The impacts of removing pharmaceutical co-payments for chronic conditions at primary care level: a pilot study in rural China

The underutilization of primary care (PC) presents a substantial challenge in enhancing the people-centeredness, quality, and efficiency of health services for patients with chronic diseases. Pharmaceutical copayments have been considered a key barrier to patient access in low- and middle-income countries. It is unclear whether the removal of pharmaceutical copayment can lead to better care and management of chronic diseases. This study sought to evaluate the impact on healthcare utilization and spending of a policy that waived fees for essential pharmaceuticals at PC facilities, piloted county-wide from 2014 in rural China. Using individual claims data from 2010 to 2017, we applied a synthetic difference-in-difference approach to estimate the policy's effects. Our sample included 9115 patients with hypertension and/or diabetes from the pilot county and 30 675 patients from the other counties in the same municipality. The policy led to a significant increase of 0.69 in the number of PC visits per patient per year (95% CI: 0.46-0.91), equivalent to a rise of 44.1%. Annual spending per person on outpatients at PC facilities increased significantly due to the policy, by 58 yuan (95% CI: 36-80), equivalent to a rise of 40.5%. As for outpatient visits at hospitals, there was a 25.8% significant reduction in the number of visits per year (-0.56; 95% CI: -0.95 to -0.16) and a nonsignificant increase in spending (45 yuan; 95% CI: -111 to 21). The annual number of admissions and spending on inpatients per person in all facilities remained stable. Using claims data, we have demonstrated that targeted removal of copayment for essential medicines successfully shifted outpatient visits and expenditure from hospitals to PC facilities but did not affect hospitalization and inpatient expenditure. Further research may be attempted to see if removing pharmaceutical copayments on people with less severe NCDs could reduce hospitalizations.