The Impact of Outpatient Pooling Reform on Abnormal Outpatient Visits: Evidence from Urban Employee Basic Medical Insurance Claims in China

The Impact of Outpatient Pooling Reform on Abnormal Outpatient Visits: Evidence from Urban Employee Basic Medical Insurance Claims in China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Impact of Outpatient Pooling Reform on Abnormal Outpatient Visits: Evidence from Urban Employee Basic Medical Insurance Claims in China Ennan Wang, Yeyi Feng, Yanan You, Zinan Zhang, Xiaoyu Xi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9415680/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: In 2023, China fully implemented outpatient pooling under the Urban Employee Basic Medical Insurance (UEBMI). While expanded outpatient coverage and lower out-of-pocket payments improved access, they also increased overuse of medical services, posing challenges to the sustainability of BMI funds. Methods: Using administrative UEBMI outpatient claims data from City A for 2020–2024, we applied a two-part model to estimate the effect of outpatient pooling on abnormal visits. We then quantified excess abnormal visits spending introduced by reform and conducted heterogeneity analyses. Results: The study included 901,566 outpatient visit records. The outpatient pooling reform was associated with increased abnormal visits. After implementation, the annual occurrence ratios of daily, monthly, and yearly abnormal visits rose by 100%, 105%, and 79%, respectively. Among patients with abnormal visits, the annual numbers of daily and monthly abnormalities increased by 0.02 and 0.05, respectively. The reform was estimated to generate approximately CNY 16.6914 million in additional abnormal-visit expenditures citywide per year. The effects were more pronounced among younger adults, older adults, flexibly employed individuals, and secondary and tertiary facilities. Drug costs drove most of the increase. Conclusion: The outpatient pooling reform significantly increased the risk of abnormal visits among insured individuals, suggesting the presence of moral hazard. These findings provide empirical evidence and policy implications for further improving the outpatient pooling system. Health insurance Outpatient pooling Abnormal visit Moral hazard Overuse Full Text Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9415680","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":633327029,"identity":"d12802ac-64df-4781-b658-65fd8a69334b","order_by":0,"name":"Ennan Wang","email":"","orcid":"","institution":"Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ennan","middleName":"","lastName":"Wang","suffix":""},{"id":633327031,"identity":"5aa23ef6-40fc-46c1-8d35-2733fce26b9f","order_by":1,"name":"Yeyi Feng","email":"","orcid":"","institution":"China Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Yeyi","middleName":"","lastName":"Feng","suffix":""},{"id":633327035,"identity":"52bc3452-aaec-47c7-82cf-64bcd015b2fd","order_by":2,"name":"Yanan You","email":"","orcid":"","institution":"China Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Yanan","middleName":"","lastName":"You","suffix":""},{"id":633327038,"identity":"3e0fcb50-6f10-4770-931e-e8d9aedccc76","order_by":3,"name":"Zinan Zhang","email":"","orcid":"","institution":"Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zinan","middleName":"","lastName":"Zhang","suffix":""},{"id":633327039,"identity":"977b21a0-68c4-40e1-8e7b-11af6114bb2d","order_by":4,"name":"Xiaoyu Xi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtUlEQVRIiWNgGAWjYDACZiD+AGEaEK+FcQZpWkC6eEjSYnCcx0zapuZOYgN78zYJhpo7hLVINrOlSecce5bYwHOsTILh2DPCWviZmY9J5zYcTmyQyDGTYGw4TFgLGzNjm7QlSIv8GyK1gG1hBNvCQ6QWoF+SLXuOPTNu40krtkg4RoQWg/NnDG/8qLkj289+eOONDzVEaAECFgkGhgMMbCBmAlEagDH5AaRlFIyCUTAKRgFOAADUaTRfz6M+hwAAAABJRU5ErkJggg==","orcid":"","institution":"China Pharmaceutical University","correspondingAuthor":true,"prefix":"","firstName":"Xiaoyu","middleName":"","lastName":"Xi","suffix":""}],"badges":[],"createdAt":"2026-04-14 12:53:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9415680/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9415680/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108796974,"identity":"4faaf05a-d04a-45b9-b2cf-47a5eac27bc2","added_by":"auto","created_at":"2026-05-08 13:37:06","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":558474,"visible":true,"origin":"","legend":"","description":"","filename":"3.manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9415680/v1_covered_de641a28-6089-4000-8fd2-2619d6b88bf6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Impact of Outpatient Pooling Reform on Abnormal Outpatient Visits: Evidence from Urban Employee Basic Medical Insurance Claims in China","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Health insurance, Outpatient pooling, Abnormal visit, Moral hazard, Overuse","lastPublishedDoi":"10.21203/rs.3.rs-9415680/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9415680/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eIn 2023, China fully implemented outpatient pooling under the Urban Employee Basic Medical Insurance (UEBMI). While expanded outpatient coverage and lower out-of-pocket payments improved access, they also increased overuse of medical services, posing challenges to the sustainability of BMI funds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Using administrative UEBMI outpatient claims data from City A for 2020–2024, we applied a two-part model to estimate the effect of outpatient pooling on abnormal visits. We then quantified excess abnormal visits spending introduced by reform and conducted heterogeneity analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe study included 901,566 outpatient visit records. The outpatient pooling reform was associated with increased abnormal visits. After implementation, the annual occurrence ratios of daily, monthly, and yearly abnormal visits rose by 100%, 105%, and 79%, respectively. Among patients with abnormal visits, the annual numbers of daily and monthly abnormalities increased by 0.02 and 0.05, respectively. The reform was estimated to generate approximately CNY 16.6914 million in additional abnormal-visit expenditures citywide per year. The effects were more pronounced among younger adults, older adults, flexibly employed individuals, and secondary and tertiary facilities. Drug costs drove most of the increase.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe outpatient pooling reform significantly increased the risk of abnormal visits among insured individuals, suggesting the presence of moral hazard. 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