Critical Illness at 40: Still a Thorn in the Medical Director's Side.

Critical illness insurance was introduced 40 years ago. Medical directors continue to be challenged and frustrated with the complexities that critical illness claims offer. This article provides insights into the continued issues and possible solutions.

Inequity in Health Services Utilization in Economically Underdeveloped Regions of Northeast China.

Background: The Chinese health system has long been committed to eliminating inequalities in health services utilization. However, few studies have analyzed or measured these inequalities in economically underdeveloped regions in China. Methods: A total of 6,627 respondents from 3,000 households in Heilongjiang Province were extracted from the Sixth National Health Services Survey. We measured horizontal inequity in both 2-week outpatient rate and annual inpatient rate, and then identified the factors contributing to inequality. Results: The horizontal inequity indices of the 2-week outpatient and annual impatient rates in Heilongjiang Province were 0.0586 and 0.1276, respectively. Household income, health status, place of residence, basic medical insurance, and commercial health insurance were found to be the main factors affecting inequality in health services utilization. The contributions of household income to these two indices were 184.03 and 253.47%, respectively. Health status factors, including suffering from chronic disease, limitations in daily activities, and poor self-rated health, played positive roles in reducing inequality in these two indices. The contributions of place of residence to these two indices were 27.21 and -28.45%, respectively. Urban Employee Basic Medical Insurance made a pro-rich contribution to these two indices: 56.25 and 81.48%, respectively. Urban and Rural Resident Basic Medical Insurance, Urban Resident Basic Medical Insurance, New Rural Cooperative Medical Scheme, and other basic medical insurance made a pro-poor contribution to these two indices: -73.51 and -54.87%, respectively. Commercial health insurance made a pro-rich contribution to these two indices: 20.79 and 7.40%, respectively. Meanwhile, critical illness insurance made a slightly pro-poor contribution to these two indices: -4.60 and -0.90%, respectively. Conclusions: The findings showed that the "equal treatment in equal need" principle was not met in the health services utilization context in Heilongjiang Province. To address this issue, the government could make policy changes to protect low-income populations from underused health services, and work to improve basic medical insurance, critical illness insurance, and social security systems.

The Basic vs. Ability-to-Pay Approach: Evidence From China's Critical Illness Insurance on Whether Different Measurements of Catastrophic Health Expenditure Matter.

Alleviating catastrophic health expenditure (CHE) is one of the vital objectives of health systems, as defined by the World Health Organization. However, no consensus has yet been reached on the measurement of CHE. With the aim of further relieving the adverse effects of CHE and alleviating the problem of illness-caused poverty, the Critical Illness Insurance (CII) program has been operational in China since 2012. In order to verify whether the different measurements of CHE matter under China's CII program, we compare the two-layer CII models built by using the basic approach and the ability-to-pay (ATP) approach at a range of thresholds. Exploiting the latest China family panel studies dataset, we demonstrate that the basic approach is more effective in relieving CHE for all insured households, while the ATP approach works better in reducing the severity of CHE in households facing it. These findings have meaningful implications for policymaking. The CII program should be promoted widely as a supplement to the current Social Basic Medical Insurance system. To improve the CII program's effectiveness, it should be based on the basic approach, and the threshold used to measure CHE should be determined by the goal pursued by the program.

Navigating a Pandemic: The Unique Role of the Medical Director.

The sudden emergence of the COVID-19 pandemic in early 2020 presented a unique challenge for medical directors of life insurance companies. Company leadership required quick answers about many issues, but two in particular: 1) the magnitude of the pandemic's impact on the insured lives portfolio and 2) the underwriting of new applicants during a pandemic. This article will describe the experiences of a global team of reinsurance medical directors during a pandemic. It may also serve to provide guidance for medical directors facing a similar challenge in the future.

Economic crisis of rural patients insured with critical illness insurance: Do working-age patients have higher financial burden?

Working-age patients are generally found to have higher healthcare expenditure than elder. China implemented critical illness insurance (CII) in 2012 to decrease the medical expenditure of patients. The aim of this study was to determine if the economic burden of rural working-age patients with CII was more serious than other age groups. A questionnaire survey was undertaken in two counties of central and western China in 2017. Comprehensive financial measurement was used, including direct costs, indirect costs and medical debt rate. All data collected were used for descriptive statistics and multivariate variance analysis. Linear regression with random effect analysis upon area was used to evaluate the differences in ages. A total of 834 rural patients were surveyed in this study. Patients aged 18-44 years had the highest lodging and food payments (3,838 Chinese Yuan [CNY]), work loss (15,350 CNY) and medical debt rate (83.24%). Patients who were of working age, sought health services out of counties, had longer length of stay, and were diagnosed with chronic illness had higher healthcare expenditure. Rural working-age patients with CII had higher direct and indirect costs, which were attributed to medical debt. The increased service capability of hospitals in counties and improved medical financial assistance may also be issues of concern.

What contributes to medical debt? Evidence from patients in rural China.

BACKGROUND: Rural households in developing countries usually have severe medical debt due to high out-of-pocket (OOP) payments, which contributes to bankruptcy. China implemented the critical illness insurance (CII) in 2012 to decrease patients' medical expenditure. This paper aimed to explore the medical debt of rural Chinese patients and its influencing factors. METHODS: A questionnaire survey of health expenditures and medical debt was conducted in two counties of Central and Western China in 2017. Patients who received CII were used as the sample on the basis of multi-stage stratified cluster sampling. Descriptive statistics and multivariate analysis of variance were used in all data. A two-part model was used to evaluate the occurrence and extent of medical debt. RESULTS: A total of 826 rural patients with CII were surveyed. The percentages of patients incurring medical debt exceeded 50% and the median debt load was 20,000 Chinese yuan (CNY, 650 CNY = US$100). Financial assistance from kin (P < 0.001) decreased the likelihood of medical debt. High inpatient expenses (IEs, P < 0.01), CII reimbursement ratio (P < 0.001), and non-direct medical costs (P < 0.001) resulted in increased medical debt load. CONCLUSIONS: Medical debt is still one of the biggest problems in rural China. High IEs, CII reimbursement ratio, municipal or high-level hospitals were the risk determinants of medical debt load. Financial assistance from kin and household income were the protective factors. Increasing service capability of hospitals in counties could leave more patiemts in county-level and township hospitals. Improving CII with increased reimbursement rate may also be issues of concern.

Individual vs household: How do different calculation patterns of catastrophic health expenditure matter? New evidence from China's critical illness insurance programme.

Reducing the incidence and severity of catastrophic health expenditure (CHE) has been considered to be one of the most fundamental goals of the global health care financing system. China, the second largest economy and the most populous country in the world, established a critical illness insurance (CII) programme in 2012 in an effort to protect Chinese residents from CHE shocks. This paper attempts to address whether the different calculation patterns (namely, individuals vs household) of CHE matter under China's CII programme. We compare two CII models built with the World Health Organization's (WHO's) standard and the Chinese standard. Exploiting the latest China family panel studies (CFPS) dataset, we demonstrate that using household as the calculation pattern is more effective in alleviating CHE under a tight premium budget, which is consistent with the international view. This finding raises concerns about the appropriate calculation pattern of CHE in policy making.

Effect of Critical Illness Insurance on Household Catastrophic Health Expenditure: The Latest Evidence from the National Health Service Survey in China.

BACKGROUND: China fully implemented the critical illness insurance (CII) program in 2016 to alleviate the economic burden of diseases and reduce catastrophic health expenditure (CHE). With an aging society, it is necessary to analyze the extent of CHE among Chinese households and explore the effect of CII and other associated factors on CHE. METHODS: Data were derived from the Sixth National Health Service Survey (NHSS, 2018) in Jiangsu Province. The incidence and intensity of CHE were calculated with a sample of 3660 households in urban and rural areas in Jiangsu Province, China. Logistic regression and multiple linear regression models were used for estimating the effect of CII and related factors on CHE. RESULTS: The proportion of households with no one insured by CII was 50.08% (1833). At each given threshold, from 20% to 60%, the incidence and intensity were higher in rural households than in urban ones. CII implementation reduced the incidence of CHE but increased the intensity of CHE. Meanwhile, the number of household members insured by CII did not affect CHE incidence but significantly decreased CHE intensity. Socioeconomic factors, such as marital status, education, employment, registered type of household head, household income and size, chronic disease status, and health service utilization, significantly affected household CHE. CONCLUSIONS: Policy effort should further focus on appropriate adjustments, such as dynamization of CII lists, medical cost control, increasing the CII coverage rate, and improving the reimbursement level to achieve the ultimate aim of using CII to protect Chinese households against financial risk caused by illness.

Liquid Biopsies and Critical Illness Insurance: Uncomfortable Bedfellows?

Liquid biopsies hold great promise for the diagnosis and treatment of cancer. Earlier recognition of recurrent and metastatic disease and better treatment choices based on liquid biopsies seem achievable in the near future. However, earlier cancer diagnosis, the most heralded application, will remain the most challenging. The impact of liquid biopsies on life insurance will be positive. The impact on critical illness insurance will be more nuanced. It will depend on 2 factors: the success of liquid biopsies as cancer screening tests and the ability of an insurer to use "genetic information" during risk selection. In jurisdictions where use is prohibited, critical illness insurance, as presently designed, may not be sustainable.

Impact of Critical Illness Insurance on the Burden of High-Cost Rural Residents in Central China: An Interrupted Time Series Study.

Critical illness insurance (CII) in China was introduced to protect high-cost groups from health expenditure shocks for the purpose of mutual aid. This study aimed to evaluate the impact of CII on the burden of high-cost groups in central rural China. Data were extracted from the basic medical insurance (BMI) hospitalization database of Xiantao City from January 2010 to December 2016. A total of 77,757 hospitalization records were included in our analysis. The out-of-pocket (OOP) expenses and reimbursement ratio (RR) were the two main outcome variables. Interrupted time series analysis with a segmented regression approach was adopted. Level and slope changes were reported to reflect short- and long-term effects, respectively. Results indicated that the number of high-cost inpatient visits, the average monthly hospitalization expenses, and OOP expenses per high-cost inpatient visit were increased after CII introduction. By contrast, the RR from BMI and non-reimbursable expenses ratio were decreased. The OOP expenses and RR covered by CII were higher than those uncovered. We estimated a significant level decrease in OOP expenses (p < 0.01) and rise in RR (p < 0.01), whereas the slope decreases of OOP expenses (p = 0.19) and rise of RR (p = 0.11) after the CII were non-significant. We concluded that the short-term effect of the CII policy is significant and contributes to decreasing OOP expenses and raising RR for high-cost groups, whereas the long-term effect is non-significant. These findings can be explained by increasing hospitalization expenses, many non-reimbursable expenses, low coverage for high-cost groups, and the unsustainability of the financing methods.

Does the critical illness insurance reduce patients' financial burden and benefit the poor more: a comprehensive evaluation in rural area of China.

BACKGROUND: Critical illness insurance (CII) is one kind of health insurance that is gradually gaining attention worldwide. China implemented CII in 2012 to decrease patients' out-of-pocket (OOP) medical payments. The aims of this study were to determine if the project had positive impacts on relieving financial burden and improving health equity. METHODS: A series of questionnaire surveys were undertaken in two counties before and after the intervention in rural China. OOP expenditure, catastrophic Health Expenditure (CHE) incidence, and associated average gap (AG) were assessed across different income groups and project durations, measuring short-term direct medical cost. Medical debt rate and amount were used to measure long-term financial burden; concentration index (CI) was calculated for equity. All data were evaluated by descriptive statistics and multi-variate variance analysis. The linear regression and logit regression with random effect analysis upon area was used to evaluate the effect of CII. RESULTS: Six hundred and thirteen and 834 patients were surveyed at baseline and final evaluation. After the program, the OOP payments of hospitalizations sharply decreased from RMB 39,363.2 to RMB 28,426.1 (p < 0.001), with the largest decrease for lowest income patients (from RMB 44,507.6 to RMB 29,214.2). With longer duration of CII, more OOP medical payments decreased. The amount of medical debt was decreased by RMB 7,209.4 among all the patients, and the decrease was highest in the highest income group (RMB 8,119.9). The CI of AG changed a lot (from -0.858 to -0.670). CONCLUSION: The CII has effectively reduced the financial burden of patients with high medical cost, whether in the short-term or a longer length of time. It also improved health equity in health service utilization and expenditure. However, rich householders still receive more benefits from the policy, government health insurance financing is increased, and the policy needs to further benefit the poor.

Critical Illness Insurance to alleviate catastrophic health expenditures: new evidence from China.

Currently, a high percentage of China's households face financial catastrophe as a direct result of excessive out-of-pocket (OOP) health expenditures. To alleviate this, China has set up the Critical Illness Insurance (CII) program since 2012. However, the current CII is still in an experimental phase and tested in 8 (out of 34) provinces, which has not been proved to be effective. This paper develops a health financing system for reducing catastrophic medical spending using a two-layer model for CII. This model partly compensates expenses exceeding the cap line of the Social Resident Basic Medical Insurance scheme to maintain the ratio of OOP expenses to total medical expenditure approximately at 20%. Adjustment coefficients based on individual net income across different regions are applied to increase fairness. The financial sustainability of the model is tested using a fund balance calculation. Finally, the two-layer model of the CII is empirically simulated with the latest provincial data from China Family Panel Studies. The results demonstrate that the model can effectively alleviate the incidence and severity of catastrophic health expenditures.

Effect Evaluation of Critical Illness Insurance under New Cooperative Medical System: Analysis Based on the Data of China Family Panel Studies / 中国卫生经济

Objective:To evaluate the implementation effects of critical illness insurance of New Cooperative Medical System(NCMS) on the occurrence rate and economic burden of major disease expenditure.Methods:Based on the peasant household data of China Family Panel Studies(CFPS) in 2014.the two-part model was applied to analyze the changes in major disease occurrence and burden after the implement of insurance.Results:NCMS critical illness insurance did not reduce the occurrence of critical disease expenditure,but signally cut down the economic burden of serious illness peasants in central and eastern China.Conclusion:The implementation effect of NCMS critical illness insurance was well in central and eastern China,but was poor in western China;the prevention and health care system of NCMS should be built,while the implementation plans and compensation level of critical illness insurance should be improved in western region.

Highly Sensitive Troponin and Critical Illness Insurance: Have the Goalposts Moved Again?

An elevated cardiac troponin is a sine qua non for the clinical diagnosis of myocardial infarction. The sensitivity of troponin assays has improved repeatedly since troponin entered clinical use in the late 1990s. Its most recent iteration, "highly sensitive" troponin will shortly enter clinical use in North America. It is able to detect amounts of troponin 10 times smaller than the current assay. As a result, more myocardial infarctions will be diagnosed. This may have an impact on the number of critical illness claims for heart attack.

How to deal with burden of critical illness: A comparison of strategies in different areas of China.

OBJECTIVES: This article aims to introduce, compare and analyze the design and development of Critical Illness Insurance systems in different parts of China under different social and economic conditions, to explain their characteristics and similarities. It may provide references to other countries, especially developing countries, to solve the problem of high medical costs. METHODS: According to the methods in Comparative Economics, 3 areas (Taicang in Jiangsu, Zhanjiang in Guangdong, Xunyi in Shanxi) which are in high, medium and low socio-economic condition respectively were chosen in China. Their critical illness insurance systems were analyzed in the study. RESULTS: Each system shares several common points, including coordinating urban and rural medical insurance fund, financing from the basic medical insurance surplus, and exploring payment reform and so on. But in the way of management, Taicang and Zhanjiang cooperate with commercial insurance agencies, but Xunyi chooses autonomous management by government. In Xunyi, multi-channel financing is relatively more dispersed, while funds of Taicang and Zhanjiang are mainly from the basic medical insurance surplus. The specific method of payment is different among these three areas. CONCLUSION: Because of the differences in economic development, population structure, and sources of funds, each area took their own mode on health policy orientation, financing, payment, coverage, and fund management to design their Critical Illness Insurance systems. This might provide references to other areas in China and other developing countries in the world.

Research on the Game Model of Purchasing Critical Illness Insurance by Commercial Insurance in New Rural Cooperative Medical System / 中国卫生经济

Objective: Developing New Rural Cooperative Medical System ( NCMS ) critical illness insurance is a relatively new operation mode for the government, which needs to provide quantify references for policy designers to help the predict decision. Methods: Through the analysis of decision process and behavior of the government and the commercial companies , the utility maximization functions for both the government and the commercial companies are set up based on the game theory. The Stackelberg model theory is then applied to figure out the relationship among different parameters in the utility maximization functions. Results and Conclusion: In the process of critical illness insurance under NCMS, the government should combine the local situation, to design reasonable polices based on the relationship among different parameters , so as to lead the NCMS critical illness insurance develop in a healthy way.

Analysis on Premium Adjustment Mechanism of Critical Illness Insurance in China / 中国卫生经济

Objective: By constructing the cash flow model, it proposed the premium adjustment mechanism of critical illness insurance(CII). Methods: Based on the practical data of critical illness insurance in China, it established some actuarial assumptions and cash flow model to simulate and analyze premium adjustment mechanism of CII. Results: ( 1) Because of the deterioration of critical illness incidence rate and the change of market interest rates , CII guaranteed premium usually resents pricing risk, which showed that the cash flow is negative, sometimes accumulated cash is negative; (2) based on the criteria of insurance cost adjustment, it is suggested that when the loss rate reached more than 70%, which could permit the insurance company adjust the premium, if the loss rate reached more than 80%, it needs to compulsory the insurance companies to adjust premium. Conclusion: The study proposes the mechanism of CII premium adjustment, provides guidance for practice.

Gaming Analysis on the Stakeholders of Catastrophic Medical Insurance Policy under the New Rural Cooperative Medical / 中国卫生经济

Objective: To understand the gambling relations between the stakeholders of catastrophic medical insurance policy under New Rural Cooperative Medical System ( NCMS) , and provide theoretical references for the smooth operation of catastrophic medical insurance policy of NCMS. Methods:Analyzing the game relationships among the four sides:the government, business insurance agencies, designated medical institutions and participating farmers suffering from catastrophic diseases through game theory. Results: The government and business insurance agency, and the government and designated medical institution belong to cooperative games. The farmers participated in catastrophic medical insurance tend to choose cooperative strategy. Non-cooperative games exist in business insurance agency, designated medical institution and participating farmers. Conclusion: Strategic relationship of close cooperation should be established between the business insurance agencies and designated medical institutions. The government should strengthen the regulatory constraints between the business insurance agencies and designated medical institutionsi, at the same time, it needs to establish the incentive mechanism soon.