School of Public Health and Management, Wenzhou Medical University, Zhejiang, 325000, Wenzhou, China.
First Affiliated Hospital of Wenzhou Medical University, Zhejiang, 325000, Wenzhou, China.
BMC Health Serv Res. 2022 May 12;22(1):630. doi: 10.1186/s12913-022-08031-0.
Facilitating the primary health care (PHC) system and maintaining people's reasonable healthcare-seeking behavior are key to establishing a sustainable healthcare system. China has employed a multitiered copayment system/medical insurance differentiated payment policies to incentivize the public to utilize PHC services through its hierarchical medical care system; however, most people still prefer visiting tertiary care hospitals. We question whether the quality gap in healthcare services reduces the effect of the multitiered copayment system, which is considered an important factor in the lack of reform in the Chinese healthcare system. Thus, we explore the effect and influencing factors of the multitiered copayment system that drives primary healthcare-seeking behavior under the current situation with a large quality gap. We also consider the hypothetical situation of a reduced gap in the future.
This study used the hypothetical quality improvement scenario to elicit people's hypothetical behaviors, and a multistage stratified cluster random sampling method. This preliminary study was conducted in 2016 using 1829 individuals from four regions of Wenzhou in Zhejiang Province: Ouhai, Ruian, Yongjia, and Taishun. A descriptive statistical analysis, chi-square analysis, Fisher's exact test, and multinomial logistic regression model were performed to introduce the effect of the multitiered copayment system, and to explore the factors affecting the selection of PHC institutions at pre- and post-change phases.
The results show that compared with the large quality gap phase, the number of respondents who believed the multitiered copayment system had an effect on their selection of PHC institutions after the equalization of healthcare services quality increased threefold (from 14.0% to 50.8%). Moreover, the main determinants in people's selection of PHC institutions changed from age and needs variables (self-rated health status) to age, needs variables (self-rated health status) and enabling variables (distance to a medical care facility).
The results indicate limited initial effects of the multitiered copayment system. However, they become more pronounced after the equalization of healthcare services quality. This study confirms that changes in the quality gap in healthcare services influence the effect of the multitiered copayment system. Hence, reducing this gap can help achieve the intended outcome of the tiered healthcare insurance schedule.
促进基层医疗保健（PHC）系统并维持人们合理的医疗保健需求行为是建立可持续医疗保健系统的关键。中国通过分级医疗保健系统，采用多层次共付制度/医疗保险差异化支付政策来激励公众利用 PHC 服务；然而，大多数人仍然更倾向于去三级保健医院就诊。我们质疑医疗服务质量差距是否会降低多层次共付制度的效果，而这被认为是中国医疗保健系统改革缺乏动力的一个重要因素。因此，我们在当前存在较大质量差距的情况下，探讨了多层次共付制度对促进基层医疗保健需求行为的效果及其影响因素。我们还考虑了未来质量差距缩小的假设情况。
本研究采用假设质量改善情景来引出人们的假设行为，并采用多阶段分层聚类随机抽样方法。这项初步研究于 2016 年在浙江省温州市的四个地区（瓯海、瑞安、永嘉和泰顺）进行，共调查了 1829 人。采用描述性统计分析、卡方分析、Fisher 确切检验和多项逻辑回归模型，介绍多层次共付制度的效果，并探讨在质量变化前后阶段影响 PHC 机构选择的因素。
结果表明，与医疗服务质量均衡化前的大质量差距阶段相比，认为在医疗服务质量均衡化后多层次共付制度对其选择 PHC 机构有影响的受访者数量增加了两倍（从 14.0%增加到 50.8%）。此外，人们选择 PHC 机构的主要决定因素已从年龄和需求变量（自我评估健康状况）转变为年龄、需求变量（自我评估健康状况）和赋权变量（医疗机构距离）。
结果表明多层次共付制度的初始效果有限。然而，在医疗服务质量均衡化后，效果变得更加显著。本研究证实，医疗服务质量差距的变化会影响多层次共付制度的效果。因此，缩小这一差距有助于实现分层医疗保险计划的预期目标。
