Trends and determinants of catastrophic health expenditure in China 2010–2018: a national panel data analysis

Abstract

Background Catastrophic health expenditures (CHE) are out-of-pocket payments (OOP) that exceed a predefined percentage or threshold of a household’s resources, usually 40 %, that can push households into poverty in China. We analyzed the trends in the incidence and intensity, and explored the determinants, of CHE, and proposed policy recommendation to address CHE. Methods A unique 5-year national urban-rural panel database was constructed from the China Family Panel Studies (CFPS) surveys. CHE incidence was measured by calculating headcount (percentage of households incurring CHE to the total household sample) and intensity was measured by overshoot (degree by which an average out of pocket health expenditure exceeds the threshold of the total sample). A linear probability model was employed to assess the trend in the net effect of the determinants of CHE incidence and a random effect logit model was used to analyse the role of the characteristics of the household head, the household and household health utilization on CHE incidence. Results CHE determinants vary across time and geographical location. From 2010 to 2018, the total, urban and rural CHE incidence all showed a decreasing tend, falling from 14.7 to 8.7 % for total households, 12.5–6.6 % in urban and 16.8–10.9 % in rural areas. CHE intensity decreased in rural (24.50–20.51 %) and urban (22.31–19.57 %) areas and for all households (23.61–20.15 %). Inpatient services were the most important determinant of the incidence of CHE. For urban households, the random effect logit model identified household head (age, education, self-rated health); household characteristics (members 65 + years, chronic diseases, family size and income status); and healthcare utilization (inpatient and outpatient usage) as determinants of CHE. For rural areas, the same variables were significant with the addition of household head’s sex and health insurance. Conclusions The incidence and intensity of CHE in China displayed a downward trend, but was higher in rural than urban areas. Costs of inpatient service usage should be a key intervention strategy to address CHE. The policy implications include improving the economic level of poor households, reforming health insurance and reinforcing pre-payment hospital insurance methods.

Financial risk protection from out-of-pocket health spending in low- and middle-income countries: a scoping review of the literature

“…Conversely, the ungenerous benefits package and fee-for-service payment system were the potential factors explaining relatively high CHE and impoverishment (i.e. low FRP) in China despite near-universal insurance coverage [65,66].…”

Multimorbidity and catastrophic health expenditure: Evidence from the China Health and Retirement Longitudinal Study

“…The different results are a reflection of varied thresholds adopted: a more relaxed threshold (≥20% OOP in CTP) was adopted in the above-cited study. Nevertheless, it is clear that the households of old people with multimorbidity have a much higher incidence of CHE compared with the national average of 8.7% using the threshold of ≥40% OOP in CTP ( 39 ). We also found that household CHE incidence increases with the number of reported chronic conditions: in the households with a respondent reporting five or more chronic conditions, the odds of household CHE almost doubled that of those reporting only two chronic conditions.…”

“…This is a common phenomenon, not just for the households with old people living with multimorbidity ( 13 , 23 , 35 , 46 , 47 ). Income inequality may exacerbate catastrophic health spending in the households with low income ( 39 , 46 ). China has prioritized central financial subsidies to the least developed western region in tackling socioeconomic disparity concerns ( 48 ).…”

“…For example, education can improve health literacy and encourage use of healthcare services ( 60 ). A larger household size is usually associated with higher awareness of care needs and higher capacity to pay for medical services ( 39 , 47 ).…”

The Impact of Multimorbidities on Catastrophic Health Expenditures among Patients Suffering from Hypertension in China: An Analysis of Nationwide Representative Data

“…Our study found that patients suffering from hypertension enrolled in URRBMI and NRCMS had a higher CHE risk, but other insurance schemes also did not protect patients from CHE. Due to the defects of a low financing level, low compensatory benefits level, and poor ability of cost-sharing [39], many studies have also found that people covered by NRCMS have a greater CHE risk [40][41][42]. Additionally, there is evidence that many NRCMS funds do not include outpatient fees, rehabilitation, or long-term care for the elderly [39], which can further explain why middle-aged and elderly patients suffering from hypertension covered by NRCMS had a high CHE risk.…”