Characterizing Cross-Provincial High-Cost Patients in Rural China: Cross-Sectional Study.
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BACKGROUND: High-cost (HC) patients, typically defined as the top 10% or 5% of patients with the highest health care costs, are responsible for over half of all health care-related spending. In China, approximately 95% of rural residents are covered by Urban and Rural Resident Basic Medical Insurance. In parallel, increasing population mobility has made it more common for rural residents to seek medical treatment and claim reimbursements across provincial boundaries. These trends underscore the importance of identifying and understanding HC patients within this group. OBJECTIVE: This study aimed to analyze the characteristics and risk factors associated with HC cross-provincial insured patients in rural China. METHODS: The study used data from the cross-provincial medical immediate reimbursement system, which contains records of inpatients who used cross-province immediate reimbursement services between 2017 and 2019. Patients whose total annual medical expenditure ranked within the top 10% of all cross-provincial inpatients were classified as HC patients. Andersen's Behavioral Model of Health Services Use was adopted to examine the factors associated with being an HC patient. Descriptive statistics and multivariable logistic regression model analyses were performed. RESULTS: A total of 2987 patients were included, with a mean age of 42.99 (SD 19.39) years. Males comprised 57.4% (1713/2987) of the total. Among all cross-provincial patients, the expenses of HC patients made up 34.5% of total expenses. The average annual hospitalization cost per HC patient was US $22,460. Results from multivariable logistic regression analysis indicated that male patients (odds ratio [OR] 1.38, 95% CI 1.06-1.79; P=.01), individuals with multiple comorbidities (OR 3.62, 95% CI 2.37-5.53; P<.001), those diagnosed with cancer (OR 2.31, 95% CI 1.61-3.31; P<.001), and patients receiving care at specialized hospitals (OR 1.61, 95% CI 1.24-2.08; P<.001) were significantly associated with HC status. CONCLUSIONS: Cross-provincial HC patients in rural China exhibited a lower concentration of total expenditure but incurred higher average annual hospitalization costs compared with local patients. This finding suggests the presence of potential cost-driving factors within this group. Identified risk factors-including sex, comorbidity status, cancer diagnosis, and hospital type-may inform the development of more equitable and efficient health financing policies, such as optimizing resource allocation and designing targeted interventions for HC patients.