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      Effects of changes in health insurance reimbursement level on outpatient service utilization of rural diabetics: evidence from Jiangsu Province, China

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          Abstract

          Background

          Outpatient reimbursement levels of the New Rural Cooperative Medical Scheme have changed in recent years in China, and those changes may have a greater impact on patients with chronic diseases due to their higher outpatient expenses. This study represents the first attempt to identify the effects of reimbursement level on outpatient service utilization for chronic patients in rural China and it also gives strong estimation results by conducting a tracer illness study in order to control for possible biases associated with studying several diseases together.

          Methods

          This study used difference-in-differences models to examine how changes in yearly maximum reimbursement amount and outpatient reimbursement rates affected rural residents with type 2 diabetes in three counties in Jiangsu Province, China. Other factors, such as sex, age and severity of illness, were also included in the model estimations. To make sure the treated group and control group are comparable, Propensity Score Match (PSM) was used to analysis the gender, age and severity of illness of the two groups.

          Results

          The results indicate that an increase in yearly maximum reimbursement amount for outpatient visits could cause an increase in yearly total outpatient expenses for patients with type 2 diabetes mellitus. However, changes in outpatient reimbursement rates between 2010 and 2011 did not significantly affect the utilization of different types of health institution.

          Conclusions

          The reimbursement rates of village clinics should be substantially increased from the existing basis and the gap of reimbursement rates among different institutions should be further widened. It is also important for village clinics to improve their services. Moreover, measures to improve the quality of care and scope of services at lower-level healthcare institutions, and promote the health service utilization of rural women should be considered.

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          Most cited references13

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          Can insurance increase financial risk? The curious case of health insurance in China.

          We analyze the effect of insurance on the probability of an individual incurring 'high' annual health expenses using data from three household surveys. All come from China, a country where providers are paid fee-for-service according to a schedule that encourages the overprovision of high-tech care and who are only lightly regulated. We define annual spending as 'high' if it exceeds a threshold of local average income and as 'catastrophic' if it exceeds a threshold of the household's own per capita income. Our estimates allow for different thresholds and for the possible endogeneity of health insurance (we use instrumental variables and fixed effects). Our main results suggest that in all three surveys health insurance increases the risk of high and catastrophic spending. Further analysis suggests that this is due to insurance encouraging people to seek care when sick and to seek care from higher-level providers.
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            The new cooperative medical scheme in China.

            The New Cooperative Medical Scheme (NCMS) is a heavily subsidized voluntary health insurance program established in 2003 to reduce the risk of catastrophic health spending for rural residents in China. In this review, we present the current collection of knowledge available regarding the performance of NCMS on the aspects of revenue collection, risk pooling, reimbursement rules and provider payment. The available evidence suggests that NCMS has substantially improved health care access and utilization among the participants; however, it appears to have no statistically significant effect on average household out-of-pocket health spending and catastrophic expenditure risk. As NCMS is rolled out to other counties, it must be careful to generalize the findings reported in the published papers and reports, because the early pilot counties were not randomly selected and there are a lot of local adaptations. In addition, we expect that NCMS could be an important opportunity to establish some trust-based institutions in the best interest of the participants to monitor provider quality and control cost inflation. Rigorous evaluations, based on richer and latest micro-level data, could considerably strengthen the evidence base for the performance and impact of NCMS.
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              Mutual health insurance in Rwanda: evidence on access to care and financial risk protection.

              Rwanda has expanded mutual health insurance considerably in recent years, which has a great potential for making health services more accessible. In this paper, we examine the effect of mutual health insurance (MHI) on utilization of health services and financial risk protection. We used data from a nationally representative survey from 2005-2006. We analysed this data through summary statistics as well as regression models. Our statistical modelling shows that MHI coverage is associated with significantly increased utilization of health services. Indeed, individuals in households that had MHI coverage used health services twice as much when they were ill as those in households that had no insurance coverage. Additionally, MHI is also associated with a higher degree of financial risk protection and the incidence of catastrophic health expenditure was almost four times less than in households with no coverage. Nonetheless, the limitations of the MHI coverage also become apparent. These promising results indicate that MHI has had a strong positive impact on access to health care and can continue to improve health of Rwandans even more if its limitations are addressed further. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.
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                Author and article information

                Contributors
                Journal
                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central
                1472-6963
                2014
                23 April 2014
                : 14
                : 185
                Affiliations
                [1 ]School of Health Policy & Management, Nanjing Medical University, Hanzhong Road 140, Nanjing 210029, Jiangsu Province, P.R China
                [2 ]Carey Business School, Johns Hopkins University, 100 International Drive, Baltimore, MD 21202, USA
                Article
                1472-6963-14-185
                10.1186/1472-6963-14-185
                3999731
                24758602
                fd193a82-0234-4b91-b94a-d718143c3c6f
                Copyright © 2014 Zhang et al.; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.

                History
                : 15 May 2013
                : 17 April 2014
                Categories
                Research Article

                Health & Social care
                outpatient reimbursement,health insurance,health service utilization,type 2 dm,china,rural health

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