CSIRO PUBLISHING

Australian Health Review

http://dx.doi.org/10.1071/AH16056

Effect of health insurance on direct hospitalisation costs

for in-patients with ischaemic stroke in China

Ma Yong1,2 PhD, Researcher

Xiong Xianjun2 PhD, Researcher
Li Jinghu2 MD, Researcher
Fang Yunyun1,3 PhD, Professor
1
School of Management, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District,
China. Email: mayong_0517@163.com
2
China Health Insurance Research Association, No. 7, Hepingli Zhangjie, Dongcheng District, Beijing, China.
Email: Xiongxianjun1@mohrss.gov.cn; Lijinghu1@mohrss.gov.cn
3
Corresponding author. Email: fyybj@vip.sina.com

Abstract
Objectives. The aim of the present study was to determine the direct medical costs of hospitalisations for ischaemic
stroke (IS) in-patients with different types of health insurance in China and to analyse the demographic characteristics of
hospitalised patients, based on data supplied by the China Health Insurance Research Association (CHIRA).
Methods. A nationwide and cross-sectional sample of IS in-patients with International Classifications of Diseases 10th
Revision (ICD-10) Code I63 who were ensured under either the Basic Medical Insurance Scheme for Employees (BMISE)
or the Basic Medical Insurance Scheme for Urban Residents (BMISUR) was extracted from the CHIRA claims database.
A retrospective analysis was used with regard to patient demographics, total hospital charges and costs.
Results. Of the 49 588 hospitalised patients who had been diagnosed with IS in the CHIRA claims database, 28 850
(58.2%) were men (mean age 67.34 years) and 20 738 (41.8%) were women (mean age 69.75 years). Of all patients, 40 347
(81.4%) were insured by the BMISE, whereas 8724 (17.6%) were insured by the BMISUR; the mean age of these groups
was 68.55 and 67.62 years respectively. For BMISE-insured in-patients, the cost per hospitalisation was RMB10 131 (95%
confidence interval (CI) 10 014–10 258), the cost per hospital day was RMB787 (95% CI 766–808), the out-of-pocket costs
per patient were RMB2346 (95% CI 2303–2388) and the reimbursement rate was 74.61% (95% CI 74.48–74.73%). For
BMISUR-insured in-patients the cost per hospitalisation was RMB7662 (95% CI 7473–7852), the cost per hospital day
was RMB744 (95% CI 706–781), the out-of-pocket costs per patient were RMB3356 (95% CI 3258–3454) and the
reimbursement rate was 56.46% (95% CI 56.08–56.84%).
Conclusions. Costs per hospitalisation, costs per hospital day and the reimbursement rate were higher for BMISE- than
BMISUR-insured in-patients, but BMISE-insured patients had lower out-of-pocket costs. The financial burden was higher
for BMISUR- than BMISE-insured in-patients. For BMISUR-insured in-patients, the out-of-pocket payment was 43.54%
of total expenses, which means the government should increase the financial investment, raise reimbursement rates and set
up differential reimbursements to meet the health needs of in-patients with different income levels.

What is known about the topic? Cardiovascular and cerebrovascular diseases are major non-communicable diseases
affecting the health of the Chinese population. The China Health Statistics Yearbook (2013) reported that across all in-
patients, 195 million (5.82%) had been discharged with a diagnosis of cerebrovascular disease. Of these, 118 million had IS,
accounting for 60.51% of all in-patients with cerebrovascular disease and 54.97% of hospitalisation costs for all
cerebrovascular disease in-patients. After the two basic insurance systems, namely the BMISE and BMISUR, had been
established, the out-of-pocket expenses for patients were reduced. However, to date there have been no studies investigating
how the different types of health insurance (i.e. the BMISE and the BMISUR) affected the costs of treatment of IS in-patients
in China.
What does this paper add? This paper reports the direct costs for patients diagnosed with IS based on data supplied by
the CHIRA. Direct hospitalisation costs depending on the type of insurance cover, age and gender were also evaluated.
What are the implications for practitioners? The present study found that the personal financial burden of disease
treatment was higher for in-patients insured under the BMISUR than BMISE. For in-patients insured under the BMISUR,
the out-of-pocket payment was 43.54% of total expenses, which means the government should increase the financial

Journal compilation
AHHA 2017 www.publish.csiro.au/journals/ahr

B Australian Health Review
investment, raise reimbursement rates and set up differential reimbursement rates to meet the health needs of patients with
different incomes.
Additional keywords: ischaemic stroke, in-patients, health insurance, direct hospitalization costs.
Received 16 September 2016, accepted 15 November 2016, published online 7 March 2017
Introduction
With recent changes in living habits, dietary preferences and
aging in China, non-communicable diseases have become sig-
nificant factors affecting human health.1 Cardiovascular and
cerebrovascular diseases, as major non-communicable diseases
(NCDs), had a considerable effect on the health of the Chinese
population. In 2008, cerebrovascular disease killed approximate-
ly 17.5 million people in China, accounting for 46% of all NCD
deaths; 7.4 and 6.7 million people died from ischaemic heart
disease and stroke respectively.2 The China Health Statistics Year
book (2013) reported that the number of patients discharged after
treatment for cerebrovascular disease was 195 million, account-
ing for 5.82% of all in-patients.3 Of these, 118 million patients had
been treated for ischaemic stroke (IS), accounting for 60.51% of
all cerebrovascular disease patients, with the costs of hospitalisa-
tion for IS patients accounting for 54.97% of costs for all patients
with cerebrovascular disease.3 Many studies have shown that IS
accounts for 60–80% of total strokes,4,5 with the percentage of IS
increasing.6–8
In order to reduce the economic burden on patients, China has
had a national health care system since 1998. The Basic Medical
Insurance Scheme for Employees (BMISE), launched in 1998,
covers urban employees and retirees, some urban residents with
flexible employment and rural migrant workers. The insurance
premiums for the BMISE are funded by employers and employ-
ees. In 2007, the Chinese government started to establish the
Basic Medical Insurance Scheme for Urban Residents (BMISUR)
to provide medical benefits to all urban residents, excluding those
covered by the BMISE. By setting up these two basic insurance
systems, the out-of-pocket payments made by patients were
reduced. In other countries, such as Germany, previous studies
have shown that hospitalisation expenses are insurance and age
specific,9 but there are no reports about how the different health
insurance schemes affect the costs of IS for in-patients in China.
Thus, the aim of the present study was to determine the direct
costs for patients diagnosed with IS, based on data supplied by
the China Health Insurance Research Association (CHIRA). The
direct hospitalisation costs according to type of care, age and
gender were also evaluated.
Methods
Data sources
The present evaluation was based on a retrospective analysis of
in-patient data from 2010 to 2012 supplied by the CHIRA for in-
patients with a diagnosis of IS (International Classifications of
Diseases 10th Revision (ICD-10; http://apps.who.int/classifica
tions/icd10/browse/2010/en#/X, accessed 29 January 2017)
Code I63). The CHIRA database contains hospital records for
in-patients across mainland China, including patients covered by
M. Yong et al.
the mainstream health insurance schemes, namely the BMISE and
BMISUR. Data from the CHIRA were subjected to a two-stage
sampling design. In the first stage, convenience sampling was
used to include four municipalities directly under the Central
Government (Beijing, Shanghai, Tianjin and Chongqing), most
provincial capital cities and other cities and counties for which
the Medical Insurance Bureau was able and willing to provide
electronic hospital record data. In the second stage, systematic
random sampling was used to extract 2% of beneficiaries from
municipalities, 5% of those from provincial capital cities and
10% of those from other participating cities and counties.10
Statistical analysis
In-patient characteristics are described using mean  s.d. values,
as well as frequencies, as appropriate. Continuous data were
analysed using analysis of variance (ANOVA). Two-sided
P < 0.05 was considered significant. In addition, 95% confidence
intervals (CIs) were determined. The statistical analyses were
conducted using SPSS version 20.0 (IBM Inc.).
Results
Sample characteristics
Of the 49 588 hospitalised patients diagnosed with IS in the
CHIRA claims database, 28 850 (58.2%) were men, with a mean
age of 67.34  11.72 years, and 20 738 (41.8%) were women
(mean age 69.75  11.24 years). With regard to age distribution,
mean age was higher for women than men, with an almost 2-year
age gap. The age distribution differed significantly between men
and women (P < 0.05). The largest proportion of hospitalised
patients was aged 70–79 years, but the proportion was higher in
females than in males over 70 years of age. The age distributions
and percentage of patients hospitalised for IS according to gender
are shown in Fig. 1.
In 2010, 2011 and 2012, the mean age of IS in-patients was
69.21  11.74, 67.68  11.49 and 68.61  11.49 years respec-
tively and the age distribution of patients did not differ signifi-
cantly among years (Fig. 2).
In terms of the two insurance schemes, 40 347 (81.4%) of
patients were insured by the BMISE and 8724 (17.8%) were
insured by the BMISUR. The mean age of patients insured by
the BMISE and BMISUR differed significantly (68.55  11.40
vs 67.62  12.30 years respectively; P < 0.05). Regardless of
insurance type (BMISE or BMISUR), the age at which IS
occurred was earlier for men than women (67.85  11.57 vs
69.62  11.08 years respectively for BMISE (P < 0.05);
64.08  12.19 vs 70.08  11.72 years respectively for BMISUR
(P < 0.05)). The age gap between genders was greater for those
insured with the BMISUR than the BMISE. The age distribution
Ischaemic stroke Australian Health Review C

40 40
Male (n = 28 850) BMISE (n = 40 743)
35 35
Female (n = 20 738) BMISUR (n = 8 845)
30 30
% Subjects

% Subjects
25 25
20 20
15 15
10 10
5 5
0 0
<30 30–39 40–49 50–59 60–69 70–79 >80 <30 30–39 40–49 50–59 60–69 70–79 >80
Age (years) Age (years)

Fig. 1. Distribution of age and percent of inpatients admitted for ischemic Fig. 3. Distribution of age and percent of inpatients admitted for ischemic
stroke inpatients by gender. stroke inpatients by types of care.

to 2012, expenditure per hospital day differed significantly for

40 each year (P < 0.05, Table 1). Costs per day were higher for men
2010 (n = 12 412)
in all years and regardless of insurance scheme and age. When
35 2011 (n = 20 206) considering the different sex, there was a significant difference
30 2012 (n = 16 971) (P < 0.05) for BMISE in-patients. The highest costs per
% Subjects

25 hospital day for BMISE-insured patients were for those aged

20
15
10
5
0 Reimbursement rates according to medical insurance
<30 30–39 40–49 50–59 60–69
Age (years)
Fig. 2. Distribution of age and percent of inpatients admitted for ischemic
stroke inpatients by years.
and percentage of in-patients admitted for IS for the different
types of insurance are shown in Fig. 3.
Costs per hospitalisation
Costs per hospitalisation were significantly higher (P < 0.05) for
BMISE-insured in-patients, above RMB2500 (A$390; RMB1 =
A$0.1428, 0.1510, 0.1738), from 2010 to 2012. The average cost
per hospitalisation did not differ significantly with age and sex.
Cost per hospitalisation was directly related to age, with the
highest costs per hospitalisation found for patients <40 and
>80 years of age. In addition, there were significant differences
among the six age groups (<40,40–49,50–59,60–69,70–79, 80)
(P < 0.05). Furthermore, with regard to the type of medical
institution, had higher costs per hospitalisation were associated
with third-level hospitals (classified by Chinese government
according to administrative ranks) compared with other types of
hospitals (P < 0.01; Table 1).
80 years, whereas for BMISUR-insured patients the highest
costs were for those aged <40 years of age, and there were
significant differences in cost (P < 0.05) among the six age
groups. In addition, costs per hospital day differed significantly
(P < 0.01) between different medical institutions (Table 1).
70–79 >80 scheme
The reimbursement rate for BMISE- and BMISUR-insured
patients differed significantly (74.61% vs 56.46% respectively;
P < 0.01). From 2010 to 2012, the reimbursement rate had in-
creased continuously (P < 0.01). For the BMISE, the reimburse-
ment rate for medical insurance continued to increase with age
(P < 0.01), with the highest reimbursement rate being 78% for those
>80 years of age. In the case of the BMISUR, the reimbursement
rate changed little with age. For both BMISE- and BMISUR-
insured patients, the reimbursement rate differed between different
types of hospitals, with the highest reimbursement rate for
hospitals below second-level hospitals (P < 0.01; Table 2).
Out-of-pocket expenses
Out-of-pocket expenses for each hospitalisation differed signif-
icantly between BMISE- and BMISUR-insured patients
(RMB2500 (A$390) vs RMB3500 (A$546) respectively;
P < 0.01). From 2010 to 2012, individual payments were signif-
icant differences (P < 0.01). With increasing age, out-of-pocket
expenses decreased for BMISE-insured patients when they
went to hospital (P < 0.01), whereas those for BMISUR-insured
patients increased. Out-of-pocket expenses were significantly
higher for third-level hospitals (P < 0.01; Table 2).

Costs per hospital day Discussion

There were no significant differences in the average costs Of patients hospitalised between 2010 and 2012, 49 588 in-
per hospital day (approximately RMB750 (A$117) per day) patients with a primary discharge diagnosis of IS were selected
between BMISE- and BMISUR-insured patients. From 2010 for analysis in the present study. Among these patients, the
D Australian Health Review M. Yong et al.

Table 1. Costs per hospitalisation and per hospital day for ischaemic stroke in-patients according to the type of insurance scheme
Data show costs with 95% confidence intervals in parentheses. BMISE, Basic Medical Insurance Scheme for Employees; BMISUR; Basic Medical Insurance
Scheme for Urban Residents; CPH, cost per hospitalisation; CPHD, cost per hospital day; TLH, third-level hospitals; SLH, second-level hospitals; BSLH, below
second-level hospitals

BMISE BMISUR
CPH (RMB) CPHD (RMB) CPH (RMB) CPHD (RMB)
Total 10 131 (10 014–10 258) 787 (766–808) 7662 (7473–7852) 744 (706–781)
Year
2010 9946 (9688–10 205) 622 (596) 7732 (7310–8155) 587 (557–617)
2011 9439 (9263–9616) 948 (900) 7500 (7186–7813) 941 (849–1034)
2012 11 143 (10 927–11 359) 715 (703) 7781 (7500–8062) 636 (616–655)
Gender
Male 10 236 (10 074–10 398) 820 (789) 7490 (7172–7807) 745 (680–810)
Female 9889 (9704–10 074) 736 (709) 7665 (7438–7892) 740 (694–786)
Age (years)
<40 11 474 (9545–13 403) 849 (681) 7932 (6280–9584) 1065 (642–1487)
40–49 9538 (8847–10 229) 918 (770) 6670 (6141–7199) 585 (512–658)
50–59 9460 (9199–9722) 809 (749) 6981 (6562–7401) 602 (566–639)
60–69 9369 (9168–9570) 705 (681) 7167 (6789–7545) 723 (644–801)
70–79 10 314 (10 096–10 532) 746 (723) 7916 (7589–8244) 798 (708–887)
80 11 832 (11 491–12 174) 947 (864) 9087 (8539–9635) 884 (798–971)
Hospitals
TLH 13 201 (12 977–13 426) 1101 (1055) 11 462 (11 006–11 918) 1204 (1094–1314)
SLH 8318 (8186–8450) 599 (582) 6911 (6700–7122) 641 (614–668)
BSLH 6534 (6254–6815) 418 (401) 4292 (4061–4522) 358 (340–376)

Table 2. Reimbursement rates and out-of-pocket costs for ischaemic stroke in-patients according to the type of
insurance scheme
Data show reimbursement rates (RR) and out-of-pocket expenses (OOP) with 95% confidence intervals in parentheses. BMISE,
Basic Medical Insurance Scheme for Employees; BMISUR, Basic Medical Insurance Scheme for Urban Residents; TLH,
third-level hospitals; SLH, second-level hospitals; BSLH, below second-level hospitals

BMISE BMISUR
RR (%) OOP (RMB) RR (%) OOP (RMB)
Total 74.61 (74.48–74.73) 2346 (2303–2388) 56.46 (56.08–56.84) 3356 (3258–3454)
Year
2010 73.55 (73.31–73.79) 2582 (2495–2669) 48.95 (48.33–49.58) 3818 (3615–4021)
2011 75.39 (75.19–75.59) 2050 (1991–2110) 61.43 (60.78–62.07) 2894 (2747–3042)
2012 74.25 (74.04–74.47) 2557 (2478–2637) 55.54 (54.96–56.11) 3568 (3404–3732)
Gender
Male 74.24 (74.08–74.41) 2418 (2361–2474) 57.38 (56.78–57.97) 3206 (3055–3357)
Female 74.95 (74.75–75.14) 2241 (2175–2306) 55.76 (55.26–56.25) 3393 (3273–3514)
Age (years)
<40 66.76 (64.96–68.55) 3600 (2885–4315) 54.46 (50.95–57.98) 3560 (2798–4322)
40–49 68.98 (68.36–69.59) 2779 (2461–3096) 56.24 (54.76–57.72) 2985 (2669–3302)
50–59 72.36 (72.06–72.65) 2421 (2331–2511) 56.07 (55.21–56.93) 3135 (2897–3373)
60–69 74.17 (73.93–74.41) 2234 (2156–2313) 56.31 (55.56–57.06) 3259 (3059–3459)
70–79 75.16 (74.95–75.36) 2306 (2235–2377) 56.08 (55.38–56.78) 3478 (3314–3642)
80 77.77 (77.44–78.09) 2423 (2322–2525) 57.17 (56.24–58.10) 3708 (3449–3966)
Hospital
TLH 72.25 (72.06–72.44) 3328 (3249–3407) 50.23 (49.58–50.89) 5563 (5319–5808)
SLH 76.23 (76.04–76.42) 1753 (1703–1804) 57.42 (56.88–57.95) 2813 (2720–2907)
BSLH 76.91 (76.55–77.27) 1236 (1165–1306) 62.73 (61.94–63.52) 1538 (1429–1647)

number of men was higher than the number of women (58% vs
42% respectively). In previous studies of IS in China, the
proportion of men and women in the patient groups varied
(~55–60% vs 45–40% respectively).11–13 In the present study,
the age at which IS occurred was earlier for men than for women,
as reported previously.5,8 In particular, a significantly higher
percentage of patients over 70 years of age were female, probably
because of male exposure at a younger age to risk factors for
stroke, such as tobacco and alcohol. Compared with data from
Western countries,14,15 China has a higher incidence of IS in
men than women for those under 80 years of age, but most very old
patients presenting with stroke (aged >80 years) are women.14,15
Ischaemic stroke
The present study revealed the direct medical costs of hospi-
talisations for in-patients admitted with IS, categorised by age,
gender, hospital type and type of insurance scheme. The average
cost of each hospitalisation for BMISE- and BMISUR-insured
patients was RMB10 000 (A$1559) and RMB7500 (A$1169)
respectively, with the costs for IS in-patients being greater than
the national average costs for in-patients in 2010, 2011 and
2012 (RMB6416 (A$916), RMB6909 (A$1043) and RMB6980
(A$A1213) respectively).3 The results of the present study
show that families and IS in-patients bear a heavy financial
burden.
With increasing age, the average financial compensation for
hospitalisation increased. The reason for this may be that the
disease is more severe for older in-patients. Yao et al.11 reported
a negative correlation between the average compensation for
hospitalisation and age for IS in-patients, but a positive correla-
tion for in-patients with haemorrhagic stroke. In a study of
hospitalisation expenditure among in-patients with cerebral in-
farction covered by the New Cooperative Medical Scheme from
2007 to 2010 in Shandong, China, average in-patient expenditure
was found to be RMB2977.16 The average hospitalisation costs
under both the BMISE and BMISUR were higher than those
under the New Cooperative Medical Scheme. In China,
although a three-level medical service network has been estab-
lished, health guarder is not yet operative. Patients can choose a
medical institution on their own if they need to see a doctor.
The present study revealed that 42% of in-patients went to third-
level hospitals and 39% went to second-level hospitals. In
addition, the costs per hospitalisation and per hospital day were
higher for in-patients insured with the BMISE. In another
study, the mean ( s.d.) cost per hospitalisation for stroke
(including IS and haemorrhagic strokes) in Tianjin, China,
was RMB16 900  18 600 and RMB12 800  15 200 for patients
insured with the BMISE and BMISUR respectively.12
The reimbursement rate in China from the BMISE is 75%,
which is the national reimbursement rate standard (and even
higher in some regions), meaning that patients will have to pay
the remaining 20–30% of all expenditure when they visit a
hospital. By setting up the BMISE, China has reduced the
annual catastrophic costs of the health payments by paying
these costs by government. However, in the case of patients
insured with the BMISUR, the reimbursement rate is only 55%,
which is 20% less than the rate with the BMISE. This gap is the
result of funding levels. In 2010, 2011 and 2012, the per capita
funding for the BMISE was RMB1759 (A$251), RMB2031
(A$307) and RMB2347 (A$408) respectively, compared with
RMB164 (A$23), RMB246 (A$37) and RMB313 (A$54) for
the BMISUR.17 The funding for the BMISUR was 10% of total
medical insurance funding. In order to reduce the economic risk
of disease in older patients, China has established various pay-
ment systems for different people, with higher reimbursement
rates for seniors. The BMISE data have prove this. However,
in the case of BMISUR-insured patients, the reimbursement rate
was the same across all ages. It is not clear why this occurred,
and future studies need to evaluate medication use and treatment
for each in-patient. In China, the BMISE covers urban employees
and the BMISUR provides medical benefits to all urban
residents, excluding those covered by the BMISE. Comparing
the two systems, we can say that members of the BMISE may be
Australian Health Review E
wealthier than BMISUR members. In theory, the government
should improve the reimbursement rate for BMISUR-insured
patients by medical insurance funding. However, the results of
the present study show that out-of-pocket payments to BMISUR-
insured patients were higher than those made by BMISE-insured
patients, and this can lead to a marked increase in health pay-
ments. In the future, the Chinese Government needs to increase
the financial investment dynamics for the BMISUR, thus reduc-
ing inequality and the individual payments made by BMISUR-
insured patients.
The present study has some limitations. First, cross-sectional
data from a random population sample were used rather than
full-year data, so we cannot calculate the total hospital costs in
any one year. Second, the data are only useful for the costs of
hospitalisation, so cannot be used to study the costs of health
services incurred in addition to in-patient costs and thus do not
reflect all the expenses incurred by any one patient. Third, in the
future we need to focus on the different effects of health service
utilisation by various types of medical insurance schemes.
In conclusion, from 2010 to 2012, there was no big change in
the sex ratio or age structure of IS in-patients. BMISE-insured
patients had higher costs than BMISUR-insured patients, such as
costs per hospitalisation, costs per hospital day and reimburse-
ment rate, but BMISE-insured patients had lower out-of-pocket
payments. This means that the financial burden was higher for
BMISUR-insured patients than for BMISE-insured patients. In
the future, the government should increase the financial invest-
ment, raise reimbursement rates and set up differential reimbur-
sements to meet the health needs of BMISUR-insured patients
with different income levels.
Competing interests
None declared.
Acknowledgements
The authors thank China Health Insurance Research Association for providing
the data used in the present study. The authors also thank the data management
and statistical teams associated with the study, specifically Zhang Jie (China
Health Insurance Research Association) and Feng Xin (Beijing Brainpower
Pharma Consulting, Beijing, China). The authors also thank the Australian
Healthcare & Hospitals Association for critical revision of the manuscript.
This study forms part of the doctorate degree of study on the Economic
Burden of Disease for Stroke Patients in China at the Beijing University of
Chinese Medicine.
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