Urban Employee Research Articles

Institutional Design and Incentives for Migrant Workers to Participate in Social Insurance in China: Evidence From a Policy Experiment in Chengdu City.

Rural-to-urban migration has increased rapidly in China since the early 1980s, with the number of migrants has reached 376 million by 2020. Despite this sharp trend and the significant contributions that migrants have made to urban development, the migrant workers have had very limited access to the social insurance that the majority of urban workers enjoy. Against the background of the social insurance system adjustment in Chengdu in 2011, this study uses a difference-in-differences (DID) model to empirically test the impacts of changes in the social insurance policy contribution rates on the social insurance participation rates of migrant workers, using the China Migrants Dynamic Survey (CMDS) data for 2009–2016. We find that the social insurance participation rate of migrant workers was significantly reduced after they were incorporated into the urban worker insurance system. There was no significant change in the wages of migrant workers, but the working hours were increased and their consumption level decreased. In other words, simply changing the social insurance model of migrant workers from “comprehensive social insurance” to “urban employee insurance” reduces the incentives for migrant workers to participate in insurance and harms the overall welfare of migrant workers. Our study indicates that the design of the social security policy is an important reason for the lower participation rate of migrants. It is necessary to solve the problem of insufficient incentives through the targeted social security policies; primarily, the formulation of a social security policy contribution rate suitable for the migrants, and the establishment of a comprehensive social security policy and the gradual integration of the social security system.

Cardiovascular Epidemiological Research in China: A Wake-up Call No One Can Afford to Ignore

One of the most elementary principles in life is that “you cannot improve what you don't measure.” In this regard, Tang and colleagues [1] are to be commended for achieving an important benchmark in cardiovascular epidemiological research. Employing the Urban Employee Basic Medical Insurance (UEBMI) database in China, these investigators examined the incidence and 3-year mortality rates of aortic dissection among almost 347 million residents in 23 provinces (i.e., covering more than 52% of the entire urban population of China).

Assessment of the satisfaction with public health insurance programs by patients with chronic diseases in China: a structural equation modeling approach

BackgroundChina has successfully sustained its universal health insurance coverage over the past decade. Although patient satisfaction has been recognized as an important indicator to measure the performance of insurance programs in China, there is a lack of evidence on how patients with chronic diseases are satisfied with China’s public health insurance programs and whether their satisfaction differs by type of insurance. We aimed to fill the evidence gap.MethodsWe established a hypothetical model that comprised patients’ awareness of insurance policies, the fulfillment of patients’ expectations of insurance benefits, patients’ perceived value of health insurance coverage, patients’ satisfaction with health insurance programs, patients’ complaints, and trust in health insurance programs. We performed a confirmatory factor analysis by using a structural equation modeling (SEM) approach to examine the hypothesized model. A model-testing survey in 10 tertiary hospitals was conducted between June and October 2018, with a valid sample of 922 insured patients with chronic diseases.ResultsThe SEM model, with good fit indices, showed that patients’ awareness of health insurance policies, insurance program’s fulfillment of expectations, and patients’ perceived value of insurance coverage, positively predicted patient satisfaction (P < 0.01). The fulfillment of patients’ expectations of insurance benefits was the major predictor of satisfaction with health insurance (coefficient = 0.593, P < 0.001), while the patients’ perceived value of insurance coverage had the largest impact on their trust in health insurance (coefficient = 0.409, P < 0.01). Compared to patients with Urban-Rural Resident Basic Medical Insurance, Urban Employee Basic Medical Insurance enrollees had a higher degree of satisfaction with insurance on average (P < 0.01). Despite differences in the degree of satisfaction, the main findings from the SEM were also proved by the multi-group analysis.ConclusionsOur findings highlight the importance of incorporating patients’ perceived value as part of the ongoing efforts to increase satisfaction with health insurance by patients, especially those who have chronic diseases. Policymakers are also suggested to formulate evidence-informed reimbursement policies that meet patients’ expectations.

One country, two systems: evidence on retirement patterns in China.

This paper documents the patterns and correlates of retirement in China using a nationally representative survey, the China Health and Retirement Longitudinal Study. After documenting stark differences in retirement ages between urban and rural residents, the paper shows that China's urban residents retire earlier than workers in many Organization for Economic Co-operation and Development countries and that rural residents continue to work until advanced ages. Differences in access to generous pensions and economic resources explain much of the urban-rural difference in retirement rates. The paper suggests that reducing disincentives created by China's Urban Employee Pension system, improving health status, providing childcare and elder care support may all facilitate longer working lives. Given spouse preferences for joint retirement, creating incentives for women to retire later may facilitate longer working lives for both men and women.

The influence of medical insurance and social security cards on the floating population's settlement intention

BackgroundMedical insurance and social security cards are an important incentive for the floating population to live a stable life in their current residence, but there has been little studies on their effect on settlement intentions. Therefore, the purpose of this paper was to study the impact of basic medical insurance for urban employees and application for personal social security cards on the settlement intentions of the floating population. With the increase of the desire to settle, the health management and the development of public health will be improved.MethodsBased on the 2017 survey data from the dynamic monitoring of China's floating population, we explored the influence of basic medical insurance for urban employees and social security cards on the floating population's settlement intentions. Additionally, this study also examined the comprehensive causal relationship, with social integration as the mediator variable. We used SPSS 21.0 software. The input method was used to analyze the influence of the above variables by binary logistic regression. Then we used AMOS22.0 software to establish the structural equation model of the relationship between the above three independent variables. Finally, we used bootstrapping method to analyze the direct effect, indirect effect and total effect of independent variables on settlement intention.ResultsThe settlement intention of members of the floating population after participating in basic medical insurance for urban employees was 23.2% higher than that of those who did not participate. The decision as to whether to apply for a personal social security card is related to their settlement intention. The standardized regression coefficients among social insurance and security, social integration, and settlement intention were positive values, and the Z values of the overall effect, indirect effect, and direct effect were all greater than 1.96; the confidence interval of the indirect effect did not include 0. We found that this model is a partial intermediary model, with an intermediary ratio of 10.66%.ConclusionsThis article highlights the important impact of basic medical insurance for urban employees and individual social security cards on the floating population. The conclusions of this study provide suggestions for the government to use when designing policies to enhance the settlement intentions of the floating population and to improve the development of public health undertakings.

Effects of green energy development on population growth and employment: Evidence from shale gas exploitation in Chongqing, China

With the maturity of horizontal drilling and hydraulic fracturing technologies, countries rich in shale gas have begun to promote the development of the shale gas industry. The impact of the booming shale gas industry on the regional economy has also become a main focus. Shale gas’ exploration and extraction may have positive spillover effects on other sectors, resulting in population growth and job creation. However, negative spillover effects can occur through rising local goods prices and its adverse effects on the local quality of life, which in turn could harm population growth and employment. By using the synthetic control method, we investigates the shale gas fields in Chongqing to reveal the relationship between population growth, employment and shale gas development in Fuling, Nanchuan and Wulong districts. Our results indicate that due to the development of the shale gas industry, the number of urban non-private sector employees in three districts and counties has decreased. From 2017 to 2018, this decline had gradually weakened and the population growth had been negatively affected.

Incidence and Survival of Aortic Dissection in Urban China: Results from the National Insurance Claims for Epidemiological Research (NICER) Study.

BackgroundAortic dissection (AD) represents a significant mortality; however, there is rare epidemiologic information about the demography of AD in Chinese, especially its incidence rate.MethodsA retrospective cohort study was established using the Urban Employee Basic Medical Insurance claims data covering 346.7 million residents from 23 provinces in China, 2015-2016. AD cases were then linked to database of the Urban Employee Basic Endowment Insurance for death information. Incidence rate was age- and sex-standardized to the 2010 China census population. The associations between AD and related factors were evaluated with Poisson regression models. Moreover, mortality and sex- and age-adjusted survival rate was estimated by Cox models.Findings6084 adult AD cases were included in incidence analysis. Totally 4692(77.1%) were men and 5641(92.7%) were Han Chinese. The overall age- and sex-adjusted incidence rate of AD was 2.78(95%CI:2.59-2.98) per 100,000 person-years. In terms of geographic disparities, the crude incidence rate was significantly higher in Northwest China than South China (4.96[95%CI:4.17-5.75] vs. 2.04[95%CI:0.38-3.71] per 100,000 person-years; risk ratio: 2.67[95%CI: 2.34-3.04]). Moreover, survival analysis of 4518 AD patients with 683 recorded deaths during follow-up (median 2.2 years) showed that overall 3-year survival was 83.7%(95%CI:82.4-84.8).InterpretationThis contemporary population-based cohort study provides a first comprehensive assessment of incidence of AD in urban Chinese adults. The distinct signatures of different incidence with respect to geographic variations may have important implications for clinical management of AD.FundingChinese Ministry of Science and Technology (2020YFC2003503, 2016YFC0903000), and National Natural Science Foundation of China (91846112, 81973132, 81961128006).

The Influence of China's COVID-19 Treatment Policy on the Sustainability of Its Social Health Insurance System.

BackgroundWhile past experiences show that a health system financing mechanism can support resilience to shocks, the impact on the sustainability of the financing system is exceptionally important considering the magnitude of the COVID-19 pandemic. The role of Social Health Insurance (SHI) in responding to the pandemic brings about an influence on insurance system sustainability. This study investigates the impact of China’s COVID-19 treatment policy on the sustainability of its SHI system, explores influences of the policy on Wuhan’s system, and discusses the effects of an assumed equivalent emergency on SHI funds for five other provincial capital cities in China.MethodsThe study was conducted using pay-as-you-go actuarial models of Urban Employee Basic Medical Insurance (UEBMI) and Urban and Rural Residents Basic Medical Insurance (URRBMI) funds, which constitute China’s basic health insurance system. Current and accumulated balances of the funds in 2020 are predicted and utilized to measure the sustainability of health insurance funds during emergencies.ResultsThe findings suggest a disparity in the capacities of insurance schemes and localities. If the surplus before 2018 is not considered, it is likely that the URRBMI fund of Wuhan would suffer a deficit, whereas the UEBMI would retain a considerable surplus. To maintain the current actuarial balance of the URRBMI fund, coverage for ordinary inpatient and outpatient expenses would have to be significantly reduced in Wuhan, potentially affecting enrollees’ wellbeing. A similar situation may occur in three other cities, some with underdeveloped economies and lower per capita income are likely to be encountered with worse situation than Wuhan.ConclusionConcerning fragmentation of China’s SHI system, to strengthen longer-term preparedness to manage future emergencies, this study suggests the integration of insurance schemes and provincial pooling, fund balance adjusting and an emergency safety net are also advised. All options call for more public health investments.

Ten-Year Poverty Alleviation Effect of the Medical Insurance System on Families With Members Who Have a Non-communicable Disease: Evidence From Heilongjiang Province in China.

Aims: Non-communicable diseases (NCD) drag the NCD patients' families to the abyss of poverty. Medical insurance due to weak control over medical expenses and low benefits levels, may have actually contributed to a higher burden of out-of-pocket payments. By making a multi-dimensional calculation on catastrophic health expenditure (CHE) in Heilongjiang Province over 10 years, it is significant to find the weak links in the implementation of medical insurance to achieve poverty alleviation.Methods: A logistic regression was undertaken to predict the determinants of catastrophic health expenditure.Results: The average CHE of households dropped from 18.9% in 2003 to 14.9% in 2013. 33.2% of the households with three or more NCD members suffered CHE in 2013, which was 7.2 times higher than the households without it (4.6%). The uninsured households with cardiovascular disease had CHE of 12.0%, which were nearly 10% points lower than insured households (20.4–22.4%). For Medical Insurance for Urban Employees Scheme enrolled households, the increasing number of NCD members raised the risk of impoverishment from 3.4 to 20.0% in 2003, and from 0.3 to 3.1% in 2008. Households with hospital in-patient members were at higher risk of CHE (OR: 3.10–3.56).Conclusions: Healthcare needs and utilization are one of the most significant determinants of CHE. Households with NCD and in-patient members are most vulnerable groups of falling into a poverty trap. The targeting of the NCD groups, the poorest groups, uninsured groups need to be primary considerations in prioritizing services that are contained in medical insurance and poverty alleviation.

Analysis of Economic Effect and Mechanism of Basic Medical Insurance for Urban Employees in China

The purpose of social basic medical insurance is to solve the problem that “medical treatment is difficult and expensive.” With the implementation of new technologies and new diagnosis and treatment methods, the price of medicine has risen sharply. Under this background, can basic medical insurance still relieve the economic pressure of patients? Based on the tracking data of China Health and Nutrition Survey (CHNS) from 2006 to 2015, by constructing Heckman sample selection model, the paper finds that the basic medical insurance for urban employees (UEBMI) leads to an increase in medical expenses, among which only 0.61% can be attributed to the release of normal medical demand and 114.47% can be attributed to moral hazard; for flexible employees, 249.52% increase can be attributed to adverse selection. Based on this, the paper puts forward two suggestions: first, promoting Hierarchical Treatment Model to control the growth of medical expenses and second, guiding flexible employees to participate in the UEBMI.

Pengaruh Kepemimpinan Lurah Terhadap Kinerja Pegawai Di Kantor Kelurahan Loa Ipuh

Organization is a social system, which requires understanding in managing an organization to run it. The combination of knowledge, reliable human resources and capable technology will make the organization achieve the targets to be achieved, besides that it also requires the role of leaders who have expertise in leading the organization. The purpose of this study was to examine more deeply about the extent to which the role of the Lurah leadership in optimizing the performance of urban village employees in providing services to the community in the Loa Ipuh urban village office. The method used in this research is a combined research (mixed methods) between quantitative and qualitative research methods. The purpose of using these two methods is that the methods used can complement each other's description of the results of the study of the phenomenon under study and to strengthen the research analysis. The results obtained are calculations carried out using the t-test, test formula showing t count 0.395859 smaller than t table 2.026, so the hypothesis is proposed that "It is suspected that there is no influence between the Lurah Leadership Function on Employee Performance at the Loa Ipuh Urban Village Office”, was rejected. In addition, the data obtained qualitatively indicate that the Lurah in leadership is quite good in planning, organizing, mobilizing, supervising. As for the quality of the work of employees in Loa Ipuh Village, it is quite good. The problem is related to employee discipline, which is sometimes still late. Keywords: Influence, Leadership, Performance.

Prevalence and Incidence of Heart Failure Among Urban Patients in China: A National Population-Based Analysis.

Large-scale and population-based studies of heart failure (HF) incidence and prevalence are scarce in China. The study sought to estimate the prevalence, incidence, and cost of HF in China. We conducted a population-based study using records of 50.0 million individuals ≥25 years old from the national urban employee basic medical insurance from 6 provinces in China in 2017. Incident cases were individuals with a diagnosis of HF (International Classification of Diseases code, and text of diagnosis) in 2017 with a 4-year disease-free period (2013-2016). We calculated standardized rates by applying age standardization to the 2010 Chinese census population. The age-standardized prevalence and incidence were 1.10% (1.10% among men and women) and 275 per 100 000 person-years (287 among men and 261 among women), respectively, accounting for 12.1 million patients with HF and 3.0 million patients with incident HF ≥25 years old. Both prevalence and incidence increased with increasing age (0.57%, 3.86%, and 7.55% for prevalence and 158, 892, and 1655 per 100 000 person-years for incidence among persons who were 25-64, 65-79, and ≥80 years of age, respectively). The inpatient mean cost per-capita was $4406.8 and the proportion with ≥3 hospitalizations among those hospitalized was 40.5%. The outpatient mean cost per-capita was $892.3. HF has placed a considerable burden on health systems in China, and strategies aimed at the prevention and treatment of HF are needed. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: ChiCTR2000029094.

Heterogeneity in Price Elasticity of Medicine Demand in China: Moderate Effect From Economic Incentive and Quality Difference.

Objectives: Previous studies have shown a wide range of drug price elasticity, but the price response to demand among various therapeutic drug categories and drug types (generic/originator) is still unexplored in China. This study estimates the price elasticity of medicine demand with regard to quality differences, unfair competition, and a regulated market.Methods: Product-level data on anti-tumor, cardiovascular disease (CVD), and antimicrobial drugs were collected from the Tianjin Urban Employees’ Basic Medical Insurance database (2008–2010). The moderating effects of quality, profit incentive, and illegal rebates are considered in a dynamic panel model.Findings: Our results suggest that the price elasticity of drug demand varies across drug categories, with least elasticity for anti-tumor drugs and most elasticity for CVD drugs (−0.192 for anti-tumor drugs vs. −0.695 for antimicrobials vs. −1.100 for CVD drugs, p < 0.01). Moreover, the absolute value of price elasticity of generic drugs is higher than that of originator drugs in anti-tumor and CVD therapeutic classes (interact: 0.716 for anti-tumor; -0.630 for CVD, p < 0.001). We believe that quality difference plays a dominant role in the interaction between quality and illegal rebates for these two kinds of generic drugs. In the antimicrobial sub-group, the absolute value of price elasticity of generic medicine is lower than that of originator drugs. We believe that, owing to the high level of unfair competition among enterprises, the role of illegal kickbacks is dominant, which reduces the price elasticity of demand for generic antimicrobial drugs.Conclusion: Our study provides an overview of the result of interaction between quality and illegal rebates in different medicine markets in China and shows that disease type is a primary factor that impacts price elasticity.

Short-Term Ambient Particulate Air Pollution and Hospitalization Expenditures of Cause-Specific Cardiorespiratory Diseases in China: A Multicity Analysis.

BackgroundAmbient air pollution is leading risk factor for health burden in China. Few studies in China have investigated the economic loss related to short-term exposure to ambient PM2.5, which could trigger acute onset of cardiorespiratory diseases within a few days.MethodsDaily ambient air pollutants data are obtained for each city from the National Air Quality Monitoring System and daily hospitalization data are obtained from the urban employee-based basic medical insurance scheme database in 74 Chinese cities with an average coverage of 88.5 million urban employees during 2016-2017. A three-stage time-series analytic approach is used in this study to investigate the impact of short-term exposure to ambient fine particulate (PM2.5) air pollution on hospital admissions, expenses and hospital stays of three cause-specific cardiorespiratory diseases, including lower respiratory infections (LRI), coronary heart disease (CHD) and stroke in the included cities.FindingsBased on the time-series analysis using daily hospitalization data, 28,560 LRI cases, 54,600 CHD cases, and 23,989 stroke cases are attributable to ambient PM2.5 in the 74 cities during the study period, and the related attributable expenses are 220 million CNY (US$ 32.9 million) for LRI, 458 million CNY (US$ 68.5 million) for CHD, and 410 million CNY (US$ 65.8 million) for stroke, respectively. These attributable numbers account for 1.45% to 2.05% of total hospital admissions and 1.10% to 1.51% of total expenses for the three diseases during 2016-2017, respectively. The attributable numbers for the three cause-specific cardiorespiratory diseases would increase to 362,007 hospital admission cases and 3.68 billion CNY expenses ($US550 million) in the entire urban employee population (299 million) in China during 2016-2017, and the related direct economic loss of absence from work would be 798 million CNY (US$ 119.3 million).InterpretationOur results support that short-term exposure to ambient PM2.5 pollution could lead to significant health and economic impacts in China. Reducing levels of ambient PM2.5 can avoid substantial health damage and expenditures, and generate appreciable economic benefits from decreasing absence from work.FundingNatural Science Foundation of China (82073509, 71903010, 71903011), and the National Key Research and Development Program of China (2017YFC0211600, 2017YFC0211601).

WITHDRAWN: The role of sustainable urban employee basic medical insurance in health risk appraisal of urban residents.

Ahead of Print article withdrawn by publisher.

Informal job search method and labour market outcomes: evidence from urban Chinese workers

ABSTRACT Using a representative sample of Chinese urban employees, we empirically study the impact of the utilization of informal job search through social networks on wage. We find a premium of initial wage associated with job referral, but the wage premium diminishes over tenure. We also find that the effect of job referral on initial wage reduces when human capital plays a more important role, or the recruitment process and the economic system are more market-oriented. Our findings are consistent with the learning theory that job referral can reduce information asymmetry between employees and employers at the beginning they meet, but the informational advantage diminishes over time as the employers know non-referred workers gradually.

The Risk Factors for Chinese Medical Economic Burden of Aging: A Cross-Sectional Study Based on Guangdong Province.

Background The proportion of aging in China is increasing, which needs more healthcare recourses. To analyze the risk factors of the direct medical economic burden of aging in China and provide the strategies to control the cost of treatment, the information was collected based on Guangdong Province's regular health expenditure accounting data collection plan. Methods The multiple linear regression models were used to explore the risk factors of inpatient expenses of the elderly in Guangdong province. Results The results revealed that hospital day, age, male patients, and patients who suffer from malignant tumors are key factors to increase the direct medical economic burden of aging. Moreover, the medical insurance for urban employees can reduce the medical economic burden, comparing with the medical insurance for urban residents. Conclusions The basic medical insurance system and the serious illness insurance system should be improved. While striving to speed up the development of regional economy, the government should pay attention to the construction of basic medical institutions in economically backward areas, increase the allocation of health human resources, and facilitate the masses to seek medical treatment nearby.

Effects of establishing a financing scheme for outpatient care on inpatient services: empirical evidence from a quasi-experiment in China

The relationship between outpatient and inpatient care is central to the current healthcare reform debate especially in developing countries. Despite the importance of this relationship to health policy makers, empirical evidence, particularly evidence that can be interpreted as causal is limited and inconclusive. This paper examines the effects of establishing a financing scheme for outpatient care on inpatient utilization and expenditure in China's Urban Employee Basic Medical Insurance scheme. Under a quasi-experimental design, we use a unique administrative insurance claim dataset and conduct a difference-in-differences analysis. Our results indicate that after the policy change, total number of admissions and total inpatient expenditure of the enrollees decreased by 0.47% and 6.05% respectively, which imply outpatient and inpatient care are substitutes, and the reduction in cost-sharing can release the underuse of the outpatient care, so as to reduce those excessive demands for inpatient care. Moreover, we present evidence that the effects on the admissions of Ambulatory Care Sensitive Conditions which should be sensitive to outpatient care intervention are relatively limited because of the lower reimbursement cap, inadequate capacity of the local primary care providers and stickiness in patients' healthcare-seeking behaviors. While the enrollees aged over 55 and retirees are more vulnerable to the medical prices, and the enrollees living in the central districts are more responsive because of the better and more accessible primary care.

The relationship between urban and rural health insurance and the self-rated health of migrant workers in Southwest China

BackgroundFollowing health insurance reforms, China’s health care system has made great progress. However, there are still huge differences between the urban and rural health insurance systems. For rural-to-urban migrant workers, there may be differences in the use of urban and rural health insurance to improve their health status. This study aimed to determine whether any disparities exist in the relationship between urban and rural health insurance and the self-rated health (SRH) of migrant workers in Southwest China from the perspective of urban and rural segmentation.MethodsUsing cross-sectional survey data on Southwest China in 2016, a representative data sample drawn from 8507 migrant workers was analysed. An ordinary least squares (OLS) model and instrumental variable (IV) estimation were used to analyse the relationship between urban and rural health insurance and the SRH of migrant workers.ResultsUsing the IV method to control the endogeneity problems associated with health insurance, this study found that there are differences in the relationship between urban and rural health insurance and the SRH of migrant workers. Urban health insurance is associated with significant improvements in the SRH of migrant workers. Compared with the NRCMS, participating in urban health insurance, including urban employee basic medical insurance (UEBMI) and urban resident basic medical insurance (URBMI), increases the likelihood of migrant workers having better SRH.ConclusionsThere are disparities in the relationship between urban and rural health insurance and the SRH of migrant workers in China. Compared to rural health insurance, urban health insurance has a more positive correlation with the health of migrant workers. Our study shows that it is necessary to integrate urban and rural health insurance to promote social equity.

Physician patient-sharing relationships and healthcare costs and utilization in China: social network analysis based on health insurance data

ABSTRACT Objectives Evidence on physician patient-sharing relationships from developing countries is limited. This study aimed to identify patient-sharing networks among physicians in China and explore the effect of attributes of physician networks on healthcare utilization and costs. Methods Retrospective analysis was undertaken based on healthcare claims from Urban Employee Basic Medical Insurance Data spanning the years 2015 to 2018. We identified patients with hypertension and modeled physician patient-sharing networks using social network analysis. Relationships among physicians were further quantified using network measures. We fitted a log-linear model to examine the association between networks and healthcare at the physician level. Results 29,321 patients, seen by 3,429 physicians from 57 hospitals in one eastern city of China were included. Physicians were connected to 21 other physicians (threshold=1 shared patients) or 7 other physicians (threshold=4, 6, or 8 shared patients). Degree and centrality measures of physicians at primary care facilities were significantly lower than those at secondary or tertiary hospitals (p < 0.001). The links between physicians at different hospital grades were weak and patients tended to flow among physicians at the same hospital grade. Compared with a low closeness centrality, a medium level was associated with fewer hospitalization costs and days, and high closeness centrality was accompanied by a sharper decrease (all P < 0.001). Conclusions Primary care physicians were located in peripheral positions in China, and the links between primary care facilities and higher-grade hospitals were still weak. Characteristics of physicians’ networks and the position of physicians in the network were associated with spending and utilization of services, but not all associations were in the same direction.