Willingness to Purchase Hypothetical Private Long-Term Care Insurance Plans in a Super-ageing Society: Evidence from Hong Kong.

Despite the soaring demand for long-term care (LTC) services in aging societies, dedicated risk-pooling mechanisms are largely absent. Private insurance has been advocated but the market remains small. This study seeks to unravel this paradox through an empirical study in Hong Kong, a super-aging society. We analyzed middle-aged individuals' willingness to purchase hypothetical private LTC insurance plans derived from a discrete choice experiment. A survey was conducted in 2020 and sampled 1,105 respondents. We noted a fairly encouraging level of acceptance but also found clear barriers toward potential purchase. The desire for self-sufficiency and preference for formal care powerfully increased individuals' interest. Cognitive difficulty, habitual adherence to out-of-pocket payment, and unfamiliarity with the LTC insurance market reduced such interest. We explained the results with reference to the changing social dynamics and drew policy implications for LTC reforms in Hong Kong and beyond.

Scaling-up through piloting: dual-track provider payment reforms in China's health system.

Gaining wide prominence in the global health arena, scaling-up increases the coverage of health innovations emerging from pilots and experimental projects to a larger scale. However, scaling-up in the health sector should not follow a linear 'pilot-diffusion' pathway in order to better facilitate local adaptation and policy refinement. This paper puts forth 'scaling-up through piloting' as a distinctive pathway for the strategic management of scaling-up in the health sector. It analyses the recent development of provider payment reforms in China, focusing particularly on the ongoing pilot programmes, namely diagnosis-related groups (DRGs) and diagnosis-intervention packet (DIP), that are being piloted in a dual-track fashion since 2020. Data were drawn from extensive documentary analysis and 20 in-depth interviews with key stakeholders, including decision-makers and implementers. This paper finds that scaling-up through piloting helps Chinese policymakers minimize the vast uncertainties associated with complex payment reforms and maximize the local adaptability of provider payment innovations. This pathway has forged a phased implementation process, allowing new payment models to be tested, evaluated, compared and adjusted in a full spectrum of local contexts before national rollout. The phased implementation creates a 'slower is faster' effect, helping reduce long-term negative consequences arising from improperly managed scaling-up in a complex system. Error detection and correction and recalibration of new policy tools can support national-level policy refinement in a more robust and dynamic fashion. Several key factors have been identified as crucial for strategic scaling-up: necessary central steering, a pragmatic piloting design, strong technical capacity and effective policy learning mechanisms.

Evaluating health policies with subnational disparities: a text-mining analysis of the Urban Employee Basic Medical Insurance Scheme in China.

Subnational disparities in most health systems often defy 'one-size-fits-all' approach in policy implementation. When local authorities implement a national policy in a decentralized context, they behave as a strategic policy actor in specifying the central mandates, selecting appropriate tools and setting key implementation parameters. Local policy discretion leads to diverse policy mixes across regions, thus complicating evidence-based evaluations of policy impacts. When measuring complex policy reforms, mainstream policy evaluation methodologies have tended to adopt simplified policy proxies that often disguise distinct policy choices across localities, leaving the heterogeneous effects of the same generic policy largely unknown. Using the emerging 'text-as-data' methodology and drawing from subnational policy documents, this study developed a novel approach to policy measurement through analysing policy big data. We applied this approach to examine the impacts of China's Urban Employee Basic Medical Insurance (UEBMI) on individuals' out-of-pocket (OOP) spending. We found substantial disparities in policy choices across prefectures when categorizing the UEBMI policy framework into benefit-expansion and cost-containment reforms. Overall, the UEBMI policies lowered enrollees' OOP spending in prefectures that embraced both benefit-expansion and cost-containment reforms. In contrast, the policies produced ill effects on OOP spending of UEBMI enrollees and uninsured workers in prefectures that carried out only benefit-expansion or cost-containment reforms. The micro-level impacts of UEBMI enrolment on OOP spending were conditional on whether prefectural benefit-expansion and cost-containment reforms were undertaken in concert. Only in prefectures that promulgated both types of reforms did UEBMI enrolment reduce OOP spending. These findings contribute to a comprehensive text-mining measurement approach to locally diverse policy efforts and an integration of macro-level policy analysis and micro-level individual analysis. Contextualizing policy measurements would improve the methodological rigour of health policy evaluations. This paper concludes with implications for health policymakers in China and beyond.

Seeking policy solutions in a complex system: experimentalist governance in China's healthcare reform.

The proliferation of "wicked" policy problems in complex systems requires an experimental approach of problem-solving. Experimentalist governance offers a conducive framework through which to seek policy solutions amidst high levels of complexity in a multilevel governance structure. This study conceptualizes four distinctive experimental modalities based on varying levels of technical complexity and interest complexity, both of which represent salient constraints for policy reforms in a complex system, the health sector in particular. Trail-blazing pilots, crowdsourcing pilots, managed pilots, and road-testing pilots are all associated with distinct mechanisms of experimentation in a multilevel governance structure. Through four illustrative cases from China's massive experimental program of public hospital reform, this study demonstrates how experimentalist governance seeks policy solutions in the health sector. Should governance arrangements, policy capacity, pragmatism, and informational devices become aligned in a conducive way, experimentalist governance can play an instrumental role in seeking solutions for difficult problems in a complex policy system. A governance structure capable of policy learning and adaptive management is the key.

The impacts of multiple healthcare reforms on catastrophic health spending for poor households in China.

Many developing nations witness systemic healthcare reforms where the expansion of health financing mechanisms and reforms of the service delivery system are being rolled out simultaneously. Yet, poorly coordinated reforms and negative interactions between multiple policies may offset synergies and undermine intended reform outcomes. This study examines how multiple healthcare reforms affect catastrophic health spending of low-income households in China. We characterize two broad types of health policy reforms: expansion- and constraint-oriented policies in the domains of financing, services delivery, and pharmaceuticals introduced since 2009. We adopt an innovative methodology by matching macro-level policy text data collected using big data techniques with micro-level health expenditure data drawn from a nationally representative survey. Employing a linear probability analysis and controlling for household and year fixed effects, we find that more expansion-oriented policies, especially in the domain of financing, increased the incidence of catastrophic health spending of poor households. In contrast, constraint-oriented policies, particularly in the domain of health services delivery, lead to a lower incidence of catastrophic health spending. This type of policy is thus better able to mitigate the positive relationship between expansion-oriented policies and the incidence of catastrophic health spending. This study suggests that while the expansion of benefit package in the domain of financing is indeed a decisive move towards universal health coverage, the essential financial protection of the poor cannot be achieved without strong and coordinated supply-side reforms towards cost containment. Health policy makers must take a strategic view of the complex interactions of multiple policy interventions in both financing and service delivery domains.

Integration of health services for the elderly in Asia: A scoping review of Hong Kong, Singapore, Malaysia, Indonesia.

Against the backdrop of rapid ageing populations, there is an increasing recognition of the need to integrate various health services for the elderly, not only to provide more coordinated care, but also to contain the rapid cost inflation driven primarily by the curative sector. Funded by the Asia-Pacific Observatory on Health Systems and Policies, this scoping review seeks to synthesize the received knowledge on care integration for the elderly in four Asian societies representing varying socioeconomic and health-system characteristics: Singapore, Hong Kong, Malaysia, and Indonesia. The search for English-language literature published between 2009 and 2019 yielded 67 publications in the final sample. The review finds that both research and practice regarding health service integration are at a preliminary stage of development. It notes a marked trend in seeking to integrate long-term elderly care with curative and preventive care, especially in community settings. Many distinctive models proliferated. Integration is demonstrated not only horizontally but also vertically, transcending public-private boundaries. The central role of primary care is highly prominent in almost all the integration models. However, these models are associated with a variety of drawbacks in relation to capacity, perception, and operation that necessitate further scholarly and policy scrutiny, indicating the robustness and persistence of siloed healthcare practices.

Preferences for private long-term care insurance products in a super-ageing society: A discrete choice experiment in Hong Kong.

There is a stark contrast between rising long-term care (LTC) demands and limited financing capacity in many ageing societies. Despite the theoretical potential of private insurance in LTC financing reforms, the reality is that the market remains remarkably underdeveloped. This study adopts a novel two-phase approach to quantitatively examine the market demand for private long-term care insurance (LTCI) in Hong Kong, one of the world's super-ageing societies. In order to examine people's preferences regarding private LTCI in Hong Kong, which has been exploring alternative LTC financing mechanisms to relieve the overburdened public system, we conducted a discrete choice experiment (DCE) in 2019 to elicit the preferences of a representative sample of 410 middle-aged adults. At first, we used data from the US National Longterm Care Survey to perform an actuarial projection for Hong Kong. In the first phase, we computed the indicative premiums based on various attributes of hypothetical private LTCI products. Undertaken in the second phase and using two econometric techniques, the DCE suggested that the most preferred hypothetical LTCI product in Hong Kong was associated with the following features: 1) a monthly benefit level of HK$20,000 or HK$25,000, 2) 3% inflation protection, and 3) 15 years of contribution. These attributes led to a monthly premium of HK$1237 (US$160)/HK$1546 (US$200) for men and HK$2150 (US$278)/HK$2687 (US$348) for women. Furthermore, we also found that the preference for LTCI products varied across people with different socioeconomic and health characteristics. These insights could inform initial market segmentation, LTCI product design, and targeted marketing in the future. This paper concludes with cautious optimism regarding the market demand for private LTCI in Hong Kong, and recommends concrete policy instruments to nurture the LTCI market, including information campaign, premium subsidies, and tax benefits.

Does health insurance coverage reduce informal payments? Evidence from the "red envelopes" in China.

BACKGROUND: Representing a major threat to both equity and efficiency of health systems, the corrupt practice of informal payments is widely found in developing and transition countries. As informal payments are more likely to occur in health systems characterized by a high out-of-pocket payment rate, it is argued that formalized prepaid health insurance programs may help to curb such practice. METHODS: Using panel data from the China Health and Retirement Longitudinal Survey, this study examined the association between changes in health insurance coverage on patient's behavior proxied with informal payments. RESULTS: The statistical results reveal that health insurance status in fact increases the probability of patients making informal payments to physicians. However, this association varies among population groups and insurance programs, particularly between social health insurance and private health insurance status. CONCLUSIONS: In a health system characterized by unequal allocation of medical resources, the dual pursuit of cost saving and quality of care may drive patients to make informal payments for personal gains. This study argues that health policy interventions aimed at curbing informal payments must be based on a thorough understanding of their complex socioeconomic causes and attack the perverse incentives in a coherent and bona fide manner.

What Affects the Demand for Long-Term Care Insurance? A Study of Middle-Aged and Older Adults in Hong Kong.

Despite the potential of private insurance in financing long-term care (LTC), its coverage remains rather limited. This study is built on a comprehensive framework to examine the demand for LTC insurance in Hong Kong, a rapidly aging Asian society. A telephone survey was conducted in 2016 to collect data that formed a sample of 1,474 middle-aged and older adults. Multivariate analysis reveals more nuanced characteristics of Hong Kong middle-aged and older adults who tend to show a demand for LTC insurance, including: (a) being younger, better educated, relatively high status, and financially literate; (b) living with children but reluctant to be a burden on the family; (c) being in a better financial situation and able to afford premiums; and (d) anticipation of LTC needs and dependence, and a preference for formal care. This study offers preliminary evidence to understand the demand structure of the LTC insurance market in an Asian society.

Able to purchase? Agency problems in China's social health insurance system and the pitfalls of third-party strategic purchasing.

The notion of strategic purchasing has gained increasing currency in the global health policy discourse. It is believed that an active prudent purchaser is able to act in the best interest of both government and consumers as a third party negotiating with providers for cost-effective care. It would be wrong, however, to assume that the formation of a third-party purchaser automatically leads to such desired outcomes. A variety of agency problems relating to incompetence often prevent purchasers from fulfilling their mandates, aggravating cost inflation. This study provides an alternative explanation for the rapid cost inflation in the Chinese health system, by focusing on the unique role played by the social health insurance administration. Provincial-level panel data analysis reveals that misaligned bureaucratic incentives and limited administrative capacity of the social health insurance administration contribute significantly to rapidly escalating costs. This study argues that despite the merit of the notion of third-party strategic purchasing, it must not be forgotten that effective purchasing hinges on certain crucial prerequisites that may not necessarily be present in reality. Appropriate alignment of the social health insurance administration's organizational mandates and development of its capacity is essential to China's move towards strategic purchasing of health services.

Health insurance reforms in Singapore and Hong Kong: How the two ageing asian tigers respond to health financing challenges?

Singapore and Hong Kong, two high-income "Tiger economies" in Asia, were ranked as the top two most efficient health systems in the world. Despite remarkable similarities in history and socioeconomic development, both economies embraced rather different paths in health care reforms in the past decades, which reflect their respective sociopolitical dynamics. Rapidly ageing populations and the anxiety about future funding of health care have prompted them to embark on major health financing reforms in the recent three years. While Singapore has transitioned to universal health coverage with the implementation of MediShield Life (MSL), Hong Kong is about to introduce the Voluntary Health Insurance Scheme (VHIS) to supplement its health care financing. Based on secondary materials including policy documents, press releases, and anecdotal reports, this essay compares these two recent reforms on their political context, drivers of reforms, and policy contents, and assesses their prospects in terms of coverage, financial protection, and major implementation challenges. The preliminary assessment suggests that while both programs are associated with certain drawbacks, those of the VHIS may be more fatal and warrant close attention. This essay concludes with a central caveat that underscores the pivotal role of the state in managing health care reforms.

Introducing voluntary private health insurance in a mixed medical economy: are Hong Kong citizens willing to subscribe?

BACKGROUND: Struggling to correct the public-private imbalance in its health care system, the Hong Kong SAR Government seeks to introduce a government-regulated voluntary health insurance scheme, or VHIS, a distinctive financing instrument that combines the characteristics of private insurance with strong government regulation. This study examines citizens' responses to the new scheme and their willingness to subscribe. METHODS: First-hand data were collected from a telephone survey that randomly sampled 1793 Hong Kong adults from September 2014 to February 2015. Univariate and multivariate methods were employed in data analysis. RESULTS: More than one third of the respondents explicitly stated intention of subscribing to the VHIS, a fairly high figure considering the scheme's voluntary nature. Multivariate analysis revealed moderate evidence of adverse selection, defined as individuals' opportunistic behaviors when making insurance purchasing decision based on their own assessment of risks or likelihood of making a claim. CONCLUSION: The excellent performance of Hong Kong's public medical system has had two parallel impacts. On the one hand, high-risk residents, particularly the uninsured, do not face a pressing need to switch out of the overloaded public system despite its inadequacies; this, in turn, may reduce the impact of adverse selection that may lead to detrimental effects to the insurance market. On the other hand, high satisfaction reinforces the interests of those who have both the need for better services and the ability to pay for supplementary insurance. Furthermore, the high-risk population demonstrates a moderate interest in the insurance despite the availability of government subsidies. This may offset the intended effect of the reform to some extent.

Towards Universal Health Coverage via Social Health Insurance in China: Systemic Fragmentation, Reform Imperatives, and Policy Alternatives.

China's remarkable progress in building a comprehensive social health insurance (SHI) system was swift and impressive. Yet the country's decentralized and incremental approach towards universal coverage has created a fragmented SHI system under which a series of structural deficiencies have emerged with negative impacts. First, contingent on local conditions and financing capacity, benefit packages vary considerably across schemes, leading to systematic inequity. Second, the existence of multiple schemes, complicated by massive migration, has resulted in weak portability of SHI, creating further barriers to access. Third, many individuals are enrolled on multiple schemes, which causes inefficient use of government subsidies. Moral hazard and adverse selection are not effectively managed. The Chinese government announced its blueprint for integrating the urban and rural resident schemes in early 2016, paving the way for the ultimate consolidation of all SHI schemes and equal benefits for all. This article proposes three policy alternatives to inform the consolidation: (1) a single-pool system at the prefectural level with significant government subsidies, (2) a dual-pool system at the prefectural level with risk-equalization mechanisms, and (3) a household approach without merging existing pools. Vertical integration to the provincial level is unlikely to happen in the near future. Two caveats are raised to inform this transition towards universal health coverage.

Explaining medical disputes in Chinese public hospitals: the doctor-patient relationship and its implications for health policy reforms.

In recent years China has witnessed a surge in medical disputes, including many widely reported violent riots, attacks, and protests in hospitals. This is the result of a confluence of inappropriate incentives in the health system, the consequent distorted behaviors of physicians, mounting social distrust of the medical profession, and institutional failures of the legal framework. The detrimental effects of the damaged doctor-patient relationship have begun to emerge, calling for rigorous study and serious policy intervention. Using a sequential exploratory design, this article seeks to explain medical disputes in Chinese public hospitals with primary data collected from Shenzhen City. The analysis finds that medical disputes of various forms are disturbingly widespread and reveals that inappropriate internal incentives in hospitals and the heavy workload of physicians undermine the quality of clinical encounters, which easily triggers disputes. Empirically, a heavy workload is associated with a larger number of disputes. A greater number of disputes are associated with higher-level hospitals, which can afford larger financial settlements. The resolution of disputes via the legal channel appears to be unpopular. This article argues that restoring a healthy doctor-patient relationship is no less important than other institutional aspects of health care reform.

The doctor-patient relationship, defensive medicine and overprescription in Chinese public hospitals: evidence from a cross-sectional survey in Shenzhen city.

Defensive medicine describes physicians' behavioral response to threats from medical malpractice litigation. Previous studies have found widespread practice of defensive medicine that is responsible for the global escalation of health care costs. Defying the traditional explanations, this study, with a case of a Chinese city, reveals that in a country where medical malpractice lawsuits are rare, physicians' self-perceived threats from patients may constitute a major reason for defensive practices. Defensive behaviors in the Chinese context mainly take the form of overprescribing diagnostic tests, procedures and drugs. The existing literature tends to explain this in terms of Chinese doctors' desire to supplement their low incomes. Behind this is a series of misaligned incentives deeply embedded in the Chinese health system. Using a cross-sectional survey of physicians, this study shows that overprescription in Chinese hospitals is driven not only by hard economic incentives, but also by doctors' motive of avoiding disputes with patients. The survey was carried out in Shenzhen City, in December 2013. A sample containing 504 licensed physicians was drawn by random sampling. Descriptive analyses identified significant dissatisfaction with income and workload as well as severe tensions between doctors and patients. Drawing from the literature on defensive medicine, multivariate analysis revealed that physicians' previous experience of medical disputes is significantly associated with defensive behaviors, particularly overprescription. Low income continued to be a critical predictor, reinforcing the target income hypothesis and suggesting the resilience of perverse economic incentives. This study sheds fresh light on China's recent health policy reforms by highlighting the critical impact of the doctor-patient relationship. The effort to contain health care costs must progress on two fronts, mitigating the tensions between doctors and patients while still reforming the remuneration scheme cautiously to enable physicians to respond to right incentives.

Health governance and healthcare reforms in China.

This article examines the role of health governance in shaping the outcomes of healthcare reforms in China. The analysis shows that the failure of reforms during the 1980s and 1990s was in part due to inadequate attention to key aspects in health governance, such as strategic interactions among government, providers and users, as well as incentive structures shaping their preferences and behaviour. Although more recent reforms seek to correct these flaws, they are insufficiently targeted at the fundamental governance problems that beset the sector. The article suggests that the Chinese government needs to heighten its efforts to enhance health governance and change the ways providers are paid if it is to succeed in achieving its goal of providing health care to all at affordable cost.