Does an innovative case-based payment scheme promote the hierarchical medical system? A tripartite evolutionary game analysis

Background: China is striving to promote a hierarchical medical system (HMS) to improve the efficiency of health resource utilization and ensure health equity. An innovative payment scheme named the “Diagnosis-Intervention Package” (DIP) has been developed recently and implemented in 71 pilot cities nationwide. Although the impact of payment reform on medical expenditure and provider behavior has been demonstrated, there is little evidence on whether the reform promotes the HMS. Methods: This study uses evolutionary game theory to formulate a tripartite evolutionary game model involving the local government (LG), superior medical institutions (SMI), and patients in implementing DIP payment reform. We also analyze the stability of each participant’s strategy and the sensitivity of parameters. Results: The results show that for LG, the additional social benefits created for other regions are crucial in influencing the evolution of the game system. SMI are more inclined to support the HMS when the proportion of patient reduction under the DIP payment scheme is low. For patients, the perceived medical quality of primary medical institutions (PMI) is the decisive factor in their strategies. Conclusion: The DIP payment scheme is more likely to promote the HMS in regions with an advanced policy framework, abundant medical resources, and high-quality primary medical services. Policymakers need to create effective incentives to boost support for the HMS from each participant. This study provides a feasible methodology for analyzing the impact of payment reforms that can be used in future research.