Presence of medical insurance and primary care experience of patients: Impact of different primary care models in southern China

Background and Objectives: China has launched a primary care-orientated healthcare reform, under which various models of Community Health Centres (CHCs) are emerging to provide primary care for the general population. Meanwhile, the expansion of medical insurance is one of the focuses under the current healthcare reform with funding support from both central and local governments. This study aimed to examine the relationships between medical insurance coverage and the quality attributes of primary care delivered by different CHC models in southern China, using an internationally developed and cross-culturally validated Primary Care Assessment Tool (PCAT) - Adult Edition from patient's perspective.

Methods: The international PCAT - Adult Edition (short version) was translated into Mandarin Chinese following a standard procedure and was cross-culturally adapted into Chinese context. It measured 5 primary care domains in which the reliability and validity were evaluated. A total of 3,360 primary care service users aged 18 or above were interviewed from 28 CHCs in Pearl River Delta, southern China, using multistage cluster sampling methodology. Multiple liner regression analysis was conducted to identify factors associated with primary care experience. PCAT scores were also compared across CHC models with regards to the presence of medical insurance after adjusting for covariates.

Results: The study achieved an overall response rate of 86.1%. The regression analysis showed that the presence of medical insurance (p<0.001) were positively associated with quality attributes of primary care measured by PCAT scores. The CHCs owned and managed by government sector showed no significant difference in PCAT scores between medically insured and uninsured service users (94.15 vs. 93.23, p=0.586). However, the CHCs owned and managed by hospital sector showed that service users who were not covered by medical insurance reported significantly lower PCAT scores than those who possessed medical insurance (87.87 vs. 92.05, p<0.001).

Conclusions: The study adds to the evidence suggesting that primary care experience received by patients in China were sensitive to the presence of medical insurance and primary care models. Primary care network based on CHCs owned and managed by the government sector may be able to deliver primary care with equal quality between patients with and without medical insurance. The findings are expected to help policy makers make better decisions in the development of the future primary care models. The lessons might also be useful for the US healthcare system which is facing similar challenge from the disparity in medical insurance to strengthen primary care.