Despite advances in healthcare delivery, access to high-quality medical care remains uneven in many countries. In systems where medical resources are limited and physician quality varies widely, patients must make important decisions about where and from whom to seek care. These choices can shape not only individual health outcomes but also the efficiency of healthcare systems.

Yuli Xu, a postdoctoral fellow at APARC’s Asia Health Policy Program, has made these questions central to her research on how institutional structures shape individual behavior and inequality in labor and health markets in both China and the United States. “I examine how policy reforms and institutional arrangements influence outcomes for families, workers, and patients, using large administrative and survey datasets,” she says

At a recent webinar, Xu presented new research examining patients’ preferences for physician continuity in China’s healthcare system. Her work explores whether patients prefer to return to the same physician even when institutional barriers to switching providers are minimal.

Watch her talk on our YouTube channel.
 

Physician Continuity in a Flexible Healthcare System

Much of the existing research on physician continuity focuses on healthcare systems in developed countries, where institutional rules strongly shape patient behavior. In those settings, referral requirements, insurance networks, and primary care gatekeeping often limit patients’ ability to switch doctors easily.

China’s healthcare system offers a very different context. “My interest in this topic was initially motivated by observing the stark differences between healthcare systems in China and the United States,” Xu says.

“In China, patients can often choose doctors directly with relatively few formal barriers, while high-quality medical resources remain scarce,” she explains. “This contrast made me interested in understanding how patients value continuity of care in a setting with fewer institutional switching frictions but greater variation in physician quality.”

Patients in China can often select physicians directly through hospital appointment systems and may visit specialists without referrals. This flexibility allows researchers to observe patient preferences more clearly, since continuity with a physician is less likely to be driven by institutional constraints.

Xu’s study draws on administrative medical claims data from residents enrolled in China’s Urban and Rural Resident Basic Medical Insurance program. The dataset includes detailed information on outpatient visits, diagnoses, expenditures, and physician identifiers. These records make it possible to track how patients choose physicians over time and whether they repeatedly return to the same doctor.

Evidence of Persistent Physician Choice

Xu’s first question is whether patients maintain consistent relationships with physicians when switching is easy. The data show that many do. Patients with chronic conditions frequently return to the same physician over multiple visits, suggesting that continuity of care remains an important factor in medical decision-making.

To analyze physician choice more systematically, Xu estimates a discrete choice model that examines how patients weigh factors such as physician experience, consultation fees, and prior interactions with the doctor.

The results reveal that prior relationships strongly influence patient decisions. Patients are significantly more likely to return to physicians they have visited in the previous six months.

The study also finds variation in preferences across patient groups. Female patients and patients with lower socioeconomic status are more likely to maintain long-term relationships with physicians. At the same time, patients respond to financial incentives. Higher consultation fees reduce the probability of selecting a physician.

These findings suggest that even in a flexible system where patients can easily switch providers, many still value stable relationships with physicians.

To estimate the causal value of physician continuity, Xu examines what happens when these patient-physician relationships are unexpectedly interrupted.

The results show clear behavioral changes. When their regular physician is absent, patients reduce visits to that department and spend less on medical care. The decline extends beyond the physician’s own department. Patients also reduce visits to other departments within the same hospital.

This pattern suggests that many patients organize multiple appointments during a single hospital visit. If a trusted physician is unavailable, patients may delay or cancel other appointments. The study also finds little evidence that patients compensate by seeking care at other hospitals. Instead, many appear to postpone care until their regular physician returns.

Implications for Healthcare Utilization and Policy

By examining how patients navigate healthcare systems with limited resources and flexible provider choice, Xu’s research offers new insights into how institutional design shapes healthcare access and efficiency.

While Xu finds no evidence of worsening short-term health outcomes within months after physicians’ absence, the research indicates that physician continuity can reduce costs for certain patients. Individuals with more severe conditions incur higher medical spending when they must see unfamiliar physicians, suggesting that established relationships may improve efficiency by facilitating information sharing and familiarity with medical histories.

“One strand of my work during my postdoc focuses on the Chinese healthcare system, where medical resources, especially high-quality physicians, are scarce and unevenly distributed,” Xu notes.

Her findings highlight the importance of stable patient-physician relationships in healthcare systems where provider quality varies. Even when patients have the freedom to choose among providers, many still demonstrate strong preferences for continuity with trusted physicians.

Research Community and Future Directions

Xu says her time at APARC has played an important role in advancing this research. “My time at APARC has provided an incredibly supportive and stimulating research environment,” she says. She credits the guidance of Karen Eggleston, director of the Asia Health Policy Program, whose expertise in health economics and Asian health systems helped shape the project.

She also highlights the broader intellectual community at Stanford. “I have had the opportunity to connect with many wonderful scholars across the Freeman Spogli Institute and Stanford more broadly,” Xu says, noting that conversations with economists and health policy researchers have helped refine her work and expand her perspective on healthcare systems.

Looking ahead, Xu plans to continue studying healthcare systems across different institutional settings. “I would encourage young scholars not to focus on only one country, but instead to study broader research questions and examine how they play out across different institutional settings,” she says. “Comparing institutions across countries can generate new insights and help identify mechanisms that might not be visible in a single context.”
 

Key Takeaways
 

• Patients in China demonstrate strong preferences for continuity with physicians despite minimal institutional barriers to switching providers.

• Physician absences lead to significant reductions in healthcare utilization within the same department and across other departments in the same hospital.

• Patients do not substitute toward other hospitals when their regular physician is unavailable, and many return to their original physician once they resume practice.

• The findings suggest that stable patient-physician relationships can improve efficiency and reduce costs in healthcare systems with flexible provider choice.

Despite technological breakthroughs, healthcare inequality remains a pressing public health challenge across developed and developing nations. Low levels of income or education mobility can exacerbate socioeconomic disparities, leaving children from disadvantaged families with fewer opportunities to improve their social and economic prospects. Moreover,  children in families with low-income backgrounds are also more likely to experience poor health outcomes, perpetuating a cycle of disadvantage.

Huixia Wang, a visiting scholar at Shorenstein APARC, sees this phenomenon as an opportunity to better understand the dynamics of intergenerational health and how to interrupt patterns of persistent health inequalities across generations. Her research aims to identify potential interventions to improve health outcomes in developing regions.

An associate professor at Hunan University, Wang has spent the 2024 fall quarter at APARC. She recently presented her research on the intricate dynamics of intergenerational health metrics, particularly in China and Indonesia. Watch her talk, “Intergenerational Persistence of Self-Reported Health Status and Biomarkers in Indonesia,” on our YouTube channel.

Barriers to Intergenerational Health

While much has been written about the transmission of income and education across generations, “much less is known about how health is passed down between generations," Wang notes, highlighting a gap in the existing research. Emphasizing that health is a crucial factor in determining overall well-being, as it affects everything from mental health to economic productivity and social mobility, she asserts that good health is linked to better educational outcomes, higher earning potential, and improved labor market performance. Poor health, on the other hand, is associated with lower educational attainment, reduced employment prospects, and higher rates of chronic illness.

Wang’s research approach centers on recognizing the multiple challenges in implementing maternal health-oriented policies. Having identified limited access to healthcare services as a significant barrier, she considers how, in many low-income and rural areas, “access to quality healthcare is constrained by poor infrastructure, lack of transportation, and shortages of healthcare professionals, making it difficult for pregnant women to receive essential care.”

Another obstacle is the prohibitive cost of healthcare. In countries where maternal health services are not subsidized or free, the financial burden of out-of-pocket expenses for transportation, medications, and other related costs can prevent women from accessing necessary care. Furthermore, Wang shows that low levels of maternal health education can contribute to poor health-seeking behaviors. “Many women may not recognize the warning signs of complications, may not fully understand the importance of prenatal care, or may be unaware of their rights to healthcare services,” she says.

Measuring Health Outcomes Across Generations

Wang acknowledges the difficulties in studying intergenerational health mobility, as it cannot be neatly defined and measured by observable metrics such as income or education. Health is much more subjective and varies from person to person. To gauge health outcomes, researchers must therefore rely on diverse and sometimes imprecise indicators, such as the presence of chronic diseases.

Moreover, to examine intergenerational mobility, researchers need data that includes health information for both parents and children. Such datasets are not always readily available, and those that do exist often lack the necessary granularity and long-term tracking to provide meaningful insights.

To overcome these challenges, Wang draws on a variety of panel data that tracks individuals over time, as well as survey data and self-reported status. For Wang, longitudinal studies are crucial for understanding how health disparities manifest and evolve over time. 

Using data from the Indonesia Family Life Survey, she combines subjective measures like self-reported health and objective measures such as pulse, BMI, hypertension, and anemia to capture a more complete picture of health mobility. This approach expands beyond previous studies, which typically relied on fewer health indicators and focused on developed countries. Her study includes a broad range of health variables and provides a unique look at the role of gender and socioeconomic factors in shaping health outcomes across generations.

Wang uses two primary methods for measuring intergenerational health mobility: one following the Intergenerational Health Association, which regresses children's health outcomes on those of their parents, and rank-rank regressions, which examine the persistence of health outcomes by analyzing percentile ranks. These techniques, adapted from income mobility research, allow her to assess health persistence and mobility across generations.

Future Directions and Policy Impact

Wang’s time at APARC has been instrumental in shaping and refining her research. "The opportunity to engage with experts from various fields [...] opened my eyes to new ways of thinking about my research," she shared. "The collaborative environment at APARC also made me realize how much I can learn from perspectives outside my immediate area of focus.”

Wang credits Stanford’s vibrant academic environment, with its rich array of seminars and talks, to broadening her understanding of Southeast Asian health systems, a subject she was less familiar with. She expressed gratitude to APARC faculty for their “invaluable guidance for both my research and my life at Stanford.” In particular,  APARC’s Asia Health Policy Program Director Karen Eggleston “dedicated a significant amount of time to advising my work, introducing me to key researchers in my field, and sharing the valuable resources that I might benefit from on campus,” Wang said.

Looking ahead, she is excited to continue exploring the role of health in intergenerational mobility, particularly in the Southeast Asian context, and plans to expand her research into the health effects of pollution, an area she has already begun to investigate. Wang also hopes to contribute to policymaking that addresses health inequality. By providing a deeper understanding of how health disparities are perpetuated across generations, she aims to inform policies that could improve health outcomes and reduce inequality in developing countries.

Wang’s research on intergenerational health mobility offers a fresh and much-needed perspective on the crucial yet understudied role of health in social mobility. She hopes her research helps policymakers and scholars address health inequalities that perpetuate socioeconomic disadvantage across generations.

Do increases in medical spending improve health outcomes? To answer this question, analysts need to quantify the net value of medical spending and measure the productivity of medical care with the output of improvement in survival and quality of life, thereby deducing for what medical conditions the “bang for the buck” is greatest and for what conditions spending outstrips gains in health improvement.

This condition-specific, quality-adjusted net value approach to health spending is known as a “satellite account for health” because it “orbits around” the national income and product accounts that include aggregate health spending to provide a clearer picture of productivity in the health sector. Thus far, researchers have applied this account to the U.S. health sector only, but it would be highly beneficial for many economies. One notable beneficiary would be South Korea, one of the most rapidly aging societies globally. Now new research by Karen Eggleston, the director of APARC’s Asia Health Policy Program, studies the link between medical spending and health outcomes in South Korea, providing evidence on the productivity of medical spending over recent decades.

The research, published by the East-West Center, develops an estimate of the net value of Korean medical spending, which has outpaced most other countries in recent decades. To generate this estimate, Eggleston compares the gains in life expectancy at birth to the increases in medical spending for 2000–2019. Data comes from Korean lifetables and medical expenditures per capita, available from the Korean Statistical Information Services.

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Eggleston shows that, even with the most conservative assumptions ($50,000 per life-year and only 10 percent of health gains due to medical care), the net value of Korean medical spending is positive and substantial. Korean life expectancy at birth increased from 76 in 2000 to 83.3 in 2019, while lifetime medical spending increased by over $19,000. The value of 7.3 additional years of life far outweighs even this rapid increase in spending, implying substantial productivity growth in Korea’s health sector.

Moreover, evidence on condition-specific spending changes and health improvements suggests that Korea’s rapid spending increases yield significant net value. Eggleston’s research indicates that improvements in survival for key conditions afflicting Koreans, such as stroke and cancer, point to productivity gains. “Korea could be a pioneer in developing a national health account that accurately measures net value by medical condition,” she writes.

Condition-specific metrics of health gain per won spent on treatment can help to guide the allocation of investments to promote longer, healthier lives. In the future, analysts could also link condition-specific improvements in survival and morbidity to earnings. Such linkage would particularly benefit South Korea, where focusing on the productivity of older adult employment is crucial given its high labor force participation and relatively low income of older Koreans.

Eggleston advocates for the Korean government to develop a national satellite account for health that can provide valuable evidence for prioritizing investments to address the country’s most pressing health challenges so that productivity improvement will contribute to longer, healthier lives. “By linking National Health Insurance and health outcome data, Korea could develop an accurate measure of medical productivity and a more accurate measure of overall economic productivity, while pioneering development of ‘health satellite accounts’ for overall populations,” Eggleston argues.

As healthcare costs for patients with non-communicable diseases such as diabetes have risen, governments and healthcare providers have sought creative measures to align financial incentives with better patient outcomes. One incentive payment system known as “pay-for-performance” (P4P), in which providers are beholden to metric-driven outcomes, represents a potential path forward for healthcare providers to improve healthcare processes, resulting in higher quality and better patient health outcomes. The evidence on the effectiveness of P4P programs, however, is mixed.

To address this uncertainty, a new study, published in The European Journal of Healthcare Economics, assesses the effectiveness, in monetary terms, of a P4P program for patients with diabetes at a hospital system in Taiwan. 

The study coauthors, including APARC’s Asia Health Policy Program Director and FSI Senior Fellow Karen Eggleston, employed new patient-level data on clinical indicators, utilization, and expenditures, combined with data from the national death registry, to better understand the costs and benefits of the P4P program. Their results show that Taiwan’s implementation of the P4P program for diabetic care yielded positive results in terms of net value, defined as the value of life years gained minus the cost of care.

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Assessing Net Value of Taiwan’s P4P

Taiwan’s Bureau of National Health Insurance (now National Health Insurance Administration) introduced P4P in 2001 and enhanced the program in 2006 with an incentive for pay-for-reporting of outcomes. Financial incentives were used to encourage continuity of care with metrics such as new patient enrollment, follow-up visits, and annual reports, each tied to a specific monetary value. The program’s features are common across P4P, so the study’s findings have implications in other settings that incorporate similar designs in their P4P programs.

The study compares two different groups of patients at a large regional hospital in Taiwan, one consisting of newly enrolled P4P patients and another using P4P patients who have been enrolled since the beginning of the program. The researchers leverage detailed clinical data not used in previous assessments of the P4P program to better identify both costs and longer-term clinical outcomes based on measured biomarkers and predicted mortality.

Using an economic cost-benefit analysis conducted from a budgetary perspective, the study is the first analysis of any P4P program that estimates changes in the quality-adjusted price index relative to usual care. The authors consider health benefits in terms of survival and predicted survival and convert them into monetary terms. This net value approach is especially useful for policymakers and healthcare administrators who implement value-based purchasing and monitor outcomes for any service delivery innovation over time.

The study finds that Taiwan’s P4P program provided a positive net value for payers and patients, ranging from $40,084 USD to $348,717 USD. These positive net value results are primarily derived from health outcomes as measured by lower mortality rates in the P4P versus non-P4P cohorts, across both newly enrolled and continuously enrolled groups of patients. According to the authors, “these encouraging findings of the positive value of quality improvement net of expenditures adds evidence to the literature that has found mixed results of P4P programs.” 

 This study develops a new model for assessing the net value of service delivery innovations like P4P programs that can be applied in other contexts globally, providing healthcare systems researchers with new tools to better understand an emergent option for incentivized care. With a more economically-translatable understanding of P4P programs, this research helps build the bridge between the oft-disparate worlds of healthcare and policy.

The second privacy concern is the potential use of health-care facility records to incriminate an institution or its clinicians for providing abortion services. Relevant records could include electronic health records, employee emails or paging information and mandatory reports to state agencies. Clinicians may not realize that if they are using an institutional email address or server, their institution likely has direct access to information and communications stored there, which can be used to search for violations. State Freedom of Information Act (FOIA) laws also allow citizens to request public records from employees of government hospitals and clinics.

“Additionally, state mandatory reporting laws for child abuse might be interpreted to cover abortions — particularly if life is defined as beginning at fertilization,” the authors note.

The third scenario is that information generated from a woman’s online activity could be used to show she sought an abortion or helped someone to do so. Many women use websites and apps that are not HIPAA-regulated or protected by patient-physician privilege, such as period-tracking apps used by millions of women that collect information on the timing of menstruation and sexual activity.

“There are many instances of internet service providers sharing user data with law enforcement, and prosecutors obtaining and using cellphone data in criminal prosecutions,” write Mello and Spector-Bagdady, adding commercially collected data are also frequently sold to or shared with third parties.

“Thus, pregnant persons may unwittingly create incriminating documentation that has scant legal protection and is useful for enforcing abortion restrictions,” they said.

The immediate problem, Mello notes, is in the states that have already banned abortion or passed restrictive laws.

“There could be a problem with states trying to reach outside their borders to prosecute people, but that could well be unconstitutional,” Mello said.

Some states’ laws sweep abortion pills into the definition of illegal abortions, she said, and there are legal obstacles to supplying the pills across state lines.

“There is a lot of energy going into figuring out a workaround right now, but it’s too soon to call,” Mello said.

Recommended Protections

So how can clinicians and health-care facilities protect their patients and themselves?

When counseling patients of childbearing age about reproductive health issues, clinicians should caution their patients about putting too much medical data online and refer them to expert organizations that will help them minimize their digital footprint.

When documenting reproductive health encounters, the authors said, clinicians should ask themselves: “What information needs to be in the medical record to assure safe, good-quality care, buttress our claim for reimbursement, or comply with clear legal directives?” For example, does information about why a patient may have experienced a miscarriage need to be recorded?

Patients and clinicians should be aware that email and texting may be seen by others, so conversations among staff about reproductive health issues may best be conducted by phone or in person.

Finally, if abortion-related patient information is sought by state law enforcement officials, a facility’s attorney should be consulted about asserting physician-patient privilege and determining whether the disclosure is mandated by law.