Lancet Regional Health. Western Pacific (Apr 2024)

Association between health insurance cost-sharing and choice of hospital tier for cardiovascular diseases in China: a prospective cohort studyResearch in context

  • Muriel Levy,
  • John Buckell,
  • Robert Clarke,
  • Nina Wu,
  • Pei Pei,
  • Dianjianyi Sun,
  • Daniel Avery,
  • Hua Zhang,
  • Jun Lv,
  • Canqing Yu,
  • Liming Li,
  • Zhengming Chen,
  • Winnie Yip,
  • Yiping Chen,
  • Borislava Mihaylova,
  • Junshi Chen,
  • Zhengming Chen,
  • Robert Clarke,
  • Rory Collins,
  • Liming Li,
  • Chen Wang,
  • Jun Lv,
  • Richard Peto,
  • Robin Walters,
  • Daniel Avery,
  • Maxim Barnard,
  • Derrick Bennett,
  • Ruth Boxall,
  • Kahung Chan,
  • Yiping Chen,
  • Zhengming Chen,
  • Johnathan Clarke,
  • Robert Clarke,
  • Huaidong Du,
  • Ahmed Edris Mohamed,
  • Hannah Fry,
  • Simon Gilbert,
  • Pek Kei Im,
  • Andri Iona,
  • Maria Kakkoura,
  • Christiana Kartsonaki,
  • Hubert Lam,
  • Kuang Lin,
  • James Liu,
  • Mohsen Mazidi,
  • Iona Millwood,
  • Sam Morris,
  • Qunhua Nie,
  • Alfred Pozaricki,
  • Paul Ryder,
  • Saredo Said,
  • Dan Schmidt,
  • Becky Stevens,
  • Iain Turnbull,
  • Robin Walters,
  • Baihan Wang,
  • Lin Wang,
  • Neil Wright,
  • Ling Yang,
  • Xiaoming Yang,
  • Pang Yao,
  • Xiao Han,
  • Can Hou,
  • Qingmei Xia,
  • Chao Liu,
  • Jun Lv,
  • Pei Pei,
  • Dianjianyi Sun,
  • Canqing Yu,
  • Naying Chen,
  • Duo Liu,
  • Zhenzhu Tang,
  • Ningyu Chen,
  • Qilian Jiang,
  • Jian Lan,
  • Mingqiang Li,
  • Yun Liu,
  • Fanwen Meng,
  • Jinhuai Meng,
  • Rong Pan,
  • Yulu Qin,
  • Ping Wang,
  • Sisi Wang,
  • Liuping Wei,
  • Liyuan Zhou,
  • Caixia Dong,
  • Pengfei Ge,
  • Xiaolan Ren,
  • Zhongxiao Li,
  • Enke Mao,
  • Tao Wang,
  • Hui Zhang,
  • Xi Zhang,
  • Jinyan Chen,
  • Ximin Hu,
  • Xiaohuan Wang,
  • Zhendong Guo,
  • Huimei Li,
  • Yilei Li,
  • Min Weng,
  • Shukuan Wu,
  • Shichun Yan,
  • Mingyuan Zou,
  • Xue Zhou,
  • Ziyan Guo,
  • Quan Kang,
  • Yanjie Li,
  • Bo Yu,
  • Qinai Xu,
  • Liang Chang,
  • Lei Fan,
  • Shixian Feng,
  • Ding Zhang,
  • Gang Zhou,
  • Yulian Gao,
  • Tianyou He,
  • Pan He,
  • Chen Hu,
  • Huarong Sun,
  • Xukui Zhang,
  • Biyun Chen,
  • Zhongxi Fu,
  • Yuelong Huang,
  • Huilin Liu,
  • Qiaohua Xu,
  • Li Yin,
  • Huajun Long,
  • Xin Xu,
  • Hao Zhang,
  • Libo Zhang,
  • Jian Su,
  • Ran Tao,
  • Ming Wu,
  • Jie Yang,
  • Jinyi Zhou,
  • Yonglin Zhou,
  • Yihe Hu,
  • Yujie Hua,
  • Jianrong Jin,
  • Fang Liu,
  • Jingchao Liu,
  • Yan Lu,
  • Liangcai Ma,
  • Aiyu Tang,
  • Jun Zhang,
  • Liang Cheng,
  • Ranran Du,
  • Ruqin Gao,
  • Feifei Li,
  • Shanpeng Li,
  • Yongmei Liu,
  • Feng Ning,
  • Zengchang Pang,
  • Xiaohui Sun,
  • Xiaocao Tian,
  • Shaojie Wang,
  • Yaoming Zhai,
  • Hua Zhang,
  • Wei Hou,
  • Silu Lv,
  • Junzheng Wang,
  • Xiaofang Chen,
  • Xianping Wu,
  • Ningmei Zhang,
  • Xiaoyu Chang,
  • Xiaofang Chen,
  • Jianguo Li,
  • Jiaqiu Liu,
  • Guojin Luo,
  • Qiang Sun,
  • Xunfu Zhong,
  • Weiwei Gong,
  • Ruying Hu,
  • Hao Wang,
  • Meng Wang,
  • Min Yu,
  • Lingli Chen,
  • Qijun Gu,
  • Dongxia Pan,
  • Chunmei Wang,
  • Kaixu Xie,
  • Xiaoyi Zhang,
  • Hongyuan Chen,
  • Liyang Liu,
  • Haiyan Gou,
  • Xun Wang,
  • Jing Ding,
  • Ning Zhang,
  • Yueshi Mao,
  • Shanshan Zhou,
  • Lirong Jin,
  • Xin Cheng,
  • Yun Lu,
  • Li Chen,
  • Zilong Hao,
  • Xiaona Xing,
  • Lei Wang,
  • Naixin Ju,
  • Yiting Mao,
  • Shuya Li,
  • Peng Du,
  • Deren Wang,
  • Xiaojia Sun,
  • Shihao You,
  • Weizhi Wang,
  • Yanmei Zhu,
  • Xiaojiu Li,
  • Yi Dong

Journal volume & issue
Vol. 45
p. 101020

Abstract

Read online

Summary: Background: Hospitals in China are classified into tiers (1, 2 or 3), with the largest (tier 3) having more equipment and specialist staff. Differential health insurance cost-sharing by hospital tier (lower deductibles and higher reimbursement rates in lower tiers) was introduced to reduce overcrowding in higher tier hospitals, promote use of lower tier hospitals, and limit escalating healthcare costs. However, little is known about the effects of differential cost-sharing in health insurance schemes on choice of hospital tiers. Methods: In a 9-year follow-up of a prospective study of 0.5 M adults from 10 areas in China, we examined the associations between differential health insurance cost-sharing and choice of hospital tiers for patients with a first hospitalisation for stroke or ischaemic heart disease (IHD) in 2009–2017. Analyses were performed separately in urban areas (stroke: n = 20,302; IHD: n = 19,283) and rural areas (stroke: n = 21,130; IHD: n = 17,890), using conditional logit models and adjusting for individual socioeconomic and health characteristics. Findings: About 64–68% of stroke and IHD cases in urban areas and 27–29% in rural areas chose tier 3 hospitals. In urban areas, higher reimbursement rates in each tier and lower tier 3 deductibles were associated with a greater likelihood of choosing their respective hospital tiers. In rural areas, the effects of cost-sharing were modest, suggesting a greater contribution of other factors. Higher socioeconomic status and greater disease severity were associated with a greater likelihood of seeking care in higher tier hospitals in urban and rural areas. Interpretation: Patient choice of hospital tiers for treatment of stroke and IHD in China was influenced by differential cost-sharing in urban areas, but not in rural areas. Further strategies are required to incentivise appropriate health seeking behaviour and promote more efficient hospital use. Funding: Wellcome Trust, Medical Research Council, British Heart Foundation, Cancer Research UK, Kadoorie Charitable Foundation, China Ministry of Science and Technology, and National Natural Science Foundation of China.

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