Realigning demand and supply side incentives to improve primary health care seeking in rural China

Has China's hierarchical medical system improved doctor-patient relationships?

BACKGROUND AND OBJECTIVE

Developing harmonious doctor-patient relationships is a powerful way to promote the construction of a new pattern of medical reform in developing countries. We aim to analyze the effects of China's hierarchical medical system on doctor-patient relationships, thus contributing to China's medical and health system reform.

METHODS

With panel data on prefectural-level cities in China from 2012 to 2019, we used a time-varying difference-in-differences model to evaluate the effect of hierarchical medical treatment policy.

RESULTS

Hierarchical medical treatment policies can significantly improve doctor-patient relationships, and this conclusion is supported by various robustness tests. And improving doctor-patient relationships can be indirectly realized by the optimization of resource allocation and saving of medical costs. In addition, the marginal effect of the pilot policy on doctor-patient relationships decreased with age within the city population. In focal cities and cities with high levels of fiscal spending on health care, the effect of the pilot policy on doctor-patient relationships was stronger.

CONCLUSION

While reinforcing the literature on the doctor-patient relationship, this study also provides a reference for further exploration of the pilot policy of hierarchical medical treatment and the development of new medical and health system reform in developing countries.

Would you zoom with your doctor? A discrete choice experiment to identify patient preferences for video and in-clinic consultations in German primary care

INTRODUCTION

The popularity of video consultations in healthcare has accelerated during the COVID-19 pandemic. Despite increased availability and obvious benefits, many patients remain hesitant to use video consultations. This study investigates the relative importance of the consultation mode compared to other attributes in patients' appointment choices in Germany.

METHODS

A discrete choice experiment was conducted to examine the influence of appointment attributes on preferences for video over in-clinic consultations. A total of 350 participants were included in the analysis.

RESULTS

The level of continuity of care (46%) and the waiting time until the next available appointment (22%) were shown to have higher relative importance than consultation mode (18%) and other attributes. Participants with fewer data privacy concerns, higher technology proficiency, and more fear of COVID-19 tended to prefer video over in-clinic consultations. The predicted choice probability of a video over a typical in-clinic consultation and opting out increased from <1% to 40% when the video consultation was improved from the worst-case to the best-case scenario.

CONCLUSION

This study provides insight into the effect of the consultation mode on appointment choice at a time when telemedicine gains momentum. The results suggest that participants preferred in-clinic over video consultations. Policymakers and service providers should focus on increasing the level of continuity of care and decreasing the time until the next available appointment to prompt the adoption of video consultations. Although participants preferred to talk to their physician in person over consulting via video per se, the demand for video consultations can be increased significantly by improving the other appointment attributes of video consultations such as the level of continuity of care.

Health and health system impacts of China's comprehensive primary healthcare reforms: a systematic review

China's comprehensive primary healthcare (PHC) reforms since 2009 aimed to deliver accessible, efficient, equitable and high-quality healthcare services. However, knowledge on the system-wide effectiveness of these reforms is limited. This systematic review synthesizes evidence on the reforms' health and health system impacts. In 13 August 2022, international databases and three Chinese databases were searched for randomized controlled trials, quasi-experimental studies and controlled before-after studies. Included studies assessed large-scale PHC policies since 2009; had a temporal comparator and a control group and assessed impacts on expenditures, utilization, care quality and health outcomes. Study quality was assessed using Risk of Bias In Non-randomized Studies of Interventions, and results were synthesized narratively. From 49 174 identified records, 42 studies were included-all with quasi-experimental designs, except for one randomized control trial. Nine studies were assessed as at low risk of bias. Only five low- to moderate-quality studies assessed the comprehensive reforms as a whole and found associated increases in health service utilization, whilst the other 37 studies examined single-component policies. The National Essential Medicine Policy (N = 15) and financing reforms (N = 11) were the most studied policies, whilst policies on primary care provision (i.e. family physician policy and the National Essential Public Health Services) were poorly evaluated. The PHC reforms were associated with increased primary care utilization (N = 17) and improved health outcomes in people with non-communicable diseases (N = 8). Evidence on healthcare costs was unclear, and impacts on patients' financial burden and care quality were understudied. Some studies showed disadvantaged regions and groups that accrued greater benefits (N = 8). China's comprehensive PHC reforms have made some progress in achieving their policy objectives including increasing primary care utilization, improving some health outcomes and reducing health inequalities. However, China's health system remains largely hospital-centric and further PHC strengthening is needed to advance universal health coverage.

Understanding primary care transformation and implications for ageing populations and health inequalities: a systematic scoping review of new models of primary health care in OECD countries and China

BACKGROUND

Many countries have introduced reforms with the aim of primary care transformation (PCT). Common objectives include meeting service delivery challenges associated with ageing populations and health inequalities. To date, there has been little research comparing PCT internationally. Our aim was to examine PCT and new models of primary care by conducting a systematic scoping review of international literature in order to describe major policy changes including key 'components', impacts of new models of care, and barriers and facilitators to PCT implementation.

METHODS

We undertook a systematic scoping review of international literature on PCT in OECD countries and China (published protocol: https://osf.io/2afym ). Ovid [MEDLINE/Embase/Global Health], CINAHL Plus, and Global Index Medicus were searched (01/01/10 to 28/08/21). Two reviewers independently screened the titles and abstracts with data extraction by a single reviewer. A narrative synthesis of findings followed.

RESULTS

A total of 107 studies from 15 countries were included. The most frequently employed component of PCT was the expansion of multidisciplinary teams (MDT) (46% of studies). The most frequently measured outcome was GP views (27%), with  < 20% measuring patient views or satisfaction. Only three studies evaluated the effects of PCT on ageing populations and 34 (32%) on health inequalities with ambiguous results. For the latter, PCT involving increased primary care access showed positive impacts whilst no benefits were reported for other components. Analysis of 41 studies citing barriers or facilitators to PCT implementation identified leadership, change, resources, and targets as key themes.

CONCLUSIONS

Countries identified in this review have used a range of approaches to PCT with marked heterogeneity in methods of evaluation and mixed findings on impacts. Only a minority of studies described the impacts of PCT on ageing populations, health inequalities, or from the patient perspective. The facilitators and barriers identified may be useful in planning and evaluating future developments in PCT.

Monetary Incentives and Early Initiation of Antenatal Care: A Matched-Pair, Parallel Cluster-Randomized Trial in Zambia

Monetary incentives are often used to increase the motivation and output of health service providers. However, the focus has generally been on frontline health service providers. Using a cluster randomized trial, we evaluate the effect of monetary incentives provided to community-based volunteers on early initiation of antenatal care (ANC) visits and deliveries in health facilities in communities in Zambia. Monetary incentives were assigned to community-based volunteers in treatment sites, and payments were made for every woman referred or accompanied in the first trimester of pregnancy during January-June 2020. We find a significant increase of about 32 percent in the number of women completing ANC visits in the first trimester but no effect on service coverage rates. The number of women accompanied by community-based volunteers for ANC in the first trimester increased by 33 percent. The number of deliveries in health facilities also increased by 22 percent. These findings suggest that the use of health facilities during the first trimester of pregnancy can be improved by providing community-based volunteers with monetary incentives and that such incentives can also increase deliveries in health facilities, which are key to improving the survival of women and newborns.

Have Lower-Income Groups Benefited More from Increased Government Health Insurance Subsidies? Benefit Incidence Analysis in Ningxia, China

China's government subsidies on the demand side - such as subsidizing medical insurance premiums - have accelerated progress towards universal health coverage. We examined whether the increased government subsidies had benefited the population, especially the poor. We conducted two rounds of household surveys and collected the annual claims reports of a rural medical insurance scheme in Ningxia (a relatively underdeveloped region in Western China). We used benefit incidence analysis to evaluate the distribution of benefit for different health services received by individuals with different living standards, as measured by the household wealth index. From 2009 to 2015, the benefit received per capita tripled from 101 to 332 CNY, most (>94%) of which was received for inpatient care. The overall distribution of benefit improved and became pro-poor in 2015 (the concentration index [CI] changed from -0.017 to -0.092), mainly driven by inpatient care. The poorer groups benefited disproportionately more from inpatient care from 2009 to 2015 (the CI changed from -0.013 to -0.093). County and higher-level inpatient care had the greatest improvements towards a pro-poor distribution. The distribution of subsidies for outpatient services significantly favoured the poorer groups in 2009, but less so in 2015 (CI changed from -0.093 to -0.068), and it became less pro-poor in village clinics (CI changed from -0.209 to -0.020). The increased government subsidies for the rural medical insurance scheme mainly contributed to inpatient care and allowed the poor to use more services at county and higher-level hospitals. China's government subsidies on the demand side have contributed to equity in benefit incidence, yet there is a noticeable increasing trend in utilizing services at higher levels of providers. Our findings also indicate that outpatient services need more coverage from rural medical insurance schemes to improve equity.

Incentive Preferences and Its Related Factors Among Primary Medical Staff in Anhui Province, China: A Cross-Sectional Study

Background: The shortage of primary medical staff is a major problem in the management of health human resources across many developing countries. By determining their preferences for various motivational and related factors, we examined the correlation between staff's motivation preference levels and staff turnover and turnover intention. This study aimed to further improve the incentive mechanism and to provide a reference for healthcare managers to formulate management strategies for the primary medical staff team.

Methods: A self-reported questionnaire survey was conducted to collect data. The basic survey content included demographic characteristics. The absolute level questionnaire and relative level questionnaire on the factors affecting motivation preference were used as the main assessment scales. A total of 1,112 primary health workers in Anhui Province were investigated. T-test, analysis of variance (ANOVA), exploratory factor analysis, and multiple linear regression analysis were performed to analyze the data.

Results: The survey respondents (45.1%) reported being satisfied with their relationship with colleagues, and other social relationships (46.9%). The Kaiser Meyer Olkin (KMO) value for the absolute preference degree for motivational factors was 0.951. Two factors (economic and non-economic factors), after using the maximum variance rotation axis method, explained 81.25% of the total variance. The regression analysis showed that primary medical staff members with low monthly income (B = −0.157) have a higher preference for non-economic factors; the higher the educational background (B = 0.133), the higher their preference for economic factors. In addition, with the increase in participants' age (B = −0.250), the preference for motivational factors gradually decreased.

Conclusion: Both economic and non-economic factors play an important role in enhancing the enthusiasm of primary medical workers and improving their work attitude. Managers should use their influence to stabilize the primary medical staff.

An External Patient Healthcare Index (EPHI) for Simulating Spatial Tendencies in Healthcare Seeking Behavior

Background

Healthcare resources are always more limited compared with demand, but better matching supply with demand can improve overall resource efficiency. In countries like China where patients are free to choose healthcare facilities, over-utilization and under-utilization of healthcare resources co-exist because of unreasonable healthcare seeking behavior. However, scholarship regarding the spatial distribution of utilization for healthcare resources, resulting from unreasonable spatial tendencies in healthcare seeking, is rare.

Methods

In this article, we propose a new External Patient Healthcare Index (EPHI) to simulate the spatial distribution of utilization for healthcare resources, based on the Two-Step Floating Catchment Area (2SFCA) method, which is widely used to assess potential spatial accessibility. Instead of using individual-level healthcare utilization data which is difficult to obtain, the EPHI uses institution-level aggregated data, including numbers of inpatient/outpatient visits. By comparing the estimated utilization (based on local healthcare institution services provision) with the expected utilization (based on local population morbidity), guest patients (e.g., patients flowing in for treatment) and bypass patients (patients flowing out) can be identified. To test the applicability of this index, a case study was carried out on China's Hainan Island. The spatial tendencies of patients for inpatient and outpatient services were simulated, then incorporated with spatial access to healthcare resources to evaluate overall resource allocation efficiency, thus guiding future resource allocations and investment for policy makers and healthcare providers.

Results

The EPHI revealed that bypass activities widely exist on Hainan Island in both inpatient and outpatient care, with patients tending to travel from less developed regions with fewer healthcare resources to more highly developed regions with more healthcare resources to receive healthcare. Comparison with spatial accessibility demonstrated how bypass activities on Hainan produced an under-utilization of doctors in less developed regions and over-utilization of doctors in more developed coastal regions.

Conclusions

This case study on Hainan Island demonstrates that this new index can very clearly identify both the sources and sinks of patient spatial tendencies. Combining these results with spatial accessibility of healthcare resources, how efficiently the available supply matches the utilization can be revealed, indicating wide-ranging applicability for local governments and policymakers.

Large hospitals' outpatient diversion system in China: Following individual intention and referral

In this study, we explored the strategies and suggestions for the outpatient diversion system of large hospitals in Chinese underdeveloped areas of primary medical care, under the consideration of balancing patients' intention and compliance with the referral system. An empirical study was conducted on the relationship among medical need, visiting intention and health-seeking behaviour to verify the effect of intention-system mixed outpatient diversion mode in China's large hospitals. Examination of the demographic characteristics, insurance, and residence information revealed that outpatients could be divided into three categories before the application of the referral system. Then, due to the implementation of the referral system, the willingness of some patients to seek medical treatment has changed. Consequently, the service path for outpatients could be consolidated into two categories with differentiated behavioural characteristics, which were respectively driven by personal intention and service system. According to the utility value intervention of the referral system for outpatient seeking behaviour, some measures and strategies can be explored to build a new system that combines personal connotation and system utility to realise the effective distribution and management of outpatients in large hospitals in Chinese underdeveloped areas.

The Effects of Chronic Disease Management in Primary Health Care: Evidence from Rural China

Health systems globally face increasing morbidity and mortality from chronic diseases, yet many - especially in low- and middle-income countries - lack strong chronic disease management in primary health care (PHC). We provide evidence on China's efforts to promote PHC management using unique five-year panel data in a rural county, including health care utilization from medical claims and health outcomes from biomarkers. Utilizing plausibly exogenous variation in management intensity generated by administrative and geographic boundaries, we compare hypertension/diabetes patients in villages within two kilometers distance but managed by different townships. Results show that, compared to patients in townships with median management intensity, patients in high-intensity townships have 4.8% more PHC visits, 5.2% fewer specialist visits, 11.7% lower likelihood of having an inpatient admission, and 3.6% lower medical spending. They also tend to have better medication adherence and better control of blood pressure. The resource savings from avoided inpatient admissions substantially outweigh the costs of the program.

Whether high government subsidies reduce the healthcare provision of township healthcare centers in rural China

Background

China’s government launched a large-scale healthcare reform from 2009. One of the main targets of this round reform was to improve the primary health care system. Major reforms for primary healthcare institutions include increasing government investment. However, there are insufficient empirical studies based on large sample to catch long-term effect of increased government subsidy and lack of sufficient incentives on township healthcare centers (THCs), therefore, this study aims to provide additional empirical evidence on the concern by conducting an empirical analysis of THCs in Shaanxi province in China.

Methods

We collected nine years (2009 to 2017) data of THCs from the Health Finance Annual Report System (HFARS) that was acquired from the Health Commission of Shaanxi Province. We applied two-way fixed effect model and continue difference-in-difference (DID) model to estimate the effect of percentage of government subsidy on medical provision.

Results

A clear jump of the average percentage of government subsidy to total revenue of THCs can be found in Shaanxi province in 2011, and the average percentage has been more than 60% after 2011. Continue DID models indicate every 1% percentage of government subsidy to total revenue increase after 2011 resulted in a decrease of 1.1 to 3.5% in THCs healthcare provision (1.9% in medical revenue, 1.2% in outpatient visit, 3.5% in total occupy beds of inpatient, 1.1% in surgery revenue, 2.1% in sickbed utilization rate). The results show that the THCs with high government subsidy reduce the number of medical services after 2011.

Conclusions

We think that it is no doubt that the government should take more responsibility for the financing of primary healthcare institutions, the problem is when government plays a central role in the financing and delivery of primary health care services, more effective incentives should be developed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07201-w.

The Impact of Catastrophic Medical Insurance in China: A five-year patient-level panel study

Background: In an effort to provide greater financial protection from the risk of large medical expenditures, China has gradually added catastrophic medical insurance (CMI) to the various basic insurance schemes. Tongxiang, a rural county in Zhejiang province, China, has had CMI since 2000 for their employee insurance scheme, and since 2014 for their resident insurance scheme. Methods: Compiling and analysing patient-level panel data over five years, we use a difference-in-difference approach to study the effect of the 2014 introduction of CMI for resident insurance beneficiaries in Tongxiang. In our study design, resident insurance beneficiaries are the treatment group, while employee insurance beneficiaries are the control group. Findings: We find that availability of CMI significantly increases medical expenditures among resident insurance beneficiaries, including for both inpatient and outpatient spending. Despite the greater financial protection, out-of-pocket expenditures increased, in part because patients accessed treatment more often at higher-level hospitals. Interpretation: Better financial coverage for catastrophic medical expenditures led to greater access and expenditures, not only for inpatient admissions-the category that most often leads to catastrophic expenditures-but for outpatient visits as well. These patterns of expenditure change with CMI may reflect both enhanced access to a patient's preferred site of care as well as the influence of incentives encouraging more care under fee-for-service payment. Funding: Stanford University's Freeman Spogli Institute for International Studies' Policy Implementation Lab and a Shorenstein Asia Pacific Research Center faculty research award provided funding for this project. Chinese translation of the abstract (Appendix 1).

From Mao to McDonaldization? Assessing the rationalisation of health care in China

China's 2009 health care reform agenda has been referred to as one of the most ambitious health policy programmes in modern history. Significant investment has combined with new structures, incentives, and regulations that have aimed to improve access, as well as gain greater control over a health care market much criticised for putting profit before patients. A range of health services research has been undertaken to analyse these efforts. Sociological perspectives have also been documented yet up to now a review and synthesis combining these various contributions has not been undertaken. By drawing on the lens of McDonaldization, the paper presents a narrative review that analyses the extent to which China's 2009 reform agenda has increased efficiency, calculability, predictability, and control over service provision. The review identifies elements of McDonaldization within China's 2009 reform agenda, however, notable gaps remain. In response to the limits of McDonaldization as a lens for understanding China's health care reform, the paper calls for alternative perspectives that are better able to understand the sociocultural dynamics shaping service provision, as well as an interdisciplinary research agenda that is able to generate new insights and understanding regarding health care in China.

Impact of differential copayment on patient healthcare choice: evidence from South Korean National Cohort Study

OBJECTIVE

We evaluate the effectiveness of mild disease differential copayment policy aimed at reducing unnecessary patient visits to secondary/tertiary healthcare institutions in South Korea.

DESIGN

Retrospective study using difference-in-difference design.

SETTING

Sample Research database provided by the Korean National Health Insurance Service, between 2010 and 2013.

PARTICIPANTS

206 947 patients who visited healthcare institutions to treat mild diseases during the sample period.

METHODS

A linear probability model with difference-in-difference approach was adopted to estimate the changes in patients' healthcare choices associated with the differential copayment policy. The dependent variable was a binary variable denoting whether a patient visited primary healthcare or secondary/tertiary healthcare to treat her/his mild disease. Patients' individual characteristics were controlled with a fixed effect.

RESULTS

We observed significant decrease in the proportion of patients choosing secondary/tertiary healthcare over primary healthcare by 2.99 per cent point. The decrease associated with the policy was smaller by 14% in the low-income group compared with richer population, greater by 19% among the residents of Seoul metropolitan area than among people living elsewhere, and greater among frequent healthcare visitors by 33% than among people who less frequently visit healthcare.

CONCLUSION

The mild disease differential copayment policy of South Korea was successful in discouraging unnecessary visits to secondary/tertiary healthcare institutions to treat mild diseases that can be treated well in primary healthcare.

Paying for performance to improve the delivery of health interventions in low- and middle-income countries

BACKGROUND

There is growing interest in paying for performance (P4P) as a means to align the incentives of healthcare providers with public health goals. Rigorous evidence on the effectiveness of these strategies in improving health care and health in low- and middle-income countries (LMICs) is lacking; this is an update of the 2012 review on this topic.

OBJECTIVES

To assess the effects of paying for performance on the provision of health care and health outcomes in low- and middle-income countries.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and 10 other databases between April and June 2018. We also searched two trial registries, websites, online resources of international agencies, organizations and universities, and contacted experts in the field. Studies identified from rerunning searches in 2020 are under 'Studies awaiting classification.'

SELECTION CRITERIA

We included randomized or non-randomized trials, controlled before-after studies, or interrupted time series studies conducted in LMICs (as defined by the World Bank in 2018). P4P refers to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. To be included, a study had to report at least one of the following outcomes: patient health outcomes, changes in targeted measures of provider performance (such as the delivery of healthcare services), unintended effects, or changes in resource use.

DATA COLLECTION AND ANALYSIS

We extracted data as per original review protocol and narratively synthesised findings. We used standard methodological procedures expected by Cochrane. Given diversity and variability in intervention types, patient populations, analyses and outcome reporting, we deemed meta-analysis inappropriate. We noted the range of effects associated with P4P against each outcome of interest. Based on intervention descriptions provided in documents, we classified design schemes and explored variation in effect by scheme design.

MAIN RESULTS

We included 59 studies: controlled before-after studies (19), non-randomized (16) or cluster randomized trials (14);  and interrupted time-series studies (9). One study included both an interrupted time series and a controlled before-after study. Studies focused on a wide range of P4P interventions, including target payments and payment for outputs as modified by quality (or quality and equity assessments). Only one study assessed results-based aid. Many schemes were funded by national governments (23 studies) with the World Bank funding most externally funded schemes (11 studies). Targeted services varied; however, most interventions focused on reproductive, maternal and child health indicators. Participants were predominantly located in public or in a mix of public, non-governmental and faith-based facilities (54 studies). P4P was assessed predominantly at health facility level, though districts and other levels were also involved. Most studies assessed the effects of P4P against a status quo control (49 studies); however, some studies assessed effects against comparator interventions (predominantly enhanced financing intended to match P4P funds (17 studies)). Four studies reported intervention effects against both comparator and status quo. Controlled before-after studies were at higher risk of bias than other study designs. However, some randomised trials were also downgraded due to risk of bias. The interrupted time-series studies provided insufficient information on other concurrent changes in the study context. P4P compared to a status quo control For health services that are specifically targeted, P4P may slightly improve health outcomes (low certainty evidence), but few studies assessed this. P4P may also improve service quality overall (low certainty evidence); and probably increases the availability of health workers, medicines and well-functioning infrastructure and equipment (moderate certainty evidence). P4P may have mixed effects on the delivery and use of services (low certainty evidence) and may have few or no distorting unintended effects on outcomes that were not targeted (low-certainty evidence), but few studies assessed these. For secondary outcomes, P4P may make little or no difference to provider absenteeism, motivation or satisfaction (low certainty evidence); but may improve patient satisfaction and acceptability (low certainty evidence); and may positively affect facility managerial autonomy (low certainty evidence). P4P probably makes little to no difference to management quality or facility governance (low certainty evidence). Impacts on equity were mixed (low certainty evidence). For health services that are untargeted, P4P probably improves some health outcomes (moderate certainty evidence); may improve the delivery, use and quality of some health services but may make little or no difference to others (low certainty evidence); and may have few or no distorting unintended effects (low certainty evidence). The effects of P4P on the availability of medicines and other resources are uncertain (very low certainty evidence). P4P compared to other strategies For health outcomes and services that are specifically targeted, P4P may make little or no difference to health outcomes (low certainty evidence), but few studies assessed this. P4P may improve service quality (low certainty evidence); and may have mixed effects on the delivery and use of health services and on the availability of equipment and medicines (low certainty evidence). For health outcomes and services that are untargeted, P4P may make little or no difference to health outcomes and to the delivery and use of health services (low certainty evidence). The effects of P4P on service quality, resource availability and unintended effects are uncertain (very low certainty evidence). Findings of subgroup analyses Results-based aid, and schemes using payment per output adjusted for service quality, appeared to yield the greatest positive effects on outcomes. However, only one study evaluated results-based aid, so the effects may be spurious. Overall, schemes adjusting both for quality of service and rewarding equitable delivery of services appeared to perform best in relation to service utilization outcomes.

AUTHORS' CONCLUSIONS

The evidence base on the impacts of P4P schemes has grown considerably, with study quality gradually increasing. P4P schemes may have mixed effects on outcomes of interest, and there is high heterogeneity in the types of schemes implemented and evaluations conducted. P4P is not a uniform intervention, but rather a range of approaches. Its effects depend on the interaction of several variables, including the design of the intervention (e.g., who receives payments ), the amount of additional funding,  ancillary components (such as technical support) and contextual factors (including organizational context).

Is the evidence on the effectiveness of pay for performance schemes in healthcare changing? Evidence from a meta-regression analysis

BACKGROUND

This study investigated if the evidence on the success of the Pay for Performance (P4P) schemes in healthcare is changing as the schemes continue to evolve by updating a previous systematic review.

METHODS

A meta-regression analysis using 116 studies evaluating P4P schemes published between January 2010 to February 2018. The effects of the research design, incentive schemes, use of incentives, and the size of the payment to revenue ratio on the proportion of statically significant effects in each study were examined.

RESULTS

There was evidence of an increase in the range of countries adopting P4P schemes and weak evidence that the proportion of studies with statistically significant effects have increased. Factors hypothesized to influence the success of schemes have not changed. Studies evaluating P4P schemes which made payments for improvement over time, were associated with a lower proportion of statistically significant effects. There was weak evidence of a positive association between the incentives' size and the proportion of statistically significant effects.

CONCLUSION

The evidence on the effectiveness of P4P schemes is evolving slowly, with little evidence that lessons are being learned concerning the design and evaluation of P4P schemes.

A realist review to assess for whom, under what conditions and how pay for performance programmes work in low- and middle-income countries

Pay for performance (P4P) programmes are popular health system-focused interventions aiming to improve health outcomes in low-and middle-income countries (LMICs). This realist review aims to understand how, why and under what circumstance P4P works in LMICs.We systematically searched peer-reviewed and grey literature databases, and examined the mechanisms underpinning P4P effects on: utilisation of services, patient satisfaction, provider productivity and broader health system, and contextual factors moderating these. This evidence was then used to construct a causal loop diagram.We included 112 records (19 grey literature; 93 peer-reviewed articles) assessing P4P schemes in 36 countries. Although we found mixed evidence of P4P's effects on identified outcomes, common pathways to improved outcomes include: community outreach; adherence to clinical guidelines, patient-provider interactions, patient trust, facility improvements, access to drugs and equipment, facility autonomy, and lower user fees. Contextual factors shaping the system response to P4P include: degree of facility autonomy, efficiency of banking, role of user charges in financing public services; staffing levels; staff training and motivation, quality of facility infrastructure and community social norms. Programme design features supporting or impeding health system effects of P4P included: scope of incentivised indicators, fairness and reach of incentives, timely payments and a supportive, robust verification system that does not overburden staff. Facility bonuses are a key element of P4P, but rely on provider autonomy for maximum effect. If health system inputs are vastly underperforming pre-P4P, they are unlikely to improve only due to P4P. This is the first realist review describing how and why P4P initiatives work (or fail) in different LMIC contexts by exploring the underlying mechanisms and contextual and programme design moderators. Future studies should systematically examine health system pathways to outcomes for P4P and other health system strengthening initiatives, and offer more understanding of how programme design shapes mechanisms and effects.

Realigning the provider payment system for primary health care: a pilot study in a rural county of Zhejiang Province, China

Aim:

This work aimed to evaluate a pre/post-reform pilot study from 2015 to 2018 in a rural county of Zhejiang Province, China to realign the provider payment system for primary health care (PHC).

Methods:

Data were extracted from the National Health Financial Annual Reports for the 21 township health centers (THCs) in Shengzhou County. An information system was designed for the reform. Differences among independent groups were assessed using Kruskal–Wallis H-test. Dunn’s post hoc test was used for multiple comparisons. Differences between paired groups were tested by Wilcoxon signed-rank test. Two-tailed P < 0.05 indicated statistical significance. Data were processed and analyzed using R 3.6.1 for Windows.

Findings:

First, payments to THCs shifted from a “soft budget” to a mixed system of line-item input-based and categorized output-based payments, accounting for 17.54% and 82.46%, respectively, of total revenue in 2017. Second, providers were more motivated to deliver services after the reform; total volumes increased by 27.80%, 19.22%, and 30.31% for inpatient visits, outpatient visits, and the National Essential Public Health Services Package (NEPHSP), respectively. Third, NEPHSP payments were shifted from capitation to resource-based relative value scale (RBRVS) payments, resulting in a change in the NEPHSP subsidy from 36.41 to 67.35 per capita among the 21 THCs in 2017. Fourth, incentive merit pay to primary health physicians accounted for 38.40% of total salary, and the average salary increased by 32.74%, with a 32.45% increase in working intensity. A small proportion of penalties for unqualified products and pay-for-performance rewards were blended with the payments. The reform should be modified to motivate providers in remote areas.

Conclusion:

In the context of a profit-driven, hospital-centered system, add-on payments – including categorized output-based payments to THCs and incentive merit pay to primary care physicians (PCPs) – are probably worth pursuing to achieve more active and output/outcome-based PHC in China.

Evaluating the effect of hierarchical medical system on health seeking behavior: A difference-in-differences analysis in China

The unbalanced allocation of healthcare resources and the underutilization of primary care facilities are the core problems that restrict the current healthcare reforms in China. In order to encourage residents to go to primary care facilities, China implemented the Hierarchical Medical System (HMS) in 2015. This study aims to evaluate the effect of HMS on health seeking behavior in China using panel data. Statistics for the study were derived from China Family Panel Studies (CFPS) 2012, 2014, 2016 and 2018, and China health and family planning statistical yearbook 2012, 2014, 2016 and 2018. We employed the difference-in-differences (DID) model with multiple periods. In total, 61,932 residents were incorporated for a final sample covered 25 provinces. The results indicated that the implementation of HMS had a significantly positive effect on the probability of urban residents going to primary care facilities for contact. However, the effect of HMS was not significant for rural residents. Basic health insurance was a significant factor for directing residents to primary care facilities. Self-assessed health, chronic disease, economic level and educational status were also found to be focal factors of health seeking behavior. In conclusion, the introduction of HMS has led to improved health seeking behavior and is worth putting more effort into. For policy makers, basic medical insurance is still an important health policy that enables systematic health seeking behavior. Initiatives to continue to expand the adjustment range of economic incentives should be adopted to promote the implementation of HMS. However, the effect of HMS in chronic disease is poor and efforts to formulate chronic disease as a breakthrough to HMS should be carried out. Moreover, the government should increase the publicity of HMS.

How are pay-for-performance schemes in healthcare designed in low- and middle-income countries? Typology and systematic literature review

BACKGROUND

Pay for performance (P4P) schemes provide financial incentives to health workers or facilities based on the achievement of pre-specified performance targets and have been widely implemented in health systems across low and middle-income countries (LMICs). The growing evidence base on P4P highlights that (i) there is substantial variation in the effect of P4P schemes on outcomes and (ii) there appears to be heterogeneity in incentive design. Even though scheme design is likely a key determinant of scheme effectiveness, we currently lack systematic evidence on how P4P schemes are designed in LMICs.

METHODS

We develop a typology to classify the design of P4P schemes in LMICs, which highlights different design features that are a priori likely to affect the behaviour of incentivised actors. We then use results from a systematic literature review to classify and describe the design of P4P schemes that have been evaluated in LMICs. To capture academic publications, Medline, Embase, and EconLit databases were searched. To include relevant grey literature, Google Scholar, Emerald Insight, and websites of the World Bank, WHO, Cordaid, Norad, DfID, USAID and PEPFAR were searched.

RESULTS

We identify 41 different P4P schemes implemented in 29 LMICs. We find that there is substantial heterogeneity in the design of P4P schemes in LMICs and pinpoint precisely how scheme design varies across settings. Our results also highlight that incentive design is not adequately being reported on in the literature - with many studies failing to report key design features.

CONCLUSIONS

We encourage authors to make a greater effort to report information on P4P scheme design in the future and suggest using the typology laid out in this paper as a starting point.

Short-term and long-term unintended impacts of a pilot reform on Beijing's zero markup drug policy: a propensity score-matched study

Background

In September 2012, Beijing, the capital of China, selected five tertiary hospitals as pilots to remove the previously allowed 15% markup for drug sales. However, while most research demonstrated the significant decrease in drug sales, the core issue of high health expenditure was not well solved because of the unintended policy impact. This study aimed to empirically evaluate the short-term and long-term unintended impacts on controlling medical expenses of Beijing’s zero markup drug policy from 2012 to 2015.

Methods

This study extracted 2012–2015 individual-level data from the Beijing Urban Employee Basic Medical Insurance (UEBMI) database and performed a propensity score-matched analysis to evaluate the short-term and long-term impacts on controlling medical expenses. All inpatients in the 5 pilot reform hospitals were selected as the intervention group, while inpatients in other tertiary hospitals were selected as the control group.

Results

A total of 520,996 inpatients were extracted in this study. For patients in the pilot hospitals, the total expenditures per admission decreased from 17,140.3 yuan in 2012 to 15,430.1 yuan in 2013 and then increased to 16,789.8 yuan in 2015. Expenditure on drugs reduced from 5811.7 yuan in 2012 to 3903.4 yuan in 2015. However, a significant substitution effect of medical consumables was first observed in the third quarter of 2014, which undermined the impact of the policy. In the long-term, the intervention group and control group demonstrated the same trend.

Conclusions

After the zero markup drug policy, expenditure on drugs revealed a continuous decline. However, the decline in total expenditure was weakened by the substitution effect of medical consumables in the long term.

Can a results-based bottom-up reform improve health system performance? Evidence from the rural health project in China

In 2008, the Rural Health Project (Health XI) was initiated in 40 Chinese counties to pilot interventions aimed at improving local health systems. Performance targets were pre-specified (results-based), and project counties were allowed to tailor their interventions (bottom-up) in recognition of the substantial regional variations. Using household data from the China National Health Services Survey in a difference-in-differences strategy combined with matching, we find that project counties have improved outcomes (both incentivized and not-directly-incentivized) in all three domains examined-medical care, public health services, and self-rated health-by 2013. In particular, the decrease in outpatient intravenous drip use and financial strain and the increase in all four components of public health services provision are robust to a variety of tests and alternative matching strategies. Results for not-directly-incentivized indicators suggest that results-based payment did not lead to multitasking problems but rather to positive spillovers. On the other hand, little improvement in inpatient-related indicators suggests that the Health XI interventions did not successfully redress the perverse incentives driving the bulk of providers' income. In general, however, our results indicate that interventions adopted in the results-based bottom-up approach generated substantial benefits given the investment.

Primary health care financing interventions: a systematic review and stakeholder-driven research agenda for the Asia-Pacific region

INTRODUCTION

Interventions targeting the financing of primary health care (PHC) systems could accelerate progress towards universal health coverage; however, there is limited evidence to guide best-practice implementation of these interventions. This study aimed to generate a stakeholder-led research agenda in the area of PHC financing interventions in the Asia-Pacific region.

METHODS

We adopted a two-stage process: (1) a systematic review of financing interventions targeting PHC service delivery in the Asia-Pacific region was conducted to develop an evidence gap map and (2) an electronic-Delphi (e-Delphi) exercise with key national PHC stakeholders was undertaken to prioritise these evidence needs.

RESULTS

Thirty-one peer-reviewed articles (including 10 systematic reviews) and 10 grey literature reports were included in the review. There was limited consistency in results across studies but there was evidence that some interventions (removal of user fees, ownership models of providers and contracting arrangements) could impact PHC service access, efficiency and out-of-pocket cost outcomes. The e-Delphi exercise highlighted the importance of contextual factors and prioritised research in the areas of: (1) interventions to limit out-of-pocket costs; (2) financing models to enhance health system performance and maintain PHC budgets; (3) the design of incentives to promote optimal care without unintended consequences and (4) the comparative effectiveness of different PHC service delivery strategies using local data.

CONCLUSION

The research questions which were deemed most important by stakeholders are not addressed in the literature. There is a need for more research on how financing interventions can be implemented at scale across health systems. Such research needs to be pragmatic and balance academic rigour with practical considerations.

Public preferences for health care facilities in rural China: A discrete choice experiment

To successfully tackle the problems with the underutilization of primary care in rural China, it is important to align resource allocation with the preferences of the rural population. However, despite growing interest in the factors influencing the rural population's choice of facility, it is unclear how much weight should be placed on these factors, especially under different scenarios of disease severity. In the first study to elicit quantified trade-offs among influential factors in choosing health care facilities, we carried out a discrete choice experiment (DCE) in rural China. We used a Bayesian efficient design to construct 36 choice sets, and then divided them into three blocks. Each block formed one version of questionnaire that contained 12 choice questions. Each question was assigned a hypothetical perceived severity scenario of either minor or severe disease. 559 Rural residents completed the DCE through face-to-face interviews in December 2017-March 2018. We used mixed logit models to analyze the choice data. The factors regarding the availability and affordability of a facility, such as visit time, travel time, and out-of-pocket cost, were highly valued. When the facilities changed simultaneously from the worst to the best case, a huge increase (from 4.8% to 66.5%) in the predicted choice probability of choosing to visit a facility was observed under perceived minor disease scenario, whereas there was no significant change under perceived severe disease scenario. Improvements to drug availability, medical professional skill and equipment in rural primary care system can induce potential medical care seeking, and redirect patient flow from higher level hospitals to primary level. Especially, township health centers, which provide service to the residents in rural communities, have great potential to be the ideal facilities for first-contact care.

Health care utilization and affordability among older people following China's 2009 health reform -- evidence from CHARLS pilot study

BACKGROUND

In 2009, China unveiled an ambitious national health care reform program, with the goal of providing equitable and affordable basic health care for everyone. This study was intended to partially fill the knowledge gap in understanding of the demand-side impact on health care utilization and affordability among older people in Zhejiang and Gansu provinces of China.

METHODS

We used two waves of data from the pilot survey of CHARLS implemented in 2008 and 2012. Chi-square tests and t tests were performed to examine whether out-of-pocket (OOP) and pharmaceutical spending (PS), as a share of total health expenditures (THEs), have significantly changed following the health reform. Two-part model was employed to confirm these changes after controlling for confounding variables. All analyses were weighted and clustered the standard errors.

RESULTS

After controlling for confounding variables, older people in 2012 were 2.1 and 6.8% more likely to use outpatient and inpatient care than they did in 2008, respectively. Among those who have at least one outpatient visit, declines of OOP-to- THEs and PS-to-THEs percentage significantly reduced 0.998 (p < 0.1) and 2.324 (p < 0.01) from 2008 to 2012, respectively. However, conditional on having at least one inpatient stay, no significant reduction in terms of the OOP-to-THEs and even increase in terms of the PS-to-THEs percentage observed between 2008 and 2012. Compared to elderly people in Gansu, Zhejiang aged people had obviously better utilization, lighter inpatient OOP burden and lower inpatient PS proportion, but higher outpatient OOP burden and PS proportion.

CONCLUSIONS

Although the OOP burden and PS portion had been reduced following the health reform, these impacts were still limited. Better results can be observed in outpatient care than in inpatient care, which provide a strong foundation for the next stage of reform.

The cost-effectiveness analysis of the New Rural Cooperative Medical Scheme in China

OBJECTIVE

The New Rural Cooperative Medical Scheme (NCMS) is a universal healthcare coverage plan now covering over 98% of rural residents in China, first implemented in 2003. Rising costs in the face of modest gains in health and financial protections have raised questions about the cost-effectiveness of the NCMS.

METHODS

Using the most recent estimates of the NCMS's health and economic consequences from a comprehensive review of the literature, we conducted a cost-effectiveness analysis using a Markov model for a hypothetical cohort between ages 20 and 100. We then did one-way sensitivity analyses and a probabilistic sensitivity analysis using Monte Carlo simulations to explore whether the incremental cost-effectiveness ratio (ICER) falls below 37,059 international dollars [Int$], the willingness-to-pay (WTP) threshold of three times per capita GDP of China in 2013.

FINDINGS

The ICER of the NCMS over the lifetime of an average 20-year-old rural resident in China was about Int$71,480 per quality-adjusted life year (QALY) gained (95% confidence interval: cost-saving, Int$845,659/QALY). There was less than a 33% chance that the system was cost-saving or met the WTP threshold. However, the NCMS did fall under the threshold when changes in the program costs, the risk of mortality and hypertension, and the likelihood of labor force participation were tested in one-way sensitivity analyses.

CONCLUSION

The NCMS appears to be economically inefficient in its current form. Further cost-effectiveness analyses are warranted in designing insurance benefit packages to ensure that the NCMS fund goes toward health care that has a good value in improving survival and quality of life.

Factors influencing choice of health system access level in China: A systematic review

OBJECTIVE

In China, patients increasingly choose to access already severely overcrowded higher level hospitals, leaving lower level facilities with low utilization rates. This situation undermines the effectiveness and efficiency of the health system. The situation tends to worsen despite policy measures aimed at improvement. We systematically review the factors affecting patient choice to synthesize scientific understanding of health system access in China. The review provides an evidence base for measures to direct patient flow towards lower level facilities.

METHODS

We screened the peer-reviewed literature published from April 2009 to January 2016 that investigates Chinese patients' choice of health care facilities at different levels and assessed 45 studies in total. We applied two structured forms to extract data on each study's characteristics, methodology, and factors.

RESULTS OF DATA SYNTHESIS

The results identified four factor types: 1) patient, 2) provider, 3) context and 4) composite: combined patient, provider, and/or context attributes. Patient factors are mentioned the most, but the evidence on patient factors is often inconclusive. Evidence suggests that the provider factors 'drug variety' and 'equipment', and composite factor 'perceived quality', push patients from lower levels towards higher levels.

CONCLUSION

Underuse of primary care facilities and overcrowding of higher level facilities will likely be amplified by current demographic trends. Evidence suggests that improving drug availability, equipment and perceived quality of primary care services can improve the situation. Well-designed research that considers the interactions between factors is called for to better inform future interventions.

Is universal and uniform health insurance better for China? Evidence from the perspective of supply-induced demand

China has achieved nearly universal social health insurance (SHI) coverage by implementing three statutory schemes, but gaps and differences in benefit levels are apparent. There is wide agreement that China should merge the three schemes into a universal and uniform SHI. However, data on the medical expenses of all inpatients in 2014 at a public Tier-three hospital suggests that supply-induced demand (SID) is a serious concern and that, under the design of the current schemes, a higher benefit level has a greater impact on the total expenses of insured patients. Thus, if SID is not effectively controlled, a universal and uniform SHI may be more harmful than beneficial in China. Finally, we suggest that China should substitute the existing fee-for-service design with a suite of bundled provider payment methods; furthermore, China should replace its current system of pricing drugs that encourages hospitals and doctors to use costlier medications.

Factors affecting patient satisfaction with ecdemic medical care: a cross-sectional study in Nanchang, China

PURPOSE

This study aimed to determine the factors that influence patient satisfaction with ecdemic medical care.

MATERIALS AND METHODS

Eight hundred and forty-four face-to-face interviews were conducted between October and November 2017 in two high-profile hospitals in Nanchang, China. Patient satisfaction was divided into lowest and highest satisfaction groups according the 80/20 rule. Demographic factors associated with patient satisfaction were identified by logistic regression models.

RESULTS

Respondents' main reasons for choosing a non-local hospital were "high level of medical treatment" (581/844), "good reputation of the hospital" (533/844), and "advanced medical equipment" (417/844). The top three items that dissatisfied the ecdemic patients were "long time to wait for treatment" (553/844), "complicated formalities" (307/844), and "poor overall service attitude" (288/844). Fewer female patients (adjusted odds ratio [AOR] =1.47, 95% confidence interval [CI] =1.03-2.11), patients with a family per-capita monthly income (FPMI) between 3,001 and 5,000 CNY (AOR =1.40, 95% CI =1.01-2.17), inpatients (AOR =1.46, 95% CI =1.01-2.13), and more patients with an FPMI >7,000 CNY (AOR =0.43, 95% CI =0.20-0.92) were detected in the lowest satisfaction group. Fewer patients with an associate's or bachelor's degree (AOR =2.40, 95% CI =1.37-4.20) and patients with an FPMI >7,000 CNY (AOR =3.02, 95% CI =1.10-8.33) were detected in the highest satisfaction group. Moreover, more inpatients (AOR =0.70, 95% CI =0.54-0.97) and those aged 46-65 years (AOR =0.63, 95% CI =0.33-0.98) were detected in the highest satisfaction group.

CONCLUSION

Findings suggested that managers of the medical facilities should note the importance of increasing their publicity through a rapidly developing media, as well as the necessity of creating a more patient-friendly medical care experience. Hospitals should also focus on the medical care experience of patients with relatively lower and higher income levels, male ecdemic patients, and ecdemic outpatients.

Does charging different user fees for primary and secondary care affect first-contacts with primary healthcare? A systematic review

Policy-makers are increasingly considering charging users different fees between primary and secondary care (differential user charges) to encourage utilisation of primary health care in health systems with limited gate keeping. A systematic review was conducted to evaluate the impact of introducing differential user charges on service utilisation. We reviewed studies published in MEDLINE, EMBASE, the Cochrane library, EconLIT, HMIC, and WHO library databases from January 1990 until June 2015. We extracted data from the studies meeting defined eligibility criteria and assessed study quality using an established checklist. We synthesized evidence narratively. Eight studies from six countries met our eligibility criteria. The overall study quality was low, with diversity in populations, interventions, settings, and methods. Five studies examined the introduction of or increase in user charges for secondary care, with four showing decreased secondary care utilisation, and three showing increased primary care utilisation. One study identified an increase in primary care utilisation after primary care user charges were reduced. The introduction of a non-referral charge in secondary care was associated with lower primary care utilisation in one study. One study compared user charges across insurance plans, associating higher charges in secondary care with higher utilisation in both primary and secondary care. Overall, the impact of introducing differential user-charges on primary care utilisation remains uncertain. Further research is required to understand their impact as a demand side intervention, including implications for health system costs and on utilisation among low-income patients.

The effects of patient cost sharing on inpatient utilization, cost, and outcome

Background

Health insurance and provider payment reforms all over the world beg a key empirical question: what are the potential impacts of patient cost-sharing on health care utilization, cost and outcomes? The unique health insurance system and rich electronic medical record (EMR) data in China provides us a unique opportunity to study this topic.

Methods

Four years (2010 to 2014) of EMR data from one medical center in China were utilized, including 10,858 adult patients with liver diseases. We measured patient cost-sharing using actual reimbursement ratio (RR) which is allowed us to better capture financial incentive than using type of health insurance. A rigorous risk adjustment method was employed with both comorbidities and disease severity measures acting as risk adjustors. Associations between RR and health use, costs and outcome were analyzed by multivariate analyses.

Results

After risk adjustment, patients with more generous health insurance coverage (higher RR) were found to have longer hospital stay, higher total cost, higher medication cost, and higher ratio of medication to total cost, as well as higher number and likelihood that specific procedures were performed.

Conclusion

Our study implied that patient cost-sharing affects health care services use and cost. This reflects how patients and physicians respond to financial incentives in the current healthcare system in China, and the responses could be a joint effect of both demand and supply side moral hazard. In order to contain cost and improve efficiency in the system, reforming provide payment and insurance scheme is urgently needed.

It's all about the money? A qualitative study of healthcare worker motivation in urban China

BACKGROUND

China's healthcare reform programme continues to receive much attention. Central to these discussions has been how the various financial incentives underpinning reform efforts are negatively impacting on the healthcare workforce. Research continues to document these trends, however, qualitative analysis of how these incentives impact on the motivation of healthcare workers remains underdeveloped. Furthermore, the application of motivational theories to make sense of healthcare worker experiences has yet to be undertaken.

METHODS

The purpose of our paper is to present a comparative case study account of healthcare worker motivation across urban China. It draws on semi structured interviews (n = 89) with a range of staff and organisations across three provinces. In doing so, the paper analyses how healthcare worker motivation is influenced by a variety of financial incentives; how motivation is influenced by the opportunities for career development; and how motivation is influenced by the day to day pressures of meeting patient expectations.

RESULTS

The experience of healthcare workers in China highlights how a reliance on financial incentives has challenged their ability to maintain the values and ethos of public service. Our findings suggest greater attention needs to be paid to the motivating factors of improved income and career development. Further work is also needed to nurture and develop the motivation of healthcare workers through the building of trust between fellow workers, patients, and the public.

CONCLUSIONS

Through the analysis of healthcare worker motivation, our paper presents a number of ways China can improve its current healthcare reform efforts. It draws on the experience of other countries in calling for policy makers to support alternative approaches to healthcare reform that build on multiple channels of motivation to support healthcare workers.

China's Health Reform Update

China experienced both economic and epistemological transitions within the past few decades, greatly increasing demand for accessible and affordable health care. These shifts put significant pressure on the existing outdated, highly centralized bureaucratic system. Adjusting to growing demands, the government has pursued a new round of health reforms since the late 2000s; the main goals are to reform health care financing, essential drug policies, and public hospitals. Health care financing reform led to universal basic medical insurance, whereas the public hospital reform required more complex measures ranging from changes in regulatory, operational, and service delivery settings to personnel management. This article reviews these major policy changes and the literature-based evidence of the effects of reforms on cost, access, and quality of care. It then highlights the outlook for future reforms. We argue that a better understanding of the unintended consequences of reform policies and of how practitioners’ and patients’ interests can be better aligned is essential for reforms to succeed.

Financial Incentives to Encourage Value-Based Health Care

This article reviews the literature on the use of financial incentives to improve the provision of value-based health care. Eighty studies of 44 schemes from 10 countries were reviewed. The proportion of positive and statistically significant outcomes was close to .5. Stronger study designs were associated with a lower proportion of positive effects. There were no differences between studies conducted in the United States compared with other countries; between schemes that targeted hospitals or primary care; or between schemes combining pay for performance with rewards for reducing costs, relative to pay for performance schemes alone. Paying for performance improvement is less likely to be effective. Allowing payments to be used for specific purposes, such as quality improvement, had a higher likelihood of a positive effect, compared with using funding for physician income. Finally, the size of incentive payments relative to revenue was not associated with the proportion of positive outcomes.

The Impact of a Pay-for-Performance Scheme on Prescription Quality in Rural China

In this prospective study, conducted in China where providers have traditionally been paid fee-for-service, and where drug spending is high and irrational drug prescribing common, township health centers in two counties were assigned to two groups: in one fee-for-service was replaced by a capitated global budget (CGB); in the other by a mix of CGB and pay-for-performance. In the latter, 20% of the CGB was withheld each quarter, with the amount returned depending on points deducted for failure to meet performance targets. Outcomes studied included indicators of rational drug prescribing and prescription cost. Impacts were assessed using differences-in-differences, because political interference led to non-random assignment across the two groups. The combination of capitated global budget and pay-for-performance reduced irrational prescribing substantially relative to capitated global budget but only in the county that started above the penalty targets. Endline rates were still appreciable, however, and no effects were found in either county on out-of-pocket spending. Copyright © 2016 John Wiley & Sons, Ltd.

Integrated care delivery and health care seeking by chronically-ill patients - a case-control study of rural Henan province, China

Objective

This study examined the impact of an Integrated Care Delivery intervention on health care seeking and outcomes for chronically-ill patients in Henan province, China.

Methods

A case-control study was carried out in six health care organizations from two counties in Henan province, China. 371 patients aged 50 years or over with hypertension or diabetes who visited either community health centers or hospitals in the Intervention or Control Counties were systematically selected and surveyed on health care seeking behavior, quality of care, and pathway of care for their major chronic condition. Bivariate analyses were performed to compare quality and value of care indicators between patients from the Intervention and Control Counties. Multivariate analyses were used to confirm these associations after controlling for patients’ demographic and health characteristics.

Results

Patients in both the Intervention and Control Counties chose their current health care providers primarily out of concern for quality of care (provider expertise and adequate medical equipment) and patient-centered care. Compared with the patients from the Control County, those from the Intervention County performed significantly better on almost all the quality and value of care indicators even after controlling for patients’ demographic and health characteristics. Significant associations between types of health care facilities and quality as well as value of care were also observed.

Conclusion

The study showed that the Integrated Care Delivery Model was critical in guiding patients’ health care seeking behavior and associated with improved accessibility, continuity, coordination and comprehensiveness of care, as well as reducing health inequities and mitigating disparities for older patients with chronic conditions.

National trends in hospital length of stay for acute myocardial infarction in China

BACKGROUND

China is experiencing increasing burden of acute myocardial infarction (AMI) in the face of limited medical resources. Hospital length of stay (LOS) is an important indicator of resource utilization.

METHODS

We used data from the Retrospective AMI Study within the China Patient-centered Evaluative Assessment of Cardiac Events, a nationally representative sample of patients hospitalized for AMI during 2001, 2006, and 2011. Hospital-level variation in risk-standardized LOS (RS-LOS) for AMI, accounting for differences in case mix and year, was examined with two-level generalized linear mixed models. A generalized estimating equation model was used to evaluate hospital characteristics associated with LOS. Absolute differences in RS-LOS and 95% confidence intervals were reported.

RESULTS

The weighted median and mean LOS were 13 and 14.6 days, respectively, in 2001 (n = 1,901), 11 and 12.6 days in 2006 (n = 3,553), and 11 and 11.9 days in 2011 (n = 7,252). There was substantial hospital level variation in RS-LOS across the 160 hospitals, ranging from 9.2 to 18.1 days. Hospitals in the Central regions had on average 1.6 days (p = 0.02) shorter RS-LOS than those in the Eastern regions. All other hospital characteristics relating to capacity for AMI treatment were not associated with LOS.

CONCLUSIONS

Despite a marked decline over the past decade, the mean LOS for AMI in China in 2011 remained long compared with international standards. Inter-hospital variation is substantial even after adjusting for case mix. Further improvement of AMI care in Chinese hospitals is critical to further shorten LOS and reduce unnecessary hospital variation.