Notes: *** p<0.001, ** p<0.01, * p<0.05;
OR, odds ratio; CI, confidence interval; ICU, intensive care unit of the
hospital; CNY, Chinese yuan renminbi.
Discussion
This paper examined the effect of PA on PHC facilities on outpatient and
inpatient utilization among rural patients with chronic diseases in the
context of the development of medical alliances in China. There were two
key findings in this study. First, PA contained the rising outpatient
and inpatient utilization for rural patients with chronic diseases in
China. Second, PA did not appear to transfer more rural patients with
chronic diseases to PHC facilities. This study added evidence to the
ongoing reform of the medical alliance in China and could provide
implications for other countries that planned similar vertical
integration of health facilities.
The fragmentation of the health system has been a worldwide problem that
leads to inefficiency, ineffectiveness, inequality, depersonalization,
and commercialization 18. The World Health
Organization has called for an integrated people-centered health system
to improve health and health care for all people, and building strong
PHC-based systems has been emphasized greatly 19.
Countries around the world are exploring different strategies of
integrated care models, such as Australia 20. PA under
the national medical alliance policy in China is an exploratory
initiative that strives to ensure appropriate training and intersectoral
action in health and coordination of comprehensive services for all
conditions across disciplines.
Our findings indicated that PA had a positive impact on containing the
rising outpatient and inpatient utilization in China. The overuse of
healthcare services has been recognized globally as a problem. Studies
have suggested that the overuse of various services ranged from
approximately 1 to 80% in the United States 21. The
overuse of healthcare services has become an increasingly serious
problem in China and has attracted more attention 22,
23. When health insurance coverage is universal, the moral hazard that
providers overprovide and patients overuse healthcare services arises,
resulting in a waste of resources and massive health expenditures23. PA under medical alliances has positive effects on
containing the increased utilization of outpatient and inpatient care,
which would help save unnecessary utilization and contain increasing
medical expenditure in the long run.
Under-resourced PHC and lack of health professionals are key barriers to
integrated care 24. PA in China’s medical alliance
policy proposed a promising solution. Doctors were sent to the lower
level PHC facilities allied to county hospitals to not only provide
medical services directly to rural patients, but also provide training
in treatment, recovery and skills in specific diseases to PHC doctors25, 26. The capabilities of PHC doctors could be
improved after PA. Patients with chronic diseases usually have more
frequent healthcare utilization and require continuous treatment and
management to prevent complications and early death27. Under the medical alliance policy, prevention
services are tailored to routine care for patients with chronic
diseases, which could help to reduce unnecessary healthcare utilization
and increase resource efficiency.
The share of outpatient PHC visits among total outpatients decreased
significantly between 2013 and 2018. This phenomenon has also been
documented in other studies 5, 23. PA under medical
alliances did not reverse the downward trend of the share of PHC
outpatient visits until now. This finding was consistent with a recent
study that found that the performance of township health centers had not
improved significantly 28. In medical alliances,
county hospitals used to be medical facilities with more resources, but
now they were empowered to also have administrative functions over PHC
facilities. Within a county, county hospitals have the advantage of
monopoly that will be further reinforced by building medical alliances12. Without competition pressure, medical alliances
will have no continuous motivation to reform and innovate. Paired
physicians attracted and transferred more patients to county hospitals
through their contact with patients. The financing schemes of township
health centers and county hospitals are different – township health
centers are fully funded by government funding but county hospitals are
only partially funded and still need to earn most of the revenue by
providing services. Therefore, PA doctors who belong to county hospitals
have incentives to attract more patients to their hospitals. Future
policies on medical alliance should pay attention to the risk of the
monopoly of county hospitals, especially in counties where local
government health departments had a weak power of coordination and
supervision. The benefit package could be delivered to the medical
alliance to incentivize prevention services and utilization of PHC.
Without data for 2013, we cannot determine whether pairing assistance
contributed to retaining patients within counties because it could be
due to differences between counties with respect to implementing medical
alliances; for example, wealthy local governments with platform support
are more likely to seek innovation in building medical alliances29. The increase in the share of visits within
counties is more a comprehensive effect of medical alliance rather than
pairing assistance alone. A study that examined the first three
provinces that implemented medical alliances found that the counties
that implemented medical alliances all had a large increase in the share
of inpatient admission within counties 30.
This study was subject to several limitations. First, the NHSS was a
repeated cross-sectional survey. Although we controlled sociodemographic
characteristics, health status, medical insurance and county
characteristics, we cannot eliminate the effect of unobserved individual
characteristics. Second, the establishment of medical alliances involves
multiple policies simultaneously, for example, enhancing the capacity of
county hospitals. Therefore, changes in the outcomes might also contain
the effect of other policies. Third, our definition for PA might not
reflect the assistance quality. Services among paired doctors from
different medical alliances in China varied. Future research could
explore better definitions and measurements for PA to strengthen the
evidence base.
Conclusions
Pairing assistance from county hospitals with PHC facilities has been a
major strategy in medical alliances to improve the healthcare delivery
system. This study examined the effect of pairing assistance on rural
patients with chronic diseases as vulnerably frequent PHC users, and we
found that pairing assistance contained the increasing outpatient visits
and inpatient admissions. Pairing assistance did not reverse the
downward trend in the share of PHC outpatient visits. Pairing assistance
under medical alliances provides a potential path toward integrated
people-centered health systems for other low- and middle-income
countries. However, the government should pay attention to avoiding the
potential monopoly of county hospitals.
Declarations
Ethical approval and consent to participate: The study has been
approved by the National Statistics Bureau of China and was performed in
accordance with the Declaration of Helsinki. Written informed consent
was obtained from all participants prior to questionnaire
administration.
Consent for publication: not applicable
Data availability: The data underlying this article will be
shared upon reasonable request to the corresponding author.
Competing interests: The authors declare that they have no
conflict of interest.
Funding: The authors received no financial support for the
research, authorship and publication of this article.
Author contributions: H.Z. conceived of the study. H.Z. and
X.L. designed the study. H.Z. and M.L. created the analysis plan. M.L.
processed the dataset and conducted the analysis. M.L. drafted the
article. H.Z, X.L, H.T. and X.C. revised the paper and contributed to
critical revision of the article.
Acknowledgements: The authors would like to thank the China
Center for Health Statistics and Information, who collected data and
assisted with data access for the study.
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