Figure 1
Fee-for-service provider payment for interferon based treatment before 2014.
Notes: FFS = fee-for-service; IP = inpatient; OOP = out-of-pocket; deductible = patient OOP payment to hospital before insurance reimbursement.
Table 1
Benefit package, expenditure, payment and cost-sharing of hepatitis C treatment in Tianjin in three phases.
| Before 2014 | 2014–2018 | After 2018 | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Insurance reimbursementpolicies/Population | Employees/Retirees1 | Residents (low to high premium contribution)2 | Employees/Retirees1 | Residents (low to high premium contribution)2 | Employees/Retirees3 | Residents (low to high premium contribution)4 | Patients in financial hardship 5 | Low-income requiring more than 3-month treatment6 | |
| Employees/Retirees | Residents (low to high premium contribution) | ||||||||
| Benefit package | Inpatient | Inpatient (day-care-ward) | Outpatient (specialty) | PAP + common outpatient7 | Specialty outpatient8 + PAP + common outpatient7 | ||||
| Medicines & services covered | Interferon + ribavirin + ADR treatment + tests | Interferon + ribavirin + ADR treatment+ tests | All DAAs marketed in China + interferon + ribavirin + ADR treatment + tests | Originator sofosbuvir | Originator sofosbuvir | Medicines & services covered | Interferon + ribavirin + ADR treatment + tests | Interferon + ribavirin +ADR treatment + tests | |
| Capitated amount per standard treatment course (US$) | 16,4009 | 11,30010 | 6,04511 | PAP covered12 + tests & medications for ADRs | 6,04511 + PAP covered13 + tests & medications for ADRs | Cost per treatment course (US$) | 16,4009 | 11,30010 | |
| Patient OOP to hospitals before insurance reimbursement (US$) | 120 | 75 | 0 | 194 | 75 | NA+757 | 1948 + NA + 120/907 | 758 + NA + 757 | |
| Insurance reimbursement rate after initial patient OOP (%) | 84/89 | 55–65 | 85/90 | 55–65 | 85/90 | 45–55 | NA/507 | 85/908/NA/55/957 | 45–558/NA/507 |
| Max insurance payment to hospitals (US$) | 13,838/14,652 | 8,979–10,611 | 9,605/10,170 | 6,215–7,345 | 4,973/5,266 | 2,687–3,284 | Up to 4507 | 4,973/5,266+up to 820–1,5007 | 2,687/2,985/3,284 + up to 4507 |
| Max patient OOP to hospitals (US$) | 2,562/1,784 | 7,421–5,789 | 1,695/1,130 | 5,085–3,955 | 1,072/780 | 3,358–2,761 | Tests & ADR medications | 1,072/780 + tests & ADR medications | 3,358/3,060/2,761 + tests & ADR medications |
| Max patient OOP rate (%) | 16/11 | 45–35 | 15/10 | 45–35 | 18/13 | 55–45 | NA | 18/13 plus14 | 55/50/45plus14 |
| No. of per capita monthly income for max patient OOP to hospitals | 3.2/2.215 | 22.6–7.616 | 1.6/1.115 | 12.5–9.716 | 1.0/0.715 | 6.8–5.616 | NA | 1.0/0.715 plus14 | 6.8–5.616 plus14 |
[i] Notes: PAP = patient-assistance program; OOP = out of pocket; DAA = direct-acting antiviral; ADR = adverse drug reaction.
Max insurance settlement with hospitals and max patient OOP were estimated based on the capitated amount per standard treatment course. Benefit package, patient OOP before getting insurance reimbursed, and insurance co-pay (%) were obtained from the key informants of Tianjin Healthcare Security Administration and Tianjin Healthcare Security Management and Settlement Center. Comprehensive insurance policies about retirees/employees and residents of Tianjin can be accessed from the website of Tianjin Human Resource and Social Security Bureau as follows: (http://hrss.tj.gov.cn/ecdomain/framework/tj/ckoocoapccolbbogkjpnifpkdgnfeahc/clbhpndaccolbbogkjpnifpkdgnfeahc.do?isfloat=1&fileid=20081114155807953&moduleIDPage=clbhpndaccolbbogkjpnifpkdgnfeahc&siteIDPage=tj&pageID=ckoocoapccolbbogkjpnifpkdgnfeahc, in Chinese, accessed March 31, 2019) and (http://hrss.tj.gov.cn/ecdomain/framework/tj/ckoocoapccolbbogkjpnifpkdgnfeahc/clbhpndaccolbbogkjpnifpkdgnfeahc.do?isfloat=1&fileid=20130428083007295&moduleIDPage=clbhpndaccolbbogkjpnifpkdgnfeahc&siteIDPage=tj&pageID=ckoocoapccolbbogkjpnifpkdgnfeahc, in Chinese, accessed March 31, 2019).
1 Employee beneficiaries of Tianjin Basic Health Insurance.
2 Residents beneficiaries of Tianjin Basic Health Insurance.
3 Employee beneficiaries of Tianjin Basic Health Insurance qualified at least three consecutive years.
4 Resident beneficiaries of Tianjin Basic Health Insurance qualified at least three consecutive years.
5 Patients in financial hardship as certified by the Tianjin Civil Affairs Bureau, and receive a minimal living allowance during the past consecutive 12 months.
6 Annual family (immediate family, defined as family members including parents, children, husband or wife) income ≤ 2.5 times of the annual family healthcare expenditures, information obtained from the key informants of PAP.
7 Costs for tests & other necessary medications for ADRs can be reimbursed by insurance following the common outpatient benefit package.
8 The first three-month treatment with originator sofosbuvir of low-income patients before applying for free originator sofosbuvir can be reimbursed by insurance following the specialty outpatient care benefit package under the capitated payment program.
9 Average costs per treatment course (CNY 110,000/48 weeks) before 2014, as reported by Ni S, Wang L. Chronic hepatitis C treatment cost is reduced in Tianjin. Tianjin Social Insurance, 2014(3):30–31.
10 The capitated amount set for the interferon per standard treatment course in 2014 (CNY 76,000/48 weeks).
11 Capitated amount set for DAA treatment per standard treatment course in 2018 (CNY 40,500).
12 Six bottles of originator sofosbuvir provided by PAP free of charge for patients in financial hardship as defined by PAP.
13 Three bottles of originator sofosbuvir provided by PAP free of charge for low-income patients as defined by PAP.
14 Including the first three-month treatment with originator sofosbuvir, which can be reimbursed by insurance following the specialty outpatient care benefit package under the capitated payment program, plus costs for tests & other necessary medications for ADRs for additional free sofosbuvir follow-up treatment provided by APA, which can be reimbursed by the insurance following the common outpatient benefit package.
15 Annual average salary per capita of Tianjin employees was applied for the calculation: CNY 67,773 in 2013, CNY 83,428 (2014–2017), CNY 7,073/month in 2018. Obtained from the National Bureau of Statistics of China. http://data.stats.gov.cn; Tianjin Municipal Human Resource and Social Security Bureau. http://hrss.tj.gov.cn/ecdomain/framework/tj/index.jsp (in Chinese, accessed March 31, 2019).
16 Annual average disposable income per capita of Tianjin residents was applied for the calculation: CNY 26,359 in 2013, CNY 32,805·11 (2014–2017), CNY 39,506 in 2018. Obtained from the National Bureau of Statistics of China. http://data.stats.gov.cn; Tianjin Statistics Bureau. http://stats.tj.gov.cn/Category_1/Index.aspx (in Chinese, accessed March 31, 2019).
Figure 2
Capitated provider payment for interferon based treatment 2014–2017.
Figure 3
Capitated provider payment for DAA based treatment with defined clinical pathway since 2018.
Notes: DAA = direct-acting antiviral; OOP=out-of-pocket.
Figure 4
Financing models for DAA treatment of hepatitis C patients in Tianjin since 2018.
Notes: IP = inpatient; OP = outpatient; PAP = patient assistance program; SOF = sofisbuvir; FFS = fee-for-service.
Figure 5
Reported cases and treatment numbers of hepatitis C covered by the Basic Health Insurance programs of Tianjin 2014–2017 vs. 2018.
Notes: DAA = direct-acting antiviral; PR = pegylated interferon + ribavirin.