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 communityWang 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