Search Results (74)

Under the dual impact of new urbanization and rural population mobility, divorced rural women in China face severe challenges in obtaining collective membership qualification for land expropriation compensation. The newly enacted Rural Collective Economic Organization Law (RCEOL) contains ambiguous provisions, hindering effective implementation. This study asks: How can collective membership qualification for divorced rural women be determined based on pre-enactment court judgments to refine the law’s ambiguities? Adopting a qualitative design, data were collected from China Judgments Online. Through systematic keyword search, 238 court judgments were retrieved and analyzed using a three-level coding procedure (open, axial, selective). The theoretical framework draws on Amartya Sen’s capability approach. Three main findings are briefly summarized. First, a concrete determination scheme is proposed: the “stable rights-obligations relationship” is operationalized via collective medical insurance purchase and non-abandonment of contracted land; “basic livelihood security” emphasizes land’s security function without requiring primary income reliance; the “stable production-living relationship” criterion should be discarded. Second, the household registration (hukou) condition is becoming ambiguous, but such ambiguity reflects governance adaptation to complexity, moving toward “de-hukouization.” Third, legal ambiguity, while challenging, creates a flexible space for adaptive rural governance. This study contributes by introducing Sen’s capability approach into the analysis of divorced rural women’s membership qualification and providing empirical grounds for clarifying Article 11 of the RCEOL. Future research may observe changes in case volume and litigant testimonies after the law’s implementation to evaluate its real effects, further enriching the discussion on institution—agency interaction. Full article

This study examines whether stricter enforcement of mandatory social insurance contributions affects corporate income tax behavior in China. In the Chinese institutional context, mandatory social insurance refers to payroll-based employer and employee contributions to five statutory programs: basic pension insurance, basic medical insurance, work-injury insurance, unemployment insurance, and maternity insurance. These programs are directly related to social sustainability because they finance old-age income security, medical protection, workplace injury compensation, unemployment support, maternity protection, and labor-market stability. Using China’s 2018 social insurance collection reform as a quasi-natural experiment, we analyze A-share listed companies from 2014 to 2024 through a difference-in-differences design based on differential exposure between private firms and state-owned enterprises. To assess the reliability of the identification strategy, we employ firm and year fixed effects, event-study analysis, placebo tests, alternative measures of tax avoidance, and propensity score matching difference-in-differences robustness checks. The findings show a tax-fee seesaw effect: private firms subject to extensive regulatory scrutiny respond to more rigorous enforcement of social insurance contributions by increasing corporate income tax avoidance. Analysis of the mechanisms shows that the Whited-Wu index of financial constraints partially explains this phenomenon. The effect is more pronounced in firms with higher labor costs and greater administrative expense intensity, indicating that the increased response is driven by labor cost exposure and organizational discretion. By contrast, the effect is weaker among firms audited by the Big Four accounting networks—Deloitte, PricewaterhouseCoopers, Ernst & Young, and KPMG—indicating that high-quality external audits constrain aggressive tax planning. Regionally, the effect is most pronounced in eastern China, where markets, labor costs, and tax-planning services are more developed. The findings contribute to the sustainable development literature by demonstrating that reforms designed to strengthen social insurance sustainability can unintentionally weaken tax compliance if payroll contributions, tax administration, and corporate financial pressures are not coordinated. The study highlights the importance of integrated fiscal governance for achieving socially sustainable and fiscally balanced development. Full article

Objective: This study examines the effect of DRG payment reform on nutritional therapy costs, hospitalization expenditures, and resource utilization among gastric cancer surgery patients using a quasi-experimental design. Methods: We conducted an interrupted time series analysis using inpatient data from a tertiary hospital in a major Chinese city between January 2018 and December 2024, including 761 gastric cancer surgery patients. Segmented regression models estimated changes in baseline trend, immediate level, and post-intervention slope for nutritional therapy expenditures, total hospitalization costs, surgical fees, and length of stay. Subgroup analyses were performed by type of medical insurance, and robustness checks were conducted. Results: Following DRG implementation, enteral nutrition costs showed a significant immediate increase (β₂ = 395.703, p = 0.032) followed by a significant downward slope change (β₃ = −7.778, p = 0.032). Total hospitalization costs demonstrated a significant immediate rise (β₂ = 15,959.403, p = 0.019) and subsequent decline (β₃ = −632.069, p < 0.001). Parenteral nutrition costs exhibited a significant immediate reduction (β₂ = −2917.276, p = 0.001) without sustained trend changes. Surgical fees showed a significant downward baseline trend (β₁ = −39.951, p < 0.001) and a significant upward slope change (β₃ = 68.107, p < 0.001). Subgroup analyses revealed that policy effects were concentrated among patients with Urban Employee Basic Medical Insurance, with no significant effects observed for those with Urban and Rural Resident Basic Medical Insurance. Robustness checks confirmed the main findings. Conclusions: DRG payment reform significantly reshaped nutritional therapy and hospitalization expenditure patterns among gastric cancer surgery patients, with effects concentrated in the employee insurance population. The observed temporal pattern, characterized by an initial change followed by a gradual trend shift, suggests the need for continuous policy monitoring, insurance-tailored strategies, and refinement of nutritional support practices within DRG frameworks. Full article

Background: The majority of the funding for the New Rural Cooperative Medical System (NCMS) is derived from fiscal subsidies, comprising central transfer payments and local fiscal matching subsidies. Local governments’ strategic behavior in response to central transfer payments may further impact NCMS compensation spending and medical economic risks. Methodology: Accordingly, this paper investigates, from both theoretical and empirical perspectives, the impact pathways through which local fiscal matching subsidies influence the medical economic risks faced by insured rural households, with central transfer payments serving as a moderating factor. This paper constructs a dynamic game framework involving the central government, local governments, and household sectors. It further applies a mediation effect model and related econometric methods to conduct empirical analysis using 87,630 observations from the China Family Panel Studies (CFPS). Results: The results show that, first, local fiscal matching subsidies significantly reduce catastrophic health expenditures for rural households under the income effect of central transfer payments. However, under the substitution effect, the opposite occurs, as local governments adopt non-cooperative strategies in response to central transfer payments. Second, these impacts exhibit regional heterogeneity, with stronger effects in eastern regions, regions with more developed secondary industries, and regions with higher fiscal self-sufficiency rates. Third, local fiscal matching subsidies influence medical economic risks through compensation spending, under the moderating role of central transfer payments. Conclusions: This paper provides a novel perspective on why the NCMS struggles to provide effective protection, thereby enriching the existing literature. Furthermore, it provides policy guidance for fiscal and healthcare reforms in countries with similar contexts to China. Based on these insights, we argue that, during the future integration process of the Basic Medical Insurance for Urban and Rural Residents, clear boundaries should be defined for local fiscal matching subsidies, and the moderating role of central transfer payments should be strategically leveraged. Full article

Background: Antipsychotic medication (APM) can cause weight gain, insulin resistance, dyslipidemias, and an increased risk of developing type-2 diabetes and cardiovascular disease among youth. The study sought to increase water consumption, reduce sugar-sweetened beverage (SSB) intake, and prevent unhealthy weight gain via a healthy lifestyle intervention among youth newly started on a second-generation APM for psychiatric treatment. Methods: This randomized controlled trial enrolled 148 Medicaid-insured youth (ages 8–17) recently starting APM. The treatment group received both a biweekly home-delivery of bottled water and parental phone support from a family navigator. In-home visits conducted at baseline, three months, and six months assessed the participants’ height/weight and dietary intake. All participants received basic healthy lifestyle education emphasizing increased water intake and decreased SSB consumption. Longitudinal linear mixed models were conducted to examine between-group and within-group changes in BMI z-scores, and water/SSB intake. Results: No significant between-group differences in BMI z-score were found at three (p = 0.908) and six months (p = 0.919). However, the within-group increase in BMI z-score in the control group was significant from baseline to three months (p = 0.029). A between-group comparison found the treatment group significantly increased their water intake at three (p = 0.006) and six months (p = 0.002). No between-group differences were identified at three and six months for the reduction in SSB, although the treatment group did demonstrate a decrease from baseline to three months (p = 0.004). Conclusions: Neither group experienced unhealthy increases (>0.5%) in BMI z-score over the six months. Providing a safe/free water supply showed a superior improvement in water consumption in the treatment group, and an initial decrease in SSB. Further studies are needed to identify feasible, effective, and sustainable lifestyle interventions tailored to this at-risk population. Full article

Background: The continuous expansion of the National Reimbursement Drug List has led to an increasing cost disparity among alternative drugs for the same indications. Under the current proportional reimbursement mechanism, choosing higher-cost treatments often results in higher compensation. Given the lack of empirical evidence on whether income affects the medication choices of insured individuals in the Chinese context, this study aims to evaluate the impact of income levels on drug selection, providing a basis for optimizing the medical insurance reimbursement policy. Methods: This study extracts data from hospitalized patients enrolled in basic medical insurance from the China Health and Retirement Longitudinal Study (CHARLS) database and preprocesses it in Excel. Subsequently, SPSS is used to conduct descriptive statistics, difference analysis, correlation analysis, and regression analysis on the processed data to explore the impact of income levels on drug selection. Results: After controlling for length of hospitalization and hospitalization costs, the regression coefficient for urban employee basic medical insurance participants is β = 0.505 (p < 0.01), and the regression coefficient for new rural cooperative medical insurance participants is β = 0.195 (p < 0.01). This means that, regardless of whether participants are enrolled in urban employee basic medical insurance or new rural cooperative medical insurance, an increase in income will lead to higher hospitalization drug costs. Conclusions: Compared to low-income insured individuals, high-income participants in the basic medical insurance are more likely to choose higher-cost drugs among alternatives, which leads to unfair reimbursement under the current proportional reimbursement system. Full article

Background: Chronic diseases have proliferated worldwide and become one of the foremost public health challenges. The provincial pooling policy of Chinese Basic Medical Insurance Program (BMIP) (hereinafter the Policy) is conducive to coordinating healthcare resources more broadly and containing medical costs more effectively, which creates opportunities to improve chronic disease patients’ health outcomes. Against this backdrop, this study aims to identify how the Policy affects chronic disease patients’ health outcomes. Methodology: Utilizing data from the China Family Panel Studies (CFPS) across 31 provinces (except Hong Kong, Macao, and Taiwan) from 2010 to 2022, we constructed a panel of 26,585 observations on chronic disease patients enrolled in the BMIP. We employed a difference-in-differences (DID) design to identify the causal effects of the Policy on self-rated health (SRH) supplemented by a series of robustness checks, including event-study analysis, placebo tests, and propensity score matching DID (PSM-DID). Results: The results show that the Policy enhances Chinese chronic disease patients’ health outcomes across various robustness assessments. However, the effects exhibit heterogeneity in that the Policy can more effectively improve the health outcomes of urban patients, low-income patients, and highly educated patients. The mechanism analysis indicates that the Policy can enhance chronic disease patients’ health outcomes by reducing the out-of-pocket ratio, increasing household income, and stimulating consumer expenditure. Furthermore, digital technology can amplify the effectiveness of the Policy in Chinese chronic disease patients’ health outcomes. Conclusions: These findings provide valuable insights into the potential of provincial pooling and digital technology to optimize Chinese chronic disease management. Full article

Objectives: This study aims to examine the impact of Diagnosis-Related Group (DRG) payment on medical costs, efficiency, and quality of healthcare services in public hospitals, providing policy recommendations for further health insurance payment reforms in China. Methods: Utilizing inpatient medical insurance settlement data from 2020 to 2023 in the selected city, we constructed a regression discontinuity design (RDD) and an interrupted time series (ITS) model to evaluate the causal effects of the DRG reform. The analysis includes 66,533 inpatient settlement records. Results: Following the reform, the average length of stay (LOS) decreased by 2 days (95% CI: −3.43 to −0.70, p < 0.01), total hospitalization expenditures dropped by 13% (95% CI: −0.26 to −0.00, p < 0.05), and expenditures from the medical insurance fund declined by 25% (95% CI: −0.39 to −0.12, p < 0.01). Additionally, examination and consultation fees were reduced by 23% (95% CI: −0.41 to −0.05, p < 0.05), although patients’ out-of-pocket burden increased by 8% (95% CI: 0.05 to 0.10, p < 0.01). In terms of healthcare quality, the 30-day readmission rate decreased by 1% (95% CI: −0.01 to −0.00, p < 0.01), and the mortality rate among low-risk patients declined by 4% (95% CI: −0.04 to −0.03, p < 0.01). We found no evidence of patient selection or denial of admission. Heterogeneity analysis revealed that the reduction in hospital stay was concentrated among enrollees under the Urban and Rural Resident Basic Medical Insurance and those treated in secondary hospitals. The policy’s effects peaked shortly after implementation but gradually attenuated over time. Conclusions: Our study offers hospital-level evidence indicating that the initial stage of DRG implementation achieved its preliminary goals of optimizing medical resource allocation and improving the efficiency of medical insurance fund utilization. However, the reform still faces several challenges. These findings may offer valuable references for developing countries pursuing reforms in primary healthcare and health insurance payment systems. Full article

Background: The intersection of aging and disability is an important social issue. The rehabilitation system of older adults with disabilities is a complex social system including various social units. This study aims to investigate the impact of the “inclusion of rehabilitation services in basic medical insurance” (IRSMI) policy on the utilization of rehabilitation services and annual household healthcare expenditure among older adults with disabilities. Methods: Using the data of China Disabled Persons’ Condition Monitoring Survey (2009–2012), this study employed the difference-in-differences method to analyze the impact of IRSMI on rehabilitation services utilization and household healthcare expenditure, and further examined the differential effects of the policy on service utilization across subpopulations with different demographic characteristics, including gender, age, and disability severity. The Heckman two-stage model corrects for sample selection bias caused by the share of households with zero health expenditures. Event-study specification was applied to assess the validity of the parallel trends assumption in the DID framework. Baron & Kenny’s three-step method was used to explore the potential mediating mechanism. Results: (1) IRSMI significantly increased the likelihood of utilizing rehabilitation services among older adults with disabilities (OR = 1.349), but this kind of promotive effect mainly focus on males (OR = 1.530), middle-aged and older disabled individuals (OR = 1.423), and those with mild disabilities (OR = 1.444). (2) The implementation of IRSMI contributed to an approximately 20.3% increase in annual healthcare expenditures for households with older adults with disabilities ($\beta$ = 0.185). (3) IRSMI significantly promoted the increase in household healthcare expenditures for high-income older adults with disabilities ($\beta$ = 0.181), but had limited impact on low- and middle-income groups. (4) Rehabilitation services utilization played a mediating role in the relationship between IRSMI and household healthcare expenditure, with about 19.0% of the increase in annual household healthcare expenditures attributable to the enhanced utilization of rehabilitation services. Conclusions: In the complex social system of rehabilitation for older adults with disabilities, the IRSMI policy significantly increases the likelihood of rehabilitation services utilization and substantially raises annual household healthcare expenditures. However, the heterogeneous effects across gender, age, disability severity, and income levels reflect structural inequities embedded in the rehabilitation system, underscoring the need for adaptive and equity-oriented interventions. Full article

Objectives: Patients with rare diseases in China face extremely high medical expenses. The current coverage framework remains inadequate in terms of coverage depth and proactive risk control, underscoring an urgent need for institutional reform. Methods: This study employs a policy content analysis approach to review the current landscape of rare disease protection in China. Drawing on risk management theory and the health capital model, it constructs an analytical framework to examine potential institutional reforms through the lens of risk response pathways and the efficiency of health investment. Results: The findings reveal that basic medical insurance (BMI) provides limited financial protection for patients with rare diseases. Among China’s 31 provincial-level administrative centers, 24 have set general outpatient reimbursement ceilings under the urban and rural resident basic medical insurance (URRBMI) at 1000 RMB or less. In comparison, 24 cities have set outpatient reimbursement limits under the urban employee basic medical insurance (UEBMI) at 6000 RMB or less. The security system relies predominantly on the BMI, while supplementary mechanisms have failed to provide effective support or continuity in coverage. Current policies are generally reactive, with coverage typically triggered only after a confirmed diagnosis and often lacking early intervention or preventive strategies. Conclusions: China’s rare disease security system urgently requires structural improvements in coverage depth and proactive risk management. The proposed Dedicated Insurance Scheme for Rare Diseases (DISRD) presents a feasible and sustainable model for China’s multi-tiered system of securing rare diseases. It provides valuable institutional insights for other countries and regions seeking to build public health systems with proactive risk control capabilities. Full article

Background: Health inequality is seen as a challenge for implementing the Healthy China Strategy. This study analyzes the income-related health inequality among urban–rural resident basic medical insurance (URRBMI) participants. Methods: This study utilized data from the 2019 China Household Finance Survey (CHFS), and the concentration index (CI) was employed to estimate the effects of income-related health inequality on participants. Results: Our findings provide clear evidence that health inequality among participants has fluctuated—narrowing, widening, and then narrowing again—in the areas of the contribution, medical treatment, and reimbursement of URRBMI, respectively. Overall, the analysis indicates a widening of health inequality post-reimbursement, with results remaining consistent. A heterogeneity analysis shows that health inequality is most pronounced among women and those with less than a middle school education. Finally, our study reveals a pro-rich trend in the actual utilization of medical services among participants, with persistent disparities in outpatient and inpatient service usage even after standardization, further exacerbating income-related health inequality. Conclusions: We recommend that the URRBMI design take participants’ income levels into account, with policies favoring disadvantaged individuals to enhance their medical security, improve access to healthcare services, and ultimately reduce health inequality. Full article

Objectives: The objective of this study is to quantify healthcare resource utilization, economic burden, and the multi-level medical security system for Spinal Muscular Atrophy (SMA) patients in Shaanxi Province, China, from a societal perspective using a survey. Methods: This observational study employed an online survey with a retrospective cross-sectional design in Shaanxi Province, China. The survey examined various aspects of SMA, including resource utilization, direct and indirect economic burdens, and co-payment mechanisms within a multi-level medical security system. Results: Following the inclusion of nusinersen in the National Reimbursement Drug List (NRDL) in 2022, the treatment rate for SMA patients increased significantly. After risdiplam was added to the NRDL in 2023, its use also saw a marked increase. Treatment costs varied by SMA type: Type 1 incurred the highest costs (RMB 300,000 or USD 41,000), followed by Type 2 (RMB 270,000 or USD 37,000), Type 3 (RMB 200,000 or USD 27,000), and Type 4 (RMB 80,000 or USD 11,000). The primary sources of costs were productivity losses due to primary caregivers (32.94%), nusinersen usage (29.29%), and risdiplam usage (17.33%). Out-of-pocket costs for SMA patients accounted for 29.29% of the total costs. In 2023, basic medical insurance covered 49% of direct costs and 32% of total costs. Patients still had to pay 25.73% of the total cost for the direct costs. Conclusions: Basic medical insurance is a critical foundation for patient security and plays a pivotal role in reimbursement. In contrast, commercial insurance has a relatively limited impact on covering the costs for SMA patients. These findings highlight the substantial healthcare burden faced by SMA patients under the current healthcare system in China. Full article

Background: The disparities in healthcare access due to varying insurance coverage significantly impact hospital outcomes, yet what is unclear is the role of insurance in providing care once the patient is in the hospital for a preventable admission, particularly in a weak gatekeeping environment. This study aimed to investigate the association between insurance types and readmission rates, healthcare expenditures, and length of hospital stay among patients with chronic ambulatory care sensitive conditions (ACSCs) in China. Methods: This retrospective observational study utilized hospitalization data collected from the Nanhai District, Foshan City, between 2016 and 2020. Generalized linear models (GLMs) were employed to analyze the relationship between medical insurance types and readmission rates, lengths of hospital stay, total medical expenses, out-of-pocket expenses, and insurance-covered expenses. Results: A total of 185,384 records were included. Among these, the participants covered by urban employee basic medical insurance (UEBMI) with 44,415 records and urban and rural resident basic medical insurance (URRBMI) with 80,752 records generally experienced more favorable outcomes compared to self-pay patients. Specifically, they had lower readmission rates (OR = 0.57, 95% CI: 0.36 to 0.90; OR = 0.59, 95% CI: 0.42 to 0.84) and reduced out-of-pocket expenses (β = −0.54, 95% CI: −0.94 to −0.14; β = −0.41, 95% CI: −0.78 to −0.05). However, they also experienced slightly longer lengths of hospital stay (IRR = 1.08, 95% CI: 1.03 to 1.14; IRR = 1.11, 95% CI: 1.04 to 1.18) and higher total medical expenses (β = 0.26, 95% CI: 0.09 to 0.44; β = 0.25, 95% CI: 0.10 to 0.40). Conclusions: This study found that different types of health insurance were associated with varying clinical outcomes among patients with chronic ambulatory care sensitive conditions (ACSCs) in China. Since the hospitalization of these patients was initially avoidable, disparities in readmission rates, lengths of hospital stay, and medical expenses among avoidable inpatient cases exacerbated the health gap between different insurance types. Addressing the disparities among different types of insurance can help reduce unplanned hospitalizations and promote health equity. Full article

Background and Objectives: This retrospective, cross-sectional, and descriptive study used claims data from the Korean Health Insurance Review and Assessment Service (HIRA) between 2010 and 2019 to analyze the trend of surgical service utilization in patients with lumbar spinal stenosis (LSS). Materials and Methods: The national patient sample data provided by the HIRA, which consisted of a 2% sample of the entire Korean population, was used to assess all patients who underwent decompression or fusion surgery at least once in Korea, with LSS as the main diagnosis from January 2010 to December 2019. An in-depth analysis was conducted to examine the utilization of surgical services, taking into account various demographic characteristics of patients, the frequency of claims for different types of surgeries, reoperation rates, the specific types of inpatient care associated with each surgery type, prescribed medications, and the overall expense of healthcare services. Results: A total of 6194 claims and 6074 patients were analyzed. The number of HIRA claims for patients increased from 393 (2010) to 417 (2019) for decompression, and from 230 (2010) to 244 (2019) for fusion. As for the medical expenses of surgery, there was an increase from United States dollar (USD) 867,549.31 (2010) to USD 1,153,078.94 (2019) for decompression and from USD 1,330,440.37 (2010) to USD 1,780,026.48 (2019) for fusion. Decompression accounted for the highest proportion (65.8%) of the first surgeries, but more patients underwent fusion (50.6%) than decompression (49.4%) in the second surgery. Across all sex and age groups, patients who underwent fusion procedures experienced longer hospital stays and incurred higher medical expenses for their inpatient care. Conclusion: The surgical service utilization of patients with LSS and the prescribing rate of opioids and non-opioid analgesics for surgical patients increased in 2019 compared to 2010. From mid-2010 onward, claims for fusion showed a gradual decrease, whereas those for decompression showed a continuously increasing trend. The findings of this study are expected to provide basic research data for clinicians, researchers, and policymakers. Full article

Multilevel semicontinuous data occur frequently in medical, environmental, insurance and financial studies. Such data are often measured with covariates at different levels; however, these data have traditionally been modelled with covariate-independent random effects. Ignoring dependence of cluster-specific random effects and cluster-specific covariates in these traditional approaches may lead to ecological fallacy and result in misleading results. In this paper, we propose Tweedie compound Poisson model with covariate-dependent random effects to analyze multilevel semicontinuous data where covariates at different levels are incorporated at relevant levels. The estimation of our models has been developed based on the orthodox best linear unbiased predictor of random effect. Explicit expressions of random effects predictors facilitate computation and interpretation of our models. Our approach is illustrated through the analysis of the basic symptoms inventory study data where 409 adolescents from 269 families were observed at varying number of times from 1 to 17 times. The performance of the proposed methodology was also examined through the simulation studies. Full article