From connectivity to coordination: a four-party evolutionary game analysis of telemedicine governance for chronic disease management in China

Telemedicine holds the potential to expand specialist service capacity and sustain care continuity; nevertheless, mere platform-level technical linkage cannot guarantee coordinated service provision for chronically ill populations. We develop a four-party evolutionary game involving the government, tertiary public hospitals, primary healthcare (PHC) institutions, and patients in China. We use replicator dynamics, equilibrium stability analysis, and numerical simulations to examine how regulation, provider costs, patient benefits, rewards, and penalties shape strategic evolution. The results show that high-level coordination depends on mutually reinforcing behavior across all four stakeholders. Strict regulation expands the conditions under which active provider and patient strategies can stabilize, but regulation alone is insufficient when implementation and collaboration costs exceed expected returns. Lower costs for tertiary-hospital implementation and substantive PHC collaboration promote provider participation, whereas higher telemedicine health and convenience benefits strengthen patient use and demand-side feedback. Rewards and penalties can support coordination when aligned with stakeholder-specific cost structures, while changes in the costs of already inactive strategies have comparatively limited effects. These findings suggest that telemedicine governance should move beyond platform expansion toward coordinated incentives, reduced provider transaction costs, improved PHC capacity, and sustained patient engagement. Because the parameters are scenario-calibrated rather than estimated from individual-level data, the results identify plausible mechanisms rather than causal policy effects.