Nonlinear association between provincial implementation intensity of county-level medical communities and patient flow patterns
- 1School of Finance, Lanzhou University of Finance and Economics
- 2School of Public Administration, Gansu University of Political Science and Law
Abstract
Introduction: As a key initiative of China’s healthcare system reform, tightly integrated county-level medical communities (CCMCs) are designed to optimize the allocation of high-quality medical resources and advance the tiered healthcare delivery system. However, evidence on their policy effects remains mixed, and most studies treat CCMC construction as a binary intervention while overlooking continuous variations in implementation intensity. Meanwhile, the international literature on integrated care and referral governance focuses largely on established universal health systems, with limited attention to how progressive reforms unfold nonlinearly in developing countries facing resource constraints and patient outflows. This study addresses two unresolved questions: does intensifying CCMC construction continuously promote local patient retention, or does it initially generate patient diversion toward county-level hospitals at the expense of grassroots resources?.
Methods: Departing from prior work that relies on dummy variables, we construct a multidimensional CCMC Construction Intensity Index (CII) covering policy coverage, organizational integration, and institutional safeguards. Using provincial panel data from 2014 to 2024 and a two-way fixed-effects model, we identify the causal relationship between CII and patient flow patterns.
Results: We observe a U-shaped association between CII and the relative scale of in-county visits, though this association is attenuated under more demanding trend controls and the estimated inflection point shows some sensitivity to sample composition. At lower levels of construction intensity, patient diversion toward county hospitals accompanies the resource integration process; once intensity crosses the threshold, substantive integration and long-term mechanisms are gradually unleashed, and patient retention within counties begins to dominate. This pattern is mirrored by an inverted U-shaped trend in out-of-county care-seeking. Heterogeneity analysis shows that these patterns are more pronounced in western regions and in areas with a higher density of private hospitals; within grassroots facilities, benefits accrue primarily to township health centers, while community stations and village clinics lag behind.
Discussion: Theoretically, this study reveals that CCMC development in China follows a threshold-dependent trajectory, contributing Chinese evidence on the nonlinear evolution of referral dynamics to the global integrated care literature and helping reconcile mixed prior findings. From a policy perspective, the findings offer empirical support for calibrating implementation intensity to local contexts and for prioritizing township health centers as the main recipients of resource devolution, so as to mitigate early-stage patient diversion and support the gradual advancement of the tiered healthcare system.
Related
- School-based high-intensity interval training for children: a focused systematic review of implementation and school-relevant outcomes
- Implementation and Training-Related Outcomes of High-Intensity Interval Training and Cognitive-Motor Training in Professional League of Legends and Valorant Players: A First Exploratory Ecological Study Across In-Game, Cognitive, and Physiological Domains
- Community-based delivery of lifesaving maternal and newborn health interventions in vulnerable Ethiopian communities: Lessons from implementation research
- Real-world implementation of AI-assisted PERT-workflow and its association with care processes and budget impact: a retrospective cohort study
- Association of synergistic trajectories between early mobilization potential and actual implementation with clinical outcomes among ICU patients with pneumonia: a multivariate latent class mixed model analysis
BibTeX
@article{shi2026nonlinear,
title = {{Nonlinear association between provincial implementation intensity of county-level medical communities and patient flow patterns}},
author = {Ting Shi and Lan Yang and Yuehong Zhang},
journal = {Frontiers in Public Health},
year = {2026},
month = oct,
doi = {10.3389/fpubh.2026.1966297},
url = {https://www.frontiersin.org/articles/10.3389/fpubh.2026.1966297/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Nonlinear association between provincial implementation intensity of county-level medical communities and patient flow patterns
AU - Ting Shi
AU - Lan Yang
AU - Yuehong Zhang
PY - 2026
DA - 2026/10/26
JO - Frontiers in Public Health
DO - 10.3389/fpubh.2026.1966297
UR - https://www.frontiersin.org/articles/10.3389/fpubh.2026.1966297/full
AB - Introduction: As a key initiative of China’s healthcare system reform, tightly integrated county-level medical communities (CCMCs) are designed to optimize the allocation of high-quality medical resources and advance the tiered healthcare delivery system. However, evidence on their policy effects remains mixed, and most studies treat CCMC construction as a binary intervention while overlooking continuous variations in implementation intensity. Meanwhile, the international literature on integrated care and referral governance focuses largely on established universal health systems, with limited attention to how progressive reforms unfold nonlinearly in developing countries facing resource constraints and patient outflows. This study addresses two unresolved questions: does intensifying CCMC construction continuously promote local patient retention, or does it initially generate patient diversion toward county-level hospitals at the expense of grassroots resources?. Methods: Departing from prior work that relies on dummy variables, we construct a multidimensional CCMC Construction Intensity Index (CII) covering policy coverage, organizational integration, and institutional safeguards. Using provincial panel data from 2014 to 2024 and a two-way fixed-effects model, we identify the causal relationship between CII and patient flow patterns. Results: We observe a U-shaped association between CII and the relative scale of in-county visits, though this association is attenuated under more demanding trend controls and the estimated inflection point shows some sensitivity to sample composition. At lower levels of construction intensity, patient diversion toward county hospitals accompanies the resource integration process; once intensity crosses the threshold, substantive integration and long-term mechanisms are gradually unleashed, and patient retention within counties begins to dominate. This pattern is mirrored by an inverted U-shaped trend in out-of-county care-seeking. Heterogeneity analysis shows that these patterns are more pronounced in western regions and in areas with a higher density of private hospitals; within grassroots facilities, benefits accrue primarily to township health centers, while community stations and village clinics lag behind. Discussion: Theoretically, this study reveals that CCMC development in China follows a threshold-dependent trajectory, contributing Chinese evidence on the nonlinear evolution of referral dynamics to the global integrated care literature and helping reconcile mixed prior findings. From a policy perspective, the findings offer empirical support for calibrating implementation intensity to local contexts and for prioritizing township health centers as the main recipients of resource devolution, so as to mitigate early-stage patient diversion and support the gradual advancement of the tiered healthcare system.
SN - 2296-2565
ER -