Heterogeneous Effects of China’s Family Mutual Aid System for Medical Savings Accounts: A Mixed‐Methods Study
Meiteng Yu, Jing Liu, Jiayue Li, Boyu Li, Tao ZhangBackground
In China, medical savings accounts (MSAs) were initially limited in covering long‐term outpatient costs for chronic diseases. To enhance financial protection, the government introduced the family mutual aid system (FMAS). This study explores the associations of FMAS with healthcare utilization and expenses, and examines its heterogeneous effects across different characteristic groups.
Methods
A mixed‐methods study was conducted in Hangzhou. The quantitative phase relied on a cross‐sectional survey of 1001 hypertensive or diabetic patients to assess outpatient and inpatient utilization and expenses. Causal forest models were applied to explore overall and subgroup‐level heterogeneous associations related to FMAS. The qualitative phase included semistructured interviews with 4 medical insurance managers, 10 outpatient physicians, and 10 patients, analyzed using the Smith Policy Implementation Process Model to identify factors driving heterogeneity.
Results
Compared with non‐FMAS users, those who used FMAS exhibited a higher likelihood of outpatient service use, accompanied by significantly greater outpatient visits (ATE = 0.821, p < 0.001), total payments (ATE = 0.271, p < 0.001), and out‐of‐pocket (OOP) payments (ATE = 0.547, p < 0.001), as well as a higher probability of seeking care at high‐tier hospitals (ATE = 0.196, p < 0.001). By contrast, they showed a lower probability of hospitalization (ATE = −0.163, p = 0.026) and lower total inpatient payments (ATE = −0.557, p < 0.001). These association‐based group differences varied across subgroups defined by age, health status, income, and education. Qualitative findings further revealed key contributors to the observed heterogeneity, including policy design and procedural convenience, promotional incentives, individual healthcare needs, socioeconomic status, insurance status, and contextual environmental factors.
Conclusions
FMAS use correlates with higher outpatient utilization and expenses, alongside reduced hospitalization rates, but may shift demand toward higher tier hospitals. Despite its financial‐protection objective, policy‐associated outcomes are complex and socially heterogeneous. Higher status groups may gain comparatively more, while vulnerable populations face potential access barriers. Targeted adjustments are needed to strengthen the scheme’s effectiveness and equity.