ObjectiveThis study examined the impact of an Integrated Care Delivery intervention on health care seeking and outcomes for chronically-ill patients in Henan province, China.MethodsA case-control study was carried out in six health care organizations from two counties in Henan province, China. 371 patients aged 50 years or over with hypertension or diabetes who visited either community health centers or hospitals in the Intervention or Control Counties were systematically selected and surveyed on health care seeking behavior, quality of care, and pathway of care for their major chronic condition. Bivariate analyses were performed to compare quality and value of care indicators between patients from the Intervention and Control Counties. Multivariate analyses were used to confirm these associations after controlling for patients’ demographic and health characteristics.ResultsPatients in both the Intervention and Control Counties chose their current health care providers primarily out of concern for quality of care (provider expertise and adequate medical equipment) and patient-centered care. Compared with the patients from the Control County, those from the Intervention County performed significantly better on almost all the quality and value of care indicators even after controlling for patients’ demographic and health characteristics. Significant associations between types of health care facilities and quality as well as value of care were also observed.ConclusionThe study showed that the Integrated Care Delivery Model was critical in guiding patients’ health care seeking behavior and associated with improved accessibility, continuity, coordination and comprehensiveness of care, as well as reducing health inequities and mitigating disparities for older patients with chronic conditions.

ObjectiveReform of the health care system in urban areas of China has prompted concerns about the utilization of Community Health Centers (CHC). This study examined which of the dominant primary care delivery models, i.e., the public CHC model, the ‘gate-keeper’ CHC model, or the hospital-owned CHC models, was most effective in enhancing access to and quality of care for patients with chronic illness.MethodsThe case-comparison design was used to study nine health care organizations in Guangzhou, Dongguan, and Shenzhen cities within Guangdong province, China. 560 patients aged 50 or over with hypertension or diabetes who visited either CHCs or hospitals in these three cities were surveyed by using face-to-face interviews. Bivariate analyses were performed to compare quality and value of care indicators among subjects from the three cities. Multivariate analyses were used to assess the association between type of primary care delivery and quality as well as value of chronic care after controlling for patients’ demographic and health status characteristics.ResultsPatients from all three cities chose their current health care providers primarily out of concern for quality of care (both provider expertise and adequate medical equipment), patient-centered care, and insurance plan requirement. Compared with patients from Guangzhou, those from Dongguan performed significantly better on most quality and value of care indicators. Most of these indicators remained significantly better even after controlling for patients' demographic and health status characteristics. The Shenzhen model (hospital-owned and -managed CHC) was generally effective in enhancing accessibility and continuity. However, coordination suffered due to seemingly duplicating primary care outpatients at the hospital setting. Significant associations between types of health care facilities and quality of care were also observed such that patients from CHCs were more likely to be satisfied with traveling time and follow-up care by their providers.ConclusionThe study suggested that the Dongguan model (based on insurance mandate and using family practice physicians as ‘gate-keepers’) seemed to work best in terms of improving access and quality for patients with chronic conditions. The study suggested adequately funded and well-organized primary care system can play a gatekeeping role and has the potential to provide a reasonable level of care to patients.

Typescript prepared by Janis Vehmaan-Kreula at UNU-WIDER. UNU-WIDER gratefully acknowledges specific programme contributions from the governments of Denmark (Ministry of Foreign Affairs, Danida) and Sweden (Swedish International Development Cooperation Agency-Sida) for ReCom. UNU-WIDER also gratefully acknowledges core financial support to its work programme from the governments of Denmark, Finland, Sweden, and the United Kingdom. The World Institute for Development Economics Research (WIDER) was established by the United Nations University (UNU) as its first research and training centre and started work in Helsinki, Finland in 1985. The Institute undertakes applied research and policy analysis on structural changes affecting the developing and transitional economies, provides a forum for the advocacy of policies leading to robust, equitable and environmentally sustainable growth, and promotes capacity strengthening and training in the field of economic and social policy-making. Work is carried out by staff researchers and visiting scholars in Helsinki and through networks of collaborating scholars and institutions around the world.

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In May 2011, a year after the passage of the Affordable Care Act (ACA), Vermont became the first state to lay the groundwork for a single-payer health care system, known as Green Mountain Care. What can other states learn from the Vermont experience? This article summarizes the findings from interviews with nearly 120 stakeholders as part of a study to inform the design of the health reform legislation. Comparing Vermont's failed effort to adopt single-payer legislation in 1994 to present efforts, we find that Vermont faced similar challenges but greater opportunities in 2010 that enabled reform. A closely contested gubernatorial election and a progressive social movement opened a window of opportunity to advance legislation to design three comprehensive health reform options for legislative consideration. With a unified Democratic government under the leadership of a single-payer proponent, a high-profile policy proposal, and relatively weak opposition, a framework for a single-payer system was adopted by the legislature - though with many details and political battles to be fought in the future. Other states looking to reform their health systems more comprehensively than national reform can learn from Vermont's design and political strategy.