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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