The Effect of Hierarchical Medical System Reform on Primary Care Utilization: Evidence from Provincial Panel Data 

Hu Jiaping  He Wendi

School of Southwest Petroleum University, Sichuan China，610500；

Abstract: China’s healthcare system is characterized by concentrated high-quality resources and underused primary care institutions. Using panel data for 31 provinces from 2010 to 2023, this study applies a difference-in-differences model to estimate the effect of the hierarchical medical system reform on primary care utilization. The baseline results show that the reform increased the share of visits to primary care institutions in pilot provinces by about 1.6 percentage points, although the statistical significance is modest. Event-study estimates indicate that the effect emerged gradually within one to two years after implementation. Regional heterogeneity analysis shows a stronger response in central China, while no stable significant effect is found in eastern or western China. Mechanism tests suggest that the reform does not mainly work through a simple expansion of primary care resources; instead, insurance payment incentives and institutional coordination appear to play a more important role. Robustness checks largely support the direction of the main findings, although statistical significance weakens under some alternative specifications. The results imply that the hierarchical medical system reform should continue to be advanced in coordination with health insurance payment reform, referral arrangements, and primary care capacity building, with policy implementation tailored to regional differences.

Keywords: hierarchical medical system reform; primary care utilization; difference-in-differences; regional heterogeneity; mechanism analysis

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