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The “Iron Triangle” of Healthcare Services: Evaluating an Integrated Healthcare Alliance’s Impact on Primary Care in Shenzhen, China Cover

The “Iron Triangle” of Healthcare Services: Evaluating an Integrated Healthcare Alliance’s Impact on Primary Care in Shenzhen, China

By: ,   and    
Open Access
|Sep 2026

References

  1. Cebul RD, Rebitzer JB, Taylor LJ, Votruba ME. Organizational fragmentation and care quality in the U.S healthcare system. Journal of Economic Perspectives. 2008;22(4):93–113. DOI: 10.1257/jep.22.4.93
  2. Gatome-Munyua A, Sparkes S, Mtei G, Sabignoso M, Soewondo P, Yameogo P, et al. Reducing fragmentation of primary healthcare financing for more equitable, people-centred primary healthcare. BMJ Global Health. 2025;10(1):e015088. DOI: 10.1136/bmjgh-2024-015088
  3. World Bank Group, World Health Organization,Ministry of Finance, National Health and FamilyPlanning Commission, Ministry of Human Resources andSocial Security. Deepening health reform in China: Building high quality and value based service delivery. https://openknowledge.worldbank.org/server/api/core/bitstreams/ab618635-7f02-5459-bfd1-cee55d848960/content (assessed 2025 July 20).
  4. Wang X, Sun X, Birch S, Gong F, Valentijn P, Chen L, et al. People-centred integrated care in urban China. Bulletin of the World Health Organization. 2018;96(12):843–852. DOI: 10.2471/BLT.18.214908
  5. Maeda JL, Lee KM, Horberg M. Comparative health systems research among Kaiser Permanente and other integrated delivery systems: A systematic literature review. The Permanente Journal. 2014;18(3):66–77. DOI: 10.7812/TPP/13-159
  6. Schilling L, Chase A, Kehrli S, Liu AY, Stiefel M, Brentari R. Kaiser Permanente’s performance improvement system, part 1: From benchmarking to executing on strategic priorities. The Joint Commission Journal on Quality and Patient Safety. 2010;36(11):484–498. DOI: 10.1016/s1553-7250(10)36072-7
  7. Humphries R. Integrated health and social care in England—progress and prospects. Health Policy. 2015;119(7):856–859. DOI: 10.1016/j.healthpol.2015.04.010
  8. Ow Yong LM, Cameron A. Learning from elsewhere: Integrated care development in Singapore. Health Policy. 2019;123(4):393–402. DOI: 10.1016/j.healthpol.2018.12.004
  9. Milstein R, Blankart CR. The Health Care Strengthening Act: The next level of integrated care in Germany. Health Policy. 2016;120(5):445–451. DOI: 10.1016/j.healthpol.2016.04.006
  10. National Health Commission, National Administration of Traditional Chinese Medicine. Notice on the pilot work of building urban medical alliances. https://www.gov.cn/zhengce/zhengceku/2019-10/08/content_5437013.htm (accessed 2025 July 20). [in Chinese].
  11. Li X, Krumholz HM, Yip W, Cheng KK, De Maeseneer J, Meng Q, et al. Quality of primary health care in China: Challenges and recommendations. Lancet. 2020;395(10239):1802–1812. DOI: 10.1016/S0140-6736(20)30122-7
  12. Cui Y, Shi L, Tang S, Yang Y, Ren L. Value evaluation for urban medical groups in China: A case from Dapeng New District in Shenzhen. Health Care Science. 2025, 4(3):206–214. DOI: 10.1002/hcs2.70014
  13. Feng S, Cheng A, Luo Z, Xiao Y, Zhang L. Effect of family doctor contract services on patient perceived quality of primary care in southern China. BMC Public Health. 2020;21(1):218. DOI: 10.1186/s12875-020-01287-7
  14. Li X, Zhang L, Li Z, Tang W. Patient choice and willingness toward gatekeepers as first-contact medical institutions in Chinese tiered healthcare delivery system: A cross-sectional study. Frontiers in Public Health. 2021;9:665282. DOI: 10.3389/fpubh.2021.665282
  15. Dunne P, Patterson C, Kilmartin M, Sladden M. Health service provision in rural and remote areas: A needs analysis. The Medical Journal of Australia. 1994;161(2):160–162. DOI: 10.5694/j.1326-5377.1994.tb127349.x
  16. Grossmann D, Srivastava S, Winkler V, Brenner S, Gupta KJ, Paliwal A, et al. Determinants of outpatient healthcare-seeking behaviors among the rural poor affected by chronic conditions in India: A population-based cross-sectional study in seven states. Global health action. 2025;18(1):2480413. DOI: 10.1080/16549716.2025.2480413
  17. Leach MJ, Gunn K, Muyambi K. The determinants of healthcare utilisation in regional, rural and remote South Australia: A cross-sectional study. Health & social care in the community. 2022;30(6):e4850–e4863. DOI: 10.1111/hsc.13894
  18. Brezzi M, Luongo P. Regional disparities in access to health care: A multilevel analysis in selected OECD countries. OECD Regional Development Working Papers. DOI: 10.1787/5jm0tn1s035c-en
  19. Tanzeem S, Ayyappan V, Ayyappan V. Addressing healthcare disparities between rural and urban communities. Healthcare Administration Leadership & Management Journal. (2025);3(4)211–214. DOI: 10.55834/halmj.3701318410
  20. Jayaprakash P, Majumdar R, Ingole S. Geographical health inequalities in India: The impact of the COVID-19 pandemic on healthcare access and healthcare inequality. International journal of health care quality assurance. 2024:42–67. DOI: 10.1108/IJHCQA-05-2023-0030
  21. Zhang M, Du X, Jia G, Xia Q, Xu Y, Wu J, et al. Comparative study on the satisfaction of healthcare service providers with the synergistic development of rural healthcare systems in China: Medical alliance counties vs. non medical alliance counties. International journal of integrated care. 2024;24(2):26. DOI: 10.5334/ijic.7677
  22. Ran Y, Gao H, Han D, Hou G, Chen Y, Zhang Y. Comparison of inpatient distribution amongst different medical alliances in a county: a longitudinal study on a healthcare reform in rural China. International journal for equity in health. 2020;19(1):142. DOI: 10.1186/s12939-020-01260-x
  23. Lu C, Zhang Z, Lan X. Impact of China’s referral reform on the equity and spatial accessibility of healthcare resources: A case study of Beijing. Social science & medicine. 2019;235:112386. DOI: 10.1016/j.socscimed.2019.112386
  24. Casalino LP, Ramsay P, Baker LC, Pesko MF, Shortell SM. Medical group characteristics and the cost and quality of care for Medicare beneficiaries. Health services research. 2018;53(6):4970–4996. DOI: 10.1111/1475-6773.13010
  25. Yang X, Chen Y, Li C, Hao M. Effects of medical consortium policy on health services: An interrupted time-series analysis in Sanming, China. Frontiers in Public Health. 2024;12:1322949. DOI: 10.3389/fpubh.2024.1322949
  26. Zhang T, Liu J, Lu B, Yan Z, Huang X, Lu W. Intended and unintended impacts of the comprehensive reform of urban public hospitals: A mixed-method study in Hangzhou, China. Frontiers in Public Health. 2022;10:979455. DOI: 10.3389/fpubh.2022.979455
  27. Baker LC, Bundorf MK, Kessler DP. Vertical integration: Hospital ownership of physician practices is associated with higher prices and spending. Health affairs. 2014;33(5):756–763. DOI: 10.1377/hlthaff.2013.1279
  28. Baker LC, Bundorf MK, Kessler DP. The effect of hospital/physician integration on hospital choice. Journal of health economics. 2016;50:1–8. DOI: 10.1016/j.jhealeco.2016.08.006
  29. Zhang Y, Stokes J, Anselmi L, Bower P, Xu J. Can integrated care interventions strengthen primary care and improve outcomes for patients with chronic diseases? A systematic review and meta-analysis. Health research policy and systems. 2025;23:5. DOI: 10.1186/s12961-024-01260-1
  30. Zhang Y, Xie S, Wang Q, Zhao Q, Chen Q, Wu T, et al. Effects of vertical integration on the healthcare system in China: A systematic review and meta-analysis. Health policy and planning. 2024;39(1):66–79. DOI: 10.1093/heapol/czad085
  31. Ianni KM, Sinaiko AD, Curto VE, Soto M, Rosenthal MB. Quality-of-care outcomes in vertical relationships between physicians and health systems. JAMA Health Forum. 2024;5(8):e242173. DOI: 10.1001/jamahealthforum.2024.2173
  32. O’Hanlon CE. Impacts of health care industry consolidation in Pittsburgh, Pennsylvania: A qualitative study. Inquiry. 2020;57:46958020976246. DOI: 10.1177/0046958020976246
  33. Kissick W. Medicine’s dilemmas: Infinite needs versus finite resources. New Haven and New London, CT: Yale University Press; 1994.
  34. Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health affairs. 2008;27(3):759–769. DOI: 10.1377/hlthaff.27.3.759
  35. Dong J, Zhang Z, Yang Y, et al. Report on development of China’s integrated health care system (2023). Beijing: Social Science Academic Press; 2024. pp. 15–17. [in Chinese].
  36. Rawaf S, Allen L, Dubois E, Majeed A, Myrup A, Raheem M, et al. Primary health care: Closing the gap between public health and primary care through integration. Geneva: World Health Organization; 2018.
  37. Bhardwaj U, Mane M, Samal S. Innovations in healthcare management: Balancing cost, quality, and access. Health Leadership and Quality of Life. 2022;1:100. DOI: 10.56294/hl2022100
  38. Barcellona C, Mariñas YB, Tan SY, Lee G, Ko KC, Chham S, et al. Measuring health equity in the ASEAN region: Conceptual framework and assessment of data availability. International journal for equity in health. 2023;22(1). DOI: 10.1186/s12939-023-02059-2
  39. Evans DB, Hsu J, Boerma T. Universal health coverage and universal access. Bulletin of the World Health Organization. 2013;91(8):546–546A. DOI: 10.2471/BLT.13.125450
  40. Gustafsson PE, Fonseca-Rodríguez O, Castel Feced S, et al. A novel application of interrupted time series analysis to identify the impact of a primary health care reform on intersectional inequities in avoidable hospitalizations in the adult Swedish population. Social Science & Medicine. 2024;343:116589. DOI: 10.1016/j.socscimed.2024.116589
  41. Bonakdari H, Pelletier JP, Martel-Pelletier J. A continuous data driven translational model to evaluate effectiveness of population-level health interventions: Case study, smoking ban in public places on hospital admissions for acute coronary events. Journal of Translational Medicine. 2020;18(1):466. DOI: 10.1186/s12967-020-02628-x
  42. National Bureau of Statistics of China. National data reports from China. https://data.stats.gov.cn/easyquery.htm?cn=C01 (accessed 2025 July 20). [in Chinese].
  43. Yuan S, Fan F, Zhu D. Effects of vertical integration reform on primary healthcare institutions in China: Evidence from a longitudinal study. International Journal of Health Policy and Management. 2022;11(9):1835–1843. DOI: 10.34172/ijhpm.2021.93
  44. Schluter PJ, Hamilton GJ, Deely JM, Ardagh MW. Impact of integrated health system changes, accelerated due to an earthquake, on emergency department attendances and acute admissions: A Bayesian change-point analysis. BMJ Open. 2016;6(5):e010709. DOI: 10.1136/bmjopen-2015-010709
  45. Li K, Hou Y, McStay F, Gonzalez-Smith J, Saunders RS. Federally Qualified Health Centers and performance of Medicare Accountable Care Organizations. JAMA network open. 2024;7(11):e2445536. DOI: 10.1001/jamanetworkopen.2024.45536
  46. Song C, Fang L, Xie M, Tang Z, Zhang Y, Tian F, et al. Revealing spatiotemporal inequalities, hotspots, and determinants in healthcare resource distribution: Insights from hospital beds panel data in 2308 Chinese counties. BMC Public Health. 2024;24(1):423. DOI: 10.1186/s12889-024-17950-y
  47. Fan R, Meng Q, Zhang L, Liu C, Han L, Liu M, et al. Physician group practice in China’s healthcare reform: A national survey on physicians’ perspectives and implementation challenges. Frontiers in health services. 2025;5:1574388. DOI: 10.3389/frhs.2025.1574388
  48. Fang P, Hu R, Han Q. Effects of healthcare reform on health resource allocation and service utilization in 1110 Chinese county hospitals: Data from 2006 to 2012. The International journal of health planning and management. 2017;32(4):400–415. DOI: 10.1002/hpm.2344
  49. Liu S, Lin J, He Y, Xu J. The service capability of primary health institutions under the hierarchical medical system. Healthcare. 2022;10(2):335. DOI: 10.3390/healthcare10020335
  50. Rocks S, Berntson D, Gil-Salmerón A, Kadu M, Ehrenberg N, Stein V, et al. Cost and effects of integrated care: A systematic literature review and meta-analysis. The European journal of health economics. 2020;21(8):1211–1221. DOI: 10.1007/s10198-020-01217-5
  51. Bond AM, Civelek Y, Schpero WL, Casalino LP, Zhang M, Pierre R, et al. Long-term spending of Accountable Care Organizations in the Medicare Shared Savings Program. JAMA. 2025;333(21):1897–1905. DOI: 10.1001/jama.2025.3870
  52. Tan H, Zhang X, Peng X, Guo D, Chen Y. Does vertical integration increase the costs for primary care inpatients? Evidence from a national pilot programme in China. Archives of Public Health. 2024;82(1):136. DOI: 10.1186/s13690-024-01378-2
  53. National Healthcare Security Administration. Statistical bulletin of medical security development in 2024. https://www.nhsa.gov.cn/art/2025/3/21/art_7_16054.html (accessed 2025 July 20). [in Chinese].
  54. Gao L, Wang X. Healthcare supply chain network coordination through medical insurance strategies with reference price effect. International journal of environmental research and public health. 2019;16(18):3479. DOI: 10.3390/ijerph16183479
  55. Luo D, Zhu X, Qiu X, Zhao J, Li X, Du Y. Healthcare preferences of chronic disease patients under China’s hierarchical medical system: an empirical study of Tianjin’s reform practice. Scientific reports. 2024;14(1):11631. DOI: 10.1038/s41598-024-62118-8
  56. Niu W, Huang J, Xing Z, Chen J. Knowledge spillovers of medical big data under hierarchical medical system and patients’ medical treatment decisions. IEEE Access. 2019,7:55770–55779. DOI: 10.1109/access.2019.2908440
  57. Song X, Wei Y, Deng W, Zhang S, Zhou P, Liu Y, et al. Spatio temporal distribution, spillover effects and influences of China’s two levels of public healthcare resources. International journal of environmental research and public health. 2019;16(4):582. DOI: 10.3390/ijerph16040582
  58. Chen J, He X, Xu Q. A study on the influence of medical insurance paying proportion to hierarchical diagnosis and treatment. China Preventive Medicine Journal. 2017,29(10):999–1002. [in Chinese]. DOI: 10.19485/j.cnki.issn1007-0931.2017.10.007
  59. Terry NP. Appification, AI, and healthcare’s new iron triangle. Journal of Health Care Law and Policy. 2017;20:117–182. DOI: 10.2139/ssrn.3020784
DOI: https://doi.org/10.5334/ijic.10192 | Journal eISSN: 1568-4156
Language: English
Page range: 22 - 22
Submitted on: Sep 7, 2025
Accepted on: Sep 22, 2026
Published on: Sep 30, 2026
Published by: Ubiquity Press
In partnership with: Paradigm Publishing Services

© 2026 Shilan Tang, Miao Yu, Xizi Wan, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.