Understanding the Implementation of Hierarchical Medical System Policy: An Interrupted Time Series Analysis of a Pilot Scheme in China

Background The Chinese healthcare system faces a dilemma between its hospital-centric approach to healthcare delivery and a rapidly aging population that requires strong primary care. To improve system efficiency and continuity of care, the Hierarchical Medical System (HMS) policy package was implemented in 2015 in Zhejiang province, China. This paper investigated the impact of HMS on the local healthcare system.MethodsWe conducted a repeated cross-sectional study with quarterly data collected between 2010 and 2018 from Yinzhou district, Ningbo. The data was analyzed with an interrupted time series (ITS) design to assess the impact of HMS on the changes of three outcome variables: primary care physicians (PCPs) patient encounter ratio (i.e., the mean quarterly number of patient encounters of PCPs divided by that of all other physicians), PCP degree ratio (i.e., the mean degree of PCPs divided by that of all other physicians), PCP betweenness centrality ratio (i.e., the mean betweenness centrality of PCPs divided by that of all other physicians). Results272,267 patients visited doctors for hypertension between 2010 and 2018. Compared to the counterfactual in the fourth quarter of 2018, the PCP patient encounter ratio rose by 42.7% (95%CI: 27.1—58.2, p<0.001), the PCP degree ratio increased by 23.6% (95%CI: 8.6—38.5, p<0.01), and the PCP betweenness centrality ratio grew by 129.4% (95%CI: 87.1—171.7, p<0.001).ConclusionsThe HMS policy can incentivize patients to visit primary care facilities and enhance the centrality of PCPs within their professional network. Local policymakers should sustain HMS policy efforts to obtain long-term and large-scale benefits.

Impact of hierarchical hospital reform on patients with diabetes in China: a retrospective observational analysis

ObjectivesWe assess whether China’s diabetes pilot hierarchical diagnosis and treatment reforms shifted patient healthcare-seeking behaviour towards primary health institutions (PHIs) and away from secondary and tertiary hospitals. From the patients’ perspective, we evaluate whether the hierarchical system saw the decline of average hospital cost, out-of-pocket (OOP) expenses and the increase of reimbursement rate in PHIs. From the health system’s perspective, we also assessed whether the share of PHIs in total costs, total visits and reimbursement rate increased and the share of secondary and tertiary hospitals decreased.MethodsData were collected from the health insurance bureau of 11 cities in Shandong Province, China between 2015 and 2017, which included 9 118 518 outpatient visits and 622 739 inpatient visits. For both inpatients and outpatients and the health system, we analysed health services-seeking characteristics including hospital costs, hospital visits, OOP expense and reimbursements of hospital costs. Binary logistic regression was conducted to analyse the influencing factors of seeking PHI health services.ResultsPHIs remained the lowest hospital cost provider, but average hospital costs declined across all three healthcare levels of PHIs, secondary hospitals and tertiary hospitals from 2015 to 2017. The hierarchical system aimed to shift patients to PHIs, increasing PHIs’ share of total hospital costs. However, the PHI share of total outpatient costs declined 12.0%, while rising 15.0% in secondary hospitals, the opposite of the goal of the hierarchical medical system. Average outpatient visits rose roughly at the same rate in PHIs (5.1%) as secondary hospitals (6.8%), with no evidence of a shift in patient visits between hospital levels over 2015–2017. Average inpatient visits fell across all levels of hospitals, with no significant difference in the rate of decline between PHIs (9.4%) and secondary (7.5%) and tertiary (7.8%) hospitals. For outpatient and inpatient services, the binary logistic regression showed that over the 2015–2017 period patients with diabetes increasingly used higher level hospitals rather than PHIs (p<0.05). The only success of the hierarchical medical system was the relative fall of OOP outpatient expenses, which fell more rapidly in PHIs (13.7%) than secondary (5.0%) and tertiary (3.5%) hospitals. However, inpatient OOP expenses fell only 2.2% for PHIs, less than half that of secondary (5.5%) and tertiary (7.4%) hospitals, the opposite of the aim of the hierarchical system reform.ConclusionsThe implementation of the hierarchical medical system for patients with diabetes did not achieve its goal of increasing PHI utilisation and decreasing secondary and tertiary hospital utilisation. Enhancing the utilisation of PHIs for diabetes and other patients requires further health reform, including educating patients on PHI use, further reforming the health insurance schemes, improving PHI facilities and encouraging referrals to PHIs from higher level hospitals.

Factors affecting health care users’ first contact with primary health care facilities in north eastern China, 2008–2018

BackgroundChina set out the vision to establishing a hierarchical medical system, with primary health care (PHC) facilities serving health care users’ first contact. Common ailments were listed, supported by a series of auxiliary policy measures. We aim to assess whether these policies were effective to prompt users’ preference to PHCs within these contexts.MethodsUsing data from three waves of National Health Service Survey, we examined trends in care users’ first contact with PHC facilities in Jilin, a north eastern province, during 2008–2018. We analysed trends and factors affecting care users’ choices, stratified by type of diseases and urban–rural settings.ResultsFrom 38 823 respondents, the survey identified 3302 health care users who sought outpatient care. 54.92% and 82.49% with diseases recommended to PHC, in urban and rural Jilin, respectively, contacted PHC facilities first. While 33.51% and 61.19% with diseases not recommended to PHC did so. Care users’ first contact with PHC facilities followed an inverse U shape during 2008–2018. Such trends were more profound among care users with hypertension and/or diabetes. Neither social health insurance coverage nor contracting with family doctors was associated with care users’ first contacts. Only 1.25% care users had referral experiences. Low perceived quality was the main barrier to choose PHC facilities.ConclusionHealth care users sought PHC in a chaotic manner in Jilin. None of the recent efforts seemed effective in prompting their preference to PHC facilities. Without levering quality of PHC, an effective hierarchical medical system could be hardly forged in China.

The Application of “Big Data Analysis + Hierarchical Medical” Model in the Context of the COVID-19

The COVID-19 epidemic has swept the world, causing serious impact and influence on economic development and residents' life in countries all over the world. This paper takes China as an example, further analyses the characteristics of China's hierarchical medical model based on the international hierarchical medical research planning, and proposes the application of “big data analysis + hierarchical medical” model for the new coronavirus epidemic and other public health emergencies based on the advantages of big data application to solve public health crises, in order to provide a reference for the planning of hierarchical medical system during the epidemic. It is expected to provide reference for the planning of hierarchical medical and health system during the epidemic, which is an innovative attempt of the medical industry.