Saturday, 30 November 2013

Chinese government acts to improve 'second rate' rural medical insurance plan

Early in November, Chen Ping arrived in Beijing on what was likely to be her last trip to the capital.
The 52-year-old stayed just two days - long enough for her to say a heartfelt farewell to the doctors and nurses in the oncology department of the Chinese PLA General Hospital who have been treating her breast cancer for eight years.
Chen, who comes from a small village in Jilin province, wanted to express her gratitude to the medical staff for helping to extend her life.
She told the staff she was grateful to have lived long enough to see her sons grow up. However, as her illness is now in the terminal stages she has decided to stop receiving treatment.
One man Chen particularly wanted to see was out of town, so she was unable to say a last goodbye to Liu Duanqi, former director of the hospital's oncology department, who supervised her treatment.
Liu, looking tired after a working trip to Gansu province, said of Chen: "She's a peasant woman with a rural hukou (household registration). That means the only public medical insurance available to her is the New Rural Cooperative Medical Scheme."
The hukou system effectively ties a person to their place of birth and registration. It usually means that they are ineligible to claim social benefits or medical insurance if they receive treatment outside the place where they are registered.
"Under the medical insurance plan, patients can only go to hospitals at the district level, which usually means village or county level. Theoretically, a patient can be transferred to larger hospitals in the cities or provincial capitals if the condition is deemed too challenging for the local doctors, but that requires going through a procedure that can be daunting. As a result, it's extremely rare for a patient to be transferred outside of their home province," said Liu.
The reality facing Chen was that if she wanted to be treated at a hospital outside her hukou, for instance in Beijing, she would have to foot the bill herself, something the increasingly frail mother of two couldn't afford to do.
"Knowing that every penny that went into Chen's cure would be deducted from the funds in her bank account, which barely existed, the doctors tried to keep the disease under control and gave her an operation at minimum cost," recalled Liu. "When she left the hospital, I gave her a prescription that cost her half of 1 yuan (8 US cents) a day. She's been using the same prescription since then."
While some observers blame Chen's predicament on China's medical insurance program, it should be pointed out that the policy works in reverse for urban dwellers, whose medical insurance doesn't cover expenses incurred out of town. However, the double whammy of financial hardship and low-quality local healthcare services means residents with a rural hukou are usually hit hardest by the policy, migrant workers especially.
"If they get ill in the city - and they probably will because of the grueling workload - they have two choices; they may visit a doctor in the city and pay with their own hard-earned money, or they may choose to take the train and head home where they are covered by insurance, but that doesn't take into account the cost of the ticket and the near-certainty of losing their job," said Liu.
Now, it seems the central government is taking step to rectify the situation. Preparatory work has started on the construction of a State-level information platform to support a cross-provincial "instant reimbursement" plan for all rural residents, according to Yang Qing, director of the Rural Health Department at the Ministry of Health.
Successful implementation of the platform would mean that rural residents would be eligible for treatment at hospitals outside the areas covered by their hukou and, crucially, wouldn't have to pay the full cost themselves.Instead, they would be required to pay the difference between the total treatment cost and the amount contributed by their local medical insurance program.
Currently, patients either have to pay the entire cost of treatment, or, in the unlikely case of a transfer, claim reimbursement after returning to their hometown and submitting the requisite details and forms to the local health authority.
"For most farmers, the fact that they have to pay first - although, they rarely have the money to do so - and then claim the money back is in itself an effective barrier, not to mention the large number of cases that become bogged down in the procedural swampland," said Liu. "For one thing, just collecting all the requisite materials and getting them rubber-stamped could prove maddening. In many cases, it would be a 'mission impossible.'"
The proposed instant reimbursement plan was specifically designed to address the issue. China's 260 million migrant workers - most of whom left their rural homes in search of better opportunities and higher pay in cities such as Beijing and Shanghai - were uppermost in the decision-makers' minds when they were formulating the policy.
Although the plan may sound like good news for migrant workers, they'll still have to wait for it to be implemented, and probably for a very long time, according to Zhang Yi, director of the Beijing New Rural Cooperative Medical Scheme Management Center. "As far as I know, the whole cross-provincial thing is still very much an idea," he said, referring to media reports that the plan will soon cover Beijing and eight provinces, including Jiangsu, Anhui, Henan and Hunan.
"Taking the regional differences into account, the New Rural Cooperative Medical Scheme is designed to operate at the district or county level. Each district has the right to make its own rules regarding the details, including the percentage of costs and the list of medicines covered by insurance. For example, Beijing has 16 districts and 13 of them have a combined rural population of three million. As a result, in Beijing alone more than 10 different schemes are being implemented at the same time," he said.
"China has nearly 3,000 counties. The realization of instant reimbursement nationwide would necessitate inputting all the relevant patient information into the computers at hospitals' cost-settlement centers simply so the staff could calculate and write off the amount covered by the specific insurance scheme the patient subscribes to in their hometown."
For many observers, the technical challenge is the least daunting aspect, dwarfed as it is by a much bigger problem - competing local interests. Local governments can recoup part of the cost of medical insurance through tax if an eligible patient is treated at a hospital within their province. However, the same government would be 'giving' money permanently to another province if the patient opted for treatment at a hospital outside the province. Given China's demographic flow, if the reimbursement plan is put into practice, cash-strapped rural provinces stand to lose money to their counterparts in the economically developed eastern and southeastern regions.
In the face of this administrative nightmare, Wang Ningli, deputy director of the Beijing Tongren Hospital, the country's most prestigious eye hospital, offered what he believed to be a radical and fundamental solution.
"In the case of migrant workers, I strongly recommend that their adopted hometown gives them the same insurance cover as regular urban citizens, on condition that they have worked there for a relatively long and continuous period of time," he said. "Failure to do this amounts to a form of discrimination."
"As for the problems long inflicted on Chinese peasants by the less-than-equitable healthcare policy, the cross-provincial reimbursement plan would only provide an analgesic, not a cure," Wang continued. "In the short term, it might serve to ease growing social tensions by turning down the volume of complaints, but in the long term, it risks creating more problems than the government could ever imagine or solve."
In other words, the plan may represent treacherous waters for policy makers, while providing little more than nominal benefit to those it is intended to help - the impoverished and neglected.
One fatal drawback, according to Wang, is the potential devastation of the already threadbare healthcare delivery system in the vast rural areas, coupled with the growing burden on overused hospitals in the cities. "If realized, the plan would channel vast numbers of people from far away to places like ours," he said, pointing to a corridor filled with parcels and backpacks left by patients who had arrived at the hospital straight from the railway station. "The immediate effect would be a compromised service, where each patient is allocated five minutes and no more."
That's unlikely to be the only disadvantage, because other factors would come into play, according to Liu. "Do you really think that those farmers, whose identity is obvious from their wind-whipped, deep-furrowed faces, would get the same treatment as wealthier, well-turned-out patients who think nothing of handing doctors a handsome amount of 'thank you' money?" he asked. "They would almost certainly face a longer wait for surgery or tests and in the meantime they would just exhaust the funds they've saved for a possible cure."
Reflecting on his recent journey to Gansu, one of China's least-developed provinces, Liu said the reimbursement plan won't lessen wealth-based healthcare inequality, but exacerbate it. "Believe me, the people who'll make the most of the new policy are those with the financial means and who happen to live outside the major cities," he said. "In the mountain village I have just visited, the local people almost never leave, no matter if they are ill or not. Why? Because they can't afford the travel tickets."
"For them - and by extension the entire rural population - the only way to offer any real help is to greatly improve the quality of local healthcare services, large parts of which are in a shocking condition at the moment," he said. "In this respect, we could learn from some of the most-developed countries," said Liu.
Wang, who gained a doctorate in ophthalmology in the United States, echoed that view. "In the US, residents of rural villages seldom travel to big cities for medical treatment because they can always reach a decent doctor within an hour's drive," he said. "In China, the rural clinics and hospitals have an extremely long way to go before they can be as effective and earn public trust."
The government has a decisive role to play, according to Liu. "The grassroots hospitals are bad for reasons we all know about: There are very few good doctors in them and for decades, we've carried out a policy that elevates city doctors while leaving their rural counterparts out in the cold. Rural doctors are badly paid, have few good teachers and zero opportunity to go abroad to pursue their academic interests. In a word, they have nothing."
Compounding the issue is the system by which all doctors in China are assessed against the same set of benchmarks, which heavily favor physicians in first-class city hospitals. "One important index the evaluators look for is the number of research papers a doctor has published in leading international journals. But, in reality, a great country doctor is one who's capable of handling localized illnesses quickly and effectively and knows how to prevent a disease that might turn into an epidemic."
For Liu, the insistence on research papers and publication is partly rooted in the urban-rural divide. "I've met many local officials and have heard them argue that rural residents should receive a lower level of medical coverage because they've paid less tax compared with city dwellers. Well, I just have one question to ask them; why are rural residents so poor?" he asked. "During the past few decades, despite changes in the political wind, the farmers always seem to have been on the losing side. It's time we gave something back to the people whose hard work has fed the entire nation."
But whatever happens in the future, it won't benefit people like Chen, struggling with the system right now. Looking back over his eight-year association with Chen, Liu said:- "The first time she came to me, she had postponed her treatment - the illness was at a critical stage and she had no money. The last time she came, a week or so ago, she knew the cancer was in full swing, but I was told that she left without even having a ultrasound scan; she's penniless and didn't want to ask us for another favor. To see a patient, a mother, give up twice has been a traumatic experience. I sometimes ask myself: what if she were able to live for another eight years?"
Source: Women of China

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