The way eye health services are financed plays a large role in the take up of surgery. When people cannot afford the high cost of eye care, they either choose not to have surgery and become blind or risk putting the family in deeper poverty by paying for the surgery. Lack of reimbursement for outpatient costs, policies for reimbursement levels for consumables, and lower reimbursement ratios for higher levels of care, among other policies, all have key implications for eye care services in China. With support from the Seeing is Believing V Project, The Fred Hollows Foundation conducted a health financing study in Yunnan, China, which aimed to explore the financial (along with other) barriers to taking up services and financial protection in eye health (particularly cataract surgery). This study also draws out implications for protecting already poor populations from further risk of financial hardship and impoverishment by ensuring by paying for eye care services.
The study was undertaken in four counties within two prefectures in Yunnan Province between 2016 and 2018. It analysed of health insurance policy changes from 2013 to 2017, reviewing existing policy and its implementation at provincial, prefecture and county levels with a focus on cataract service. Barriers to taking up surgery and out of pocket costs and burdens were explored through focus group discussions and a purpose designed telephone interview. In total, 212 patients were interviewed. Half of the surveyed patients had undergone surgery (between 2017 and 2018).
In general, the proportion of health insurance contributions paid by the patient compared with government subsidies has increased over time in Yunnan province. The level of required co-payment (or deductible) also increased over time, placing additional financial pressures on households. In addition to higher co-payments / deductibles, the proportion of total expenses covered under the NCMS and URBMI schemes are higher at lower levels of care. This means that patients requiring surgical services and other services only available at higher levels of care are particularly susceptible to incurring catastrophic levels of out of pocket health expenses, lowering financial protection. This has particular implications for eye health where cataract surgery can only be conducted at county hospital level upwards and for DR treatment which can only be provided at the prefecture level hospital and above.
A further concern influencing the level of out of pocket costs paid by patients is that outpatient services are rarely covered under NCMS / URBMI. According to the policy, outpatient costs can only be reimbursed in local village and township clinics with per visit, per month and per annual caps (under NCMS). Data from the telephone interviews showed that only one fifth of diagnoses (20.3%) occur at lower levels of the system such as in township clinics. This has implications for higher out of pocket costs due to lower proportionate reimbursements at higher levels of care. When providers choose to deliver services in an inpatient setting, this further increases an already high rate of cost escalation in the health system.
Costs and reimbursement of intra-ocular lenses (IOLs), which are inserted into patients’ eyes during cataract surgery to replace the cloudy lens that cataract causes, play a key role on driving up the out of pocket costs. Data collected from the hospitals showed that the cost of an IOL ranges from 156 Yuan to nearly 10,000 Yuan (US$22-US$1,400). The majority of IOLs were in the range of 1500 and 3500 Yuan with an average out of pocket payment of 2219 Yuan across prefecture level hospitals and 1065 Yuan at county level hospitals. Incentives created by higher margins and other benefits arising from imported IOLs being used by hospitals creates the risk that patients could be unknowingly misled to purchasing higher priced IOLs (on the assumption they are receiving higher quality lenses or patient outcomes, when it actually does not make a difference.) In addition, the cost of staying in hospital is a key factor for high out of pocket costs for surgery. Data from the 106 patients interviewed by telephone who had cataract surgery showed that patient having higher lengths of stay (defined as more than 3 days) experienced higher out of pocket surgery costs.
Overall, cataract surgical patients in both prefectures experienced similar out of pocket costs from cataract surgery at a median of USD280 across both prefectures. Using data on average per capital incomes from county level Statistical Communique of the National Economics and Social Development committees for 2016, out of pocket costs from cataract surgery in the study counties represented between 2% and 8.5% of an urban resident’s annual income and between 6% and 25% of a rural resident’s annual income – an extraordinarily high proportion. Data also shows that a far greater proportion of patients in the poorest quartile reported difficulties paying for their cataract surgery and nearly half of those (47.6%) in the poorest quartile, had to borrow money or sell assets to pay for their cataract surgery. It can lead to even further household impoverishment over a long period from loss of resilience (through selling of assets) or from further debt being incurred.
Despite the above, the overwhelming barrier to surgery was the perception that it was unnecessary (50% of those not having had surgery) with the second highest reasons being fear of the surgery itself (15.1%). Only 9% said cost expectations were a barrier, though this was the third highest reason. Given the high burden of out of pocket costs shown above, however, this could be the result of people being used to high costs associated with health care systems or because cost is not well known up front. Price expectation was not a major determinant of choice of facility but this is much more likely to be due to the lack of knowledge on likely cost or even potential range of the charge across facilities.
Existing health financing arrangements under the newly merged NCMS / URBMI eye health services represent potentially large out of pocket costs to patients and therefore financial hardship risks, particularly to poorer rural populations of Yunnan. Greater regulation of IOL charges along with standardised information about cataract surgery and IOLs given to patients across the province may help increase financial risk protection.
For potential coverage, cost efficiency and financial access, coverage of outpatient costs for selected services and procedures should be considered, such as outpatient based day surgery, cataract surgery. In addition, simplification of reimbursement regulations along with greater consistency and transparency in charges would be useful.
To date, much of the quantitative analysis provided has been based on relatively small numbers when differences between and within areas is considered. In addition, given time limitations and concerns regarding participation, a rapid approach to gathering out of pocket costs and financial barrier information was undertaken through telephone interviews. Similarly, the out of pocket cost question was limited to one overall amount rather than listing different aspects of the care pathway and inputs. Such overall estimates have a tendency to underestimate out of pocket costs, making the above estimated out of pocket costs unreliable. To address the above limitations, follow up work is planned as part of the last phase of the project. This will involve face to face household surveys in the study areas which will provide more robust estimates of out of pocket burden.
It was difficult to access health insurance related data from government departments, so the Project involved key informants from the health commission from the beginning of the research. Another challenge was to draw attention of government at national level on health financing arrangement and financial protections. To address that, the project received experts from Beijing University who were involved in the study, and linked the research and its results with national medical reform initiatives at the national level. Finally, changing the national health financing policy takes a long time, therefore it is important to have a long-term approach and evidence to advocate for change at the policy-level.
Ms WANG Jing, Senior Project Officer, firstname.lastname@example.org
Ms. NI Ming, Project Manager, email@example.com
Ms. Amanda Huang, Country Manager, firstname.lastname@example.org
 The New Cooperative Medical Scheme (NCMS).
 The Urban Residents Basic Medical Insurance (URBMI)