Question

Provide a description of the current heatlhcare system in China.

Answer 1

The current Chinese health insurance system

The insurance schemes, the UEBMI and the URBMI for employees and residents in the urban areas and the NRCMS for residents in the rural areas, now cover all Chinese citizens. However, the three insurance programs differ in how they are financed and operated. presents the characteristics of the three health insurance schemes. In addition to the three basic health care insurances, insurances for critical illness, medical assistance (MA), and emergency disease assistance exist. Together they form a complete insurance system that protects Chinese citizens from expenses related to medical conditions. In the literature, the reform of the Chinese Health Insurance System has already been introduced by, for example, the World Health Organization’s and the World Bank’s reports.I briefly describe the Chinese health insurance system here.

rban Employee Basic Medical Insurance (UEBMI)

The UEBMI was initiated in 1994 and formally launched in 1998 to replace the previous insurance system for urban employees and retired employees.1In this new insurance system, both employers and employees contribute to the annual premium equal to 8% of the payroll. Employers pay 6% as tax and employees pay 2%, while retired employees who already paid for the minimum required number of years (25 years for males and 20 years for females) do not have to contribute the premium.It is a mandatory program. Seventy percent of the employer contribution goes to social pooled funds, which are used for inpatient reimbursements and critical outpatient reimbursements. The rest of premium goes to individual medical savings accounts, which can be directly used for outpatient care and purchase of registered medicine.

Urban Residence Basic Medical Insurance (URBMI)

The URBMI was initiated in 2007 and formally launched in 2009 to cover urban residents who were not covered by the UEBMI.10 It is a voluntary program. The annual premium is largely paid by the government, while individuals pay for a small proportion. The premium has increased with time. For example, the premium increased from 131 yuan in 2008 to 570 yuan in 2016.19,20 Of the premium in 2016, 420 yuan is paid by the government and 150 yuan is paid by the individual.20 At the beginning, the insurance program covered inpatient care only. Outpatient reimbursements were included in 2009. The proportion of reimbursements in the URBMI has increased with time and reached 70% for inpatients and 50% for outpatients in 2014.21 Both the UEBMI and the URBMI funds are pooled at the prefectural/municipal level and managed by the Ministry of Human Resource and Social Security.

New Rural Cooperative Medical Scheme (NRCMS)

The NRCMS was initiated in 2003 and formally launched in 2006 to cover rural residents. It is a voluntary program. Similar to the URBMI, the annual premium is largely paid by the government, while individuals pay a small proportion. The premium has increased with time. For example, the premium increased from 30 yuan in 2003 to 411 yuan in 2014. At the beginning, the insurance program covered only inpatient care. In 2009, all premiums were pooled at the county level and then divided into outpatient funds and hospitalization (inpatient) funds. The first one accounts for ~30% of total funds while the second one represents 67% of the total. The remaining 3% is allocated for a risk fund. The compensation ratio for inpatient care has increased with time and reached 75% in 2010. The NRCMS is managed by the National Health and Family Planning Commission. By the end of 2014, 736 million rural residents had joined the NRCMS, corresponding to 98.9% of the rural population.

Critical illness insurance

Critical illness insurance is an extension of the basic medical care system that gives further security to urban and rural residents if large medical expenses are incurred from their critical illness. Two documents on implementing and comprehensively implementing critical illness insurance for urban and rural residents were issued in 2012 and 2015. The 2015 document states that the critical illness insurance should cover all participants in the URBMI and the NRCMS, no extra premium should be paid for the insurance, and the insurance reimbursement proportion for medical expenditures should reach 50% by the end 2015. China’s critical illness insurance program helped 1.15 million patients in 2014.25

MA program

The target of MA is people in the existing social security network, such as low income households, who get the minimum living allowance from the government. The MA program was introduced by paying premiums for the target residents in the NRCMS in 2003, and covered the target residents in URBMI in 2007. MA covers part of the remainder of a medical bill that is not reimbursed by the NRCMS and the URBMI. The MA program is managed by the Ministry of Civil Affairs and pooled at the county level by the Bureau of Civil Affairs. In 2011, financial assistance from MA was received by 1.8% of the NRCMS enrollees and 3% of the URBMI enrollees.

Emergency disease assistance

An emergency disease assistance program was issued by the Chinese Government (the State Council of China) to help individuals with an unknown identity who have emergency diseases, or individuals who cannot afford to pay for emergency situations. The assistance fund is mainly financed by local government and donations. Medical health care institutions involving specific emergency disease assistance can apply for reimbursements.

Integrating the basic medical insurance systems for urban and rural residents

In January 2016, the State Council issued a document on Integrating the Basic Medical Insurance Systems for Urban and Rural Residents to establish a unified basic medical insurance system for urban and rural residents regarding insurance premium, breadth (proportion of the population covered), depth (proportion of the health costs covered), and scope (type of health services covered). The administration of the two insurance systems will also be unified. The premium of the UEBMI is much higher than the premium of the URBMI and the NRCMS leading to substantial benefit variations across insurance programs However, the gap has decreased due to the increase in premiums and in the reimbursement proportion of the URBMI and the NRCMS in recent years, and the increase of the number of the disease in the critical illness insurance. The number of enrollees in the URBMI and the NRCMS increased rapidly within a few years after initiation of the insurance programs, which largely contributes to universal health insurance coverage in China.

Health information system and selected health registers and projects

Reforming the Chinese health care system is an extremely complicated process. Health information technology (HIT) has been recognized as one of eight important support systems in achieving success of the reform.

Construction of electronically individual health care records

In 2009, the Chinese Ministry of Health proposed a plan to build a model gradually for regional integrated and coordinated health care services based on digitized health records of residents. National standards for a number of health databanks, for example, women’s and children’s health maintenance information, and a hospital information platform have been developed. “Regulation on medical records management in medical institutions” requires that all medical institutions at any level must establish the medical record management system using a unique medical record identification (ID) number. The medical record ID number should also be linked with the ID number of a patient. In 2011, 9.5 billion yuan was allocated to promote HIT in hospitals, including the establishment of electronic medical records, which refer to patient records for clinical purposes, or electronic health records, which refer to longitudinal health data on the population across care settings.The Ministry of Health established a standards bureau office and a series of standards regarding architecture, regulations, and function profiles of electronic medical records were issued. Nearly every health care provider has set up its own electronic health records system. Within hospitals, electronic health records are also linked to the health insurance systems for payment of claims with unique patient ID number. However, the electronic health records systems vary significantly between hospitals and are usually not integrated or interoperable. Patients often have to bring with them a printed health record if they would like to see doctors in different hospitals. In 2011, the Ministry of Health began to develop the “Resident Health Card” project. The card links the individual’s electronic health and medical records and will provide the key link for cross-institutional, transregional data sharing.

Data from the medical insurance scheme

Data from basic medical insurance schemes are becoming rich resources for research. A few studies have been conducted based on data from the basic medical insurance schemes. For example, the Beijing UEBMI scheme included 13 million residents in 2012. Of these, 5 million used some form of health care service or made visits to clinics. Associated clinical records are available in the database. The Nanjing Medical Insurance Information System was established in 2000 and records all medical insurance data, including the Nanjing UEBMI population. Information on patient hospital visits is submitted to the system automatically including diagnosis, medicine prescribed, and health care costs.

Existing health registers and research projects

With the development of electronic medical records and health insurance databases, existing health registers and research projects may potentially be expanded. Some registers and projects are reviewed below.

Surveillance for communicable diseases

China has conducted surveillance for communicable diseases via the disease surveillance points (DSPs) system in order to control these diseases since 1950. The DSP system covers 161 counties and districts in 31 provinces and is used primarily for surveillance of communicable diseases. In January 2004, a real-time, case-specific, and web-based disease surveillance system was set up.33,35,36 The system monitors 37 communicable diseases and included death reports from April 2004. The state CDC developed a nationwide web-based automated system for outbreak detection and rapid response to communicable diseases.37

Cancer registries

The oldest local cancer registries in China were established in Henan in 1959, in Shanghai in 1964, and in Jiangsu in 1972.38,39 In 2002, there were 48 cancer registries in China covering ~73 million citizens (5.7% of the population). The National Central Cancer Registry of China (NCCR) was established in the same year to collect and evaluate cancer data reported from local cancer registries.40 In 2008, the Ministry of Health launched a national program to support cancer registries. The number of population-based registries at county level or above increased to 308 covering of 300 million people (22%) in 2014.40 However, the quality of the local cancer registries varies.39–41

Epidemiological research projects on cancer and other chronic diseases

The Shanghai cohort study recruited 18,244 men aged 45–64 years in Shanghai during 1986–1989 to study risk factors for cancer and other chronic diseases, including cardiovascular disease and diabetes.42 More than 35 peer-reviewed articles have been published based on the cohort.43–45 Another two large studies, the Shanghai Women’s Health Study (SWHS) and the Shanghai Men’s Health Study (SMHS) were launched in 1996 and 2002, aiming to investigate the etiology of cancer and other chronic diseases.46–49 A total of 74,741 women aged 40–70 years were recruited for the SWHS in 1996–200046,47 and 61,480 men aged 40–74 years were recruited for the SMHS in 2002–2006. Both studies are prospective cohort studies with information on diet, reproductive history, hormone use, physical activity, weight history, and body measurements. Biological samples, including urine, blood, and buccal cells, were collected. The cohorts have been followed up using both medical record linkage and active follow-ups.

In 2004, the Chronic Disease and Risk Factor Surveillance was set up in China via the DSP system to study hypertension, diabetes, stroke, obesity, and other conditions.34 Participants were chosen using a multi-stage stratified clustering sample method and represent 1% of the population. Household questionnaires and individual questionnaires collected information on behavioral risk factors and self-reported chronic disease. Anthropometric measurements, blood pressure measurements, and blood tests were also included. In 2004, the Kadoorie Study of Chronic Disease in China (KSCDC) was launched.50,51 It is a nationwide, prospective cohort study involving 10 diverse localities (five rural counties and five urban districts). The KSCDC is an open-ended prospective study with broad research aims. Data were collected by face-to-face interviews and physical examinations. Both plasma and buffy coat samples were collected and stored. KSCDC recruited ~500,000 adults initially aged 35–74 years from the general population across China from 2004 to 2009.52 The KSCDC is the largest blood-based prospective study ever conducted in the world. It was carefully designed with a range of comprehensive computerized systems for reliable and efficient data collection and management. China also participated in the Prospective Urban Rural Epidemiological (PURE) study,53 which enrolled individuals aged 35–70 years from 17 countries to examine primary risk factors for obesity, hypertension, dysglycemia dyslipidemia, and cardiovascular diseases. In China, 115 (45 urban and 70 rural) communities from 12 provinces participated, and 46,285 persons were recruited from 2005 to 2009.54 Participants were followed for incident cardiovascular disease and death for 10 years

this data retracted from china goverment and WHO