Impact of the Hierarchical Medical System on the Perceived Quality of Primary Care in China: A Quasi-Experimental Study

OBJECTIVES: Although the implementation of the hierarchical medical system (HMS) has been shown to improve the allocation of medical resources and patient health seeking behavior, its role on patients’ perceived quality of primary care remains unexplored. The purpose of this study was to assess the impact of the implementation of the HMS on rural and urban residents’ perceived quality of primary care.

METHODS: Data were obtained from the China Household Panel Study from 2012, 2014, 2016, and 2018. A total of 40,011 rural residents and 22,482 urban residents were included as the research participants for analysis. The multiple time period difference-in-difference method was used to capture changes in patients’ perceived quality of primary care before and after the introduction of the HMS.

RESULTS: This study has three key findings. First, the implementation of the HMS results in varying effects on individuals’ perceived quality of primary care among rural and urban residents. The perceived quality of primary care declined by an average of 18% among rural residents (OR: 0.82, 95% CI: 0.68~0.99), while there was no significant change among urban residents (OR: 1.13, 95% CI: 0.87~1.46). Second, the implementation of the HMS only has short-term impacts on reducing rural residents’ perceived quality of primary care, with its long-term impacts being not statistically significant. Third, patients with chronic diseases perceive poorer quality of primary care after the implementation of the HMS.

CONCLUSIONS: The HMS have a limited effect on improving residents’ perceived quality of primary care, especially for those living in rural areas. Policy makers are suggested to take into account patients’ experiences and feelings as measures of the quality attributed to the HMS implementation.