Does introducing outpatient pooling scheme reduce socioeconomic inequality in healthcare utilization? Evidence from a longitudinal study in China, 2011–2020

Does introducing outpatient pooling scheme reduce socioeconomic inequality in healthcare utilization? Evidence from a longitudinal study in China, 2011–2020 | 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 Does introducing outpatient pooling scheme reduce socioeconomic inequality in healthcare utilization? Evidence from a longitudinal study in China, 2011–2020 Tao Zhang, Meiteng Yu, Jing Liu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4653481/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 China, persistent health care inequalities coexist with universal health coverage due to limited financial protection for outpatient care. To address this issue, the Chinese Urban Employee Basic Medical Insurance implemented an outpatient pooling scheme, aiming to alleviate cost-sharing burdens for outpatients. This study assesses the impact of this policy on socioeconomic disparities in outpatient care utilization. Methods Data from five waves of the China Health and Retirement Longitudinal Study (2011–2020) were utilized. Outcome variables included the possibility of outpatient visits, visits to hospitals and primary care facilities, as well as outpatient expenditures and out-of-pocket (OOP) payments. Propensity score matching formed a matched sample, and the concentration index (CI) for outcomes was calculated for policy-implementing and non-implementing groups. Decomposition of the CI and its changes were performed to identify the outpatient pooling's contribution to inequalities in outpatient care. Results The CI value for the likelihood of outpatient visits decreased from 0.1142 in 2011 to 0.0972 in 2020, with outpatient pooling contributing positively (4.14%) to this reduction. However, inequalities across different facility types increased over time. The CI for visits to hospitals changed from 0.0069 to 0.0431, and the CI for visits to primary care facilities changed from 0.0064 to -0.1091. The implementation of the policy counteracted these growing inequalities. Despite persistent pro-rich inequalities in outpatient expenditures and OOP payments, their CI values exhibited a substantial decline, and outpatient pooling played a pivotal role in steering the trend towards improving equity. Conclusion The introduction of the outpatient pooling scheme significantly contributes to diminishing pro-rich inequalities in outpatient care. However, socioeconomic disparities in the utilization of primary care and advanced services continue to widen despite the counteractive effects of policy implementation. Future interventions should adopt a comprehensive approach, extending beyond mere insurance benefits coverage, to address and rectify these persisting inequalities. Outpatient pooling scheme Cost-sharing Healthcare equity Outpatient care utilization China Figures Figure 1 Figure 2 Figure 3 Figure 4 Full Text Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile.docx 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-4653481","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":327031408,"identity":"45addfab-e27b-4e88-98a9-d48d72a79499","order_by":0,"name":"Tao Zhang","email":"","orcid":"","institution":"Hangzhou Normal University","correspondingAuthor":false,"prefix":"","firstName":"Tao","middleName":"","lastName":"Zhang","suffix":""},{"id":327031409,"identity":"f050fcb4-1fd8-403e-9e67-a4fec0f09afa","order_by":1,"name":"Meiteng Yu","email":"","orcid":"","institution":"Hangzhou Normal 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2011-2020.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4653481/v1/b88ca55af41b36e4dadc040c.png"},{"id":61067196,"identity":"08375191-eeaa-47f2-8f15-e280a74485bb","added_by":"auto","created_at":"2024-07-25 07:52:22","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":65163,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe contribution of outpatient pooling to changes in CI of possibility of outpatient visits (A), visit to hospitals (B), primary healthcare facilities (C), outpatient expenditures (D) and OOP payments (E) over the period from 2011 to 2020.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4653481/v1/342737c29f939562a16c31de.png"},{"id":62462845,"identity":"518aa5fc-26ae-45a9-831a-a0b4106ffcf7","added_by":"auto","created_at":"2024-08-14 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Evidence from a longitudinal study in China, 2011–2020","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":"Outpatient pooling scheme, Cost-sharing, Healthcare equity, Outpatient care utilization, China","lastPublishedDoi":"10.21203/rs.3.rs-4653481/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4653481/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn China, persistent health care inequalities coexist with universal health coverage due to limited financial protection for outpatient care. To address this issue, the Chinese Urban Employee Basic Medical Insurance implemented an outpatient pooling scheme, aiming to alleviate cost-sharing burdens for outpatients. This study assesses the impact of this policy on socioeconomic disparities in outpatient care utilization.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData from five waves of the China Health and Retirement Longitudinal Study (2011\u0026ndash;2020) were utilized. Outcome variables included the possibility of outpatient visits, visits to hospitals and primary care facilities, as well as outpatient expenditures and out-of-pocket (OOP) payments. Propensity score matching formed a matched sample, and the concentration index (CI) for outcomes was calculated for policy-implementing and non-implementing groups. Decomposition of the CI and its changes were performed to identify the outpatient pooling's contribution to inequalities in outpatient care.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe CI value for the likelihood of outpatient visits decreased from 0.1142 in 2011 to 0.0972 in 2020, with outpatient pooling contributing positively (4.14%) to this reduction. However, inequalities across different facility types increased over time. The CI for visits to hospitals changed from 0.0069 to 0.0431, and the CI for visits to primary care facilities changed from 0.0064 to -0.1091. The implementation of the policy counteracted these growing inequalities. Despite persistent pro-rich inequalities in outpatient expenditures and OOP payments, their CI values exhibited a substantial decline, and outpatient pooling played a pivotal role in steering the trend towards improving equity.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe introduction of the outpatient pooling scheme significantly contributes to diminishing pro-rich inequalities in outpatient care. However, socioeconomic disparities in the utilization of primary care and advanced services continue to widen despite the counteractive effects of policy implementation. Future interventions should adopt a comprehensive approach, extending beyond mere insurance benefits coverage, to address and rectify these persisting inequalities.\u003c/p\u003e","manuscriptTitle":"Does introducing outpatient pooling scheme reduce socioeconomic inequality in healthcare utilization? 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