Zhang Liangwen, Yu Xingyuan, Fang Ya
State Key Laboratory of Vaccines for Infectious Diseases, Xiang An Biomedicine Laboratory, National Innovation Platform for Industry-Education Integration in Vaccine Research, School of Public Health, Xiamen University, Xiamen Fujian, 361102, People's Republic of China.
Key Laboratory of Health Technology Assessment of Fujian Province, School of Public Health, Xiamen University, Xiamen Fujian, 361102, People's Republic of China.
BMC Public Health. 2025 Jul 9;25(1):2418. doi: 10.1186/s12889-025-23018-2.
The Chinese government is advancing the development of the County Medical Community (CMC) to establish an integrated healthcare delivery network and ensure health equity. Recently, Global Budget (GB) economic incentives have been implemented in CMC. Although the impact of GB on medical expenditure has been demonstrated, there is little evidence on whether GB promotes collaboration among various providers.
This article takes Sanming City, a typical example of China's healthcare reform, as a case study, and uses data from 2016 to 2023 on the operation of CMC. Interrupted time series analysis was used to evaluate the long-term impact of GB on inpatient costs, cost structure and service delivery.
The analyses indicate that, although the direct impact of the GB on inpatient costs is not significant, it sustains a rational structure of inpatient cost and optimizes the delivery of inpatient services at all levels of institutions. With respect to inpatient cost structure, the proportion of drug costs in secondary hospitals (SHs) (β = 0.127, P < 0.001) and tertiary hospitals (THs) (β = 0.120, P < 0.05) increased after the GB, the proportion of testing and inspection costs in primary healthcare institutions (PHIs) decreased (β = -0.215, P < 0.05). In terms of service delivery, the average length of stay in SHs (β = -0.053, P < 0.05) and THs (β = -0.032, P < 0.001) decreased, and the admission per 100 outpatients (β = 0.058, P < 0.001) in PHIs increased. The robustness analysis corroborated the robustness of the results.
This article provides empirical evidence that GB mechanisms can enhance service coordination among different levels of healthcare providers, which provides valuable lessons for promoting integrated healthcare and achieving health equity in China and in low- and middle-income countries.
中国政府正在推进县域医共体（CMC）建设，以建立一体化医疗服务网络并确保健康公平。近期，县域医共体实施了总额预算（GB）经济激励措施。尽管总额预算对医疗支出的影响已得到证实，但关于总额预算是否促进了各医疗服务提供者之间的协作，相关证据却很少。
本文以中国医疗改革的典型城市三明市为例进行案例研究，并使用了2016年至2023年县域医共体运行的数据。采用中断时间序列分析来评估总额预算对住院费用、成本结构和服务提供的长期影响。
分析表明，尽管总额预算对住院费用的直接影响不显著，但它维持了住院费用的合理结构，并优化了各级医疗机构的住院服务提供。在住院成本结构方面，总额预算实施后，二级医院（SHs）（β = 0.127，P < 0.001）和三级医院（THs）（β = 0.120，P < 0.05）的药品费用占比增加，基层医疗卫生机构（PHIs）的检验检查费用占比下降（β = -0.215，P < 0.05）。在服务提供方面，二级医院（β = -0.053，P < 0.05）和三级医院（β = -0.032，P < 0.001）的平均住院日缩短，基层医疗卫生机构每100名门诊患者的住院人次增加（β = 0.058，P < 0.001）。稳健性分析证实了结果的稳健性。
本文提供了实证证据，表明总额预算机制可以加强不同层级医疗服务提供者之间的服务协调，这为中国以及中低收入国家促进整合型医疗服务和实现健康公平提供了宝贵经验。
