22 Provinces in China Implement Tiered Diagnosis and Treatment System to Optimize Healthcare Resource Allocation

To alleviate the difficulties and high costs associated with accessing medical care, and to ensure the rational allocation of healthcare resources, the State Council issued the Guiding Opinions on Advancing the Construction of a Tiered Diagnosis and Treatment System in 2015. This initiative deployed the establishment of such a system across China and deepened the reform of the pharmaceutical and healthcare sectors. According to the author’s preliminary review, 22 provincial-level regions have formulated implementation plans for advancing the construction of a tiered diagnosis and treatment system. These include Hebei, Shanxi, Liaoning, Shanghai, Jiangsu, Zhejiang, Anhui, Fujian, Jiangxi, Henan, Hubei, Guangdong, Shenzhen, Guangxi, Hainan, Chongqing, Sichuan, Yunnan, Shaanxi, Heilongjiang, Qinghai, and Xinjiang. Meanwhile, six other provinces—Jilin, Shandong, Tianjin, Hunan, Guizhou, and Ningxia—are gradually launching pilot programs for tiered diagnosis and treatment.

High-quality medical resources are systematically and effectively decentralized to lower-tier facilities, with the county-level patient visit rate reaching 90%.

Currently, the healthcare landscape in China is characterized by overcrowding at large hospitals and underutilization of smaller facilities. To alleviate the difficulties in accessing medical care, it is imperative to implement a tiered diagnosis and treatment system and optimize the allocation of medical resources.

The tiered diagnosis and treatment system refers to a model in which medical institutions of different levels and service capabilities assume responsibility for treating diseases based on their severity, urgency, and complexity. It facilitates timely and convenient two-way referrals according to changes in patients' conditions, thereby establishing a tiered care pattern characterized by initial consultations at primary care facilities, two-way referrals, separate management of acute and chronic conditions, and coordinated collaboration between upper- and lower-level institutions, ensuring that patients receive appropriate treatment.

Among the provinces that have issued implementation plans for tiered diagnosis and treatment, Guangdong, Fujian, Jiangxi, Hubei, Shanxi, Henan, Gansu, Yunnan, and others have set targets to raise the proportion of medical visits within county-level jurisdictions to approximately 90% and increase the share of consultations at primary healthcare institutions to 65% of the total within two to five years. To boost consultation volumes at primary healthcare institutions and basically achieve the goal of managing serious illnesses within counties, it is necessary to systematically and effectively decentralize high-quality medical resources, strengthen the workforce of primary healthcare professionals with a focus on general practitioners, and leverage the role of general practitioners as “gatekeepers” of residents’ health. In addition, relaxing market entry barriers for private healthcare providers, encouraging physicians to practice at multiple sites, and increasing the enrollment rate in family doctor contracting services are also key measures to advance tiered diagnosis and treatment and safeguard residents’ health.

Clarify the Functional Positioning of Various Medical Institutions and Establish Standards for Tiered Referrals

To achieve the healthcare delivery pattern of “minor illnesses treated in the community, major illnesses referred to hospitals, and rehabilitation returned to the community,” it is essential to clearly define the functional roles of various medical institutions and establish standardized procedures for tiered diagnosis and referral.

Shanxi’s implementation plan for tiered diagnosis and treatment has defined the disease categories covered under the system and standardized the tiered care procedures. Anhui has classified pediatric internal medicine hospitals into three tiers, each with distinct scopes of practice and assigned responsibilities. Fujian, based on its provincial context, has clarified the functional roles of various medical institutions, established standard guidelines for tiered referrals, and implemented a two-way referral system. Sichuan was the first in China to issue guidelines for two-way referrals; last year, it saw a decline in the proportion of outpatient visits at large hospitals, demonstrating the initial effectiveness of its tiered diagnosis and treatment system. Hunan has strictly differentiated the functions of hospitals at different levels, using single-disease entities as key indicators to determine the types of cases treated, cost levels, reimbursement rates, monitoring methods, and performance evaluation criteria for each tier, thereby gradually establishing a new order for tiered diagnosis and treatment.

Increase the reimbursement rate for primary care diagnosis and treatment, and leverage the guiding role of pricing

Change people’s healthcare-seeking habits to avoid the tendency to rush to large hospitals for minor ailments such as headaches and fever. Fully leverage the economic leverage of medical service pricing and health insurance reimbursement rates, and guide patient behavior by implementing differentiated fee structures and reimbursement standards across healthcare institutions of different tiers.

Jiangsu has established a tiered and classified diagnosis and treatment model for acute, subacute, and chronic diseases, while explicitly directing health insurance payment policies toward primary care facilities. Fujian’s implementation plan for tiered diagnosis and treatment clarifies the rationalization of price ratios among medical services, establishes a dynamic adjustment mechanism for medical service pricing, and implements differentiated pricing policies. It also increases the reimbursement rates for outpatient and inpatient services at primary healthcare institutions under basic medical insurance, thereby widening the reimbursement gap between primary care facilities and hospitals of different tiers or those inside and outside county jurisdictions. Hubei is advancing reforms in health insurance payment systems by establishing a composite payment model dominated by diagnosis-related group (DRG) payments, supplemented by capitation and per-service-unit payments. The province is exploring bundled capitation payments for chronic disease patients at primary healthcare institutions to promote the orderly flow of patients.