Table 2.

Facilitating characteristics for successful care integration and features from the Chinese pilots

	Description	Comments on Chinese models
Defined population or health conditions covered by the programme	Fully integrated systems integrate primary and hospital care across an entire population. Disease management programmes attempt to do the same but focus on particular groups within the population that share certain characteristics, such as age, a common disease or condition, or a geographical area21, 41	Most have defined population by geographical location but do not focus on a particular health condition38, 39, 42, 43, 44, 45
Provider payment incentives to coordinate care	Bundled payments encourage care coordination by allocation of a fixed fee to provide a full range of services for a defined population within a certain time period across providers at various facility levels Pay-for-performance components are also increasingly being used to reward or penalise primary care physicians for improved preventive care and chronic disease management17, 21, 22, 46, 47, 48, 49	Most pilots do not include provider payment change. According to Shanghai's government guidance, social insurance is supposed to pay an integrated delivery network a global budget that covers all the providers within the network. To what extent it has been implemented is unclear38, 39, 42, 43, 44, 45
Patient incentives	Tiered reimbursement structures, referrals for specialist services, approvals for expensive diagnostic tests, and insurance discounts for engagement in health promotion activities or registering with accredited integrated delivery organisations motivate consumers to access the health-care system in the most cost-effective way21, 41, 47	For most pilots, there is no differential tiered reimbursement schedule from SHI specifically developed to incentivise patients to use primary health care In some models, reimbursement rates for referred cases are higher than for non-referred cases In most models, obtaining referrals from community health centres fast tracks patients for appointments at higher-level hospitals38, 39, 42, 43, 44, 45
Role of primary health care	In several countries, registration with general practitioners is compulsory or highly incentivised financially with primary care providers acting as gatekeepers to the wider health-care system Multispecialty medical groups are made up of doctors from a number of specialties who take on a budget to provide all or some of the services needed by the population that they serve Transitional care models redirect care from hospital settings back towards the community, shifting care from physicians towards more multidisciplinary teams that include nurses, therapists, and social care workers All service delivery setups include some kind of case management with primary health care at the centre17, 41, 47	Most pilots are set up with the purpose of reduction of overcrowding at tertiary hospitals by redirecting patients to a lower level of facilities. They are not set up for care-coordination according to clinical protocols In most cases, community centres are supposed to play the gatekeeping role. Whether this has been successfully implemented is not known Primary health-care providers do not seem to play a core role in care-coordination. In fact, most of the networks are led by tertiary hospitals38, 39, 42, 43, 44, 45
Decision support for providers	Peer review, standardised care protocols, cross-disciplinary interactions, and training increasingly broadens the scope of various health-care professionals to act as patient care coordinators26, 41, 46, 50	There is no explicitly defined care coordinator for the full continuum of services for a patient and period of time across the health facilities within the group Higher-level facilities second experts to the next lower level for training Whether there are multidisciplinary team based practice is unclear38, 39, 42, 43, 44, 45
Health information system	The use of standardised electronic health records that are interoperable across provider institutions is common in high performance integrated systems21, 22, 25, 41	All have realised the essential role of health information technology in integrated care systems. Some integrated care groups (eg, Ruijin-Luwan), have established medical information exchange platforms and participated in information exchange across providers and care settings38, 39, 42, 43, 44, 45
Enabling regulations	Regulation and changes in organisational infrastructure facilitating the clinical integration of providers are less common and need strong government leadership and support from health-care professionals. Often what is necessary is a relaxation of regulations that impede clinical integration41, 46, 48	The integration between providers has been impeded by some nationwide regulations. For instance, the number of health facilities where a doctor can practice is regulated (eg, three affiliations per doctor), which means that doctors cannot practice in all health facilities within a network. Also, there are regulations about what drugs each level of facility can dispense. If a patient is referred down to a community centre for rehabilitation, the community centre might not have the medicine that the patient needs. Some pilots are attempting to relax these restrictions51, 52

SHI=social health insurance.