The data of medical expenses from the medical records of inpatients with NRCMS in Fujian Province showed that the NRCMS had made some achievements but its protective effect was limited. The hospitalization expenses and OOP ratio had decreased, and reimbursement ratio had increased for rural patients with malignant tumor from 2007 to 2016. However, the reimbursement ratio was still less than 50% and the out-of-pocket expenses still exceeded annual disposable income among patients with surgery in 2016. The disparity between coastland and inland in medical expenditure burden had statistically narrowed from 2007 to 2010, but the disparity between two areas did not significantly change from 2011 to 2016 whether among patients without or with surgery.
The Statistical Yearbook of Fujian province in 2017 reported that the number of rural population had gradually declined from 17.56 million in 2007 to 14.10 million in 2016 due to rural urbanization . Conversely, this study displayed that the number of rural inpatients with malignant tumor gradually increased during the same period. To some extent, the inconformity indirectly reflected that the prevalence rate of malignant tumor continuously increased. With the development of economy, the per capita disposable income and health awareness of residents increased so that the residents would go to hospital when they were ill [19, 20]. In addition, the unceasing improvement of NRCMS promoted the participation rate increasing which also resulted in the rise of hospital admissions [21, 22].
The State Council of China increased investments to deepen the health-care system reform between 2009 and 2011 [23, 24]. This reform focused on five aspects: basic medical security system, essential medicine system, grassroots health care services system, equity of public health service and public hospitals reform, which aimed to reduce the disease economic burden and improve the accessibility and equity of health service for residents . Although the hospitalization expenses increased, the reimbursement ratio increased and OOP ratio decreased, and the disparity between coastland and inland in medical expense indicators had statistically narrowed from 2007 to 2010. This study also showed that hospitalization expenses and OOP ratio rapidly declined starting from 2011 and reimbursement ratio was highest in 2012. These results verified the achievements which had been made by the deepening reform on health-care.
The hospitalization expenses and OOP ratio had slight rise and reimbursement ratio had about 5% reduction in 2014 compared to the previous year. It may be related to the positive effect of deepening reform on health-care gradually diminishing over time . With some problems which occurred during the deepening reform stage solved and the reform further deepened , the hospitalization expenses and OOP ratio decreased and the reimbursement ratio increased again from 2015. However, the disparity between coastland and inland in medical expense indicators did not significantly change from 2011 to 2016.
High-level hospitals with high-quality medical resources, including sophisticated experts, advanced equipment, high-quality medical service and so on, were mainly concentrated in coastland, accompanied with higher medical expenses than those in inland [27, 28]. Some inland patients who needed surgery and had better economic condition would tend to be admitted in high-level hospitals, expecting higher likelihood of survival. In this case, they faced higher consumption level which may be the reason the surgery expenses obviously increased. In contrast to increased surgery expenses, the hospitalization expenses decreased which may be associated with the positive effect of National Essential Medicines Policy on reducing medicines expenses [29, 30].
The inland patients had higher reimbursement ratio than coastland patients that may be due to the following two reasons: First, inland patients would tend to choose the treatments and pharmaceuticals which could be covered by medical insurance reimbursement directory. Second, the government took a series of measures for low-level hospitals to reallocate the medical resources, in order to encourage the patients to be admitted in hospitals which located in their place of household . One of the measures is to decrease deductible and increase reimbursement ratio in low-level hospital. The average level of deductible (reimbursement ratio) was 200 yuan (70–90%) in township hospitals, 500 yuan (60–80%) in county hospitals, 800 yuan (50–70%) in municipal hospitals and 1500 yuan (45–60%) in provincial hospitals.
Although NRCMS played an important role in reducing medical expenses and increasing reimbursement ratio for rural inpatients with malignant tumor, their medical expenditure burden was still heavy. This study showed that out-of-pocket expenses were in decline from 2007 to 2016, but they still accounted for more than 55% of hospitalization expenses in 2016. It was obviously different from that the proportion of individual medical expenditure decreased from 44.05% in 2007 to 28.78% in 2016 which was reported by China Health Statistical Yearbook in 2017 . Nevertheless, the difference could be explained. Most of rural resident had no regular physical examination for economic reasons. They were usually diagnosed as malignant tumor in middle and / or late stage with serious condition [33, 34]. In addition, the treatment of malignant tumor was more complicated and the treatment cycle was longer than the other diseases, and fewer anticarcinogens were covered by medical insurance reimbursement directory . Therefore, the proportion of individual medical expenses for patients with malignant tumor was much higher than the average level. Furthermore, per capita annual disposable income of Fujian rural residents increased year by year, but the OOP ratio was about 40% among patients without surgery and even 1.2 times among patients with surgery in 2016. The inland patients had higher OOP ratio than coastland patients. These findings implied that it was absolutely a catastrophic event if only one person in a family suffered from malignant tumor in China, especially for inland families.
Low-income residents whose household per capita income were below the local minimum living standard were admitted to participate in the basic medical insurance system with lower insurance premium than non-low income residents [23, 25]. When they get illness, they can be safeguarded by medical assistance system except for basic medical insurance system with lower deductible and higher reimbursement ceiling than non-low income patients [25, 31, 36]. Besides, low-income patients would tend to choose conservative treatment and the treatments which could be covered by medical insurance reimbursement directory. These were consistent with the results of this study that low-income patients had lower medical expenses and OOP ratio, and higher reimbursement ratio. The difference between coastland and inland low-income patients in OOP ratio was not statistically significant, implying that the medical expenditure burden was similar between two areas.
Several issues should be considered in this study. First, the trend of disparity between coastland and inland in medical expenditure burden for patients with surgery from 2011 to 2016 was assessed due to few data before 2011. Second, because of the long time span and purpose to determine whether the changes of disparity differed across surgery or not, the trend of disparity between coastland and inland were reported in two phases: from 2007 to 2010 and from 2011 to 2016. Third, the findings of multivariate analyses which were adjusted for gender, age, tumor site and hospital level were only described in the Results section; Finally, two limitations should be considered: the individual income could not be assessed limited by the data source. However, the per capita annual disposable income of each county was using which could also reflect the income situation of patients to some degree; Because medical record management systems differed across different hospitals, a patient whom may be admitted to different hospitals across regions could not be traced.