The incidence of diabetes in China has increased rapidly in recent years, reaching 9.7% of the general population in 2017 . There are about 136 million diabetes patients worldwide, and diabetes has become a serious public health problem. There are many risk factors for diabetes, and the disease is a life-long condition. With disease progression, patients may develop any number of a variety of severe complications, such as blindness, kidney failure and gangrene. In China, 73.2% of patients with diabetes suffer from chronic complications, and the treatment costs of these complications account for > 80% of the total medical costs of patients with diabetes. Among these chronic complications, cardiovascular disease, cerebrovascular disease and kidney disease are the main causes of the disability and death of patients with diabetes. The medical expenses generated by this disease are also the most important part of the total expenses in China . The medical expense burden of diabetes patients is so heavy that in 2016 the total medical expenses added up to 100 billion RMB, accounting for 5% of the medical expenses for all chronic non-communicable diseases. The out-of-pocket costs accounted for 30% of the total expense. Diabetes mellitus places tremendous financial pressure on Chinese society and on the individual patient’s family. The risk of a diabetic patient’s family falling into poverty is high .
In our study, the medical expenses for managing diabetes in Hainan Province added up to 242.17 billion RMB, accounting for 28.3% of the total medical expenses for managing endocrine, nutritional and metabolic diseases (855.71 billion RMB). This suggests that government and health institutions should pay more attention to the financial burden of diabetes and implement additional measures to control the medical expenses. We also found that in terms of diabetes management, the medical and drug expenses for outpatients are higher than those for inpatients. One reason is that patients prefer outpatient treatment and therefore spend more on drug expenses than inpatients because this incurable chronic disease requires long-term medication. Drugs, diagnosis and treatment costs are long-term burdens for patients with chronic diseases . Cost ratios between people with and without diabetes have been reported to range from 1.5 to 4.4, which is different from cost ratios in other diseases [13,14,15]. Jacobs et al. found the largest differences in health expenses came from prescribed medication in pharmacies (cost ratio diabetes:no diabetes: 2.2) .
We found that the age and sex of the patient, number of days hospitalized, type of operation, type of medical insurance payment, type of medical institution, level of medical institution and hospitalization expenses had a significant impact on the total medical expense, in accordance with results reported previously . The medical cost of surgical patients is significantly higher than that of other patients, which may be a direct result of the severity of the disease and the higher cost of treatment. Medical insurance has been found to have the potential to promote an increase in medical expenses, with health insurance impacting on a patient’s ability to pay and a doctor’s behavior regarding diagnosis and treatment . In our study, we reached the same conclusion. One explanation is that patients reimbursed by medical insurance can afford more treatment than self-paid patients. The former prefer high-tech, highly effective therapies and expensive drugs when choosing treatment methods and means, so their costs are likewise higher than those of self-paid patients. The longer the hospital stay per capita, the higher the cost of treatment. Compared with non-surgical patients, surgical patients stay in the hospital longer, and medical expenses naturally increase. The medical expenses of patients with diabetes mellitus and associated conditions are considerably higher than those of other patients, which may be directly related to the severity of the disease and the cost of treatment .
In terms of overall cost, hospital expenditure occupies the dominant position, with drug and inspection charges in hospitals being higher than those of other institutions. The drug and inspection charges of primary institutions are < 20% of total medical expenditure, possibly due to patients’ trust in hospitals being higher than that in primary healthcare institutions. Due to the serious shortage of medical technical personnel at the primary care level, patients cannot get access to a superior hospital for further study for a long time, and it would appear that the professional level of these personnel cannot be timely and effectively improved. At the same time, the serious shortage of funds in medical institutions providing primary care is a common social phenomenon, Therefore, the technical staff and equipment of primary institutions cannot meet the needs of patients, so they cannot gain the trust of “patients with minor diseases.” As a result, the outpatient service and inpatient visits of grassroot institutions are seriously insufficient, which leads to various drug and inspection charges being fewer and lower [20, 21]. The acceleration of urbanization and the lag in providing basic health facilities to meet demand means that high-quality medical resources are concentrated in large general hospitals . Consequently, Chinese patients prefer hospitals for better treatments, a preference that is related to the functional orientation, diagnosis and treatment capacity of such institutions. Overall, the role of primary healthcare institutions in the treatment of diabetes needs to be further strengthened . According to the policy of graded diagnosis and treatment in China, especially the prevention of diabetes, the management of diabetes patients, the prognosis of disease, the rehabilitation of primary medical and health institutions and the role of medical and health institutions at all levels can be improved. The present state is one of the reasons why the economic burden of diabetes is so heavy.
Regarding the service function of medical expenses of diabetes, there is a large difference between Hainan Province and the whole country, with the costs of hospitalization for diabetes in Hainan Province being about ten percentage points higher than the overall national level. This may be due to the high prevalence of diabetes mellitus in Hainan Province and the long-term hospitalization required. An analysis of the different types of medical institutions revealed that most expenses are spent in outpatient costs and drugs. In Ulrich et al.’s study, diabetes patients with insulin monotherapy or with a combination of insulin and oral antidiabetic drugs had significantly elevated costs compared with individuals without diabetes (3.98 vs. 2.58, respectively) .
Diabetes mellitus is common among the elderly: the higher the age, the higher the medical expense . Our research showed that the hospitalization expenses of patients aged < 75 years old increased with age. However, in the final analysis, it is not age itself that was found to cause elevated medical expenses; rather, the decline of the functions of the human immune system and organs play a role. A decline of organ functions translates into more basic diseases; consequently, elderly diabetic patients may have one or more complications and need more care as the disease progresses, resulting in higher costs than patients in other age groups . In recent years, however, there has been a trend for diabetic patients to be younger, attributed in part to the large changes in lifestyle and the living environment, greater working pressure, disordered dietary structure and irregular lifestyle that have appeared in the last decades. In comparison to older patients, patients in the younger age groups have short disease onset time, relatively single-treatment indicators, fewer complications and lower treatment costs. Thus, the results of our age distribution analysis gives a clear indication that people in the age group associated with high expenses should pay great attention to the prevention of diabetes.
Suggestion to Policy-Makers
Controlling Hospitalization Expenses and Improving Medical Insurance
Studies on hospitalization costs for the management of diabetes mellitus and other diseases have shown that the number of hospitalization days are a positive correlation factor affecting hospitalization costs and that, consequently, limiting hospitalization days is an effective way to control medical costs . Diabetic patients can reduce hospitalization rates by regulating their diet to control blood sugar, taking medicine on time and undergoing regular examinations to reduce complications.
The medical insurance management department should improve the level of medical insurance supervision and management, monitor the expenditure of hospitalization expenses for patients with different types of medical insurance, ensuring it is kept within a reasonable range, ensure the rational use of the funds available and regulate the unreasonable increase in hospitalization expenses. Reimbursement to the outpatient is still too low, resulting in large out-of-pocket expense. Therefore, the medical insurance management department should also pay more attention to this reimbursement ratio and make some adjustments.
Using Hierarchical Diagnosis and the Treatment System to Control Medical Expense
Medical expenses for diabetes in Hainan Province were mainly in high-level medical institutions, and there is little patient flow to primary healthcare institutions. Therefore, to reduce the economic burden of disease, it is necessary to improve both the role of primary healthcare institutions in the treatment of diabetes and the healthcare system so that patients receive good advice in choosing a primary healthcare institution . Healthcare management institutions should strengthen the vocational skills training of medical staff in primary institutions, dispatch doctors from higher hospitals to attend clinics at the primary care level and improve the ability of healthcare workers at the grassroots level to manage chronic diseases similar to diabetes. The government should attach importance to the construction of basic facilities and support and encourage primary care medical institutions to carry out public health services, with the aim to increase the rate of patients visiting primary healthcare institutions.
Strengthen Prevention Measures and Curb the Prevalence of Diabetes
In the early stage of diabetes, strict control of blood glucose is an effective measure to reduce and delay microvascular complications [29, 30]. The American Diabetes Association published “Diabetes Medical Standards”, which recommends that adult diabetes screening should start at age 45 years . Basic medical institutions provide comprehensive preventive care for elderly patients with diabetes, including lectures on diabetes that provide patients with knowledge of the disease that will enable them to better interpret and communicate their condition and interpret the problems they may encounter, and conducting research on the patient’s daily diet, exercise habits, blood sugar monitoring, and drug use. Specific preventive and healthcare measures can be formulated according to each patient’s condition in terms of lifestyle changes, exercise and diet regimens, massage, among others. Nursing staff should regularly conduct telephone return visits and family return visits and establish online communication groups to solve the problems encountered by patients in real-time. In this way, patients can be encouraged to maintain good living habits in terms of diet, exercise and lifestyle .
Diabetes on its own is associated with high healthcare costs, but complications of the eye, kidney and cardiovascular and nervous systems may also arise, and these significantly increase the medical expenses. In this study we adopted SHA 2011, an internationally accepted healthcare accounting method, to study only the costs associated with the primary diagnosis and treatment of diabetes; the complications of diabetes were not included in the calculation. Future studies will explore the costs related to diabetes and complications. We only researched the direct financial burden of medical expenses for treating diabetic patients; any indirect cost burdens were not considered. In future studies, we will continue to explore the indirect burden accounting method so as to more accurately assess the economic pressures placed on diabetes patients.