Guo Minjiang, Jiang Xiaotong, Liu Yang, Liu Yang, Zhang Fangyuan, Zhang Zhongyuan, Li Yazi
Health Insurance Information Research Department, Institute of Medical Information, Chinese Academy of Medical Sciences, Beijing, China.
Information Technology Office, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 9 Dongdan Santiao, Dongcheng District, Beijing, 100730, China, 86 13810084409.
JMIR Public Health Surveill. 2025 Jun 11;11:e54234. doi: 10.2196/54234.
High-cost (HC) patients, typically defined as the top 10% or 5% of patients with the highest health care costs, are responsible for over half of all health care-related spending. In China, approximately 95% of rural residents are covered by Urban and Rural Resident Basic Medical Insurance. In parallel, increasing population mobility has made it more common for rural residents to seek medical treatment and claim reimbursements across provincial boundaries. These trends underscore the importance of identifying and understanding HC patients within this group.
This study aimed to analyze the characteristics and risk factors associated with HC cross-provincial insured patients in rural China.
The study used data from the cross-provincial medical immediate reimbursement system, which contains records of inpatients who used cross-province immediate reimbursement services between 2017 and 2019. Patients whose total annual medical expenditure ranked within the top 10% of all cross-provincial inpatients were classified as HC patients. Andersen's Behavioral Model of Health Services Use was adopted to examine the factors associated with being an HC patient. Descriptive statistics and multivariable logistic regression model analyses were performed.
A total of 2987 patients were included, with a mean age of 42.99 (SD 19.39) years. Males comprised 57.4% (1713/2987) of the total. Among all cross-provincial patients, the expenses of HC patients made up 34.5% of total expenses. The average annual hospitalization cost per HC patient was US $22,460. Results from multivariable logistic regression analysis indicated that male patients (odds ratio [OR] 1.38, 95% CI 1.06-1.79; P=.01), individuals with multiple comorbidities (OR 3.62, 95% CI 2.37-5.53; P<.001), those diagnosed with cancer (OR 2.31, 95% CI 1.61-3.31; P<.001), and patients receiving care at specialized hospitals (OR 1.61, 95% CI 1.24-2.08; P<.001) were significantly associated with HC status.
Cross-provincial HC patients in rural China exhibited a lower concentration of total expenditure but incurred higher average annual hospitalization costs compared with local patients. This finding suggests the presence of potential cost-driving factors within this group. Identified risk factors-including sex, comorbidity status, cancer diagnosis, and hospital type-may inform the development of more equitable and efficient health financing policies, such as optimizing resource allocation and designing targeted interventions for HC patients.
高成本（HC）患者通常被定义为医疗保健成本最高的前10%或5%的患者，他们占所有医疗保健相关支出的一半以上。在中国，约95%的农村居民参加了城乡居民基本医疗保险。与此同时，人口流动性增加使得农村居民跨省就医和报销更为普遍。这些趋势凸显了识别和了解该群体中HC患者的重要性。
本研究旨在分析中国农村地区HC跨省参保患者的特征及相关危险因素。
本研究使用了跨省医疗即时报销系统的数据，该系统包含2017年至2019年期间使用跨省即时报销服务的住院患者记录。年度医疗总支出位列所有跨省住院患者前10%的患者被归类为HC患者。采用安德森医疗服务利用行为模型来研究与成为HC患者相关的因素。进行了描述性统计和多变量逻辑回归模型分析。
共纳入2987例患者，平均年龄为42.99（标准差19.39）岁。男性占总数的57.4%（1713/2987）。在所有跨省患者中，HC患者的费用占总费用的34.5%。每位HC患者的平均年度住院费用为22,460美元。多变量逻辑回归分析结果表明，男性患者（比值比[OR]为1.38，95%置信区间为1.06 - 1.79；P = 0.01）、患有多种合并症的个体（OR为3.62，95%置信区间为2.37 - 5.53；P < 0.001）、被诊断患有癌症的患者（OR为2.31，95%置信区间为1.61 - 3.31；P < 0.001）以及在专科医院接受治疗的患者（OR为1.61，95%置信区间为1.24 - 2.08；P < 0.001）与HC状态显著相关。
与本地患者相比，中国农村地区的跨省HC患者总支出集中度较低，但平均年度住院费用较高。这一发现表明该群体中存在潜在的成本驱动因素。已识别的危险因素，包括性别、合并症状态、癌症诊断和医院类型，可能为制定更公平、高效的医疗融资政策提供参考，例如优化资源配置和为HC患者设计有针对性的干预措施。
