OBJECTIVES: Disparities in the utilization, expenditures, and quality of care by insurance type have been well documented. Such comparisons have yet investigated in the end-of-life (EOL) settings in China where public insurance covers over 95% of the Chinese population. This study examined the associations between health insurance and EOL care in the last six months of life: outpatient services, emergency department (ED) visit, inpatient services, intensive care unit (ICU) admissions, expenditures, and place of death.

METHODS: A population-based retrospective study of 398 patients diagnosed with cancer, survived more than 6 months after diagnosis, and died from July 2015 to June 2017 in urban Yichang, China. Descriptive analysis and multivariate regressions were used to investigate the bivariate and independent associations, respectively, of health insurance with EOL healthcare utilization, expenditures and place of death.

RESULTS: Urban Employee Basic Medical Insurance (UEBMI) beneficiaries visited EDs more frequently than Urban Resident-based Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NRCMS) beneficiaries (marginal effects [95% Confidence Interval]: 2.51 [1.49-2.81] and 1.92 [1.24-2.60], respectively). NRCMS and UEBMI beneficiaries had more hospitalizations than URBMI beneficiaries (1.04 [0.25-1.94] and 0.73 [0.11-1.36], respectively). Compared to URBMI beneficiaries, NRCMS beneficiaries and UEBMI beneficiaries had ¥16,001 and ¥44,002 higher expenditures. Similarly, UEBMI beneficiaries were the most likely to die at hospitals, followed by NRCMS (UEBMI vs. NRCMS: 0.27 [0.07-0.47]) and URBMI (UEBMI vs. URBMI: 0.72 [0.58-0.86]) beneficiaries.

CONCLUSIONS: The disproportionately higher utilizations of EOL care among NRCMS and URBMI beneficiaries, compared to UEBMI beneficiaries, raised concerns regarding quality of EOL care and financial burdens of NRCMS and URBMI beneficiaries. Targeted hospice care intervention might be warranted to address EOL care for these beneficiaries in China.