{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T16:06:54Z","timestamp":1792598814374,"version":"4.5.0"},"reference-count":51,"publisher":"Public Library of Science (PLoS)","issue":"5","license":[{"start":{"date-parts":[[2025,5,22]],"date-time":"2025-05-22T00:00:00Z","timestamp":1747872000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:p>As global healthcare costs continue to rise, concerns about health equity have become increasingly prominent. In response, China introduced the Diagnosis-Intervention Packet (DIP) reform in 2021 to optimize healthcare resource allocation and control costs. While the reform has been widely discussed in terms of its overall cost-control effects, its heterogeneous impact on low-income populations, especially across different hospital tiers, remains unclear. This study aims to fill this gap by examining the differentiated impact of the DIP reform on low-income patients\u2019 inpatient service utilization. Using multi-stage interrupted time series (ITS) analysis, we analyzed 1.17 million hospitalization records from low-income patients in City S, a pilot city in central China. The study reveals that DIP significantly reduced total hospitalization costs and length of stay (LOS) but led to increased readmission rates, indicating a trade-off between efficiency gains and potential risks to care quality. The reform\u2019s effects varied by hospital tier: primary hospitals saw increased demand for non-acute hospitalization due to reduced out-of-pocket (OOP) payments, exposing resource shortages; secondary hospitals balanced cost control and revenue by shortening stays and increasing admission frequency, which raised readmission risks; and tertiary hospitals, treating critically ill patients, enhanced treatment completeness, though multiple hospitalizations were still needed for full recovery. The study introduces a two-dimensional framework\u2014 \u201chospital tier-policy cycle\u201d\u2014demonstrating that differences in service capacity across hospital levels are central to the heterogeneous effects of the DIP reform. These findings suggest that future policies should strengthen primary care resources, introduce quality assurance mechanisms, and consider bundled payment models for critical care. This research contributes valuable insights for optimizing equity in DIP reform and offers implications for similar healthcare payment systems globally.<\/jats:p>","DOI":"10.1371\/journal.pone.0323194","type":"journal-article","created":{"date-parts":[[2025,5,22]],"date-time":"2025-05-22T17:34:07Z","timestamp":1747935247000},"page":"e0323194","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":10,"title":["Impact of Diagnosis-Intervention Packet (DIP) reforms on inpatient services for low-income populations in central China: A multi-stage interrupted time-series analysis"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-1930-2436","authenticated-orcid":true,"given":"Keyi","family":"Shen","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yingying","family":"Tao","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yile","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ziqian","family":"Jin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chengcheng","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dan","family":"Wu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1895-8607","authenticated-orcid":true,"given":"Xuehui","family":"Meng","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,5,22]]},"reference":[{"issue":"10","key":"pone.0323194.ref001","doi-asserted-by":"crossref","first-page":"925","DOI":"10.1001\/jama.2022.14606","article-title":"Aligning value-based payments with health equity: a framework for reforming payment reforms","volume":"328","author":"AS Navathe","year":"2022","journal-title":"JAMA"},{"key":"pone.0323194.ref002","doi-asserted-by":"crossref","first-page":"1008863","DOI":"10.3389\/fpubh.2023.1008863","article-title":"Establishment and application of the performance appraisal system for hierarchical diagnosis and treatment in China: a case study in Fujian province","volume":"11","author":"Q Wu","year":"2023","journal-title":"Front Public Health"},{"issue":"2","key":"pone.0323194.ref003","article-title":"Progress on catastrophic health spending in 133 countries: a retrospective observational study","volume":"6","author":"A Wagstaff","year":"2018","journal-title":"Lancet Glob Health"},{"key":"pone.0323194.ref004","doi-asserted-by":"crossref","first-page":"215","DOI":"10.1016\/S1386-5056(03)00044-3","article-title":"Case mix use in 25 countries: a migration success but international comparisons failure","volume":"70","author":"FH Roger France","year":"2003","journal-title":"Int J Med Inform"},{"issue":"4","key":"pone.0323194.ref005","doi-asserted-by":"crossref","first-page":"2064","DOI":"10.1111\/1475-6773.12749","article-title":"Early impact on outpatients of mandatory adoption of the diagnosis-related group-based reimbursement system in Korea on use of outpatient care: differences in medical utilization and presurgery examination","volume":"53","author":"SJ Kim","year":"2018","journal-title":"Health Serv Res"},{"issue":"4","key":"pone.0323194.ref006","doi-asserted-by":"crossref","first-page":"359","DOI":"10.1016\/j.healthpol.2020.01.007","article-title":"The effects of DRGs-based payment compared with cost-based payment on inpatient healthcare utilization: a systematic review and meta-analysis","volume":"124","author":"Z Meng","year":"2020","journal-title":"Health Policy"},{"issue":"1","key":"pone.0323194.ref007","doi-asserted-by":"crossref","first-page":"1","DOI":"10.5582\/bst.2023.01027","article-title":"Comparison of diagnosis-related groups (DRG)-based hospital payment system design and implementation strategies in different countries: the case of ischemic stroke","volume":"18","author":"Y Liu","year":"2024","journal-title":"Biosci Trends"},{"issue":"5","key":"pone.0323194.ref008","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1056\/NEJM198408023110505","article-title":"Will payment based on diagnosis-related groups control hospital costs?","volume":"311","author":"JE Wennberg","year":"1984","journal-title":"N Engl J Med"},{"issue":"16","key":"pone.0323194.ref009","doi-asserted-by":"crossref","first-page":"1122","DOI":"10.1056\/NEJM199004193221606","article-title":"Do the poor cost more? 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\u2014concurrently on preventing from large-scale risk of relapse to poverty due to illness","volume":"428","author":"Z Bao","year":"2023","journal-title":"Insur Stud"},{"key":"pone.0323194.ref045","doi-asserted-by":"crossref","first-page":"112981","DOI":"10.1016\/j.socscimed.2020.112981","article-title":"Incentives to use primary care and their impact on healthcare utilization: evidence using a public health insurance dataset in China","volume":"255","author":"M Shen","year":"2020","journal-title":"Soc Sci Med"},{"issue":"2","key":"pone.0323194.ref046","doi-asserted-by":"crossref","first-page":"240","DOI":"10.3122\/jabfm.2016.02.150159","article-title":"Underuse of primary care in China: the scale, causes, and solutions","volume":"29","author":"D Wu","year":"2016","journal-title":"J Am Board Fam Med"},{"key":"pone.0323194.ref047","doi-asserted-by":"crossref","first-page":"1168429","DOI":"10.3389\/frhs.2023.1168429","article-title":"Community hospitals of the future-challenges and opportunities","volume":"3","author":"SKA Phang","year":"2023","journal-title":"Front Health Serv"},{"key":"pone.0323194.ref048","article-title":"Impact of the DRG-based reimbursement system on patient care and professional practise: perspectives of Swiss hospital physicians","volume":"145","author":"M F\u00e4ssler","year":"2015","journal-title":"Swiss Med Wkly"},{"issue":"5","key":"pone.0323194.ref049","doi-asserted-by":"crossref","first-page":"609","DOI":"10.1093\/heapol\/czad018","article-title":"Effectiveness of hierarchical medical system policy: an interrupted time series analysis of a pilot scheme in China","volume":"38","author":"H Hu","year":"2023","journal-title":"Health Policy Plan"},{"key":"pone.0323194.ref050","first-page":"531","article-title":"The economics of moral hazard: comment","volume":"58","author":"MV Pauly","year":"1968","journal-title":"Am Econ Rev"},{"key":"pone.0323194.ref051","first-page":"102","article-title":"Moral hazard or release of medical demand? 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