The cream-skimming behaviors of tertiary hospitals under medical alliances: evidence from China

This study demonstrated that tertiary hospitals "siphoned-off" outpatients with public health insurance coverage from primary care facilities. Outpatients who were older, were male, with chronic diseases, and with public health insurance coverage were more likely to experience not only higher referral rates but poorer quality of outpatient care after being referred from tertiary hospitals to primary care facilities. Tailored policies are required to protect and compensate the most vulnerable population groups.