Yu Meiteng, Liu Jing, Zhang Tao
Department of Health Policy and Management, School of Public Health, Hangzhou Normal University, Hangzhou, China.
Administrative Office, Shantou University School of Medicine Affiliated Yuebei People's Hospital, Shaoguan, China.
Int J Equity Health. 2025 Jan 14;24(1):11. doi: 10.1186/s12939-025-02375-9.
With the implementation of the hierarchical medical system (HMS) in China, Zhejiang Province introduced an innovative payment scheme called "payment method by disease types with point counting". This scheme was initially adopted in Jinhua in July 2017, and was later integrated with the "same disease, same price" policy in Hangzhou in January 2020. This study aimed to investigate the impact of these reforms on the distribution of health service volume.
Data were obtained from 104 hospitals, including 12 tertiary and 14 secondary hospitals from each of four regions: Jinhua (intervention) vs. Taizhou (control), and Hangzhou (intervention) vs. Ningbo (control). A total of 3848 observation points were examined using two sets of controlled interrupted time series analyses to assess the effects of this new case-based payment, without and with "same disease, same price", on the proportion of discharges, total medical revenue and hospitalization revenue. The Herfindahl-Hirschman Index (HHI) were analyzed to evaluate changes in market competition.
Following the introduction of the new case-based payment without "same disease, same price", secondary hospitals in Jinhua experienced a significant decline in the proportion of discharges (β = -0.1074, p = 0.047), total medical revenue (β = -0.0729, p = 0.026), and hospitalization revenue (β = -0.1062, p = 0.037) compared to those in Taizhou, while tertiary hospitals showed a non-significant increase. After incorporating "same disease, same price", the proportion of discharges (β = 0.2015, p = 0.031), total medical revenue (β = 0.1101, p = 0.041) and hospitalization revenue (β = 0.1248, p = 0.032) in Hangzhou's secondary hospitals increased compared with Ningbo's, yet the differences in both the level and trend changes between tertiary hospitals in the two cities were not statistically significant. The HHI in Jinhua (β = 0.0011, p = 0.043) presented an upward trend during the pilot period of the case-based payment, while the HHI in Hangzhou (β = -0.0234, p = 0.021) decreased immediately after the introduction of "same disease, same price".
This new case-based payment scheme may worsen the disproportionate distribution of service volume across hospitals of different levels. While "same disease, same price" shows potential benefits, further evidence is needed to assess its effectiveness in promoting HMS. Policymakers should consider hospital interests in payment design and address unintended strategic behaviors.
随着中国分级医疗体系（HMS）的实施，浙江省引入了一种名为“疾病诊断相关分组点数法付费”的创新支付方案。该方案于2017年7月在金华市首次采用，随后于2020年1月在杭州市与“同病同价”政策相结合。本研究旨在调查这些改革对卫生服务量分布的影响。
数据来自104家医院，包括来自四个地区的各12家三级医院和14家二级医院：金华（干预组）与台州（对照组），以及杭州（干预组）与宁波（对照组）。使用两组对照中断时间序列分析对总共3848个观察点进行检查，以评估这种新的按病例付费方式（有无“同病同价”）对出院比例、医疗总收入和住院收入的影响。分析赫芬达尔-赫希曼指数（HHI）以评估市场竞争的变化。
在引入无“同病同价”的新按病例付费方式后，金华市的二级医院与台州市相比，出院比例（β = -0.1074，p = 0.047）、医疗总收入（β = -0.0729，p = 0.026）和住院收入（β = -0.1062，p = 0.037）均显著下降，而三级医院则有不显著的增加。纳入“同病同价”后，杭州市二级医院的出院比例（β = 0.2015，p = 0.031）、医疗总收入（β = 0.1101，p = 0.041）和住院收入（β = 0.1248，p = 0.032）与宁波市相比有所增加，但两市三级医院在水平和趋势变化上的差异均无统计学意义。金华市的HHI（β = 0.0011，p = 0.043）在按病例付费试点期间呈上升趋势，而杭州市的HHI（β = -0.0234，p = 0.021）在引入“同病同价 ”后立即下降。
这种新的按病例付费方案可能会加剧不同级别医院之间服务量分布的不均衡。虽然“同病同价”显示出潜在益处，但需要更多证据来评估其在促进分级医疗体系方面的有效性。政策制定者在支付设计中应考虑医院利益，并应对意外的战略行为。
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