How to promote orderly access to medical care: an empirical analysis based on the Chinese experience

Objective: This study focuses on the implementation of China's hierarchical diagnosis and treatment system, conducting an in-depth analysis from three dimensions-healthcare service framework, policy experimentation, and service utilization patterns-aiming to provide valuable insights for the construction and improvement of an orderly medical order in other countries of the world. Methods: , this study proposes a three-dimensional framework for China's hierarchical diagnosis and treatment system, categorizes medical institutions into three distinct levels, and systematically analyzes structural variations in outpatient and inpatient service provision across different medical institutional tiers from 2007 to 2022. Results: The analysis reveals notable shifts in healthcare-seeking patterns in China: regarding first-contact care, the proportion of urban/rural residents initiating care at primary healthcare institutions demonstrates overall contraction, while secondary hospitals show increased first-contact shares, and tertiary hospitals maintaining stable utilization around 8.0%. In outpatient services, primary institutions retain the highest annual visit volumes, yet tertiary hospitals exhibit the strongest average annual growth rate. Structural variation analysis shows both tiers are primary contributors to system-wide changes-primary institutions demonstrate pre-dominantly negative VSV (Value of Structural Variation) trends, contrasted by tertiary hospitals' consistently positive VSV. For inpatient care, tertiary hospitals display the most rapid service expansion, with sustained positive VSV since 2010 and structural contribution rates exceeding 35%. This trajectory has positioned tertiary institutions as the primary inpatient service providers. Conclusion: (1) China has established clear functional roles for different medical institutions across distinct tiers of care, thereby laying a solid foundation for orderly patient referrals; (2) The evolving distribution of healthcare services across different tiers of medical institutions in China suggests that gaps remain between the current patient referral patterns and the intended objectives of the hierarchical medical system, particularly for inpatient services; (3) China's policies to promote the hierarchical diagnosis and treatment system exhibit distinct regional characteristics, highlighting the need to further expand the implementation scope of these policies to promote the formation of an orderly healthcare-seeking pattern; (4) The role of tertiary hospitals in China's hierarchical diagnosis and treatment system requires further optimization; (5) Developing integrated healthcare delivery systems with vertically coordinated services and horizontally regulated competition among medical institutions at all levels should be a critical future direction for China's health system reform.