Understanding provider behavioral responses to capitation prepayment systems: an integrated mixed-methods approach

BACKGROUND: Provider payment mechanisms are critical policy tools for shaping healthcare delivery, yet their effectiveness is mediated by contextual and organizational factors. This study examines the implementation of capitation prepayment under China's Integrated County Healthcare Consortium (ICHC) system, aiming to elucidate the complex interplay of factors influencing provider behavioral responses and the resulting system dynamics. METHODS: We conducted a mixed-methods study in Datong prefecture, China. Qualitative data from 63 semi-structured interviews with county hospital physicians and administrators were analyzed using Latent Dirichlet Allocation (LDA) to identify key influencing factors. Social Network Analysis (SNA) and Interpretative Structural Modeling (ISM) were employed to examine the interrelationships and hierarchical structure of these factors. A System Dynamics Model (SDM) was developed using longitudinal data (2015-2019) from 15 county hospitals to simulate the incentive mechanisms of capitation prepayment. RESULTS: The analysis revealed four primary domains influencing provider behavior under capitation prepayment: (1) external environmental factors (population characteristics, economic conditions, market competition), (2) institutional resources (bed capacity, workforce, medical equipment), (3) management strategies (particularly cost-control measures), and (4) service delivery outcomes. Management strategies emerged as the most direct determinant of provider behavior, while environmental factors and institutional resources moderated the effects of payment incentives. The SDM simulations indicated potential unintended consequences, including cost-shifting from inpatient to outpatient services. CONCLUSION: The study demonstrates that provider responses to capitation prepayment are predominantly driven by institutional cost-control measures, mediated by contextual and resource factors. Policy implementation should address potential unintended consequences through strengthened referral mechanisms between county and tertiary hospitals and enhanced monitoring of service shifting. These findings contribute to the global understanding of payment reform implementation in resource-constrained settings and highlight the importance of contextual adaptation in payment system design.