Changes in financial burden, healthcare utilization for cancer patients in East, Central and West China

Objective: This study aims to investigate the cancer epidemiology and impact of healthcare system reform on patient out-of-pocket expense, presence of catastrophic health expenditures (CHE), healthcare utilization, and inpatient/outpatient medical expenditure in China after 2009 from the perspective of health system reforms.

Methods: This study is a mixed-methods study, includes an analysis of quantitative data and key informant interviews with major stakeholders. Quantitative analysis was performed on data collected from the China Health and Retirement Longitudinal Study (CHARLS) in 2011 and 2018 to investigate the correlation between cancer prevalence, CHE incidence (households that spend 40% of their non-food incomes on healthcare), and socioeconomic characteristics. This analysis explored the healthcare utilization and out-of-pocket expenses (OOPE) of cancer patients across different socioeconomic status groups and in urban and rural areas, as well as in the eastern, central, and western regions. Key informant interviews were conducted with major stakeholders including physicians, scholars, and disease control leaders/managers. The transcripts of the interviews were coded and analyzed for themes on the results of the quantitative study, inequalities in healthcare service utilization, and inequalities in healthcare insurance finance.

Results: The self-reported prevalence rate of cancer increased from 0.93% in 2011 to 1.02% in 2018. The incidence of CHE of cancer patients increased from 45.40% in 2011 to 58.50% in 2018. Urban-Rural Resident Basic Medical Insurance (URRBMI) beneficiaries are more likely to experience CHE than Urban Employee Basic Medical Insurance (UEBMI) beneficiaries. In 2018, the incidence of CHE was significantly lower in the group with the highest socioeconomic status compared to other groups. Compared to 2008 and 2011, the outpatient visit rate for cancer patients decreased by 7% in 2018, while the hospitalization rate significantly increased by nearly 30%. Urban residents have a higher hospitalization rate, which may be related to the concentration of hospitals providing cancer treatment services in cities, and urban employees enjoy a more comprehensive health insurance benefit package. In groups with higher socioeconomic status, cancer patients tend to have higher rates of outpatient visits and hospitalizations. This may be due to their greater ability to afford the expenses associated with cancer treatment.Both the average outpatient visits expenditure and the average inpatient care expenditure have increased significantly (outpatient visits expenditure per time increased by ¥500, and inpatient per time increased by ¥7000 from 2011 to 2018). While healthcare expenditure has significantly increased, the percentage of out-of-pocket expenses (OOPE) has decreased. Reasons for the decrease include more cancer drugs being included in the reimbursement list, a reduction in the medical insurance deductible, and an increase in the reimbursement ratio.

Conclusions: The health system reforms have improved access to healthcare services, especially inpatient care, and improved drug accessibility. However, inequality in healthcare service utilization and healthcare insurance financing still exists. Inequality is mainly reflected in urban-rural differences and different socioeconomic statuses. To address inequalities within the country, China needs to take a series of coordinated actions. Include improving mechanisms used to mobilize the health insurance funds in China, and making comprehensive changes to health insurance benefit packages and healthcare resource contributions.