Medical Insurance Information Systems in China: Mixed Methods Study

Abstract

Background Since the People’s Republic of China (PRC), or China, established the basic medical insurance system (MIS) in 1998, the medical insurance information systems (MIISs) in China have effectively supported the operation of the MIS through several phases of development; the phases included a stand-alone version, the internet, and big data. In 2018, China’s national medical security systems were integrated, while MIISs were facing reconstruction. We summarized China’s experience in medical insurance informatization over the past 20 years, aiming to provide a reference for the building of a new basic MIS for China and for developing countries. Objective This paper aims to sort out medical insurance informatization policies throughout the years, use questionnaires to determine the status quo of provincial MIIS-building in China and the relevant policies, provide references and suggestions for the top-level design and implementation of the information systems in the transitional period of China’s MIS reform, and provide a reference for the building of MIISs in developing countries. Methods We conducted policy analysis by collecting the laws, regulations, and policy documents—issued from 1998 to 2020—on China's medical insurance and its informatization; we also analyzed the US Health Insurance Portability and Accountability Act and other relevant policies. We conducted a questionnaire survey by sending out questionnaires to 31 Chinese, provincial, medical security bureaus to collect information about network links, system functions, data exchange, standards and specifications, and building modes, among other items. We conducted a literature review by searching for documents about relevant laws and policies, building methods, application results, and other documents related to MIISs; we conducted searches using PubMed, Elsevier, China National Knowledge Infrastructure, and other major literature databases. We conducted telephone interviews to verify the results of questionnaires and to understand the focus issues concerning the building of China’s national MIISs during the period of integration and transition of China's MIS. Results In 74% (23/31) of the regions in China, MIISs were networked through dedicated fiber optic lines. In 65% (20/31) of the regions in China, MIISs supported identity recognition based on both ID cards and social security cards. In 55% (17/31) of the regions in China, MIISs at provincial and municipal levels were networked and have gathered basic medical insurance data, whereas MIISs were connected to health insurance companies in 35% (11/31) of the regions in China. China’s MIISs are comprised of 11 basic functional modules, among which the modules of business operation, transregional referral, reimbursement, and monitoring systems are widely applied. MIISs in 83% (20/24) of Chinese provinces have stored data on coverage, payment, and settlement compensation of medical insurance. However, in terms of data security and privacy protection, pertinent policies are absent and data utilization is not in-depth enough. Respondents to telephone interviews universally reflected on the following issues and suggestions: in the period of integration and transition of MISs, close attention should be paid to the top-level design, and repeated investment should be avoided for the building of MIISs; MIISs should be adapted to the health care reform, and efforts should be made to strengthen the informatization support for the reform of payment methods; and MIISs should be adapted for the widespread application of mobile phones and should provide insured persons with more self-service functions. Conclusions In the future, the building of China’s basic MIISs should be deployed at the national, provincial, prefectural, and municipal levels on a unified basis. Efforts should be made to strengthen the development of standard codes, data exchange, and data utilization. Work should be done to formulate the rules and regulations for security and privacy protection and to balance the right to be informed with the mining and utilization of big data. Efforts should be made to intensify the interconnectivity between MISs and other health systems and to strengthen the application of medical insurance information in public health monitoring and early warning systems; this would ultimately improve the degree of trust from stakeholders, including individuals, medical service providers, and public health institutions, in the basic MIISs.

Issues related to the health status, work pressure and occupational environments of medical staff at level A tertiary public hospitals in Shanghai

“…Current medical service salaries do not fully reflect the technical and labor value of medical staff, and as a result, medical staff feel that there is a pay-return imbalance. On December 28, 2019, at the 15th meeting of the Standing Committee, the 13th National People's Congress passed the Basic Medical Hygiene and Health Promotion Law of the People's Republic, which provides a unique personnel, salary, and reward system that reflects the professional characteristics and technical labor value of medical and health personnel (4,5).…”

The positive association between internal migration and hospitalization among the older adults in China: Regional heterogeneity and chronic disease management

“…With respect to migrants diagnosed with chronic disease, pre-adulthood migration and pre-retirement migration were found irrelevant to hospitalization, whereas post-retirement migrants were at a higher risk of hospitalization (OR = 1.51; 95% CI: 1.04-2. 19). Notably, the highest OR (1.98; 95% CI: 1.36-2.89) in the study reveals the population group most susceptible to hospitalization, the post-retirement urban migrants with unconfirmed chronic conditions living in eastern China.…”

“…In addition, previous research has discovered a strong substitution element between outpatient services and inpatient services ( 19 ). Owing to the non-portability of health insurance ( 20 ), Chinese migrants are unable to meet the expenses at the location where they receive outpatient services, thereby reducing outpatient visits and preferring treatment delay ( 21 , 22 ). Inadequate access to care has been linked to physical disability, cognitive impairment, and an increased risk of mortality ( 23 ).…”

“…Considerable migrants receive deficient chronic disease management (18). In addition, previous research has discovered a strong substitution element between outpatient services and inpatient services (19). Owing to the non-portability of health insurance (20), Chinese migrants are unable to meet the expenses at the location where they receive outpatient services, thereby reducing outpatient visits and preferring treatment delay (21,22).…”

A Questionnaire Based on A Sub-Regional Hierarchical Level Showed the Following: Application of Medical Accident Insurance is Suitable in Shanghai, China

“…A complete medical risk insurance system shouldn't only include the medical liability insurance, should also include the medical accident insurance and medical personnel practice insurance [10]. Although the Chinese law has always encouraged the establishment of medical accident insurance, it is still blank or at the exploring stage in the most regions of China [11]. In China, voluntary or semi-compulsory insurance has been implemented in the transportation, tourism and other industries.…”