《中国医疗保险制度的转型发展与创新》课程教学资源（参考资料）The Luohu Model：A Template for Integrated Urban Healthcare Systems in China

Wang,X,et al.The Luohu Model:A Template for Integrated Urban mesd18 Healthcare Systems in China.International Journal of Integrated Care2018;18(4):3,1-10.DOl:https:/1doi.org/10.5334/jic.3955 POLICY PAPER The Luohu Model:A Template for Integrated Urban Healthcare Systems in China Xin Wang,Xizhuo Sunt,Fangfang Gongt,Yixiang Huang,Lijin Chen', Yong Zhang'and Stephen Bircht Introduction:Emerging from the epidemiological transition and accelerated aging process,China's fragmentated healthcare systems struggle to meet the demands of the population.On Sept 1st 2017, China's National Health and Family Planning Commission encouraged all cities to learn from the Luohu model of integration adopted in Luohu as an approach to meeting these challenges.In this paper,we study the integration process,analyze the core mechanisms,and conduct preliminary evaluations of integrated policy development in the Luohu model. Policy development:The Luohu hospital group was established in Aug 2015,consists of five district hospitals,23 community health stations and an institute of precision medicine.The group adopted a series of professional,organizational,system,functional and normative strategies for integrated care, which was provided for the residents of Luohu,especially for the elderly population and patients with chronic conditions.According to a preliminary evaluation of the past two years,the Luohu model showed improvement in the structure and process towards integrated care.New preventive programs conducted in the hospital group resulted in changes of disease incidence.Residents were more satisfied with the Luohu model.However,spending exceeded the global budget for health insurance because of short-term increases in the demand for health care. Lessons learned:First,engagement of multiple stakeholders is essential for the design and implementa- tion of reform.Second,organizational integration is a prerequisite for integrated care in China.Third, effective care integration requires alignment with payment reforms.Fourth,normative integration could promote collaboration in an integrated healthcare system. Conclusion:Core strategies and mechanisms of the Luohu model will promote integrated care in urban China and other countries facing the same challenges.However,it is necessary to study the effects of the Luohu model over the long term and continue to strive for integrated care. Keywords:integrated care;hospital group;district healthcare system Introduction efficiency,cost escalation,and poor patient experiences Healthcare systems worldwide have been designed pri-[6,7].As a developing country getting old before getting marily to deal with single,acute,and short-term illnesses rich,China's healthcare systems are facing considerable [1,2].However,emerging from the epidemiological tran-challenges of fragmented care.In China,there were 231 sition and an accelerated population aging process,frag- million people aged 60 years or over in China(16.7%of mentated healthcare provided by traditional healthcare the population)[8]in 2016.Among them,more than 100 systems in most countries cannot meet the demands of million had at least one chronic noncommunicable dis- the population,especially the elderly,many of whom ease [9].Further,626 deaths,21,020 disability adjusted often have chronic diseases 3-5.Moreover,the tradi- of life years(DALY)and 8,879 years lived with disability tional healthcare system has suffered from low levels of (YLDS)per 100,000 population were attributed to chronic noncommunicable disease [10].It is predicted that the percentage of people aged 60 or over will increase from School of Public Health,Health Development Research Center, 12.4%in 2010 to 28%in 2040 [11].These challenges Sun Yat-sen University,74 Zhongshan 2nd Road, Guangzhou,CN indicate a need for urgency in transition from fragmented t Shenzhen Luohu Hospital Group,No.47 Youyi Road, care to integrated care in China's healthcare systems. Shenzhen,CN Current fragmented healthcare delivery in China is hos- Centre for the Business and Economics of Health,University pital-centered and treatment-dominated,with little effec- of Queensland,AU tive collaboration among institutions in different tiers of Corresponding author:Yixiang Huang (huangyx@mail.sysu.edu.cn) the system [12].In the 1980s,China moved to a market

Introduction Healthcare systems worldwide have been designed pri￾marily to deal with single, acute, and short-term illnesses [1, 2]. However, emerging from the epidemiological tran￾sition and an accelerated population aging process, frag￾mentated healthcare provided by traditional healthcare systems in most countries cannot meet the demands of the population, especially the elderly, many of whom often have chronic diseases [3–5]. Moreover, the tradi￾tional healthcare system has suffered from low levels of efficiency, cost escalation, and poor patient experiences [6, 7]. As a developing country getting old before getting rich, China’s healthcare systems are facing considerable challenges of fragmented care. In China, there were 231 million people aged 60 years or over in China (16.7% of the population) [8] in 2016. Among them, more than 100 million had at least one chronic noncommunicable dis￾ease [9]. Further, 626 deaths, 21,020 disability adjusted of life years (DALY) and 8,879 years lived with disability (YLDS) per 100,000 population were attributed to chronic noncommunicable disease [10]. It is predicted that the percentage of people aged 60 or over will increase from 12.4% in 2010 to 28% in 2040 [11]. These challenges indicate a need for urgency in transition from fragmented care to integrated care in China’s healthcare systems. Current fragmented healthcare delivery in China is hos￾pital-centered and treatment-dominated, with little effec￾tive collaboration among institutions in different tiers of the system [12]. In the 1980s, China moved to a market POLICY PAPER The Luohu Model: A Template for Integrated Urban Healthcare Systems in China Xin Wang* , Xizhuo Sun† , Fangfang Gong† , Yixiang Huang* , Lijin Chen* , Yong Zhang* and Stephen Birch‡ Introduction: Emerging from the epidemiological transition and accelerated aging process, China’s fragmentated healthcare systems struggle to meet the demands of the population. On Sept 1st 2017, China’s National Health and Family Planning Commission encouraged all cities to learn from the Luohu model of integration adopted in Luohu as an approach to meeting these challenges. In this paper, we study the integration process, analyze the core mechanisms, and conduct preliminary evaluations of integrated policy development in the Luohu model. Policy development: The Luohu hospital group was established in Aug 2015, consists of five district hospitals, 23 community health stations and an institute of precision medicine. The group adopted a series of professional, organizational, system, functional and normative strategies for integrated care, which was provided for the residents of Luohu, especially for the elderly population and patients with chronic conditions. According to a preliminary evaluation of the past two years, the Luohu model showed improvement in the structure and process towards integrated care. New preventive programs conducted in the hospital group resulted in changes of disease incidence. Residents were more satisfied with the Luohu model. However, spending exceeded the global budget for health insurance because of short-term increases in the demand for health care. Lessons learned: First, engagement of multiple stakeholders is essential for the design and implementa￾tion of reform. Second, organizational integration is a prerequisite for integrated care in China. Third, effective care integration requires alignment with payment reforms. Fourth, normative integration could promote collaboration in an integrated healthcare system. Conclusion: Core strategies and mechanisms of the Luohu model will promote integrated care in urban China and other countries facing the same challenges. However, it is necessary to study the effects of the Luohu model over the long term and continue to strive for integrated care. Keywords: integrated care; hospital group; district healthcare system * School of Public Health, Health Development Research Center, Sun Yat-sen University, 74 Zhongshan 2nd Road, Guangzhou, CN † Shenzhen Luohu Hospital Group, No. 47 Youyi Road, Shenzhen, CN ‡ Centre for the Business and Economics of Health, University of Queensland, AU Corresponding author: Yixiang Huang (huangyx@mail.sysu.edu.cn) Wang, X, et al. The Luohu Model: A Template for Integrated Urban Healthcare Systems in China. International Journal of Integrated Care, 2018; 18(4): 3, 1–10. DOI: https://doi.org/10.5334/ijic.3955

Art.3,page 2 of 10 Wang et al:The Luohu Model economy,and the government dramatically reduced hospi- tricts in Shenzhen,with an area of 78.36 km2 and a popu- tal funding.Responding to these reductions,hospitals tried lation of 1.4 million.Per capital Gross Domestic Product to earn revenues by providing more profitable health care (GDP)in Luohu was $25,200 in 2016 [23].It also has the primarily diagnosis and treatment rather than prevention largest proportion of the elderly residents in Shenzhen. and rehabilitation.The traditional three-tier healthcare sys It is estimated that the number of elderly individuals and tem collapsed,and primary health care stations no longer patients with chronic conditions exceeds over 451,000. served as gatekeepers 13.Since new health reforms were The government of Luohu has the tradition of reform,not introduced in 2009,China's government has been encour- only in economy but also in health. aging health care provision in primary health stations by Luohu District has five district-level hospitals and 83 financial subsidies and a program entitled Equalization of community health stations.While most cities with two- Basic Public Health Services [14.However,measures to level primary health care institutions [24].Luohu has improve collaboration among institutions and reduce frag- only one-level community health stations.Furthermore, mentation of services have been insufficient. all 83 community health stations are affiliated with one Over the last decade,integrated care has been sug- of the five hospitals.For example,the community health gested as one strategy for promoting coordinated health management center in the Luohu General Hospital is care delivery,improving the quality of care and reduc- in charge of 18 community health stations,managing ing costs [15-17].In 2016,the report "Deepening health human resources,finance,assets and service delivery in reform in China"[18].published by the World Health each station.Also located in Luohu is a city-level gen- Organization(WHO),World Bank(WB),and the Chinese eral hospital with 2,000 beds,under the charge of the Government,proposed strengthening healthcare in China Shenzhen city government.The numbers of beds and through a tiered health care delivery system in accord- physicians in the city hospital exceed those in the five ance with a People-Centered Integrated Care model.In independent district hospitals.The expansion of the April 2017,the General Office of the State Council issued a city hospital has been associated with the weakening of Guideline for constructing Medical Consortia [19].In the the ability of district hospitals and community health guideline,four types of medical consortia were suggested: stations to provide care as patients are free to seek ser hospital groups in urban areas,medical associations in vices at the city hospital directly.Therefore,"line up for rural areas,cross-regional specialist alliances and tele- 3 hours,treatment for 3 minutes"became a problem collaboration networks in remote areas.Medical consortia in Luohu,especially for the elderly and patients with thus became a main means for achieving People-Centered chronic diseases.The Luohu health reform system aims Integrated Care.On Sept 1st 2017,China's National Health to achieve "less illness,fewer hospital admissions,lower and Family Planning Commission introduced the Luohu financial burdens,and better services"25 by develop- model,an approach to healthcare integration pioneered ment of a community-based and prevention-oriented in Luohu District,to the entire country and encouraged integrated care system. all cities to learn from it [20].Subsequently,more than 1,500 policy makers from health and other social sectors Process of the Luohu reform in 321 cities received on-site training in the Luohu model. Figure 1 shows the timeline of the Luohu reform.In The aims of this study are to introduce the Luohu model, February 2015,the district government began with the to evaluate its effects and to explore lessons learned.With concept "Shifting focus from treatment to health".After enhancement of the Belt and Road health collaboration 10 rounds of expert consultations,the Luohu hospital [21,22],health reforms in urban China may have a con- group was established in Aug 2015.It consists of five siderable impact on other countries'health systems,espe- district hospitals,23 community health stations,and an cially low-and-middle-income countries facing the same institute of precision medicine,along with six resource challenges.Moreover,features of healthcare integration sharing centers and six administrative centers(Figure 2). in China,which may differ from those in European coun After being established,the hospital group adopted a tries,may provide references for other countries. series of reforms.In Dec 2015,a Quality Management Center took action to improve the quality of care in all Development of the Luohu Model institutions,especially in community health stations.In Background of Shenzhen City and the Luohu District May 2016,a new health insurance policy,"Global budget, China's Reform and Opening in 1980s began in Shenzhen balance retained",was introduced which funded hospitals City,which,in 2016,ranked first in economic competitive- via global budgets and allowed institutions to retain any ness among cities nationwide.Luohu is one of the ten dis- funds not spent during the financial year.At the same Figure 1:Timeline of the Luohu reform

Art. 3, page 2 of 10 Wang et al: The Luohu Model economy, and the government dramatically reduced hospi￾tal funding. Responding to these reductions, hospitals tried to earn revenues by providing more profitable health care, primarily diagnosis and treatment rather than prevention and rehabilitation. The traditional three-tier healthcare sys￾tem collapsed, and primary health care stations no longer served as gatekeepers [13]. Since new health reforms were introduced in 2009, China’s government has been encour￾aging health care provision in primary health stations by financial subsidies and a program entitled Equalization of Basic Public Health Services [14]. However, measures to improve collaboration among institutions and reduce frag￾mentation of services have been insufficient. Over the last decade, integrated care has been sug￾gested as one strategy for promoting coordinated health care delivery, improving the quality of care and reduc￾ing costs [15–17]. In 2016, the report “Deepening health reform in China” [18], published by the World Health Organization (WHO), World Bank (WB), and the Chinese Government, proposed strengthening healthcare in China through a tiered health care delivery system in accord￾ance with a People-Centered Integrated Care model. In April 2017, the General Office of the State Council issued a Guideline for constructing Medical Consortia [19]. In the guideline, four types of medical consortia were suggested: hospital groups in urban areas, medical associations in rural areas, cross-regional specialist alliances and tele￾collaboration networks in remote areas. Medical consortia thus became a main means for achieving People-Centered Integrated Care. On Sept 1st 2017, China’s National Health and Family Planning Commission introduced the Luohu model, an approach to healthcare integration pioneered in Luohu District, to the entire country and encouraged all cities to learn from it [20]. Subsequently, more than 1,500 policy makers from health and other social sectors in 321 cities received on-site training in the Luohu model. The aims of this study are to introduce the Luohu model, to evaluate its effects and to explore lessons learned. With enhancement of the Belt and Road health collaboration [21, 22], health reforms in urban China may have a con￾siderable impact on other countries’ health systems, espe￾cially low- and-middle-income countries facing the same challenges. Moreover, features of healthcare integration in China, which may differ from those in European coun￾tries, may provide references for other countries. Development of the Luohu Model Background of Shenzhen City and the Luohu District China’s Reform and Opening in 1980s began in Shenzhen City, which, in 2016, ranked first in economic competitive￾ness among cities nationwide. Luohu is one of the ten dis￾tricts in Shenzhen, with an area of 78.36 km2 and a popu￾lation of 1.4 million. Per capital Gross Domestic Product (GDP) in Luohu was $25,200 in 2016 [23]. It also has the largest proportion of the elderly residents in Shenzhen. It is estimated that the number of elderly individuals and patients with chronic conditions exceeds over 451,000. The government of Luohu has the tradition of reform, not only in economy but also in health. Luohu District has five district-level hospitals and 83 community health stations. While most cities with two￾level primary health care institutions [24], Luohu has only one-level community health stations. Furthermore, all 83 community health stations are affiliated with one of the five hospitals. For example, the community health management center in the Luohu General Hospital is in charge of 18 community health stations, managing human resources, finance, assets and service delivery in each station. Also located in Luohu is a city-level gen￾eral hospital with 2,000 beds, under the charge of the Shenzhen city government. The numbers of beds and physicians in the city hospital exceed those in the five independent district hospitals. The expansion of the city hospital has been associated with the weakening of the ability of district hospitals and community health stations to provide care as patients are free to seek ser￾vices at the city hospital directly. Therefore, “line up for 3 hours, treatment for 3 minutes” became a problem in Luohu, especially for the elderly and patients with chronic diseases. The Luohu health reform system aims to achieve “less illness, fewer hospital admissions, lower financial burdens, and better services” [25] by develop￾ment of a community-based and prevention-oriented integrated care system. Process of the Luohu reform Figure 1 shows the timeline of the Luohu reform. In February 2015, the district government began with the concept “Shifting focus from treatment to health”. After 10 rounds of expert consultations, the Luohu hospital group was established in Aug 2015. It consists of five district hospitals, 23 community health stations, and an institute of precision medicine, along with six resource sharing centers and six administrative centers (Figure 2). After being established, the hospital group adopted a series of reforms. In Dec 2015, a Quality Management Center took action to improve the quality of care in all institutions, especially in community health stations. In May 2016, a new health insurance policy, “Global budget, balance retained”, was introduced which funded hospitals via global budgets and allowed institutions to retain any funds not spent during the financial year. At the same Figure 1: Timeline of the Luohu reform

Wang et al:The Luohu Model Art.3,page 3 of 10 time,salary reform was instituted to motivate staff.In Strategies of the Luohu model Sept 2016,a prescription of three month was allowed Based on the Rainbow Model of integrated care developed for patients with one of ten types of chronic conditions by Valentijn and colleagues [26,27],integration pro- to seek treatment,to avoid unnecessary outpatient vis- cesses at the macro-level (system integration),meso-level its to district hospitals.In Nov 2016,the hospital group (organizational and professional integration).micro- encouraged specialists in district hospitals to set up clinics level (clinical integration)and cross-level (functional and in community health stations,to increase the proportion normative integration)contribute to integrated care.The of first contacts occurring in primary health stations.In strategies taken in Luohu for constructing a community- July 2017,the charter of the hospital group was amended based and prevention-oriented integrated care system are based on lessons learned from the preceding two years. summarized in Figure 3.There are strategies regarding Thus,the establishment of the hospital group provided professional,organizational,system,functional and nor- the basis for the ensuring reforms. mative integration.Among these are three core strategies Supervisory Board Expert Committee Workers'Congress Luohu hospital group Party Committee President Accountant 5 hospitals ces 6administrative 23 nters health Figure 2:Organizational structure of the Luohu hospital group. 1.1 Multidisciplinary family doctor teams Professional 2.1 Close hospital group integration 5 1 Shared vision in the hospital group (including five hospitals.one research 5.2 Build trust between residents institute.six health resources sharing centers. six administrative centers.twenty-three CHSe) and family doctor toams 2 Organizational Normative integration People- integration centered 3 Systom Functional integration integration 3.1 Global budget,balance retention 4.1 Platform for two-way referrals 3.2 Six administrative centers 4.2 Health Luohu APP and 4G 3.3 Six resources-sharing centers mobile nursing Figure 3:Strategies for an integrated care system in Luohu

Wang et al: The Luohu Model Art. 3, page 3 of 10 time, salary reform was instituted to motivate staff. In Sept 2016, a prescription of three month was allowed for patients with one of ten types of chronic conditions to seek treatment, to avoid unnecessary outpatient vis￾its to district hospitals. In Nov 2016, the hospital group encouraged specialists in district hospitals to set up clinics in community health stations, to increase the proportion of first contacts occurring in primary health stations. In July 2017, the charter of the hospital group was amended based on lessons learned from the preceding two years. Thus, the establishment of the hospital group provided the basis for the ensuring reforms. Strategies of the Luohu model Based on the Rainbow Model of integrated care developed by Valentijn and colleagues [26, 27], integration pro￾cesses at the macro-level (system integration), meso-level (organizational and professional integration), micro￾level (clinical integration) and cross-level (functional and normative integration) contribute to integrated care. The strategies taken in Luohu for constructing a community￾based and prevention-oriented integrated care system are summarized in Figure 3. There are strategies regarding professional, organizational, system, functional and nor￾mative integration. Among these are three core strategies Figure 2: Organizational structure of the Luohu hospital group. Figure 3: Strategies for an integrated care system in Luohu

Art.3,page4 of 10 Wang et al:The Luohu Model for establishment of the hospital group.In the hospital paid by the group.To avoid physicians'reducing services group.Detailed integrated care was provided for the resi- to increase the balance of health insurance,the quality dents,especially for the elderly and patients with chronic management center is responsible for supervising physi- conditions. cians'practices. The third strategy involved building family doctor teams Three core strategies in each community health station.Family doctor teams The first strategy was the establishment of a hospital group play an important role in promoting effective resource in the form of an independent corporation.Six resource utilization,reducing costs and improving patient sat- sharing centers were organized using the resources of the isfaction [28.However,a dearth of general practition- respective centers in the former five hospitals,including a ers hindered the development of family doctor teams in medical testing center,a radiographic center,an informa- China[29].The Luohu hospital group recruited general tion center,a health management center,a logistics and practitioners throughout the world,hired international distribution center and a disinfection and supply center, general practitioner experts for on-site clinical train- along with six administrative centers to manage all insti- ing and encouraged position shifts for some specialists. tutions in the group,including a human resource center,a In community health stations,each family doctor team financial center,a quality management center,a research consists of a general practitioner (leader),nurses,health and education center,a community health station man- promotion staff and a public health physician and may agement center and an integrated management center. also include specialists,pharmacists,nutritionists,and Twelve centers provide resources and management for psychologists.Specialists are provided with an incentive the entire hospital group.After the organizational inte- of $100 per day to set up clinics in the community health gration,there were 1,172 beds,3,479 staff,and 778 stations or serve as a member of a family doctor team in physicians in the group.The president is responsible for community health stations in their spare time.A list of the group under the leadership of a council.Among 12 ten identified tasks of the family doctor team (including council members,there are policy makers from the Dis- health education,case management for pregnant women trict Government,Health and Family Planning Commis- etc.)was widely publicized to make residents understand sion and resident representatives.The president has the the team's responsibilities.The family doctor team was capacity to make plans and coordinate activities for all expected to change the behavior of staff in community institutions in the group.All institutions in the group health stations and provide a platform for the transition share management,services,benefits and responsibilities from hospital-centered treatment-dominated care to com- The second strategy was the development of a new munity-based prevention-first care. health insurance policy,"Global budget,balance retained". Shenzhen's Social Insurance Fund Administration,which Integrated care for the elderly is affiliated with the Human Resources and Social Security In Aug 2014,a Rehabilitation Center for the elderly was Bureau,is responsible for collecting and managing the introduced by the general district hospital in Luohu and social insurance fund of the entire city.Coordinated by began to explore integrated care for the elderly [301.After Shenzhen's Health and Family Planning Commission, the establishment of the Luohu hospital group,an inte- Luohu became the first pilot for this new health insur- grated care system for the elderly was formed based on ance policy.The global budget of the hospital group in home care and community care supplemented by hospi- 2016 was given by the total cost of health insurance for talization. registered residents in the previous year multiplied by the Home care.Staff in community health stations provide average growth rate of the health insurance fund in 2016. nursing,rehabilitation,and palliative care for the disa- It should be noted that registered residents could seek bled elderly by setting up beds in the patients'homes.The health care in any institutions inside or outside the hos District's Ministry of Finance provides a subsidy for home pital group.Wherever the residents received health care, care.Community care delivery varies between communi- the hospital group had to pay for them,unlike a Health ties.First,through collaboration with community health Maintenance Organizations model where the organization stations,day care centers in the community provide drug is only accountable for care provided within the organiza- management,rehabilitation and health education for tion.Any surplus at the end of the year is retained and the elderly.Second,day care centers affiliated with hos- can be used for staff bonuses.The incentive and restraint pitals provide treatment,nursing,rehabilitation,and mechanisms formed by this policy aimed to change the case management for the elderly using multi-profession behavior of district hospitals.On the one hand,hospitals teams.Third,social service centers inside each commu- have to pay more attention to helping community health nity health station provide integrated care for the elderly. stations provide prevention and case management.Only Hospitalization care.The geriatric hospital in the hospital in this way can they reduce illnesses and the demand for group provides not only nursing and rehabilitation services hospitalization and hence reduce the health insurance but also diagnostic and treatment services for the elderly. cost of the group.On the other hand,hospitals will make efforts to improve the quality of health services and gain Integrated care for patients with chronic conditions the residents'trust to avoid patients seeking health ser- The Luohu hospital group explored integrated care and vices outside the group.The cost for registered patients case management for patients with chronic diseases. seeking treatment in hospitals outside the group will be Public health physicians were allocated to community

Art. 3, page 4 of 10 Wang et al: The Luohu Model for establishment of the hospital group. In the hospital group. Detailed integrated care was provided for the resi￾dents, especially for the elderly and patients with chronic conditions. Three core strategies The first strategy was the establishment of a hospital group in the form of an independent corporation. Six resource￾sharing centers were organized using the resources of the respective centers in the former five hospitals, including a medical testing center, a radiographic center, an informa￾tion center, a health management center, a logistics and distribution center and a disinfection and supply center, along with six administrative centers to manage all insti￾tutions in the group, including a human resource center, a financial center, a quality management center, a research and education center, a community health station man￾agement center and an integrated management center. Twelve centers provide resources and management for the entire hospital group. After the organizational inte￾gration, there were 1,172 beds, 3,479 staff, and 778 physicians in the group. The president is responsible for the group under the leadership of a council. Among 12 council members, there are policy makers from the Dis￾trict Government, Health and Family Planning Commis￾sion and resident representatives. The president has the capacity to make plans and coordinate activities for all institutions in the group. All institutions in the group share management, services, benefits and responsibilities. The second strategy was the development of a new health insurance policy, “Global budget, balance retained”. Shenzhen’s Social Insurance Fund Administration, which is affiliated with the Human Resources and Social Security Bureau, is responsible for collecting and managing the social insurance fund of the entire city. Coordinated by Shenzhen’s Health and Family Planning Commission, Luohu became the first pilot for this new health insur￾ance policy. The global budget of the hospital group in 2016 was given by the total cost of health insurance for registered residents in the previous year multiplied by the average growth rate of the health insurance fund in 2016. It should be noted that registered residents could seek health care in any institutions inside or outside the hos￾pital group. Wherever the residents received health care, the hospital group had to pay for them, unlike a Health Maintenance Organizations model where the organization is only accountable for care provided within the organiza￾tion. Any surplus at the end of the year is retained and can be used for staff bonuses. The incentive and restraint mechanisms formed by this policy aimed to change the behavior of district hospitals. On the one hand, hospitals have to pay more attention to helping community health stations provide prevention and case management. Only in this way can they reduce illnesses and the demand for hospitalization and hence reduce the health insurance cost of the group. On the other hand, hospitals will make efforts to improve the quality of health services and gain the residents’ trust to avoid patients seeking health ser￾vices outside the group. The cost for registered patients seeking treatment in hospitals outside the group will be paid by the group. To avoid physicians’ reducing services to increase the balance of health insurance, the quality management center is responsible for supervising physi￾cians’ practices. The third strategy involved building family doctor teams in each community health station. Family doctor teams play an important role in promoting effective resource utilization, reducing costs and improving patient sat￾isfaction [28]. However, a dearth of general practition￾ers hindered the development of family doctor teams in China [29]. The Luohu hospital group recruited general practitioners throughout the world, hired international general practitioner experts for on-site clinical train￾ing and encouraged position shifts for some specialists. In community health stations, each family doctor team consists of a general practitioner (leader), nurses, health promotion staff and a public health physician and may also include specialists, pharmacists, nutritionists, and psychologists. Specialists are provided with an incentive of $100 per day to set up clinics in the community health stations or serve as a member of a family doctor team in community health stations in their spare time. A list of ten identified tasks of the family doctor team (including health education, case management for pregnant women etc.) was widely publicized to make residents understand the team’s responsibilities. The family doctor team was expected to change the behavior of staff in community health stations and provide a platform for the transition from hospital-centered treatment-dominated care to com￾munity-based prevention-first care. Integrated care for the elderly In Aug 2014, a Rehabilitation Center for the elderly was introduced by the general district hospital in Luohu and began to explore integrated care for the elderly [30]. After the establishment of the Luohu hospital group, an inte￾grated care system for the elderly was formed based on home care and community care supplemented by hospi￾talization. Home care. Staff in community health stations provide nursing, rehabilitation, and palliative care for the disa￾bled elderly by setting up beds in the patients’ homes. The District’s Ministry of Finance provides a subsidy for home care. Community care delivery varies between communi￾ties. First, through collaboration with community health stations, day care centers in the community provide drug management, rehabilitation and health education for the elderly. Second, day care centers affiliated with hos￾pitals provide treatment, nursing, rehabilitation, and case management for the elderly using multi-profession teams. Third, social service centers inside each commu￾nity health station provide integrated care for the elderly. Hospitalization care. The geriatric hospital in the hospital group provides not only nursing and rehabilitation services but also diagnostic and treatment services for the elderly. Integrated care for patients with chronic conditions The Luohu hospital group explored integrated care and case management for patients with chronic diseases. Public health physicians were allocated to community

Wang et al:The Luohu Model Art.3,page5 of 10 health stations and became members of family doctor collaboration between district hospitals and community teams.Health care delivery for patients with chronic health stations promoted patient referral in the hospital diseases changed from treatment-dominated to preven- group.No patient was referred from hospitals to commu- tion-first based on three strategies. nity health stations for follow-up or rehabilitation services First,the group paid more attention to preventive care. in 2015,but in 2016 over 10,000 patients were referred For example,regular lectures were given in each commu- from hospitals in the group to community health stations nity and a Healthy Luohu app was designed for improving to receive the right care at the right place. residents'health literacy.In cooperation with the govern- Outcome evaluation.During the past two years,4,596 ment,the group helped to construct two jogging trails for more patients with diabetes,4,995 more patients with residents,to cultivate exercise.Moreover,free pneumonia hypertension and 822 more patients with severe mental vaccinations were provided for those over 60 years of age illness were enrolled in case management (Table 1). in2016. Compared with Jun 2014-Dec 2015,there were more new Second,the group introduced screening programs for cancer cases per month identified during Jun 2015-Jun diseases with high morbidity and mortality,with particu- 2016.There was a decrease in pneumonia cases in the lar focus on cancers.Screening programs for breast cancer, second year after reform.Residents'satisfaction with com- cervical cancer,lung cancer,liver cancer,and gastrointes- munity health stations in Luohu ranked first among the tinal cancer were introduced [24],to support early diag- ten districts of Shenzhen in 2015 and 2016.However,the nosis and treatment. mean cost per resident of all types of health care increased Third,physicians prepared individualized healthcare fom$675.3to$844.2. plans for patients and provided medical treatment and non-drug guidance regularly in collaboration with general Discussion practitioners.There is a Referral Gateway between general Stakeholders pushing the reform practitioners in community health stations and hospi- The District government of Luohu gave priority to health, tals in the group.Whenever patients need the services and set the direction for the reform by 'shifting focus from of specialists,physicians will refer them to one of the treatment to health".The District government helped the group's hospitals and continue to follow up. District Health and Family Planning Commission to coor- dinate with the Ministry of Finance,Human Resources and Evaluation of the Luohu model Social Security Bureau and Social Insurance Fund Admin- Framework istration,to ensure that supporting measures would be in Devers and colleagues [31]suggested that healthcare place.Further,the District government increased financial integration be evaluated in three dimensions:readiness subsidies to the group,especially community health sta- of integration(structure),internal process of integration tions.In 2016,the Ministry of Finance invested $112 mil- (process),and outcomes of integration (outcome).Selec- lion (accounting for 27.2%of all health expenditures in tion of the second-and third-level indicators was based the district)in the group. on a review of the literature,as well as on the aims of and Staff in the group contributed efforts to the reform. programs in the Luohu model.In this study,we adopted Physicians and nurses adopted a philosophy of serving six indicators to evaluate "structure",eight indicators patients,improving treatment capacity,and strengthen- system to evaluate "process"and 12 indicators to evaluate ing collaboration with team members.Meanwhile,the outcome"(Table 1). reform of salary payments enhanced the enthusiasm of all staff in the group. Results of evaluation Along with staff in the hospital group,residents helped Structure evaluation.In respect of infrastructure,the busi- create and share processes and outcomes of the reform. ness area of community health stations increased from Only by placing residents at the center of the system could 410m2 in Jun 2015 to 903m2 in Jun 2017.The assets the hospital group set the goal of constructing an inte- value of equipment across all community health stations grated care system.Before the reform,patients regarded increased from $2.73 million in Jun 2015 to $4.04 million the community health station as the last choice for service in Jun 2017.The number of general practitioner doubled. because they did not trust the quality of services available The number of public health physician increased from there.Now,42.6%residents regard community health sta- 2 to 30,while 49 specialists set up clinics in community tions as the first contact for health care.Overall,demands health stations,and 238 family doctor teams were devel- of residents have been driving the reform. oped during the same period. Process evaluation.By June 2017,580,000 residents had Strategies for integrated care been registered with general practitioners in the hospi- Some European projects have suggested that organizational tal group.The proportion of all hospitalizations going integration alone is unlikely to deliver better outcomes, to the group hospitals increased,which reduced the cost and that efforts must focus on clinical and service integra- of health insurance in the whole hospital group.In the tion.Other researchers have suggested that effective care group.The proportion of outpatient visits in community coordination can be achieved without the need for the for- health stations increase from 29.49%to 42.60%.This is a mal integration of organizations [32,33].Different from promising indicator that community health stations are most international experience,most pilot programs [34, acting for gatekeeper of the hospital group.Meanwhile, 35 in China mostly began with organizational integration

Wang et al: The Luohu Model Art. 3, page 5 of 10 health stations and became members of family doctor teams. Health care delivery for patients with chronic diseases changed from treatment-dominated to preven￾tion-first based on three strategies. First, the group paid more attention to preventive care. For example, regular lectures were given in each commu￾nity and a Healthy Luohu app was designed for improving residents’ health literacy. In cooperation with the govern￾ment, the group helped to construct two jogging trails for residents, to cultivate exercise. Moreover, free pneumonia vaccinations were provided for those over 60 years of age in 2016. Second, the group introduced screening programs for diseases with high morbidity and mortality, with particu￾lar focus on cancers. Screening programs for breast cancer, cervical cancer, lung cancer, liver cancer, and gastrointes￾tinal cancer were introduced [24], to support early diag￾nosis and treatment. Third, physicians prepared individualized healthcare plans for patients and provided medical treatment and non-drug guidance regularly in collaboration with general practitioners. There is a Referral Gateway between general practitioners in community health stations and hospi￾tals in the group. Whenever patients need the services of specialists, physicians will refer them to one of the group’s hospitals and continue to follow up. Evaluation of the Luohu model Framework Devers and colleagues [31] suggested that healthcare integration be evaluated in three dimensions: readiness of integration (structure), internal process of integration (process), and outcomes of integration (outcome). Selec￾tion of the second- and third-level indicators was based on a review of the literature, as well as on the aims of and programs in the Luohu model. In this study, we adopted six indicators to evaluate “structure”, eight indicators system to evaluate “process” and 12 indicators to evaluate “outcome” (Table 1). Results of evaluation Structure evaluation. In respect of infrastructure, the busi￾ness area of community health stations increased from 410m2 in Jun 2015 to 903m2 in Jun 2017. The assets value of equipment across all community health stations increased from $2.73 million in Jun 2015 to $4.04 million in Jun 2017. The number of general practitioner doubled. The number of public health physician increased from 2 to 30, while 49 specialists set up clinics in community health stations, and 238 family doctor teams were devel￾oped during the same period. Process evaluation. By June 2017, 580,000 residents had been registered with general practitioners in the hospi￾tal group. The proportion of all hospitalizations going to the group hospitals increased, which reduced the cost of health insurance in the whole hospital group. In the group. The proportion of outpatient visits in community health stations increase from 29.49% to 42.60%. This is a promising indicator that community health stations are acting for gatekeeper of the hospital group. Meanwhile, collaboration between district hospitals and community health stations promoted patient referral in the hospital group. No patient was referred from hospitals to commu￾nity health stations for follow-up or rehabilitation services in 2015, but in 2016 over 10,000 patients were referred from hospitals in the group to community health stations to receive the right care at the right place. Outcome evaluation. During the past two years, 4,596 more patients with diabetes, 4,995 more patients with hypertension and 822 more patients with severe mental illness were enrolled in case management (Table 1). Compared with Jun 2014–Dec 2015, there were more new cancer cases per month identified during Jun 2015–Jun 2016. There was a decrease in pneumonia cases in the second year after reform. Residents’ satisfaction with com￾munity health stations in Luohu ranked first among the ten districts of Shenzhen in 2015 and 2016. However, the mean cost per resident of all types of health care increased from $675.3 to $844.2. Discussion Stakeholders pushing the reform The District government of Luohu gave priority to health, and set the direction for the reform by “shifting focus from treatment to health”. The District government helped the District Health and Family Planning Commission to coor￾dinate with the Ministry of Finance, Human Resources and Social Security Bureau and Social Insurance Fund Admin￾istration, to ensure that supporting measures would be in place. Further, the District government increased financial subsidies to the group, especially community health sta￾tions. In 2016, the Ministry of Finance invested $112 mil￾lion (accounting for 27.2% of all health expenditures in the district) in the group. Staff in the group contributed efforts to the reform. Physicians and nurses adopted a philosophy of serving patients, improving treatment capacity, and strengthen￾ing collaboration with team members. Meanwhile, the reform of salary payments enhanced the enthusiasm of all staff in the group. Along with staff in the hospital group, residents helped create and share processes and outcomes of the reform. Only by placing residents at the center of the system could the hospital group set the goal of constructing an inte￾grated care system. Before the reform, patients regarded the community health station as the last choice for service, because they did not trust the quality of services available there. Now, 42.6% residents regard community health sta￾tions as the first contact for health care. Overall, demands of residents have been driving the reform. Strategies for integrated care Some European projects have suggested that organizational integration alone is unlikely to deliver better outcomes, and that efforts must focus on clinical and service integra￾tion. Other researchers have suggested that effective care coordination can be achieved without the need for the for￾mal integration of organizations [32, 33]. Different from most international experience, most pilot programs [34, 35] in China mostly began with organizational integration

Art.3,page6 of 10 Wang et al:The Luohu Model Table 1:Evaluation results of the Luohu model. First-level Second-level Third-level indicator Jun2014- Jun2015-Jun2016- indicator indicator Jun 2015 Jun 2016 Jun 2017 Structure Area of CHS* Average area of CHS*(m2) 410 749.5 903 Assets of Assets of equipment of all CHSs*(million,S) 2.76 3.50 4.09 CHS* Human No.of general practitioners 89 147 194 resources of CHS* No.of physicians providing public health 2 4 30 services No.of specialists setting up practices in 0 0 西 CHSs* No.of family doctor teams 0 198 238 Process Utilization of No.of residents registered with general 0 0.15 0.58 general practitioners practitioners Proportion of residents registered with 0 12.5 38.7 general practitioners (% Utilization of No.of inpatients in the hospital group 3021 5434 7034 inpatients Proportion of inpatients hospitalized in the 15.3 19.3 21.9 hospital group compared with all registered inpatients(%) Utilization in No.of outpatients served by CHSs(million) 0.795 2.02 2.25 CHS* Percentage of CHSs"*patients of all patients 29.49 36.87 4260 in the group (% Two-way No.of down-referral patients 0 4365 5647 referral No.of up-referral patients 1442 3084 4937 Outcome Case No.of patients with diabetes under case 5624 8210 10220 Management management Proportion of diabetes patients under case 66.88 67.23 69.54 management (% No.of patients with hypertension under 19667 22579 24662 case management Proportion of hypertension patients under 65.5 66.0 68.2 case management (% No.of patients with severe mental illness 1113 1402 1335 under case management Proportion of patients with severe mental 10.6 11.2 11.8 illness under case management (% Incidence Incidence of infectious disease(1/100,000) 351.5 350.7 300.4 and mortality Mortality rate under 5(%0) 2.5 2.4 1.3 New cases of pneumonia 734 511 283 New cases of cancer 631林 590 523 Patients' Rank of patients'satisfaction among ten Second First First experience districts in Shenzhen City Cost Cost of all types of health care for each S675.3 S844.2 registered resident in the group *CHS is short for community health station. **Time period of the data is from Jun 2014 to Dec 2015 which is a prerequisite for integrated care in China because ful than the Health and Family Planning Commission and public hospitals represent the vast majority of providers,hospitals are more powerful than primary healthcare insti- the Social Insurance Fund Administration is more power- tutions [36].In this context,organizational integration led

Art. 3, page 6 of 10 Wang et al: The Luohu Model which is a prerequisite for integrated care in China because public hospitals represent the vast majority of providers, the Social Insurance Fund Administration is more power￾ful than the Health and Family Planning Commission and hospitals are more powerful than primary healthcare insti￾tutions [36]. In this context, organizational integration led Table 1: Evaluation results of the Luohu model. First-level indicator Second-level indicator Third-level indicator Jun 2014– Jun 2015 Jun 2015– Jun 2016 Jun 2016– Jun 2017 Structure Area of CHS* Average area of CHS* (m2 ) 410 749.5 903 Assets of CHS* Assets of equipment of all CHSs* (million, $) 2.76 3.50 4.09 Human resources of CHS* No. of general practitioners 89 147 194 No. of physicians providing public health services 2 4 30 No. of specialists setting up practices in CHSs* 0 0 49 No. of family doctor teams 0 198 238 Process Utilization of general practitioners No. of residents registered with general practitioners 0 0.15 0.58 Proportion of residents registered with general practitioners (%) 0 12.5 38.7 Utilization of inpatients No. of inpatients in the hospital group 3021 5434 7034 Proportion of inpatients hospitalized in the hospital group compared with all registered inpatients (%) 15.3 19.3 21.9 Utilization in CHS* No. of outpatients served by CHSs (million) 0.795 2.02 2.25 Percentage of CHSs’* patients of all patients in the group (%) 29.49 36.87 4260 Two-way referral No. of down-referral patients 0 4365 5647 No. of up-referral patients 1442 3084 4937 Outcome Case Management No. of patients with diabetes under case management 5624 8210 10220 Proportion of diabetes patients under case management (%) 66.88 67.23 69.54 No. of patients with hypertension under case management 19667 22579 24662 Proportion of hypertension patients under case management (%) 65.5 66.0 68.2 No. of patients with severe mental illness under case management 1113 1402 1335 Proportion of patients with severe mental illness under case management (%) 10.6 11.2 11.8 Incidence and mortality Incidence of infectious disease (1/100,000) 351.5 350.7 300.4 Mortality rate under 5 (‰) 2.5 2.4 1.3 New cases of pneumonia 734** 511 283 New cases of cancer 631** 590 523 Patients’ experience Rank of patients’ satisfaction among ten districts in Shenzhen City Second First First Cost Cost of all types of health care for each registered resident in the group – $675.3 $844.2 * CHS is short for community health station. ** Time period of the data is from Jun 2014 to Dec 2015

Wang et al:The Luohu Model Art.3,page7 of 10 by the government is the first and best choice for changing group,such as pneumonia vaccination for residents over providers'behavior for three reasons.First,it makes health 60 years old,also increased cost.However,the prevention insurance reform possible.The city's Social Insurance Fund program should reduce demands for care in the future. Administration strictly controls the cost of each institute Hence,it is necessary to study the effects of the Luohu [37],and signs an annual agreement with them.A hospi- model on financial burdens over a longer term. tal or community health station has no voice in negotiat- According to design in the second-round reform of the ing with the Social Insurance Fund Administration about Luohu model,general management center will be responsi- the amount of funding or the payment method.It is not ble for evaluation in the group,collaborated with information possible for the government to negotiate about health center.They will adopt more indicators related to people-cen- insurance reform with the Social Insurance Fund Admin- tered care,population health and financial burden.It will sup- istration for one institute,but it may be possible for a port time series analysis of the effect in the future. hospital group.Second,the concept of integrated care pro- motes collaboration among providers.Under the "Global More lessons from Luohu budget,balance retained"policy,hospital revenue before The one size fits all'approach does not apply here. the reform changed to cost to the hospital group after the China's National Health and Family Planning Commis- reform.Therefore,hospitals are willing to collaborate with sion introduced lessons from the Luohu model to all cities community health stations to reduce cost.Last but not nationwide,but not every city could or should adopt all least,integration makes full use of the power to change its strategies.Each community should design its models physicians'behaviors.The Chinese Medical Doctor Associa- in the context of the local healthcare system. tion is responsible for the regulation and the qualification In addition to the core strategies identified above, of doctors,but it cannot control or regulate the behavior three additional points can inform policy makers.The of each doctor.Only institutions in the group may have an first is to involve multiple stakeholders,especially payers, impact on physicians'behavior by hiring,assessing and dis- in policy making and strategy designing.In China,the missing them.In summary,organizational integration pro- Health and Family Planning Commission is responsible vided the first step to integrated care and it provides a basis for the population's health,but various ministries for the adoption of other strategies in China. have the means to control the provision of health care. However,a potential disadvantage of the Luohu model The Development and Reform Commission plans and is the lack of clinical integration strategies.There is no sets prices for health care.The Human Resources and shared cross-institutional clinical pathway or guideline, Social Security Bureau allocates insurance funds for both of which are tools to promote clinical integration. health care and decides on human-resource allocations. However,Luohu is designing its second-round of reform The Ministry of Finance sets the financial budget for and taking clinical integration into account. health.In Luohu,the District government led the reform and coordinated the joint activities of the Health and Evaluation of integrated care Family Planning Commission and other ministries,espe- There are two limitations of the evaluation performed in cially the Human Resources and Social Security Bureau. this study.First,the evaluation was conducted two years Researches [38,43]in other countries have identified after establishment of the group,which may be too short the important role of health insurance in providing a time period.Rutten-van Molken [38]suggested that integrated care.We therefore suggest that the conduct some EU-funded projects may need a minimum of five of health reforms be aligned with payment reforms in years to prove themselves.On the other hand.limited health insurance.Second,normative integration could be comparative indicators cannot show the complete picture promoted by the existence of a shared mission and work of reform,and the lack of individual data did not support values.Normative integration is a less tangible but essen- statistical analysis of the effect.Data such as coordina- tial feature to promote inter-sectorial collaboration and tion among institutions and each institute's capacity for ensure consistency between tiers of an integrated system providing services were not collected before June 2015. [26.In Shenzhen,community health stations have been So,some effects cannot be measured by before-after com- affiliated with district hospitals since 2011.This has pro- parison.Compared with other pilot cases,the percentage vided a shared mission,management,and values that of patients who were two-way referral was higher,as was provide a foundation for mutual trust and collaboration the percentage of patients going to community health among them.Third,as suggested by the World Health stations for care [39,40].In addition,the proportions of Organization's Global Strategy on people-centered and patients with diabetes,hypertension,and severe mental integrated health services 43,engagement of residents illness under case management were higher than the and community is essential for health reform.On the one mean proportion(38%)in Guangdong province [41,42]. hand,to meet their demands,residents registered with The goal of"less financial burden"was not achieved in the Luohu model were involved in policy making and the past two years,with more new cancer cases and excess strategy designing in the hospital group.On the other expenditure by the health insurance fund.However, hand,for example,the hospital group collaborated with this may have resulted from the short-term increase in the administrators of sports and social care to construct demand for health services as new screening programs jogging trails for residents,promoting the benefits of for residents over 50 identified previously unknown cases. exercise.The Luohu model engages not only residents At the same time,prevention programs conducted in the but also all potential resources in the community

Wang et al: The Luohu Model Art. 3, page 7 of 10 by the government is the first and best choice for changing providers’ behavior for three reasons. First, it makes health insurance reform possible. The city’s Social Insurance Fund Administration strictly controls the cost of each institute [37], and signs an annual agreement with them. A hospi￾tal or community health station has no voice in negotiat￾ing with the Social Insurance Fund Administration about the amount of funding or the payment method. It is not possible for the government to negotiate about health insurance reform with the Social Insurance Fund Admin￾istration for one institute, but it may be possible for a hospital group. Second, the concept of integrated care pro￾motes collaboration among providers. Under the “Global budget, balance retained” policy, hospital revenue before the reform changed to cost to the hospital group after the reform. Therefore, hospitals are willing to collaborate with community health stations to reduce cost. Last but not least, integration makes full use of the power to change physicians’ behaviors. The Chinese Medical Doctor Associa￾tion is responsible for the regulation and the qualification of doctors, but it cannot control or regulate the behavior of each doctor. Only institutions in the group may have an impact on physicians’ behavior by hiring, assessing and dis￾missing them. In summary, organizational integration pro￾vided the first step to integrated care and it provides a basis for the adoption of other strategies in China. However, a potential disadvantage of the Luohu model is the lack of clinical integration strategies. There is no shared cross-institutional clinical pathway or guideline, both of which are tools to promote clinical integration. However, Luohu is designing its second-round of reform and taking clinical integration into account. Evaluation of integrated care There are two limitations of the evaluation performed in this study. First, the evaluation was conducted two years after establishment of the group, which may be too short a time period. Rutten-van Mölken [38] suggested that some EU-funded projects may need a minimum of five years to prove themselves. On the other hand, limited comparative indicators cannot show the complete picture of reform, and the lack of individual data did not support statistical analysis of the effect. Data such as coordina￾tion among institutions and each institute’s capacity for providing services were not collected before June 2015. So, some effects cannot be measured by before-after com￾parison. Compared with other pilot cases, the percentage of patients who were two-way referral was higher, as was the percentage of patients going to community health stations for care [39, 40]. In addition, the proportions of patients with diabetes, hypertension, and severe mental illness under case management were higher than the mean proportion (38%) in Guangdong province [41, 42]. The goal of “less financial burden” was not achieved in the past two years, with more new cancer cases and excess expenditure by the health insurance fund. However, this may have resulted from the short-term increase in demand for health services as new screening programs for residents over 50 identified previously unknown cases. At the same time, prevention programs conducted in the group, such as pneumonia vaccination for residents over 60 years old, also increased cost. However, the prevention program should reduce demands for care in the future. Hence, it is necessary to study the effects of the Luohu model on financial burdens over a longer term. According to design in the second-round reform of the Luohu model, general management center will be responsi￾ble for evaluation in the group, collaborated with information center. They will adopt more indicators related to people-cen￾tered care, population health and financial burden. It will sup￾port time series analysis of the effect in the future. More lessons from Luohu The ‘one size fits all’ approach does not apply here. China’s National Health and Family Planning Commis￾sion introduced lessons from the Luohu model to all cities nationwide, but not every city could or should adopt all its strategies. Each community should design its models in the context of the local healthcare system. In addition to the core strategies identified above, three additional points can inform policy makers. The first is to involve multiple stakeholders, especially payers, in policy making and strategy designing. In China, the Health and Family Planning Commission is responsible for the population’s health, but various ministries have the means to control the provision of health care. The Development and Reform Commission plans and sets prices for health care. The Human Resources and Social Security Bureau allocates insurance funds for health care and decides on human-resource allocations. The Ministry of Finance sets the financial budget for health. In Luohu, the District government led the reform and coordinated the joint activities of the Health and Family Planning Commission and other ministries, espe￾cially the Human Resources and Social Security Bureau. Researches [38, 43] in other countries have identified the important role of health insurance in providing integrated care. We therefore suggest that the conduct of health reforms be aligned with payment reforms in health insurance. Second, normative integration could be promoted by the existence of a shared mission and work values. Normative integration is a less tangible but essen￾tial feature to promote inter-sectorial collaboration and ensure consistency between tiers of an integrated system [26]. In Shenzhen, community health stations have been affiliated with district hospitals since 2011. This has pro￾vided a shared mission, management, and values that provide a foundation for mutual trust and collaboration among them. Third, as suggested by the World Health Organization’s Global Strategy on people-centered and integrated health services [43], engagement of residents and community is essential for health reform. On the one hand, to meet their demands, residents registered with the Luohu model were involved in policy making and strategy designing in the hospital group. On the other hand, for example, the hospital group collaborated with the administrators of sports and social care to construct jogging trails for residents, promoting the benefits of exercise. The Luohu model engages not only residents but also all potential resources in the community

Art.3,page8 of 10 Wang et al:The Luohu Model Conclusion 5.Yip,W and Hsiao,W.Harnessing the privatization China's vanguard community-based integrated care model of China's fragmented health-care delivery.Lancet. emerged in the Luohu district as a response to the chal- 2014;384:805-818.D01:https::/doi.org/10.1016/ lenges of the epidemiological transition and accelerated S0140-6736(14)61120-X population aging in China.Although the Luohu model 6.Majeed,A.Primary care in Europe:Entering was introduced to all cities in China,its effectiveness in the age of austerity.Journal of Ambulatory Care other healthcare systems are uncertain.As the first case Management,2012;35:162-166.DOl:https://doi. recognized by the National Health and Family Planning org/10.1097/JAC.0b013e31824b45f4 Commission,the core strategies and mechanisms of the 7.National healthand family planningcommission. 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Ministry of civil affairs of the People's Republic Acknowledgements of China;2016.[cited 2017 6 Nov]Available The authors thank the Health and Family Planning Commis- from: http://www.mca.gov.cn/article/zwgk/ sion of Shenzhen City and Guangdong Province for support- mzyw/201708/20170800005382.shtml. ing the design and implementation of the Luohu model.And 9.WHO.National Health and Family Planning Commis- we thank all colleagues in the Luohu hospital group. sion of the PRC,Age International,Age UK.China coun- try assessment report on aging and health;2015. Reviewers 10.Institute for Health Metrics and Evaluation Sjoerd Postma,Chief of Party,USAID/Health Sector Resil- GBD 2016.University of Washington.[Webpage on iency Project,Palladium,Afghanistan. the Internet].[cited 2017 Nov 1]Available from: One anonymous reviewer. https://vizhub.healthdata.org/gbd-compare/. 11.United Nations Department of Economic and Funding Information Social Affairs (UN DESA).World population This work was supported by National Natural Science prospects:The 2012 revision.Volume : Foundation of China (grant number:71804202)and demographic profiles.New York (NY):UN DESA, National Social Science Fund of China(grant number: Population Division;2013a.[cited 2016 10 June]. 18BGL218).The funders had no role in study design,data Available from:http://esa.un.org/WPP/. collection and analysis,preparation of the manuscript,or 12.Xu,Land Meng,Q.The Report of the fifth National decision to publish. 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Art. 3, page 8 of 10 Wang et al: The Luohu Model Conclusion China’s vanguard community-based integrated care model emerged in the Luohu district as a response to the chal￾lenges of the epidemiological transition and accelerated population aging in China. Although the Luohu model was introduced to all cities in China, its effectiveness in other healthcare systems are uncertain. As the first case recognized by the National Health and Family Planning Commission, the core strategies and mechanisms of the Luohu model will promote integrated care in urban China and other countries facing the same challenges. Moreover, they will benefit universal health coverage and the realiza￾tion of the full potential of the contributions of primary health care to sustainable development goals [44]. Acknowledgements The authors thank the Health and Family Planning Commis￾sion of Shenzhen City and Guangdong Province for support￾ing the design and implementation of the Luohu model. 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