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Background: The accessibility and fairness of the floating population's access to basic public health services have an important impact on improving the health level of the whole population. Existing studies have shown that medical insurance and social integration have an impact on basic public health services, but there are few studies on the specific influence path between the three. Therefore, the research purpose of this paper is to explore the effects of medical insurance for urban and rural residents and basic medical insurance for urban employees on the utilization of basic public health services, and to analyze the mediating effect of social integration. Methods: The data in this paper are derived from the 2017 China Mobile Population Dynamic Monitoring Survey data, which collects information on 31 provinces (regions, cities) and Xinjiang Production and Construction Corps mobile population 169,989 people, all of whom come from China's relatively concentrated mobile population inflow areas (NHC FPSCo. 2021. Floating Population Service Center of NHC). After deleting part of the missing data and replacing the mean value, 154,586 people were finally included in the analysis. The proportion is 90.9%. Based on the data of China's floating population dynamic survey in 2017,we used Logistic regression method to analyze the effects of basic medical insurance for urban and rural residents, basic medical insurance for urban employees and social integration on the utilization of basic public health services. Then we used the Bootstrap method of structural equation model to analyze the mediating effect of social integration. Results: Medical insurance for urban and rural residents (β = 0.236;95%CI:1.195 ~ 1.342) has positive impact on health education, it (β = 0,190;95%CI:1.150 ~ 1.272) also has positive impact on the establishment of residents' health records. Social integration (including political participation (β = 0.312;95%CI:1.324 ~ 1.410),activity participation (β = 0.724;95%CI:2.009 ~ 2.119), identity (β = 0.421; 95%CI:1.387 ~ 1.675))has positive impact on health education, it ((β = 0.312;95%CI:1.324 ~ 1.410), (β = 0.404;95%CI:1.463 ~ 1.534), (β = 0.282;95%CI:1.191 ~ 1.477)) also has positive impact on the establishment of residents' health records. In addition, BMIUE (β = 0.169;95%CI:1.150 ~ 1.219) has an impact on the establishment of residents' health records. The direct effect of medical insurance on the utilization of public health services was 0.092 (95%CI: 0.093 ~ 0.103), social integration was a partial mediator, the mediating effect was 0.127 (95%CI: 0.108 ~ 0.127), and the mediating effect size was 57.73%. Conclusions: Medical insurance can directly promote the floating population to use basic public health services, and can indirectly promote the improvement of public health service utilization level through social integration. [ABSTRACT FROM AUTHOR]

Background: Medical insurance and social security cards are an important incentive for the floating population to live a stable life in their current residence, but there has been little studies on their effect on settlement intentions. Therefore, the purpose of this paper was to study the impact of basic medical insurance for urban employees and application for personal social security cards on the settlement intentions of the floating population. With the increase of the desire to settle, the health management and the development of public health will be improved. Methods: Based on the 2017 survey data from the dynamic monitoring of China's floating population, we explored the influence of basic medical insurance for urban employees and social security cards on the floating population's settlement intentions. Additionally, this study also examined the comprehensive causal relationship, with social integration as the mediator variable. We used SPSS 21.0 software. The input method was used to analyze the influence of the above variables by binary logistic regression. Then we used AMOS22.0 software to establish the structural equation model of the relationship between the above three independent variables. Finally, we used bootstrapping method to analyze the direct effect, indirect effect and total effect of independent variables on settlement intention. Results: The settlement intention of members of the floating population after participating in basic medical insurance for urban employees was 23.2% higher than that of those who did not participate. The decision as to whether to apply for a personal social security card is related to their settlement intention. The standardized regression coefficients among social insurance and security, social integration, and settlement intention were positive values, and the Z values of the overall effect, indirect effect, and direct effect were all greater than 1.96; the confidence interval of the indirect effect did not include 0. We found that this model is a partial intermediary model, with an intermediary ratio of 10.66%. Conclusions: This article highlights the important impact of basic medical insurance for urban employees and individual social security cards on the floating population. The conclusions of this study provide suggestions for the government to use when designing policies to enhance the settlement intentions of the floating population and to improve the development of public health undertakings. [ABSTRACT FROM AUTHOR]

Background: China initiated a reform of the health insurance system in the late 1990s. The new insurance, Urban Employee Basic Medical Insurance (UEBMI), is employment-based, which makes it more difficult than it used to be for those unemployed or informal employed (most of whom are women) to be covered by health insurance. Methods: Based on three large sample of micro datasets, we first use statistical methods to identify gender differences in health insurance. Next, we construct a logistic regression model to capture the differences in insurance coverage across age groups using the parameter of interaction terms for gender and age groups. Results: Based on data from a demographic survey that covers a large sample, we find that in the below 50 (in 2005) or 60 (in 2015) years age group, the coverage gap of UEBMI between men and women was relatively smaller, while a larger disparity existed in the above 50 (in 2005) or 60 (in 2015) group. Moreover, gender differences in health insurance were more significant in the low-education group, while no gender differences were found in the high-education group. Conclusions: This paper explains the gender gap in health insurance and the reason for the wider gap among older people. Our study indicates that because the UEBMI in China mainly covers people with formal jobs, a lower labor participation rate (even much lower in formal jobs) of women has led to their greater difficulty in obtaining health insurance. Since the older women's greater difficulty in obtaining jobs or susceptibility to lay-offs during the period of the UEBMI's implementation, the possibility of being covered was even much lower. In fact, it was because of the combined effects of the UEBMI system and the labor market condition at that time that older women had a lower proportion of being covered under the UEBMI. [ABSTRACT FROM AUTHOR]

Objective: To analyze the degree, evolution and causes of socioeconomic inequality in perceived access to health services among the older adults in China. Methods: The data used in this study were drawn from the 4 waves of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) in 2008, 2011, 2014, 2018. Erreygers index (EI) was used to measure socioeconomic inequality in perceived access to health services in each survey wave. A panel logit regression model was used to examine the impact of socioeconomic status on perceived access to health services. The recentered influence function (RIF) regression decomposition method was used to explore the causes of socioeconomic inequality in perceived access to health services. Inverse probability weighting (IPW) was employed to adjust estimates for missing responses and loss to follow-up. Results: "Pro-rich" socioeconomic inequality in perceived access to health services in China was found with inequality falling through time. The older adults with higher incomes, who had adequate financial support, and those who were wealthier compared with other residents reported lower socioeconomic inequality in perceived access to health services. Having basic health insurance and access to care resources when ill can help alleviate such inequalities. Conclusions: Socioeconomic inequality in perceived access to health services was shown to be responsive to policies that enhance health insurance coverage and support the provision of (paid and unpaid) caregiving for the older adults. [ABSTRACT FROM AUTHOR]

Background: Inequalities in demographic, socio-economic and health status for China labor force place them at greater health risks, and marginalized them in the utilization of healthcare services. This paper identifies the inequalities which limit the utilization of health services among China labor force, and provides a reference point for health policy. Methods: Data were collected from 23,505 participants aged 15 to 65, from the 2014 China Labor Force Dynamic Survey (a nationwide cross-sectional survey covering 29 provinces with a multi-stage cluster, and stratified, probability sampling strategy) conducted by Sun Yat-sen University. Logistic regression models were used to study the effects of demographic (age, gender, marital status, type of hukou and migration status), socio-economic (education, social class and insurance) and health status (self-perceived general health and several chronic illnesses) variables on the utilization of health services (two-week visiting and hospitalization during the past 12 months). Goodness of fit was assessed using Hosmer-Lemeshow test. Discrimination ability was assessed based on the area under the receiver operating curve (AUC). Results: Migrants with more than 1 (OR 2.80, 95% CI 1.01 ~ 7.82) or none chronic illnesses (OR 1.26, 95% CI 1.01 ~ 7.82) are more likely to be two week visiting to the clinic than non-migrants; migrants with none chronic illnesses (OR 0.61, 95% CI 0.45 ~ 0.82) are less likely to be in hospitalization during the past 12 months than non-migrants. Female, elder, hukou of non-agriculture, higher education level, higher social class, purchasing more insurance and poorer selfperceived health were predictors for more utilization of health service. More insurance benefited more two-week visiting (OR 1.12, 95% CI 1.06 ~ 1.17) and hospitalization during the past 12 months (OR 1.12, 95% CI 1.07 ~ 1.18) for individuals with none chronic illness but not ≥1 chronic illnesses. All models achieved good calibration (Hosmer-Lemeshow test's P range of 0.258-0.987) and discrimination (AUC range of 0.626-0.725). Conclusions: This study has shown that there are inequalities of demographic, socio-economic and health status in the utilization of health services for China labor force. Prudent health policy with equitable utilization of health services eliminating mentioned inequalities should be a priority in shaping China's healthcare system reform. [ABSTRACT FROM AUTHOR]

Background: The inequity of healthcare utilization in rural China is serious, and the urban-rural segmentation of the medical insurance system intensifies this problem. To guarantee that the rural population enjoys the same medical insurance benefits, China began to establish Urban and Rural Resident Basic Medical Insurance (URRBMI) nationwide in 2016. Against this backdrop, this paper aims to compare the healthcare utilization inequity between URRBMI and New Cooperative Medical Schemes (NCMS) and to analyze whether the inequity is reduced under URRBMI in rural China. Methods: Using the data from a national representative survey, the China Health and Retirement Longitudinal Study (CHARLS), which was conducted in 2015, a binary logistic regression model was applied to analyze the influence of income on healthcare utilization, and the decomposition of the concentration index was adopted to compare the Horizontal inequity index (HI index) of healthcare utilization among the individuals insured by URRBMI and NCMS. Results: There is no statistically significant difference in healthcare utilization between URRBMI and NCMS, but in outpatient utilization, there are significant differences among different income groups in NCMS; high-income groups utilize more outpatient care. The Horizontal inequity indexes (HI indexes) in outpatient utilization for individuals insured by URRBMI and NCMS are 0.024 and 0.012, respectively, indicating a pro-rich inequity. Meanwhile, the HI indexes in inpatient utilization under the two groups are − 0.043 and − 0.028, respectively, meaning a pro-poor inequity. For both the outpatient and inpatient care, the inequity degree of URRBMI is larger than that of NCMS. Conclusions: This paper shows that inequity still exists in rural areas after the integration of urban-rural medical insurance schemes, and there is still a certain gap between the actual and the expected goal of URRBMI. Specifically, compared to NCMS, the pro-rich inequity in outpatient care and the pro-poor inequity in inpatient care are more serious in URRBMI. More chronic diseases should be covered and moral hazard should be avoided in URRBMI. For the vulnerable groups, special policies such as reducing the deductible and covering these groups with catastrophic medical insurance could be considered. [ABSTRACT FROM AUTHOR]

Background: China has since the beginning of this millennium engaged in substantial Universal Health Coverage (UHC) reforms. This paper adds evidence on how equity in level of health service utilization changed after UHC reforms. Methods: Our study was based on household survey data from 30 counties in Sichuan province in 2004 and 2011. We introduce an unusual outcome variable, namely level of healthcare utilization. Concentration index (CI) was used to measure income based inequality in level of healthcare utilization. Horizontal index (HI) was used to assess whether inequalities are inequitable. We decomposed the concentration index to measure the factors contributing to inequality in level of utilization. Oaxaca type decomposition was applied to control whether identified changes were attributable to changed inequality or to other factors. Results: Pro-rich inequity in level of healthcare utilization increased after UHC reforms. Overall, a higher proportion of users sought services at county hospitals or higher in 2011 compared with 2004. Richer users were considerably more likely than the poor to seek care at hospitals rather than at clinics or health centers, and the pro-rich inequality in level of healthcare utilization was highly inequitable. Insurance enrollment became the main driver of pro-rich inequity in level of healthcare utilization after reforms, while health needs became less important for determining level of care, all disfavoring low income groups. Conclusions: Assessments of equity should pay attention to inequalities in level of healthcare utilization. Our results indicate that in China, wide insurance coverage is insufficient to ensure equity in level of healthcare utilization. On the contrary, type of insurance enrollment has become a main driver of inequity in level of utilization. Hence, equalizing health insurance schemes would be of crucial importance in order to improve health equity in China. Moreover, UHC reforms should strengthen the primary sector and limit non-needs based use of high-level hospitals in order to promote equitable use of healthcare services. [ABSTRACT FROM AUTHOR]

Introduction: Young and middle-aged people are important participants in the fight against health insurance fraud. The study aims to investigate the differences in their willingness to report health insurance fraud and the factors influencing it when it occurs in familiar or unfamiliar healthcare settings. Methods: Data were obtained from a validated questionnaire from 828 young and middle-aged people. McNemar's test was used to compare the public's willingness to report under the two scenarios. Chi-square tests and multiple logistic regression analysis were used to analyze the determinants of individuals' willingness to report health insurance fraud in different scenarios. Results: Young and middle-aged people were more likely to report health insurance fraud in a familiar healthcare setting than in an unfamiliar one (McNemar's χ²=26.51, P < 0.05). Their sense of responsibility for maintaining the security of the health insurance fund, the government's openness about fraud cases, and the perception of their ability to report had significant positive effects on the public's willingness to report in both settings (P < 0.05). In a familiar healthcare setting, the more satisfied the public is with government measures to protect whistleblowers, the more likely they are to report (OR = 1.44, P = 0.025). Those who perceive the consequences of health insurance fraud to be serious are more likely to report than those who perceive the consequences to be less serious (OR = 1.61, P = 0.042). Conclusion: Individuals are more likely to report health insurance fraud in familiar healthcare settings than in unfamiliar ones, in which their awareness of the severity of the consequences of health insurance fraud and their perceived risk after reporting it play an important role. The government's publicizing of fraud cases and enhancing the public's sense of responsibility and ability to maintain the safety of the health insurance fund may be a way to increase their willingness to report, regardless of whether they are familiar with the healthcare setting or not. [ABSTRACT FROM AUTHOR]

Objective: By analyzing the gap of hospitalization service among floating population covered by different medical insurance in Jiangsu Province, this paper aimed to understand the current situation of hospitalized health service utilization (HHSU) among floating population, and to provide policy suggestions for improving HHSU of floating population with different health insurance. Methods: The data of this study were obtained from "the National Dynamic Monitoring Survey of Floating Population in 2014". A total of 12,000 samples of floating population in Jiangsu Province were selected. 57.15% for men and 42.85% for women; 46.95% for those under 30 years old, 39.67% for 30 to 45 years old, 13.38% for over the age of forty-five. Using descriptive statistical analysis, chi-square test, exploratory factor analysis, logistic regression and stepwise multiple linear regression, the paper analyzed the difference of HHSU of floating population with different medical insurance in 2014. This study divided basic medical insurance into 3 categories: MIUE (Medical Insurance of Urban Employee), other medical insurances (including new rural cooperative medical system and the medical insurance for urban residents) and no medical insurance. Results: The hospitalization rate of floating population with MIUE (89.95%) was higher than the rate of floating population with other medical insurances (74.76%) and the gap is 15.19%. It was also higher than the rate of floating population with no medical insurance (67.57%) and the gap is 22.38%. (chi-square = 24.958, p = 0.000). 15.34% of floating population with MIUE spent more than 1600 dollars during hospitalization. It was lower than floating population with other medical insurances (16.19%) and no medical insurance (21.62%). The gaps respectively were 0.85 and 6.28% (chi-square = 10.000, p = 0.040). There existed significant differences among hospitalization medical expenses that floating population with different basic medical insurances spent. (chi-square = 225.206, p = 0.000) The type of basic medical insurance had statistical significance on whether the patients were hospitalized (p = 0.003) and whether they were hospitalized (p = 0.014). Logistic regression analysis results showed that "Social structure" (Education, Hukou, Insurance status and Work status) were significantly associated with Should be hospitalized but not and "Education" were significantly associated with Inpatient facilities selection. The stepwise multiple linear regression results presented that "Demography" and "Floating area" influenced In-hospital medical cost and "Social structure" and "Gender" influenced Reimbursement of in-hospital medical cost. Conclusion: Medical insurance type affects the hospitalization health service utilization of floating population, including Should be hospitalized but not and Reimbursement of in-hospital medical cost. [ABSTRACT FROM AUTHOR]

Background: Although primary health care (PHC) has been proven to be effective in preventing and treating chronic diseases, the visits rate of PHC institutions is still not ideal. Some patients initially express a willingness to visit PHC institutions but end up seeking health services at non-PHC institutions, and the reasons for this behavior remain unclear. Therefore, the objective of this study is to analyze the factors that contribute to behavioral deviations among chronic disease patients who originally intended to visit PHC institutions. Methods: Data were collected from a cross-sectional survey among chronic disease patients with original intention to visit PHC institutions in Fuqing City, China. The analysis framework was guided by Andersen's behavioral model. Logistic regression models were employed to analyze the factors affecting the behavioral deviations among chronic disease patients with a willingness to visit PHC institutions. Results: A total of 1,048 individuals were finally included and about 40% of the participants with the original willingness to seek care from PHC institutions finally chose non-PHC institutions in their subsequent visits. The results of logistic regression analyses indicated that at the predisposition factor level, older participants (aOR60-69 = 0.602, P < 0.01; aOR70-75 = 0.475, P < 0.01) were less likely to have behavioral deviations. At the enabling factor level, compared to those covered by Urban Employee Basic Medical Insurance (UEBMI) and not reimbursed, those covered by Urban–Rural Resident Basic Medical Insurance (URRBMI) (aOR = 0.297, P < 0.01), and those answering that reimbursement from medical institutions was convenient (aOR = 0.501, P < 0.01) or very convenient (aOR = 0.358, P < 0.001) were less likely to have behavioral deviations. At the need factor level, participants who visited PHC institutions due to illness last year (aOR = 0.348, P < 0.001) and with polypharmacy (aOR = 0.546, P < 0.01) were less likely to have behavioral deviations compared to those without the visit of PHC institutions and not taking polypharmacy, respectively. Conclusions: The deviations between the original willingness of PHC institution visits and subsequent behavior among chronic disease patients were associated with a number of predisposing, enabling, and need factors. Developing the health insurance system, strengthening the technical capacity of PHC institutions, and steadily developing a new concept of orderly healthcare-seeking behavior among chronic disease patients, will help promote their access to PHC institutions as well as improve the effectiveness of the tiered medical system for chronic disease care. [ABSTRACT FROM AUTHOR]

Background: For patients with rare diseases (RD), misdiagnosis (or erroneous diagnosis) is one of the key issues that hinder RD patients' accessibility to timely treatment. Yet, little is known about the main factors that are associated with RD patients' misdiagnosis. The objective of this study is to analyze data from a national survey among 2040 RD patients from China to explore the association between misdiagnosis and various factors, including patients' demographics, socio-economic status, medical history, and their accessibility to RD information.Results: Three binary logistic regression analyses were performed to assess the relationships between misdiagnosis and level of rarity of the RDs (mild, moderate, and severe), demographics, health insurance levels, and accessibility to disease-related information by using the total sample, and the adult and non-adult sub-samples. We found that accessibility to RD information is the most critical factor influencing the patients' chances of being misdiagnosed (odds ratio [OR] = 4.459, p < 0.001). In other words, the greater the difficulty in accessing the information on RD management, the higher the possibility of experiencing misdiagnosis. Such influences of information accessibility on misdiagnosis were repeatedly discovered when examining the adult (OR = 3.732, p < 0.001) and the non-adult (OR = 5.174, p < 0.001) sub-samples. The association between perceived economic status and misdiagnosis was only significant in the total sample. The only other factor significantly associated with misdiagnosis was disease multimorbidity: participants who reported no multimorbidity are less likely to experience misdiagnosis (OR = 0.42, p < 0.001).Conclusions: Our study indicated that patients with RDs who have difficulty in accessing disease-related information are two to five times more likely to have experienced misdiagnosis. Even after adjusting for the patients' age, gender, economic levels, and education levels, the impact of information accessibility was still significant. Our finding highlights the importance of access to information in reducing misdiagnosis among RD patients. [ABSTRACT FROM AUTHOR]

Background: Cancer is the second leading cause of death globally, causing a substantial economic burden on cancer suffers and their families. The aim of this study is to explore the prevalence, determinants and consequences of catastrophic health expenditure (CHE) among urban and rural end-of-life (EOF) cancer patients in China. Methods: Using respondent-driven sampling and face-to-face interviews, field research was conducted with a specialist questionnaire. Data were collected on 792 cancer patients who died between June 2013 and June 2016 in China. The determinants of household catastrophic expenditure were identified by multivariate logistic regression. Findings: It is found that more than 80% of cancer patients received life-extending treatment. Extremely high rates of CHE were identified among EOL cancer patients, at 94.3% for urban families and 96.1% for rural families. After spending for health, 84.1% of urban and 91.1% rural EOL cancer patient households were impoverished, falling below the poverty line. For both urban and rural households, income was the most significant factor associated with catastrophic health expenditure (CHE). Health insurance did not adequately compensate for CHE. Rural families experienced higher CHE, lower levels of health care utilization, a different mix of health care access and higher rates of borrowing for out-of-pocket (OOP) health care expenditures than urban families. Both urban and rural households suffered long-term economic disadvantage due to CHE and borrowing for OOP medical care expenses. Conclusions: EOL cancer patients experienced severe CHE, with families forced into poverty. With only about 1% of EOL cancer patients receiving palliative care, developing palliative care services and expanding the acceptance of palliative care in China is both urgent and essential. To help address impoverishment due to CHE, China should also develop targeted programs to reduce income inequality, especially rural-urban inequalities; increase access to health care; and accelerate health reform. Increasing the retirement age would provide households with more savings and wealth to withstand CHE. [ABSTRACT FROM AUTHOR]

Background: Inequalities in health care services are becoming an increasing concern in the world including in China. This study measured the income-related inequalities of residents in Hangzhou of China in access to general practice and specialist care and identified socioeconomic factors associated with such inequalities. Methods: A cross-sectional questionnaire survey was conducted on 1048 residents in ten urban communities in Hangzhou, China. The percentage and frequency of respondents visiting general practice (GP) and hospital specialist clinics over the past four weeks prior to the survey were estimated. Income-related inequalities in access to these services were measured by the concentration index. Logistic regression and Poisson regression models were established to decompose the contributions of socioeconomic factors (residency, income, education, marital status, and social health insurance) to the inequalities in the probability and frequency of accessing these services, respectively, after adjustment for the needs factors (age, sex and illness conditions). Results: The GP services were in favor of the poor, with a concentration index of − 0.0464 and − 0.1346 for the probability and frequency of GP visits, respectively. In contrast, the specialist services were in favor of the rich, with a concentration index of 0.1258 and 0.1279 for the probability and frequency of specialist visits, respectively. Income is the biggest contributor to the inequalities, except for the frequency of visits to specialists in which education played the greatest role. Conclusions: Income-related inequalities in GP and specialist care are evident in China. Policy interventions should pay increasing attention to the emergence of a two-tier system, potentially enlarging socioeconomic disparities in health care services. [ABSTRACT FROM AUTHOR]

Background: The equity of medical services utilization for elderly individuals enrolled in different basic social medical insurance systems holds significant meaning for social harmony against a background of demographic aging and a growing wealth gap in China. This study is to explore the equity of the three medical insurance systems in southwest China with the aim of providing recommendations for relevant policy. Methods: A total of 9600 elderly people insured through basic social medical insurance were selected and interviewed with a questionnaire. This study used a binary logistic regression model to investigate the effect of household income for medical services utilization and adopted a concentration index to measure the inequity of medical services utilization among elderly participants enrolled in different medical insurance categories. Results: Outpatient services utilization was almost identical in the different insurance systems (78.5%, 77.7% and 78.6%). There were no statistically significant differences according to income level in the Urban Employee Basic Medical Insurance (UEBMI) and Urban Resident Basic Medical Insurance (URBMI) programs, but in the New Cooperative Medical Scheme (NCMS), higher-income groups tended to utilize more services. The corresponding concentration index (CI) values were 0.0162, 0.0173 and 0.0179 respectively. The NCMS showed a lower hospitalization rate than UEBMI and URBMI (17.7% vs 24.2% and 24.9%). The higher income group utilized hospitalization more, regardless of the insurance system. The corresponding CI values were 0.0817, 0.0605 and 0.0319 respectively. Conclusion: The equity of medical services utilization for elderly exist in all three health insurance systems, in particular, the inequities in utilization of hospitalization were more severe than outpatient services. UEBMI and URBMI were better than NCMS in the equity of outpatient services. Although NCMS was more equitable than URBMI and UEBMI in terms of hospitalization, this was based on "overall low utilization of hospitalization regardless of income levels" in NCMS compared with URBMI and UEBMI. The disparities of the three basic social medical insurance systems should be eliminated. For low-income residents, specific insurance policies including reducing deductible, covering more medical service and increasing reimbursement ratio could be considered. [ABSTRACT FROM AUTHOR]