By studying the effects of the multitiered copayment system, our findings demonstrate that its introduction had different effects at the pre- and post-change phase. Compared with the pre-change phase, the number of respondents who believed the multitiered copayment system had an impact on their PHC institutions’ selection at the post-change phase had a threefold increase (from 14.09–50.90%), and the multitiered copayment system started to play a positive role.
At the pre-change phase, owing to the large gaps in the quality of healthcare services, and the small gap in the copayment rate in different tiers of hospitals, the effect of the reduction in the multitiered copay rate on people’s primary healthcare-seeking behavior was limited. This result corresponds with the results from a numerical experiment which concluded that in order to affect people’s primary healthcare-seeking behavior, the optimal copayment difference should be large enough, such as 37% in tertiary hospitals and 4% in PHC institutions . However, such a gap in the copayment rate would increase health and healthcare inequity. It was a challenge to increase the effectiveness of the multitiered copayment system by adjusting the copayment rate at the pre-change phase. Therefore, the multitiered copayment system failed to show a meaningful effect in the significant gap of quality in healthcare services.
The results of the multinomial logistic regression analysis, at the pre-change phase, indicate that the age of the respondents and their needs factor of self-rated health status are the main determinants of their PHC institutions’ selections. Further, these factors have also been proven in previous studies [19, 20]. Age has been identified as the most common variable, which is similar in our study as well. We found that older people are more likely to change their primary healthcare-seeking behavior due to the copayment rate reduction. This may be because the older adults are most likely to have chronic diseases that need continuous care , and the diagnosis and treatment of chronic disease are highly standardized. In other words, the services required by older adults do not usually require advanced technology and equipment. Meanwhile, people with chronic conditions often report moderate or poor self-rated health status , which means that there is a sizable overlap between the elderly and those with moderate and poor self-rated health status . However, those with poor self-rated health scores tend to believe that they have more complicated disease, need higher levels of treatment, and that the services in PHC institutions cannot meet their medical care needs. Thus, due to their higher frequency of hospital visit and lower needs in diagnosis and treatment, the elderly and those with moderate self-rated health status would be motivated by the copayment rate reduction in PHC institutions.
As mentioned above, the effect of the multitiered copayment system will be improved at the post-change phase. The role of the gap in the quality of healthcare services in PHC institutions was found in South Korea (non-equalization in services quality) and the United Kingdom (UK) (even equalization in services quality). In the UK, the general practitioner system is the focal point of PHC . And the UK’s National Health Service attach great importance to the quality of their healthcare service . Thus, the key to system effectiveness is that the general practitioners always provide high quality of healthcare services . However, in Korea, in order to guide patients with mild disease to PHC institutions, a copayment policy was implemented . In this policy, the copay rates for outpatients are 30% in clinics and pharmacies, 40% in hospitals, 50% in general hospitals, and 60% in tertiary hospitals . However, the result of this copayment policy in Korea had little effect [27, 28], which was consistent with the findings from other studies in China, and ours. As the quality of healthcare services in Korea is similar to that of China’s, which also has a large gap between the higher tier hospitals and those PHC institutions, allocation of medical care resources also tended to be biased towards higher tier hospitals. Thus, patients consider physicians in tertiary hospitals to be more qualified and prefer to choose these highly qualified physicians for healthcare, which resulted in the unsatisfactory effect from the multitiered copayment system . All these evidences show that the gap in quality of healthcare services is the key factor that determines the effectiveness of the multitiered copayment system.
At the post-change phase, age and the enabling factor of distance to a medical care facility, transformed from needs factor (self-rated health status), were the critical factors affecting people’s PHC institutions’ selection. At this phase, people no longer consider the gap in healthcare services quality, because irrespective of the type of hospitals they visit, they would receive the same quality of treatment. Thus, the convenience of healthcare access is the primary factor for them to consider. In general, PHC institutions are closer to people’s homes, which makes it more convenient for people to receive healthcare services. Additionally, PHC institutions offer better coverage rate, shorter wait times, and located in residential areas, healthcare workers there may be familiar with patients, which will make it easier to receive targeted healthcare services . In this case, not only the elderly or people with moderate self-rated health status, but also others with healthcare needs can benefit from the reduced copay to receive care; thus, more people would visit those PHC healthcare facilities.