Private hospital expansion in China: a global perspective

Sociodemographic factors impacting the spatial distribution of private dental clinics in major cities of Peoples Republic of China

OBJECTIVES

Investigate the geographical distribution of private dental practices in major Chinese cities and analyze the variables influencing this distribution.

METHODS

This study used Python to extract various types of Point of Interest (POI) data spanning from 2016 to 2022 from the AutoNavi map. A 1km*1km grid was constructed to establish the study sample. Additional spatial pattern data, including nighttime lighting, population, and air quality data, were integrated into this grid. Global Moran's I index was used to analyze the spatial autocorrelation. The spatial lag model was used to explore the influencing factors of private dental practice distribution.

RESULTS

This study reveals a specific clustering pattern for private dental practices in major Chinese cities. The primary influencing factors include nighttime lights, population density, and housing prices, suggesting that dental practices are typically concentrated in highly developed regions with dense populations and high housing costs. Additionally, we discovered that patterns vary across different metropolises, with the most pronounced clustering patterns and substantial inequalities found in the most developed areas.

CONCLUSIONS

This study establishes that factors such as regional development and population density positively correlate with private dental practice. Additionally, it reveals a strong mutual correlation in the clustering of dental practices, which does not show a substantial correlation with public resources. Finally, it suggests that the spatial heterogeneity pattern implies a rising necessity to tackle inequality issues within urban areas as economic development progresses.

The allocation and utilization efficiency of hospital beds in Sichuan Province, China

OBJECTIVE

To analyze the allocation and utilization efficiency of hospital beds in Sichuan Province, China, and to provide a scientific basis for improving the rational allocation and efficient utilization.

METHODS

The supply and demand balance method, health resource agglomeration degree (HRAD), bed efficiency index and bed utilization model were used to evaluate the allocation and utilization efficiency of hospital beds in Sichuan Province from 2017 to 2021.

RESULTS

The number of hospital beds per 1000 population in Sichuan Province increased from 4.97 in 2017 to 5.94 in 2021. The overall supply and demand ratio of hospital beds in Sichuan Province is between 0.85 and 1.01, and the supply and demand situation is a basically balanced situation. The HRAD of hospital beds in Ya'an, Aba, Ganzi and Liangshan is <1, indicating that the equity of hospital beds by geography in these regions is low. The difference between HRAD and population agglomeration degree (PAD) in 9 regions, including Deyang, Aba, Ganzi and Liangshan, is <0, indicating that there are insufficient hospital beds in these areas relative to the agglomerated population. The bed efficiency index of hospital beds in 17 regions, including Chengdu, Zigong, Aba and Ganzi, are all <1, which means that hospital beds are operating with low efficiency. The bed utilization model of Panzhihua is efficiency type, that of Zigong, Deyang and Ziyang is pressure bed type, and that of Nanchong and Ya'an is idle type.

CONCLUSION

The hospital bed allocation in Sichuan Province is relatively good, and the supply and demand situation is in a basically balanced situation. The hospital bed allocation in Aba, Ganzi and Liangshan is insufficient by geography and population. The overall operational efficiency of hospital beds is low, and there are more idle and pressure bed utilization models.

Rapid growth of private hospitals in China: emerging challenges and opportunities to health sector management

China's private hospital market has experienced rapid growth over the last decade, with private hospitals now outnumbering public hospitals by a factor of two. This policy analysis uses available data and existing literature to analyze China's rapidly changing hospital market, identify key challenges resulting from rapid private hospital growth, and present recommendations to ensure future sustainable private hospital development in the country. Our analysis shows that while private hospitals outnumber public hospitals, outpatient visits and hospitalizations remain higher among public hospitals, while per-patient expenditure remains higher among private hospitals. Key challenges to private hospital development include limited government financial support, high tax burdens, difficulty in workforce recruitment and retainment, poor government regulation and oversight, and dissipating public trust. Recommendations to address these challenges include opening government contract bidding to private hospitals, creating a system that allows private hospitals to enter national health insurance schemes, reducing tax pressure on private hospitals, defining a legal system for market entry and exit of private hospitals, improving a system of supervision, and monitoring and evaluation of private hospital operation and performance.

Feminization of the health workforce in China: exploring gendered composition from 2002 to 2020

BACKGROUND

Feminization of health workforce has been globally documented, but it has not been investigated in China. This study aims to analyze changes in the gendered composition of health workforce and explore the trend in different types of health workforce, health organizations and majors within China's health system.

METHODS

The data were collected from China Health Statistical Yearbook from 2002 to 2020. We focused on health professionals including doctors, nurses, and pharmacists in health organizations. Trend analysis was employed to examine the change in the ratio of female health workforce over 18 years. The estimated average annual percent change (AAPC) was estimated, and the reciprocals of variances for the female ratios were used as weights.

RESULTS

In China, health professionals increased from 4.7 million in 2002 to 10.68 million in 2020. Health professionals per 1000 population increased from 3.41 in 2002 to 7.57 in 2020. The ratio of female health professionals significantly increased from 63.85% in 2002 to 72.4% in 2020 (AAPC = 1.04%, 95% CI 0.96-1.11%, P < 0.001). Female doctors and pharmacists increased 4.7 and 7.9 percentage points from 2002 to 2020. Female health workers at township health centers, village clinics, centers for disease control and prevention had higher annual increase rate (AAPC = 1.67%, 2.25% and 1.33%, respectively) than those at hospital (0.70%) and community health center (0.5%). Female doctors in traditional Chinese medicine, dentistry and public health had higher annual increase rate (AAPC = 1.82%, 1.53% and 1.91%, respectively) than female clinical doctor (0.64%).

CONCLUSIONS

More women are participating in the healthcare sector in China. However, socially lower-ranked positions have been feminizing faster, which could be due to the inherent and structural gender norms restricting women's career. More collective and comprehensive system-level actions will be needed to foster a gender-equitable environment for health workforce at all levels.

Understanding Factors Influencing Geographic Variation in Healthcare Expenditures: A Small Areas Analysis Study

Dramatic geographic variations in healthcare expenditures were documented by developed countries, but little is known about such variations under China's context, and what causes such variations. This study aims to examine variations of healthcare expenditures among small areas and to determine the associations between demand-, supply-factors, and per capita inpatient expenditures. This cross-sectional study utilized hospital discharge data aggregated within delineated hospital service areas (HSAs) using the small-area analysis approach. Linear multivariate regression modeling with robust standard errors was used to estimate the sources of variation of per capita inpatient expenditures across HSAs covering the years 2017 to 2019; the Shapley value decomposition method was used to measure the respective contributions of demand-, supply-side to such variations. Among 149 HSAs, demand factors explained most of the (87.4%) overall geographic variation among HSAs. With each 1% increase in GDP per capita and urbanization rate was associated with 0.099% and 0.9% increase in inpatient expenditure per capita, respectively, while each 1% increase in the share of females and the unemployment rate was associated with a 0.7% and 0.4% reduction in the per capita inpatient expenditures, respectively. In supply-side, for every 1 increase in hospital beds per 1000 population, the per capita inpatient expenditures rose by 2.9%, while with every 1% increase in the share of private hospitals, the per capita inpatient expenditures would decrease by 0.4%. With Herfindahl-Hirschman Index decrease 10%, the per capita inpatient expenditures would increase 1.06%. This study suggests demand-side factors are associated with large geographic variation in per capita inpatient expenditures among HSAs, while supply-side factors played an important role. The evaluation of geographic variations in per capita inpatient expenditures as well as its associated factors have great potential to provide an indirect approach to identify possibly existing underutilized or overutilized healthcare procedures.

Disparity in hospital beds' allocation at the county level in China: an analysis based on a Health Resource Density Index (HRDI) model

BACKGROUND

As approximately 3/4 of the population lives in county-level divisions in China, the allocation of health resources at the county level will affect the realization of health equity. This study aims to evaluate the disparity in hospital beds at the county level in China, analyze its causes, and discuss measures to optimize the allocation.

METHODS

Data were drawn from the Chinese County/City Statistical Yearbook (2001-2020). The health resource density index (HRDI) was applied to mediate between the influence of demographic and geographical factors on the allocation of hospital beds. The trends of HRDI allocation were evaluated through the growth incidence curve and the probability density function. The regional disparity in the HRDI was examined through the Lorenz curve, and Dagum Gini coefficient. The contribution of the Gini coefficient and its change were assessed by using the Dagum Gini decomposition method.

RESULTS

From 2000 to 2019, the number of hospital beds per thousand people at the county level in China increased dramatically by 1.49 times. From the aspect of the HRDI, there were large regional disparities at the national level, with a Gini coefficient of 0.367 in 2019 and in the three subregions. In 2019, the Gini coefficient of the HRDI exhibited regional variations, with the highest value observed in the western region, followed by the central region and the eastern region. Decomposition reveals that the contribution of interregional disparity changed from the dominant factor to the least important factor, accounting for 29.79% of the overall disparity and the contribution of trans-variation intensity increased from 29.19% to 39.75%, whereas the intraregional disparity remained stable at approximately 31% and became the second most important factor.

CONCLUSION

The regional disparity in hospital beds allocation at the county level in China was large and has not improved substantially. Trans-variation intensity was the main reason for the overall disparity and changes, and the intraregional disparity was more important than the interregional disparity for the overall disparity.

Chinese Patients' Virtual Consultation Use of Different Sponsorship Types of Telemedicine Platforms: A Cross-Sectional Study in Zhejiang Province, China

Background: Virtual consultation has been one of the most prevalent direct-to-consumer telemedicine services in China. However, little is known about patients' virtual consultation use of different sponsorship types of telemedicine platforms. This study aimed to examine Chinese patients' virtual consultation use and identify the factors that affect consultation use of different sponsorship types of platforms. Methods: We conducted a cross-sectional survey on 1,653 participants in tier 1, tier 2, and tier 3 hospitals in 3 cities with different income levels, in Zhejiang Province, in May and June 2019. Multinomial logistic regression analysis was used to identify the factors that affect patients' virtual consultation use of different sponsorship types of platforms. Results: The most frequently used consultation platform was digital health company-sponsored platforms (36.60%), hospital-sponsored platforms (34.57%), doctors' personal social media (11.09%), other company-sponsored platforms (9.24%), and medical e-commerce company-sponsored platforms (8.50%). The patients' virtual consultation use of different sponsorship types of platforms was determined by education levels, monthly income levels, perceived health status, internet use, and city income levels. Conclusions: Chinese patients' virtual consultation service use varied by platform sponsorship type. Digital health company-sponsored platforms owned advantages over other platform types in high-end consumers with higher education levels, higher income levels, living in high-income cities, and active in internet use. This study implied that different sponsorship types of direct-to-consumer telemedicine platforms in China differ from each other in online health care resource allocation, business model, and competitive advantage.

Functions, advantages and challenges facing private healthcare organisations in China's healthcare system: a qualitative analysis through open-ended questionnaires

OBJECTIVES

The medical reform in 2009 stimulated the growth of private healthcare organisations in China, but there is still room for their further development in the healthcare market. The objectives of the study were to provide more information about the healthcare market in China and to explore the challenges private healthcare organisations faced.

DESIGN

Qualitative descriptive study using a web-based open-ended questionnaire and thematic content analysis. Data were collected between 12 February and 20 February 2020.

SETTING

This study was conducted in China.

PARTICIPANTS

124 respondents from private healthcare organisations across 20 provinces in China.

RESULTS

Our content analysis identified three themes: (1) functioning and positioning of the healthcare institutions: current private healthcare organisations generally serve as a supplement to public hospitals and focus more on specialised medical and high-end services; (2) institutions' advantages: private healthcare organisations can flexibly respond to market demands, formulate effective strategies, introduce advanced management concepts and methods, provide personalised and diversified services, and introduce new technologies which can stimulate market vitality and promote healthy competition; and (3) institutions' challenges: private healthcare organisations face difficulties in professional development and talent cultivation, branding and establishing a reputation, and the policies for institution establishment, tax and medical insurance pose drawbacks to their development.

CONCLUSION

This study illustrates that private healthcare organisations need more government support for further development, such as providing a fairer insurance strategy and taxation policy, affording ground for a more equitable scientific research environment and promotion opportunities, and evaluating reputation score for healthcare institutions.

Evaluating the Impact of COVID-19 on Hospital Profit Compensation Activities: A Difference-in-Differences Event Study Analysis in China

The impact of the 2019 coronavirus disease (COVID-19) pandemic is still being revealed, and little is known about the effect of COVID-19-induced outpatient and inpatient losses on hospital operations in many counties. Hence, we aimed to explore whether hospitals adopted profit compensation activities after the 2020 first-wave outbreak of COVID-19 in China. A total of 2,616,589 hospitalization records from 2018, 2019, and 2020 were extracted from 36 tertiary hospitals in a western province in China; we applied a difference-in-differences event study design to estimate the dynamic effect of COVID-19 on hospitalized patients' total expenses before and after the last confirmed case. We found that average total expenses for each patient increased by 8.7% to 16.7% in the first 25 weeks after the city reopened and hospital admissions returned to normal. Our findings emphasize that the increase in total inpatient expenses was mainly covered by claiming expenses from health insurance and was largely driven by an increase in the expenses for laboratory tests and medical consumables. Our study documents that there were profit compensation activities in hospitals after the 2020 first-wave outbreak of COVID-19 in China, which was driven by the loss of hospitalization admissions during this wave outbreak.

The relationship between hospital ownership, in-hospital mortality, and medical expenses: an analysis of three common conditions in China

BACKGROUND

Private hospitals expanded rapidly in China since 2009 following its national health reform encouraging private investment in the hospital sector. Despite long-standing debates over the performance of different types of hospitals, empirical evidence under the context of developing countries remains scant. We investigated the disparities in health care quality and medical expenses among public, private not-for-profit, and private for-profit hospitals.

METHODS

A total of 64,171 inpatients (51,933 for pneumonia (PNA), 9,022 for heart failure (HF) and 3,216 for acute myocardial infarction (AMI)) who were admitted to 528 secondary hospitals in Sichuan province, China, during the fourth quarters of 2016, 2017, and 2018 were selected for this study. Multilevel logistic regressions and multilevel linear regressions were utilized to assess the relationship between hospital ownership types and in-hospital mortality, as well as medical expenses for PNA, HF, and AMI, after adjusting for relevant hospital and patient characteristics, respectively.

RESULTS

The private not-for-profit (adjusted OR, 1.69; 95% CI, 1.08, 2.64) and for-profit (adjusted OR, 1.67; 95% CI, 1.06, 2.62) hospitals showed higher in-hospital mortality than the public ones for PNA, but not for AMI and HF. No significant differences were found in medical expenses across hospital ownership types for AMI, but the private not-for-profit was associated with 9% higher medical expenses for treating HF, while private not-for-profit and for-profit hospitals were associated with 10% and 11% higher medical expenses for treating PNA than the public hospitals. No differences were found between the private not-for-profit and private for-profit hospitals both in in-hospital mortality and medical expenses across the three conditions.

CONCLUSION

The public hospitals had at least equal or even higher healthcare quality and lower medical expenses than the private ones in China, while private not-for-profit and for-profit hospitals had similar performances in these aspects. Our results added evidences on hospitals' performances among different ownership types under China's context, which has great potential to inform the optimization of healthcare systems implemented among developing countries confronted with similar challenges.

Constructing healthcare services markets: networks, brokers and the China-England engagement

BACKGROUND

Healthcare services is an expanding international market with which national healthcare systems engage, and from which they benefit, to greater and lesser degrees. This study examines the case of the China-England engagement in healthcare services as a vehicle for illuminating the way in which such market relationships are constructed.

FINDINGS

China and England have different approaches to the international healthcare services market. Aware of the knowledge and technology gaps between itself and the leading capitalist nations of the West in healthcare, as in other sectors, the Chinese leadership has encouraged a variety of international engagements to facilitate the bridging of these gaps including accessing new supply and demand relationships in international markets. These engagements are situated within an approach to health system development based on establishing broad policy directions, allowing a degree of local innovation, initiating and evaluating pilot studies, and promulgating new programmatic frameworks at central and local levels. The assumption is that the new knowledge and technologies are integrated into this approach and implemented under the guidance of Chinese experts and leaders. England's healthcare system has the knowledge resources to provide the supply to meet at least some of the China demand but has yet to develop fully the means to enable an efficient market response, though such economic engagement is supported by the UK's trade related departments of state. As a result, the development of China-England commercial relationships in patient care, professional education and hospital and healthcare service development has been led largely by high status NHS Trusts and private sector organisations with the entrepreneurial capacity to exploit their market position. Drawing on their established international clinicians and commercial teams with experience of domestic private sector provision, these institutions have built trust-based collaborations sufficiently robust to facilitate demand-supply relationships in the international healthcare services market. Often key to the development of relations required to make commercial exchange feasible and practicable are a range of international brokers with the skills and capacity to provide the necessary linkage with individual healthcare consumers and institutional clients in China. Integral to the broker role, and often supplied by the broker itself, are the communication technologies of telemedicine to enable the interaction between consumer and healthcare provider, be this in patient care, professional education or healthcare service development.

CONCLUSIONS

Although England's healthcare system has the knowledge required to respond to China's market demand and such economic engagement is supported and actively encouraged by the UK's trade related departments of state, the response is constrained by multiple domestic demands on its resources and by the limits of the NHS approach to marketisation in healthcare.

Impact of the presence of private hospitals on the spatial equality of healthcare accessibility in Beijing, China

Providing equal geographical access to hospitals, either in the public or private healthcare sector, is vital and will benefit public health in general. Against the background of the partial privatization of the healthcare sector, the impact of private hospitals on equal healthcare access has been a highly neglected issue. We have applied an assessment methodology to study this situation by comparing the status quo scenario with one without private hospitals, based on accessibility analysis and spatial equality measurements. The case study of Beijing, China revealed a double-sided impact. With the presence of private hospitals, the Gini coefficient of spatial accessibility in urban districts was reduced from 0.03391 to 0.03211, while it increased from 0.1734 to 0.1914 in suburban districts. Thus, private hospitals improved spatial equality in urban districts in Beijing but jeopardized it in suburban districts. These research findings should enlighten policymakers to promote healthcare equality but would also need to be repeated in some other big cities.

Healthcare preferences of the general Chinese population in the hierarchical medical system: A discrete choice experiment

Background

Chinese health insurance system faces resource distribution challenges. A patient-centric approach allows decision-makers to be keenly aware of optimized medical resource allocation.

Objective

This study aims to use the discrete choice model to determine the main factors affecting the healthcare preferences of the general Chinese population and their weights in the three scenarios (chronic non-communicable diseases, acute infectious diseases, and major diseases).

Methods

This study firstly identified the key factors affecting people's healthcare preferences through literature review and qualitative interviews, and then designed the DCE questionnaire. An online questionnaire produced by Lighthouse Studio (version 9.9.1) software was distributed to voluntary respondents recruited from mainland China's entire population from January 2021 to June 2021. Participants were required to answer a total of 21 questions of three scenarios in the questionnaire. The multinomial logit model and latent class model were used to analyze the collected data.

Results

A total of 4,156 participants from mainland China were included in this study. The multinomial logit and latent class model analyses showed that medical insurance reimbursement is the most important attribute in all three disease scenarios. In the scenario of "non-communicable diseases," the attributes that participants valued were, from the most to the least, medical insurance reimbursement (45.0%), hospital-level (21.6%), distance (14.4%), cost (9.7%), waiting time (8.3%), and care provider (1.0%). As for willingness to pay (WTP), participants were willing to pay 204.5 yuan, or 1,743.8 yuan, to change from private hospitals or community hospitals to tertiary hospitals, respectively.

Conclusions

This study explores the healthcare preferences of Chinese residents from a new perspective, which can provide theoretical reference for the refinement of many disease medical reimbursement policies, such as developing different reimbursement ratios for various common diseases and realizing rational configuration of medical resources.

Real-World Perspectives From Surgeons and Oncologists on Resectability Definition and Multidisciplinary Team Discussion of Stage III NSCLC in People's Republic of China, Hong Kong, and Macau: A Physician Survey

Introduction

Decision-making in diagnosis and management of stage III NSCLC remains complex owing to disease heterogeneity and diverse treatment options, and often warrants multidisciplinary team discussion. Specifically, the selection of patients for multimodality approaches involving surgical resection presents notable challenges owing to heterogeneity in guideline definitions and the subjective, case-specific nature of evaluating resectability on the basis of preoperative assessments.

Methods

An internet- and paper-based survey was conducted in 2020 among lung cancer specialists in the People's Republic of China, Hong Kong, and Macau. This survey captured perspectives on stage III NSCLC on real-world diagnosis/staging practice, definition and evaluation of resectability using case scenarios, and preferred treatment paradigms.

Results

A total of 60 completed responses were obtained (60.0% surgeons; 40.0% oncologists). The surgeons' and oncologists' responses differed most in the assessment of resectability in specific case scenarios despite overall agreement on top factors determining resectability (T stage, lymph node size, and lymph node location). Of the 17 scenarios, specialists agreed (≥80%) on four "resectable" and six "unresectable" scenarios; of the seven scenarios with less than 80% agreement, surgeons and oncologists had diverging responses for six scenarios. Multidisciplinary team discussions were available in most of the respondents' institutions but usually covered only selected (<50%) stage III cases.

Conclusions

This survey used a comprehensive set of stage III NSCLC case scenarios to understand how working definitions of resectability may differ between surgeons and oncologists, and thus, identify types of cases to prioritize for multidisciplinary discussions to maximize limited resources. In parallel, the development of a multidisciplinary expert consensus on treatment approaches could complement local institutional expertise as a reference for decision-making.

From conventional healthcare to e-health: Social and spatial transformation. Using a comparison between Hong Kong and Mainland China

BACKGROUND AND AIM

Does spatial organization of healthcare access still matter in China? I assess how e-health has transformed the notion of healthcare access and what spatial dimension of healthcare means in China today and in the near future. I also consider a dynamic perspective to propose keys to anticipate upcoming changes. Hong Kong has a very efficient healthcare system with a dense network of high-level hospitals and a high level of healthcare access. In major Chinese urban centers, a deliberate policy to improve healthcare availability has resulted in a spectacular increase in the number of healthcare structures over the last two decades. This includes urban healthcare centers and outpatient clinics. Nevertheless, the most of the population faces explicit and implicit financial penalties to get full healthcare access. To solve the problem, a digital health revolution is emerging.

METHODS

I use a qualitative case study approach. I conducted a series of semi-structured, face-to-face interviews to evaluate experiences, expectations, and opinions of patients regarding healthcare access and its associated financial burden as well as their use of digital health.

RESULTS

I assessed how e-health has transformed the notion of healthcare access and what spatial dimension of healthcare means today and in the near future in China. I also considered a dynamic perspective to propose keys to anticipate upcoming changes. Healthcare centers tend to shift from a place to get cured to a link within an e-healthcare pathway. For instance, this is a place to get e-prescribed medication. Advantages of this shift include a reduction in the cost of healthcare and remote access to highly qualified medical staff, bypassing the lack of trust in the quality of care offered in local hospitals.

CONCLUSION

A forward-looking approach suggests that e-healthcare is becoming the entry point to healthcare for a large part of the population.

RELEVANCE TO PATIENTS

This study informs the policy makers of upcoming changes, and contributes to understanding and anticipating modifications needed in the healthcare system.

Director's Perceived Competition and Its Relationship with Hospital's Competitive Behaviors: Evidence from County Hospitals in China

Background

This study was conducted for assessing the degrees of perceived competition reported by county hospital directors in rural China as well as hospitals’ competitive behaviors in response to competition.

Methods

The data were collected from Analysis of Provider Payment Reforms on Advancing China’s Health (APPROACH) project which had been implemented among county hospitals in China’s Guizhou province. Competition was measured by asking hospital directors to rate the levels of competitive pressure as they perceived. Hospitals’ competitive behaviors were obtained by asking hospitals’ directors about specific strategies they had adopted. A multivariable linear regression model was developed to examine the relationship between perceived competition and the positivity of competitive behavior, and multivariable logistic regressions were used to evaluate the influence of perceived competition on the adoption of specific competitive strategies.

Results

Among 218 directors engaged in this study, 210 (96.3%) directors reported the perception of certain degrees of competition, for which the competitive pressure was mainly posed by public hospitals (42.4%). Director-perceived competition level was found to be positively associated with the positivity of competitive behavior, and directors under higher competitive pressure were found to be more likely to adopt multiple competitive strategies including improving the efficiency of hospitals’ internal management, optimizing hospitals’ environment as well as promoting health-care services.

Conclusion

This study suggested that almost all of the county hospital directors in rural China perceived certain degrees of competitive pressure, and higher levels of perceived competition were found to be significantly associated with increased positivity in adopting competitive strategies. Our findings are expected to provide evidence-based implications for the implementation of a series of pro-competition policies throughout health-care reforms.

The Comparison Between Different Hospital Market Definition Approaches: An Empirical Analysis of 11 Representative Diseases in Sichuan Province, China

Objective: This study aims to provide empirical evidence for the controversy about whether the inference is consistent if alternative hospital market definition methods are employed, and for which definition method is the best alternative to the predicted patient flow approach.

Data sources: Collecting data from the discharge data of inpatients and hospital administrative data of Sichuan province in China in the fourth quarter of 2018.

Study Design: We employed Herfindahl–Hirschman Index (HHI) as the proxy of market competition used as an example to measure the hospital market structure. Correlation coefficients of HHIs based on different definition methods were assessed. The corresponding coefficient of each HHI estimated in identical regression models was then compared. In addition, since the predicted patient flow method has been argued by the literature of its advantages compared with the previous approaches, we took the predicted patient flow as a reference to compare with the other approaches.

Data Extraction Methods: We selected the common diseases with a significant burden, and 11 diseases were included (902,767 hospitalizations).

Principal Findings: The correlation coefficients of HHIs based on different market definition methods are all significantly greater than 0, and the coefficients of HHIs are different in identical regression models. Taking the predicted patient flow approach as a reference, we found that the correlation coefficients between HHIs based on fixed radius and predicted patient flow approach is larger than others, and their parameter estimates are all consistent.

Conclusion: Although the HHIs based on different definition methods are significantly and positively correlated, the inferences about the effectiveness of market structure would be inconsistent when alternative market definition methods are employed. The fixed radius would be the best alternative when researchers want to use the predicted patient flow method to define the hospital market but are hindered by the data limitations and computational complexity.

Chinese Patients' Intention to Use Different Types of Internet Hospitals: Cross-sectional Study on Virtual Visits

Background

The issuing of regulation schemes and the expanding health insurance coverage for virtual visits of internet hospitals would incentivize Chinese providers and patients to use virtual visits tremendously. China’s internet hospitals vary in sponsorship. However, little is known about patients’ intention to use virtual visits delivered by different sponsorship types of internet hospitals.

Objective

The goal of the research is to examine patients’ intention to use virtual visits, as well as virtual visits delivered by different sponsorship types of internet hospitals. In addition, we will identify determinants of patients’ intention to use virtual visits, as well as intention to use virtual visits delivered by different sponsorship types of internet hospitals.

Methods

A cross-sectional survey of 1653 participants was conducted in 3-tier hospitals in 3 cities with different income levels in May and June 2019. Binary logistic regression analysis was used to identify the factors that affect patients’ intention to use virtual visits. Multinomial logistic regression analysis was conducted to identify the determinants of the intention to use virtual visits delivered by different sponsorship types of internet hospitals (ie, enterprise-sponsored, hospital-sponsored, and government-sponsored).

Results

A total of 76.64% (1145/1494) of adult participants were online medical information seekers, and 87.06% (969/1113) of online medical information seekers had intention to use virtual visits. Public hospital–sponsored internet hospitals were the most prevalent ones among Chinese patients (473/894, 52.9%), followed by the provincial government internet hospital platform (238/894, 26.6%), digital health companies (116/894, 13.0%), medical e-commerce companies (48/894, 5.4%), private hospitals (13/894, 1.5%), and other companies (6/894, 0.7%). Gender, education, monthly income, and consumer type were significantly associated with the intention to use virtual visits. Gender, age, education, city income level, consumer type, and trust in the sponsor of a health website were significantly associated with the patient’s intention to use virtual visits delivered by 3 different sponsorship types of internet hospitals.

Conclusions

Chinese patients who were online medical information seekers had high intention to use virtual visits and had different intentions to use virtual visits delivered by different sponsorship types of internet hospitals. Public hospitals, the government, and digital health companies were the top 3 sponsorship types of internet hospitals that patients had intention to use. Trust in a health website sponsor significantly influenced the patient’s intention to use virtual visits delivered by different sponsorship types of internet hospitals. Gender, education, and consumer type were the factors significantly associated with both the intention to use virtual visits and the intention to use virtual visits delivered by different sponsorship types of internet hospitals.

Does hospital competition lead to medical equipment expansion? Evidence on the medical arms race

With the implementation of a series of pro-competition policies in China, the hospital market competition has been intensified dramatically over the past decade. Based on previous literature, such competition is very much likely to bring about an upgoing trend in the promotion and expansion of medical facilities among hospitals as an essential strategy for attracting patients, which is known as Medical Arms Race (MAR). Comprehensive evaluations have been conducted by previous studies on the consequences of the MAR, which, however, merely provided inadequate empirical evidence on the relationship between hospital competition and MAR. Utilizing the variations in hospital competition across various regions and through different time periods in Sichuan Province as a prototype representative of the nationwide situation, a dynamic panel data model was established and adopted in this study for investigating whether intensified hospital competition had resulted in the expansion of medical facilities in China during the corresponding time period. The geopolitical boundaries and Herfindahl-Hirschman Index (HHI) were respectively employed to define the hospital market and measure the competition degree. We found that a 10% reduction in HHI is associated with an 8.79% increase in regional total costs of advanced medical equipment per capita, suggesting that hospital competition would lead to medical equipment expansion. Our results provide novel evidence on MAR which is particularly applicable for the healthcare system in China, providing suggestions for nationwide healthcare reform in order to mitigate potential negative outcomes induced by the implementation of pro-competition policies.

The Association of Market Mix of Hospital Ownership With Medical Disputes: Evidence From China

The prevalence and severity of medical disputes in China have attracted the attention of society and academia, and how to alleviate medical disputes has become a major concern. Following the implementation of a series of policies, the private sector in China’s hospital market has expanded rapidly over the past decade. It remains unknown whether the market mix of hospital ownership could alleviate medical disputes, this study aims to bridge the gap. Data are collected from all hospitals (2171) in Sichuan province, China, from 2012 to 2015. Using a negative binomial hurdle model, the results show that for hospitals with disputes, the private hospital market share has an inverted U-shaped relationship with the number of disputes. However, no significant relationship is found between the private hospital market share and the probability of dispute occurrence. For hospitals with disputes, competition plays a protective role in the effect of the private hospital market share on the number of disputes, hindering the increase in the number of disputes and facilitating a more rapid drop. However, medical quality is found to play an insignificant role in that effect. The findings also support encouraging new private hospitals in China rather than privatizing existing public hospitals.

The Evolving Hospital Market in China After the 2009 Healthcare Reform

Since the initiation of national healthcare reform in 2009, China’s hospital market has witnessed significant change. To provide a brief description about its evolving process, China Health Statistical Yearbook data and Sichuan administrative data from 2009 to 2017 were used in this article. An overall upward trend of hospital delivery capacity was found in this study, which increased from 3.12 million beds and 1.09 million doctors in 2009 to 6.12 million and 1.80 million in 2017, respectively, while the primary healthcare institutions presented fairly slow development pace. Growing proportion of medical resources and patients gathered in hospitals, especially tertiary hospitals. While private hospitals demonstrated an increasingly important role in hospital market with growing share of capacity and service, their average capacity, especially the human resource, was found to be much lower than that of public hospitals and the gaps are still widening. The competition among hospitals grouped by homogeneous ownership types has predominated the increasingly intensified hospital market competition in China. In order to adapt to the raising demand of health care in China, it is highly recommended that strategies forged at governmental levels be focused on primary care promotion, guiding the development of private hospitals as well as on promoting orderly competition in the hospital market.