The identity of the benefits of the medical insurance system among the medical insurance- related professionals: A cross-sectional study of a northern city in China

doi:10.21203/rs.3.rs-3323334/v1

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Research Article

The identity of the benefits of the medical insurance system among the medical insurance- related professionals: A cross-sectional study of a northern city in China

https://doi.org/10.21203/rs.3.rs-3323334/v1

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Background:

The identity of the benefits of medical insurance system (IBMIS) can reflect the quality of the implementation of medical insurance policies and is valuable feedback during the deepening reform phase of medical insurance system（MIS）. This research aims to analyze the factors affecting IBMIS from the perspective of medical insurance-related professionals and to propose corresponding policy recommendations.

Methods:

In 2021, we conducted a cross-sectional questionnaire survey (n=1829) in Heilongjiang Province to obtain the data. Interviewees were selected by multi-stage stratified cluster random sampling. A binary logistic regression model was used to determine the factors affecting the IBMIS.

Results:

Overall, 66% (1,207) of medical insurance-related professionals had a high IBMIS. The logistic regression model showed that high IBMIS was positively correlated with the following dimensions: policy capacity (OR=1.562), financial burden (OR=1.512), and convenience (OR=1.300). The seven significant influencing factors (P<0.05) of the high IBMIS include: “Relief of financial burden for people with serious diseases”（OR=2.341）, “Medical insurance's ability to solve major problems that people expect” （OR=1.604）, “Governance capacity of the medical insurance administrative agencies and management Institution” （OR=1.499）, “Effectiveness of governance for off-site medical reimbursement issues”（OR=1.436）, “Effectiveness of medical insurance Payment Reform” （OR=1.399）, “The extent of information construction of medical insurance” （OR=1.361）, “Equity of medical insurance system policies” （OR=0.753）。

Conclusion:

The government should focus on reforming the medical insurance system in the following three areas: First, the management sector of medical insurance needs to continue to enhance its policy capacity, especially its ability to address the difficulties of the insured and its ability to collaborate in governance; second, it should continue to improve the affordability of out-of-pocket expenses for patients with serious diseases and expand the scope of reimbursement under the MIS to relieve the insured's financial burden; third, by strengthening the medical insurance infrastructure, the settlement service for medical treatment in other places will be made more convenient.

medical insurance system

medical insurance-related professionals

identity of the benefits

binary logistic regression

China's medical insurance system (MIS) is in a critical period of reform and has developed rapidly in various aspects in recent years [1, 2]. By the end of 2022, more than 1.36 billion people had been enrolled in the country's basic medical insurance. With the financing level and government investment increasing year by year [3], medical insurance has played a vital role in promoting the accessibility and equity of healthcare services [4, 5], and alleviating " poverty caused by disease and returning to poverty due to disease " [6]. However, previous studies have shown that the efforts made in the reform of the MIS have not been effective in enhancing the identity of the benefits of medical insurance system (IBMIS) of the insured, resulting in their low satisfaction with the MIS[7-9]. Improving the universality of medical insurance and allowing the insured to experience real benefits is a major goal of MIS reform. Medical insurance-related professionals are not only participants in the design and implementation of the MIS, but also actual evaluators and users. Their evaluation of IBMIS is a reflection under the influence of multiple factors, especially based on the actual use of various important mechanisms of4 medical insurance [10]. Therefore, it is essential to study the level, influencing factors of the medical insurance-related professionals ' IBMIS.

An analysis of the domestic and international literature reveals that among the various studies related to the MIS, the perspectives of the studies are mainly based on the insured [11, 12], patients[13, 14], the elderly [15-17], civil servants [18], and migrant workers[19]. And the scholars analyzed different research topics, such as the attitudes or choices of different groups of people towards various types of MIS [18, 20-22], the analysis of the main beneficiaries of the basic MIS[19, 23], the impact of medical insurance coverage on healthcare utilization and health outcomes[24-26], the impact of the MIS on alleviating the financial burden of the insured[27], the impact of the MIS on reducing the health poverty [28, 29], the impact of the MIS on increasing the rate of utilization of the MIS or the rate of enrollment in medical insurance[30, 31], comparative study of existing medical insurance policies [13], evaluation of the effectiveness of the medical insurance policy implementation [32]. Despite the valuable efforts made in previous research, certain deficiencies persist within the current literature. First, a few analyses of the IBMIS have been conducted based on the perspective of medical insurance-related professionals. Second, subjective assessments of the IBMIS are rarely discussed [33]. Third, there is a lack of evaluations of IBMIS across multiple dimensions.

Regarding the opinions of medical insurance-related professionals on the IBMIS, many scholars have conducted qualitative studies through interviews with the administrators of the MIS [34, 35], but the systematic quantitative study is still deficient. To make up for the lack of perspectives in previous research, we conducted a quantitative analysis from the perspectives of medical insurance-related professionals. Because insured are mainly concerned about the coverage of the MIS and the equity of the service [14, 17], and they are more inclined to judge from the perspective of their interests, which leads to a certain degree of bias in the judging criteria. On the other hand, medical insurance-related professionals can assess the MIS more objectively from the macro and micro dimensions. The opinions of medical insurance-related professionals on MIS reform can reflect the deficiencies of current medical insurance reform.

Although the question of whether MIS benefits the insured can be reflected by a series of objective data indicators, such as the reimbursement ratio of medical expenses and the proportion of OOP medical expenses to the annual income of the family. However relevant researches have shown that objective data indicators actually have a weak correlation with their political attitudes [36] and that the people's subjective feelings and evaluations about the reforms of the social system are often the constituents of the evaluation of the social reforms. Hongge Ma et al. analyzed and found that medical insurance has a contributing effect on residents' sense of well-being and access [37].

Kotakorpi and Laamanen found that increased government expenditure on social security can effectively enhance the life satisfaction of the public[38]. Empirical evidence suggests that political factors are particularly essential for achieving inclusive development in developing countries and that government welfare policies and social security system have a positive impact on people's well-being [39, 40]. As an important social security system formulated by governmental departments, simply studying the impact of increasing its expenditure on well-being cannot provide more specific reform suggestions for the future policy formulation of the MIS, and subjective well-being indicators are more subjective psychological feelings. There is a need to explore subjective evaluation indicators that are more applicable to the MIS.

Based on the foundation and insufficient of previous researches, we draw on subjective evaluation indicators such as "sense of happiness", "life satisfaction", "sense of gain"[41], and "sense of reform gains and losses " [42]. Based on the Hierarchy of Needs Theory [43] and the Social Comparison Theory [44], proposed the concept of " Identity of the Benefits of Medical Insurance System (IBMIS) ", which means that multi-parties of interest (individuals, groups, and organizations) need to transform the objective gain into an internal positive experience, and to assess the degree of benefit of insured in the MIS, it is a subjective experience of obtaining the actual financial benefits and universal rights of the MIS, and is a subjective assessment of the degree of identification with the insured’s needs satisfaction from the MIS.

In summary, current research analyzing IBMIS from the perspective of medical insurance-related professionals is grossly insufficient. As the policy designer and implementer of the MIS, how do they evaluate the IBMIS? What factors affect the insured's IBMI? How to further enhance the insured's IBMIS? The answers to these questions are decisive for promoting the future reform of the MIS. Therefore, based on the perspective of medical insurance-related professionals, we will conduct a quantitative research method to analyze the diﬀerences in the evaluation of insured with diﬀerent levels of the IBMIS and the inﬂuencing factors of the IBMIS. This study will provide new views for policymakers and other countries to further optimize the practical aspects of medical insurance reform.

2.1 Research design

We draw on the theory of user experience (UE) to design an analytical framework for the IBMIS [45]. In addition, lots of literatures have shown that factors such as "financial burden [46], convenience[12, 47], equity [48], regulation [49], informatization [12, 50], and policy quality [9] [50] " can influence people's experience of perceived benefits from MIS. Based on the above theory and literatures, we designed a 2-part questionnaire. The demographic and socioeconomic characteristics of interviewees were in first part. Interviewees 'evaluations of key performance areas of the MIS were in second part.

2.2 Sampling and data collection

The cross-sectional questionnaire survey was conducted from January to March 2021. We used multi-stage stratified cluster random sampling to select interviewees. We conducted the first phase of sampling in 12 cities including Harbin and Daqing in Heilongjiang Province. At the institutional level, the second stage of sampling was carried out, specifically grouping the staff of medical insurance administrative agencies and management institutions, medical insurance departments in hospital, medical insurance research institutions, and government agencies, and all selected staff members were invited to participate in the questionnaire survey. As the survey was conducted during the COVID-19 epidemic period, the data for this research was collected online through the Questionnaire Star platform. To ensure the quality of the data, four questionnaire auditors from Harbin Medical University performed the quality control of the questionnaire to ensure the authenticity and completeness of the questionnaire. In the end, 1897 interviewees completed the questionnaire, and after excluding unqualified questionnaires, we included 1829 samples in the analysis. We use Cronbach's α to assess the reliability of the data, and the Cronbach's α coeﬃcient in this research was 0.779 (>0.7)[51], which was within the acceptable range of reliability, indicating that the questionnaire reliability was good.

2.3 Variables

2.3.1 Dependent variable

The dependent variable was the IBMIS of medical insurance-related professionals. Interviewees responded on a 5-point Likert-type scale (1= completely disidentify, 2=disidentify, 3= neither disidentify nor identify, 4=identify, 5= completely identify).

To comply with the modeling requisites of logistic regression, we partitioned the respondents’ selections into two distinctive categories: 0=Low IBMIS (including completely disidentify, disidentify, neither disidentify nor identify); and 1 = High IBMIS (including identify and completely identify).

2.3.2 Independent variables

To prevent overlooking crucial variables, we not only incorporated the independent variables explored in prior significant research [46] [47] [48] [49] [12] [9] [50], but also sought guidance from relevant experts. we finally take the assessment of the six aspects of the MIS, namely, financial burden, convenience, equity, regulation, informatization, and policy capacity, as the independent variables.

The independent variables ’meanings were as below: (1) Evaluation of financial burden refers to the subjective experience of the MIS in reducing the financial burden of individuals or families due to expenditure on medicine. (2) Evaluation of convenience refers to the experience of convenience in accessing public services of medical insurance for all insured, including the floating population. (3) Evaluation of equity refers to the insured' experience of the equity of MIS, measures, and treatment related to their interests in the process of using medical insurance. (4) The evaluation of regulation refers to the experience of the MIS that the medical insurance fund is not abused or used in violation of the law through the medical insurance fund supervision policy and the medical insurance payment policy, so that the insured have a sense of regulation in the process of the use and management of the medical insurance fund. (5) Evaluation of informationization refers to the effectiveness of the MIS in informationization and information sharing, and the improvement of insured's experience of the efficiency of information transmission in inquiring and handling medical insurance-related business through online means. (6) Evaluation of policy capacity refers to the evaluation of the ability of the medical insurance department to scientifically formulate and effectively implement medical insurance policies.

Interviewees responded on a 5-point Likert-type scale (1 = very poor, 2 = poor, 3 = neither poor nor good, 4 = good, 5 = very good) to score the specific problems in the key performance areas of MIS (including the financial burden, convenience, equity, regulation, informatization, policy capacity).To comply with the modeling requisites of logistic regression, we partitioned the respondents’ selections into two distinctive categories: 0 = poor (including very poor, poor, neither poor nor good) and 1 = good (including good and very good).

The answers to the evaluation of the six key performance areas of the MIS (including the financial burden, convenience, equity, regulation, informatization, and policy capacity) were assigned a value: "poor" was assigned a value of 0; "good" was assigned a value of 1. The scores of the entries under each dimension are added together as the total score of the dimension, and the higher the score, the higher the positive evaluation of each dimension.

2.3.3 Control variables

In statistical analysis, we ensured control over the confounding impact caused by the demographic and socioeconomic attributes of the survey participants.

2.4 Statistical analysis

The analysis of data was performed utilizing SPSS version 25.0. Initially, the Chi-square test was employed to establish the correlation between the IBMIS and each independent variable. Then, to analyze the factors which were influenced the IBMIS, we constructed two binary logistic regression models. The first model was designed to analyze the effect of each dimension on the IBMIS. The second model is a nested binary logistic regression model with eight sub-models. Model 1 was the baseline model, which only analyzed the socio-demographic characteristics as control variables. Models 2 to 7 included the financial burden, convenience, equity, regulation, informatization, and policy capability variables of medical insurance, respectively. Model 8 was a model that includes all variables. All models were tested by the Hosmer–Lemeshow test with p-values greater than 0.05, indicating that the models fit well (Table 3). After multiple cointegration analyses, the test results showed that Tolerance > 0.1 and VIF < 10, and there was no multiple cointegration between the variables.

3.1 Basic information of the interviewees

Among the 1829 interviewees, the majority of the interviewees were female (68.4%); most of the interviewees were under 45 years of age (66.2%); their education level was above bachelor's degree (63.6%); their title level was mostly junior (47.0%) and intermediate (38.0%); their work units were mainly concentrated in the medical insurance management Institution (75.0%) and medical insurance administrative agencies (10.1%); and their organization level was mainly at the district and county levels ( 59.3%) predominated (Table 1).

3.2 Analysis of differences

Descriptive analysis of the data showed that 66% of the interviewees had a high IBMIS. The Chi-square tests showed that there were differences between the two groups in the evaluation of IBMIS for 16 out of the 25 entries in the six dimensions of the healthcare system's key performance areas. Interviewees with a high IBMIS generally gave more positive assessments to the six dimensions of financial burden, convenience, equity, regulation, informatization, and policy capability of the MIS than those with a low IBMIS. Among the interviewees with a low IBMIS, 40.4% and 46.5% of interviewees respectively thought the medical insurance's ability to solve major problems which people expect, and the governance capacity of the medical insurance administrative agencies and management Institution were insufficient; 75.6% of interviewees thought that the financial burden of insured with serious disease has not been effectively relieved; 58.7% of interviewees thought that the scope of the coverage of the MIS was insufficient; 59.7% of interviewees thought that the governance effectiveness of the problem of reimbursement of medical treatment in other places was not good; and 59.7% of interviewees thought that the governance effectiveness of the problem was not good. 59.6% of interviewees thought that the governance of the problem of reimbursement for medical care in different places was ineffective (Table 2).

3.3 Logistic regression model

After considering potential variables that may affect the results, binary logistic regression analysis shown that IBMIS was influenced by multiple dimensions, in order: policy capacity (OR=1.562), financial burden (OR=1.512), and convenience (OR=1.300) (Table 3).

A binary logistic regression nested model was used to further analyze the influencing factors of IBMIS. In terms of the explanatory strength of the sub-models on the IBMIS, the explanatory power of model 8 on the IBMIS was 31.5%, which was the strongest among all the models. It can be inferred that all six dimensions related to the key performance areas of the MIS are significant predictors of IBMIS.

After eliminating confounding factors, the logistic regression model 8 identified six factors (p <0.05) that significantly influence IBMIS:" Relief of financial burden for people with serious diseases (OR=2.341)," " Medical insurance's ability to solve major problems that people expect " (OR=1.604), " Governance capacity of the medical insurance administrative agencies and management Institution " (OR=1.499), "Effectiveness of governance for off-site medical reimbursement issues" (OR=1.436), "Effectiveness of medical insurance payment reform" (OR=1.399), "Degree of medical insurance informationization" (OR=1.361), and " Equity of MIS policies" (OR=0.753) (Table 4).

At present, China's MIS is in a critical period of reform, and feedback from different stakeholders on the implementation of medical insurance policies will have certain guiding significance for the future development of medical insurance policies. Given that the connotation and structure of the IBMIS in previous studies are not clear, and there are few quantitative studies on the IBMIS from the perspective of medical insurance professionals, this research investigates the subjective evaluation of medical insurance-related professionals on the IBMIS, and evaluates the implementation effect of current medical insurance policies in key performance areas based on their professional knowledge, In order to supplement the lack of evaluation perspective and explore the problems in the current MIS, we aim to find the direction for future medical insurance reform. The following section summarizes the current status, influencing factors, and policy recommendations of the IBMIS found in this study:

4.1 Evaluation of the implementation of the current MIS

The results of the descriptive analysis of the IBMIS show (Table 2) that all interviewees gave mostly positive evaluations of the development of the key areas of China's MIS, but gave more negative than positive evaluations of the policy equity situation of the MIS and the construction of medical insurance informatization. Similar studies have also shown that inequity among MISs and insufficient development of medical insurance informationization are the reasons for insured’s dissatisfaction with medical insurance policies [13, 15, 52]. According to the current fund-raising System, there is a large gap between the fundraising Standards of employee and resident medical insurance, which increases the difficulty of the MIS in realizing the goal of universality and equity [16, 53], leading to differences in the degree of medical insurance benefits between different groups of insured people, and therefore, the improvement of benefit equity should be a concern in the reform of future medical insurance policies[23]. It has also been shown that the lack of information leads to a low participation rate of medical insurance among the non-urban working population (especially the rural and migrant populations), and that the participation rate can be increased by 23-26% by enhancing their perception of the benefits of medical insurance [31].

4.2 IBMIS still needs to be enhanced

This study found that 66% of the interviewees had a high IBMIS. In comparison to foreign studies, the number of patients who were satisfied with public medical insurance policies in Indonesia was 42.9%[40]. Only 20–29% of Romanians had positive perceptions of healthcare provision, and the assessment of their healthcare system by the people was comparatively poorer compared to Western nations[20]. 64.0% of Europeans showed a positive perception of their national healthcare and MIS, with wealthier countries and those that spend a higher percentage of their national income on health being more likely to maintain a positive perception[54]. The above findings are similar to those of Hongge Ma [37] and Kotakorpi [38], in that social security system has an enhancement effect on residents' sense of well-being and acquisition.

Therefore, it can be inferred that, as an important social security system, when the insured obtains greater benefits from the MIS, it will increase their sense of gain from the system, which will enhance their sense of identification with the system and give them positive assessments. Analyzing the current development of global medical insurance, the gap between China's MIS and that of major developed countries is gradually narrowing, and people's positive evaluation of the MIS is higher than that of other developing countries, and is gradually converging with that of developed countries.

At the same time, this study also found that medical insurance-related professionals have a higher positive evaluation of the MIS than the insured. Some researchers found that via a questionnaire survey of 3,231 Chinese insured that 51.3% of the insured had a low or moderate level of satisfaction with MIS[8]. The reason for this situation may be due to the contradiction between the growing health demands of the insured and the limited medical insurance resources, and the discrepancy between their actual experience and their actual expectations, which results in the insured’ insufficient perception of the public welfare and the perception of benefits[55]. It is also possible that there are flaws in China's policy dissemination strategy for medical insurance [9]， which leads to a low level of knowledge of medical insurance policies among insured, thus causing insured’ evaluations of the policies to deviate from the reality. This study analyzes from the perspective of professionals, reduces cognitive bias and misjudgment caused by information asymmetry, and, considering the actual development of the current MIS, may gain evaluations of the benefits of the MIS that may better reflect the real situation.

Based on the above discussion, this study concludes that the level of IBMIS can reflect to a certain extent the degree of perfection of the development of the MIS and the value of the MIS in the minds of the public. IBMIS is related to the performance of the design and actual operation of the system itself, as well as the degree of public perceptions of the system itself.

4.3 Improving the policy capacity of medical insurance system is a prerequisite

This study found through data analysis that medical insurance-related professionals' perception of medical insurance policy capacity (OR=1.562) directly affects their evaluation of IBMIS, especially " Medical insurance's ability to solve major problems that people expect " (OR=1.604) and " Governance capacity of the medical insurance administrative agencies and management Institution" (OR=1.499), which were considered insufficient by 40.4% and 46.5% of interviewees with a low IBMIS, respectively. China's medical insurance policy quality is significantly influenced by its policy capacity. The policy capacity includes good institutional design, communication within and outside the organization, effectiveness of administration, and recognition of citizens' rights[56]. The ability to solve the major problems expected by the people reflects the ability of medical insurance to design a people-oriented system and implement policies; the ability to govern reflects the ability of medical insurance institutions to collaborate both inside and outside the organization.

Since the formation of the National Healthcare Security Administration (NHSA) in 2018, breakthrough progress has been made in deepening the reform of the MIS, and the world's largest multi-level basic medical insurance network has been established, while pioneering many policy measures with Chinese characteristics and achieving greater successes. For example, the policy of poverty alleviation through medical insurance benefited the poor population for a cumulative total of 480 million person-time in 2018, helping to alleviate their financial burdens by nearly 330 billion RMB yuan; After the outbreak of the COVID-19 at the end of 2019, the NHSA did a very good job in providing medical coverage for the COVID-19 treatment and the cost of the COVID-19 vaccine and inoculation, effectively reducing the burden on the public and the government, and pioneering the Chinese model of medical insurance to respond to public health emergency. The above achievements reflect the continuous improvement of the policy capacity of MIS, which has ensured the quality of the policy and enormously enhanced the IBMIS of the people.

However, similar studies have shown that insured are usually dissatisfied with the policy quality of MIS, which may be due to the inefficiency of the current multi-level MIS that is not yet perfect, which gives the insured a negative impression of the policy capacity of MIS[57]； or it may be due to the misunderstandings caused by the policy publicity, which leads to the insured believing that they don't get all of the benefits described in the medical insurance policy, and therefore, they believe that the policy has not been well implemented [9].

4.4 Continuing to alleviate the financial burden on insured is the key

Through data analysis, this study found that interviewees ' assessments of financial burden (OR=1.512) would directly affect their evaluation of the IBMIS, especially regarding the relief of financial burden for insured with serious diseases (OR=2.341). Among the interviewees with a low IBMIS, 75.6% thought that the financial burden of insured with serious diseases had not been effectively relieved, and 58.7% believed that the coverage of medical insurance was insufficient. This study is consistent with the findings of related studies that although the proportion of personal health expenditure of China's residents declined from 34.34% in 2012 to 27.7% in 2021, it is still higher than the average 10%-20% range of developed countries, and the financial burden of the insured is still serious[15] [59]， especially for the patients with serious diseases, which still hasn't been completely alleviated [60, 61].

Some insured have reported that not enough medicines are reimbursable by medical insurance, especially for catastrophic diseases. However, some researches have shown that as the expansion of medical insurance coverage in China has reduced the share of out-of-pocket (OOP) medical costs in total health expenditures, the OOP medical costs of the medical insurance population are about 43% lower than those of the non-medical insurance population [62], and the insurance reforms have led to a 35.2% reduction in outpatient OOP payments for urban employee enrollees[63]. The results of a study in Massachusetts, USA, showed that public medical insurance benefits and premium subsidies reduced the universal health-inclusive poverty rate by a significant one-third[28].In Vietnam, medical insurance plays a crucial role in mitigating the risk of rural households falling into poverty, leading to a significant reduction of approximately 19% [64].

Based on the above discussion, it can be deduced that inadequate coverage of medical insurance services and security, especially the economic risk-sharing mechanism for people with serious diseases, has reduced the positive evaluation of the effect of the MIS in reducing financial burdens.

4.5 Improving the convenience of MIS services is an effective approach

Data analysis in this study revealed that interviewees' assessments of convenience (OR=1.300) directly affect their IBMIS, especially concerning the " Effectiveness of governance for off-site medical reimbursement issues " (OR=1.436), which is ineffective by 59.6% of the interviewees with low IBMIS. A study on cross-regional healthcare-seeking in China showed that the most common problems encountered by patients included failure to be reimbursed for outpatient expenses (71.0%) and delayed reimbursement (59.4%) [65]. At present, there are 125 million cross-provincial migrants in China, with a strong demand for cross-regional healthcare-seeking. With the increasing proportion of cross-regional healthcare-seeking and high expenses, off-site medical reimbursement has become a difficult problem for insured and administrators to face.

According to the statistical data annual reports of the NHSA, as of the end of 2022, the number of inter-provincial networked designated medical institutions for hospitalization expenses was 63,000, which is more than a seven-fold increase compared to the end of 2017, but compared to the total number of health care institutions in the country, there is great room for improvement. In addition to the impact of the existing system design, the degree of the insured's perception of the convenience of MIS also affects the efficiency of their utilization of medical insurance services, which in turn causes them to give a negative evaluation of their experience of the convenience of MIS services[12].

In Germany, about 50% of low-income households prefer social medical insurance, while in the high-income group, this percentage drops to 20%, because private commercial medical insurance provides a more convenient medical experience and cost settlement services compared to social medical insurance, and the convenience of MIS services was influencing the insured's preference for different types of medical insurance choices[18]. Medical insurance is a quasi-public goods, and whether insured can enjoy medical insurance services in a convenient and timely manner will directly affect their experience of using them, which is an important factor for insured to judge the public services of medical insurance, and directly affects their IBMIS.

4.6 Policy recommendations

Based on the findings of this paper, to continuously improve the IBMIS, the MIS needs to focus on the following aspects of reform work in the future:

First, based on the interviewees' evaluation of the implementation of the MIS, China's medical insurance reform needs to make up for the shortcomings and promote the overall progress, especially in the aspects of equity and information development of the medical insurance policy, and continue to deepen the reform, and solve the bottlenecks in the process of the medical insurance reform step by step, so as to continue to equitably expand the beneficiary's scope and the extent of the benefits of the insured.

Secondly, in the future, in order to continuously enhance the IBMIS, it is necessary not only to continue to improve the policy itself, but also to strengthen the publicity of various aspects of the MIS, to increase the level of public perceptions of the medical insurance policy.

Third, as Bloom states, any healthcare reform program will ultimately need to address the institutional arrangements inherent in the system [58]， and increasing the relative attention of the government is an important policy tool for improving efficiency [57]. Policymakers and implementers of the MIS need to continue to pay attention to the improvement of policy capacity, especially the ability to address the difficulties of the insured and institutional governance capacity, because only if the policy capacity is sufficiently high, more people-oriented medical insurance policies can be formulated and implemented, which will enable the insured to benefit more from the MIS and enhance their IBMIS.

Fourth, in addition to continuing to play a fundamental and systematic role in reducing the burden of medical costs on the public and preventing poverty from being caused by illness and returning to poverty, China's MIS needs to improve the affordability of OOP expenses for patients with serious diseases and expand the scope of reimbursement to increase the IBMIS.

Fifth, in terms of service provision, the MIS needs to continue to simplify the filing service for cross-regional healthcare-seeking and increase the number of networked designated medical institutions for cross-regional expense settlement, so as to make it more convenient for insured to settle medical expenses in other places. Moreover, in terms of medical insurance policy and information propaganda, the medical insurance propaganda department needs to provide information that is more easily accessible and comprehensible in order to improve the efficiency of dissemination of information, so as to increase the perceptions of insured on the convenience of MIS services, and to reduce the incidence of incidents of not being able to enjoy the convenience of the services of the medical insurance due to the lack of information.

China's medical insurance reform is advancing in the direction of "people-oriented, equity and universality", and to satisfy the medical insurance demands of the whole population, it is necessary to carry out sufficient and difficult demands assessment and benefit adjustment. Therefore, this study evaluates IBMIS from the perspective of medical insurance-related professionals, to quantitatively analyze the differences in the evaluation results of interviewees with different levels of IBMIS with respect to the medical insurance key performance areas and the factors influencing the IBMIS.

This study showed that only 66% (1,207) of medical health-related professionals had a high level of IBMIS and that there was a significant effect of medical insurance policy capacity, financial burden, and convenience on IBMIS. To improve insured people's IBMIS, the government should focus on the following three aspects of reform: first, the medical insurance department needs to continue to strengthen its policy capacity, especially its ability to solve the difficulties of insured people and its ability to collaborate with institutions in governance; second, it should continue to improve the affordability of OOP expenses for patients with serious disease and expand the reimbursement scope of the MIS to alleviate insured people's financial burden; third, by strengthening the informationization infrastructure and information dissemination services, the settlement service for off-site medical treatment will become more convenient.

In addition, to continue to improve the IBMIS, it is necessary to continue to deepen the reform of the MIS in terms of equity and the development of information technology in the future, and at the same time to strengthen the publicity of various aspects of the MIS, to improve the public's perceptions of the medical insurance policy and the utilization rate.

The current paper was formed using subjective perception data reported by individuals, and it is important to note that cognitive information has a specific timeframe of recall. Hence, the judgments made regarding the relevant aspects may experience inaccuracies due to recall bias. Additionally, considering condition constraints, the survey sample only represents conditions in Heilongjiang Province and it is uncertain whether it can be generalized nationwide. To gain a comprehensive understanding of the situation in China, further investigations encompassing a wider scope of regions are necessary. Furthermore, the data encompassed a cross-sectional analysis, restricting the establishment of causality based on the results.

Despite these limitations, we believe that the findings and outcomes derived from this study offer valuable insights into the ongoing reform of medical insurance.

Medical insurance system (MIS);

Identity of the benefits of medical insurance system（IBMIS);

medical insurance-related professionals (MIRP);

National Healthcare Security Administration (NHSA);

out-of-pocket (OOP);

odds ratios (ORs).

Acknowledgments

The authors would like to thank all the participants in this study.

Authors’ contributions

Conceptualization: Zili Zhou, Linghan Shan, Ye Li, Zheng Kang, Mingli Jiao, Yanhua Hao，Qunhong Wu; Data collection: Zili Zhou, Xin Zhang, Jiahui Wang, Huan Liu; Data analysis and original draft writing: Zili Zhou, Xin Zhang, Jiahui Wang, Yanguang Chen; Interpretation of data: Zili Zhou, Linghan Shan, Ye Li, Qunhong Wu; Substantively revised the manuscript: Zili Zhou, Yanguang Chen, Linghan Shan, Ye Li, Zheng Kang, Mingli Jiao, Yanhua Hao, Qunhong Wu.

All authors read and approved the final manuscript.

Funding

This work was supported by the National Social Science Foundation of China (Grant No.19AZD013)

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Harbin Medical University. Each participant participating in this study obtained informed consent, and collected data would only be used in the scope of the study. All methods were carried out in accordance with relevant guidelines and regulations or declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Author details

¹Department of Social Medicine, School of Health Management, Harbin

Medical University, No.157 Baojian Road, Nangang District, Harbin 150081,

China.

²Department of Health Management, School of Humanities and Management, Guilin Medical University, No.1 Zhiyuan Road, Lingui District, Guilin541199, China

³School of Politics and Public Administration, Soochow University, No.199 Renai Road, Wuzhong District, Suzhou 215123, China.

⁴Department of Health Management, School of Nursing, Guilin Medical University, No.1 Zhiyuan Road, Lingui District, Guilin541199, China

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Table 1 Characteristics of all interviewees (n=1829)

Characteristic of respondent			N (%)	Low IBMIS (%)		High IBMIS (%)	χ²	P-value
Total		1829(100)		622(44.0)	1207(66.0)
Gender							0.235	0.628
	Female	1251(68.4)		430(69.1)	821(68.0)
	Male	578(31.6)		192(30.9)	386(32.0)
Age (years)							0.37	0.543
	≤44	1211(66.2)		406(65.3)	805(66.7)
	≥45	618(33.8)		216(34.7)	402(33.3)
Level of education							4.562	0.207
	College and below	665(36.4)		232(37.3)	433(35.9)
	Bachelor	1056(57.7)		345(55.5)	711(58.9)
	Master	90(4.2)		39(6.3)	51(4.2)
	PhD and above	18(0.7)		6(1.0)	12(1.0)
Major							7.552	0.183
	Clinical medicine	416(22.7)		150(24.1)	266(22.0)
	Medical insurance, social security	251(13.7)		81(13)	170(14.1)
	Management Science	327(17.9)		98(15.8)	229(19.0)
	Finance	376(20.6)		138(22.2)	238(19.7)
	Law	95(5.2)		39(6.3)	56(4.6)
	Other	364(19.9)		116(18.6)	248(20.5)
Type of work unit							13.207	0.01
	Government department	133(7.3)		56(9.0)	77(6.4)
	Universities or Research Institutes	34(1.9)		11(1.8)	23(1.9)
	Medical institutions	106(5.8)		47(7.6)	59(4.9)
	Medical Insurance Administrative agencies	185(10.1)		50(8.0)	135(11.2)
	Medical Insurance Management Institution	1371(75.0)		458(73.6)	913(75.6)
Institutional class							1.421	0.491
	District and County Level	1084(59.3)		357(57.4)	727(60.2)
	Prefectural and municipal level	577(31.5)		204(32.8)	373(30.9)
	Provincial level and above	168(9.2)		61(9.8)	107(8.9)
Academic title							3.356	0.187
	Junior and below	859(47.0)		291(46.8)	568(47.1)
	Intermediate	695(38.0)		225(36.2)	470(38.9)
	Deputy Senior and above	275(15.0)		106(17.0)	169(14.0)

Table 2 Characteristics of overall IBMIS （n=1829）

Variables		N (%)	Low IBMIS (%)	High IBMIS (%)	χ²	P-value
Financial burden
Relief of financial burden for people with Serious diseases					259.758	<0.001
	Good	927(50.7)	152(24.4)	775(64.2)
	Poor	902(49.3)	470(75.6)	432(35.8)
Sustainability of medical insurance funds					215.309	<0.001
	Good	1058(57.8)	213(34.2)	845(70.0)
	Poor	771(42.2)	409(65.8)	362(30.0)
The width and depth of medical insurance coverage					14.756	<0.001
	Good	870(47.6)	257(41.3)	613(50.8)
	Poor	959(52.4)	365(58.7)	594(49.2)
The proportion of varieties of drugs procured by centralized bidding to commonly used drugs					0.030	0.862
	Good	1183(64.7)	404(65)	779(64.5)
	Poor	646(35.3)	218(35)	428(35.5)
Convenience
Effectiveness of governance for off-site medical reimbursement issues					225.658	<0.001
	Good	1168(63.9)	251(40.4)	917(76.0)
	Poor	661(36.1)	371(59.6)	290(24.0)
Effectiveness of under-insurance management for vulnerable people and migrants					187.081	<0.001
	Good	1115(61.0)	244(39.2)	871(72.2)
	Poor	714(39.0)	378(60.8)	336(27.8)
Effectiveness of treatment for the problem of difficulties in connecting medical insurance benefits and guarantees					227.462	<0.001
	Good	1028(56.2)	198(31.8)	830(68.8)
	Poor	801(43.8)	424(68.2)	377(31.2)
Convenience of the location of the local medical insurance office					5.781	0.016
	Good	1108(60.6)	353(56.8)	755(62.6)
	Poor	721(39.4)	269(43.2)	452(37.4)
Effectiveness of treatment for the problem of medical treatment in different places (inflow and outflow)					0.605	0.437
	Good	1134(62.0)	378(60.8)	756(62.6)
	Poor	695(38.0)	244(39.2)	451(37.4)
Equity
Equity of medical insurance system policies					0.146	0.702
	Good	764(41.8)	256(41.2)	508(42.1)
	Poor	1065(58.2)	366(58.8)	699(57.9)
The current state of medical insurance inequity between different regions and systems					0.724	0.395
	Good	1001(54.7)	349(56.1)	652(54.0)
	Poor	828(45.3)	273(43.9)	555(46.0)
The economic security function of the insured to cope with catastrophic expenses					4.027	0.045
	Good	980(53.6)	313(50.3)	667(55.3)
	Poor	849(46.4)	309(49.7)	540(44.7)
The ability of vulnerable people to participate in the medical insurance fund raising process					6.984	0.008
	Good	905(49.5)	281(45.2)	624(51.7)
	Poor	924(50.5)	341(54.8)	583(48.3)
Regulation
The effectiveness of the work of medical insurance fund supervision					194.525	<0.001
	Good	1172(64.1)	263(42.3)	909(75.3)
	Poor	657(35.9)	359(57.7)	298(24.7)
Medical insurance fund use management rules situation					3.401	0.065
	Good	1147(62.7)	372(59.8)	775(64.2)
	Poor	682(37.3)	250(40.2)	432(35.8)
The normative situation of the way of medical insurance fund supervision					0.221	0.638
	Good	1361(74.4)	467(75.1)	894(74.1)
	Poor	468(25.6)	155(24.9)	313(25.9)
Effectiveness of medical insurance Payment Reform					238.386	<0.001
	Good	1124(61.5)	230(37.0)	894(74.1)
	Poor	705(38.5)	392(63.0)	313(25.9)
Informatization
The extent of information construction of medical insurance					167.417	<0.001
	Good	897(49.0)	174(28.0)	723(59.9)
	Poor	932(51.0)	448(72.0)	484(40.1)
Capacity for information sharing					6.137	0.013
	Good	1155(63.1)	417(67.0)	738(61.1)
	Poor	674(36.9)	205(33.0)	469(38.9)
Information sharing of medical insurance information among departments					2.018	0.155
	Good	676(37.0)	216(34.7)	460(38.1)
	Poor	1153(63.0)	406(65.3)	747(61.9)
Policy capability
Overall efficiency of medical insurance system operations					63.288	<0.001
	Good	1403(76.7)	409(65.8)	994(82.4)
	Poor	426(23.3)	213(34.2)	213(17.6)
Medical insurance's ability to solve major problems that people expect					137.017	<0.001
	Good	1389(75.9)	371(59.6)	1018(84.3)
	Poor	440(24.1)	251(40.4)	189(15.7)
Governance capacity of the medical insurance administrative agencies and management Institution					169.967	<0.001
	Good	1326(72.5)	333(53.5)	993(82.3)
	Poor	503(27.5)	289(46.5)	214(17.7)

Table 3 Logistic regression analysis

variables	β	Wald	P-value	OR	95% Confidence Interval
After adding the control variables
Financial burden（The score range is 0 to 4 points）	0.414	48.812	＜0.001	1.512	1.347	1.699
Convenience（The score range is 0 to 5 points）	0.262	24.396	＜0.001	1.300	1.171	1.442
Equity（The score range is 0 to 4 points）	-0.087	2.774	0.096	0.917	0.827	1.016
Regulation（The score range is 0 to 4 points）	0.049	0.536	0.464	1.050	0.922	1.195
Informatization（The score range is 0 to 3 points）	0.096	2.143	0.143	1.101	0.968	1.251
Policy capability（The score range is 0 to 3 points）	0.446	46.867	＜0.001	1.562	1.375	1.775
Constants	-1.534	5.468	0.019	0.216
Hosmer-Lemeshow Test P-value	0.791
Pseudo R²	0.270
No. of Observations	1829.000

Table 4 Logistic regression analysis（OR \Exp(B)）

Variables		Model 1	Model 2	Model 3	Model 4	Model 5	Model 6	Model 7	Model 8
Financial burden（reference: Poor）
	Relief of financial burden for people with serious diseases		3.66***						2.341***
	Sustainability of medical insurance funds		2.652***						1.245
	The width and depth of medical insurance coverage		1.240!						1.158
	The proportion of varieties of drugs procured by centralized bidding to commonly used drugs		1.133						1.235!
Convenience（reference: Poor）
	Effectiveness of under-insurance management for vulnerable people and migrants			1.48**					1.013
	Effectiveness of treatment for the problem of difficulties in connecting medical insurance benefits and guarantees			2.723***					1.288
	Effectiveness of governance for off-site medical reimbursement issues			2.267***					1.436*
	Convenience of the location of the local medical insurance office			1.050					1.050
	Effectiveness of governance for off-site medical reimbursement issues			1.016					1.088
Equity（reference: Poor）
	Equity of medical insurance system policies				1.015				0.753*
	The ability of vulnerable people to participate in the medical insurance fundraising process				1.241*				1.043
	The current state of medical insurance inequity between different regions and systems				0.908				0.814!
	The economic security function of the insured to cope with catastrophic expenses				1.154				1.181
Regulation（reference: Poor）
	The effectiveness of the work of medical insurance fund supervision					2.454***			1.188
	Medical insurance fund use management rules situation					1.049			0.949
	The normative situation of the way of medical insurance fund supervision					0.881			0.832
	Effectiveness of medical Insurance Payment Reform					3.507***			1.399*
Informatization（reference: Poor）
	The extent of information construction of medical insurance						4.094***		1.361*
	Capacity for information sharing						0.713**		0.951
	Information sharing of medical insurance information among departments						1.130		1.120
Policy capability（reference: Poor）
	Overall efficiency of medical insurance system operations							1.310*	1.210
	Medical insurance's ability to solve major problems that people expect							2.491***	1.604**
	Governance capacity of the medical insurance administrative agencies and management Institution							3.315***	1.499**
Demographic and socioeconomic characteristics
	Gender (reference: Man)	0.949	0.927	0.793!	0.962	0.762*	0.793*	0.830	0.791!
	Age (years)(reference: ≥45)	1.040	0.987	0.965	1.045	1.050	1.000	0.875	0.915
	Level of education （reference: PhD）
	College and below	0.913	0.985	0.688	0.902	0.650	0.745	0.714	0.756
	Bachelor	1.014	1.189	0.831	0.982	0.746	0.915	0.853	0.894
	Master	0.722	0.892	0.620	0.691	0.575	0.735	0.703	0.686
	Major（reference: Other）
	Clinical medicine	0.902	0.871	0.965	0.890	0.908	0.922	0.920	0.937
	Medical insurance, social security	0.994	1.187	1.166	1.012	1.160	1.086	1.074	1.284
	Management Science	1.146	1.157	1.183	1.148	1.124	1.115	1.067	1.111
	Finance	0.841	0.889	0.954	0.849	0.878	0.815	0.808	0.907
	Law	0.690	0.643	0.658	0.687	0.622!	0.692	0.653	0.656
	Type of work unit（reference: Medical insurance management Institution）
	Government department	0.708!	0.862	0.802	0.742	0.767	0.723	0.871	0.972
	Universities or Research Institutes	1.079	1.727	1.790	1.023	1.819	1.223	1.648	2.068
	Medical institutions	0.692	1.227	1.095	0.720	1.103	0.782	1.118	1.554
	Medical Insurance Administrative agencies	1.339	1.253	1.314	1.354!	1.315	1.399!	1.276	1.333
	Institutional class（reference: Provincial level and above）
	District and County Level	0.983	0.869	0.871	0.962	0.876	0.897	0.805	0.804
	Prefectural and municipal level	0.910	0.853	0.813	0.894	0.832	0.825	0.794	0.805
	Academic title（reference: Deputy Senior and above）
	Junior and below	1.140	1.032	1.103	1.147	1.019	1.079	1.109	1.061
	Intermediate	1.272	1.263	1.375!	1.273	1.270	1.265	1.279	1.333
	Constants	1.975	0.553	0.827	1.765	1.047	1.843	0.610	0.383
	Hosmer-Lemeshow Test P-value	0.213	0.189	0.805	0.876	0.443	0.188	0.246	0.140
	Pseudo R²	0.019	0.246	0.229	0.026	0.222	0.150	0.182	0.315
	No. of Observations	1829	1829	1829	1829	1829	1829	1829	1829
	Significance codes: p<0.001, * p<0.01, p<0.05, ! p<0.1.*

No competing interests reported.

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The identity of the benefits of the medical insurance system among the medical insurance- related professionals: A cross-sectional study of a northern city in China

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Abstract

1. Background

2. Methods

3. Results

4. Discussion

5. Conclusion

6. Limitations

Abbreviations

Declarations

References

Tables

Additional Declarations

Status:

Version 1