Sample
Baoji City, which is located in the middle of Shaanxi Province, is the second largest city in that province and has a population of 3.72 million. Its population consists mostly of rural residents, who account for 78.27% of the total population [19]. The per capita income of urban residents was CNY 29,475 in 2015, whereas that of the rural residents was CNY 9511 [20].
The study site was Feng County, which is located in the southwest of Baoji City in Shaanxi Province. By the end of 2015, there were 0.11 million people in this county. The rural residents accounted for 53.88% of the population. According to the Sixth National Census [21], the age distribution of the population of Feng County is similar to that of Baoji City. The population younger than 14 years were 13.14% in Feng County and 14.32% in Baoji City, and the population between 15 and 59 years old were 73.61% and 73.08%, respectively. The population aged 60 years or older accounted for 13.25% and 12.60% of the total. The per capita income of the urban residents of Feng County was CNY 30,432 in 2015, whereas that of the rural residents was CNY 10,236 [22].
The data used in this study were collected by all the primary medical institutions that provided basic public health services and basic medical services, such as treatment for common diseases, to residents of Feng County at the county, township, and village levels. The data were collected through the daily outpatient and inpatient information system and then summarized by the information department of the Health Bureau of Baoji City, Shaanxi Province, and analysed anonymously. The data mainly consisted of outpatient data from 2009 (July to December, n = 20,459) to 2011 (n = 65,258 in 2010, n = 59,036 in 2011). Because data from the first half of 2009 were missing, we used the data from the second half of 2009 to replace them. We used the data from the same period in 2010 to estimate the missing data for the county hospital in the third quarter of 2011. At the same time, inpatient data for 2011 were also used (n = 3662). After removing duplicates and incomplete records, there were a total of 3500 records.
Demographic characteristics
This section contained information on the gender, ethnicity, and age of the outpatients and inpatients.
Outpatient characteristics
This section included outpatient prescription medications, treatment details, and outpatient expenditures.
Inpatient characteristics
This section included medical expenses for hospitalization, expense distributions, admission dates, discharge dates, and diagnoses of diseases. Data from the 2008 National Health Survey [23] and the 2012 Chinese Health Statistics Yearbook were also used [24].
Measures
For both outpatients and inpatients, the patient’s age was considered the age on the date of service in years.
Relevant definitions
According to the Chinese census register standard, we classified agriculture registered permanent residence as the rural population, and non-agriculture registered permanent residence as the urban population.
Burden refers to the heavy economic burden of the disease, that is, the proportion of the medical expenses attributed to the residents represents a high proportion of the total household expenditures.
Benefit means benefits for the insured people. In this paper, we considered decreased medical expenses and increased compensation as benefits for the insured population.
Reimbursement rate is defined as the proportion of the reimbursement amount to the actual amount for outpatients.
Compensation rate is defined as the proportion of the number of outpatients from medical reimbursement to the actual number of outpatients.
Government contribution is defined as the proportion that comes from the government finances.
Deductible means the standards of basic medical security. In an insurance policy in China, the deductible is the amount that must be paid out of pocket by the policyholder before an insurance provider will pay any expenses.
China’s administrative units are currently based on a three-tier system, dividing the nation into provinces, counties and townships. The country is divided into provinces, autonomous regions and municipalities directly under the Central Government. A province or an autonomous region is subdivided into autonomous prefectures, counties, autonomous counties and cities. A county or an autonomous county is subdivided into townships, ethnic townships and towns.
According to the Hospital Classification System issued by Ministry of Health of People’s Republic of China, hospitals in China are classified into primary (tier-1), secondary (tier-2) and tertiary (tier-3) institutions, which is known as the hospital level in China [25].
Patient flow (%) is defined as proportion of the number of patients at the different levels of hospitals to the number of actual patients in the corresponding year.
Primary medical institutions are typically a township hospital that contains less than 100 beds. They are tasked with providing preventive care, minimal health care and rehabilitation services. Secondary hospitals tend to be affiliated with a medium size city, county or district and contain more than 100, but less than 500 beds. They are responsible for providing comprehensive health services, as well as medical education and conducting research on a regional basis. Tertiary hospitals round out the list as comprehensive or general hospitals at the city, provincial or national level, with a bed capacity exceeding 500. They are responsible for providing specialist healthcare services and perform a bigger role with regard to medical education and scientific research.
Statistical analysis
SPSS 19.0 and STATA 12.0 were used for all analyses, and P < 0.05 was set as the required level of statistical significance. Due to the enormous volume of data and the short time span, we performed a predominantly descriptive analysis that included frequencies, percentages, and other descriptive statistics.
Regression discontinuity (RD) and the chi-squared (χ2) test were used to compare the ratios of medical expenses before and after the implementation of the IURMIS. Because medical expenses are often skewed, they were converted to logarithmic form, with 2 as the base of the logarithm, before the regression models were applied. Additionally, the covariates in the analysis of the change in the average expense before and after the implementation of the IURMIS included time, age, gender and hospital level. A nonparametric test (the Wilcoxon two-sample test) was used to compare the medical expenses before and after the implementation of the IURMIS.
We used the consumer price index of China in 2009 to adjust for inflation.