ASPPH logo


Member Research & Reports

Member Research & Reports

Texas A&M and Jiangsu University Researchers study effects of “Treatment-before-Deposit” Policy on Patient Satisfaction and Physician Trust in China

China is undergoing an ambitious reform of their health care system including expanding universal health insurance coverage to 90 percent of the population as well as transforming the public hospital-based health care system into a primary care-based delivery system. As these changes are implemented, more attention is being paid to relationships between patients and providers and the importance of patient trust in physicians, both of which are crucial for optimal health outcomes.

One of the reforms being tested in China is a new policy known as treatment-before-deposit, or TBD. Under this policy, patients receive care before paying for treatment instead of needing to pay in full beforehand. This new policy could affect patients’ perceived service quality, which has been shown to correlate to patient trust, but little is know about the effects of the TBD policy.

To gain a better understanding of this new policy and its effects on perceived quality and physician trust, Shinduk Lee, DrPH and other colleagues from the Texas A&M School of Public Health along with Dr. Wenxin Wang from Jiangsu University in China, studied how the TBD policy affected patient perceived service satisfaction and levels of physician trust. Their study, published in the International Journal of Health Planning and Management, analyzed data on more than 3,000 patients from 12 regional hospitals in China, some that had implemented a TBD policy and some that had not, to measure the effects of the policy on physician trust and perceived quality.

Prior to the ongoing health care reform efforts in China, patients typically had to pay for treatment in full before receiving care. This can lead to delayed treatment, which can further exacerbate health issues. Patients with health insurance would be reimbursed later, though there were sometimes delays in this process.

“Under TBD, patients would only need to pay the portion that would not be reimbursed by their health insurance, reducing their financial burden and avoiding the stress involved with navigating the bureaucratic nature of seeking reimbursement,” Dr. Lee said. “Additionally, research has found that making services more affordable can increase perceived quality, perhaps because patient expectations are higher when they pay more out of pocket.”

In this study, Dr. Lee and colleagues collected demographic data, such as age, gender, ethnicity, education and income, on patients from 12 regional hospitals with varying TBD policies. They also measured perceived service quality and physician trust levels using well-tested surveys. The researchers then analyzed the data, producing four different statistical models. These models measured associations between TBD policy and physician trust, TBD policy and perceived quality, perceived quality and physician trust and TBD policy and physician trust with perceived quality as a mediating variable. In other words, benefiting from TBD policy would affect physician trust by increasing perceived service quality rather than directly.

Dr. Lee and his colleagues found that patients who had benefited from the TBD policy had higher levels of physician trust and perceived quality and that patients with higher levels of perceived service quality had higher levels of physician trust. Their analyses also showed that when controlling for perceived service quality, TBD had no statistically significant effect on physician trust, meaning that perceived quality is indeed a mediating factor. They also found that higher levels of life satisfaction, higher income and a higher baseline trust in hospitals were associated with higher levels of both perceived service quality and physician trust.

Although this study is limited by its cross-sectional nature and lack of long-term follow up, the findings point to positive effects from decreasing financial burdens on patients and removing stress of coming up with funding for procedures and seeking insurance reimbursement. The researchers note that the higher levels of perceived satisfaction among patients benefiting from TBD are in line with previous research on health care affordability and perceived quality and on perceived quality and physician trust.

This study serves as an important first step in understanding the effects of the TBD policy as part of China’s overall health care reform efforts.

“Further research using more baseline measures of perceived quality and trust and monitoring of outcomes over time is needed to get the full picture of what effects the TBD policy has. However, the results thus far show promise in improving patient-provider relationships, which are a crucial part of the health care equation,” Dr. Lee said.