How hospital autonomy affects provider payment reform effectiveness

Background Provider payment reforms (PPRs) have demonstrated mixed results for improving health system efficiency. Since PPRs require health care organisations to interpret and implement policies, the organizational characteristics of hospitals may affect the effectiveness of PPRs. Hospitals with more autonomy have the flexibility to respond to PPRs more efficiently, but they may not if the autonomy previously facilitated behaviours that counter the PPR's objective. This study examines whether hospitals with higher autonomy responds to PPRs more effectively. Methods We used data from a matched‐pair, cluster randomized controlled PPR intervention in a resource‐limited Chinese province between 2014 and 2018. The intervention reformed the reimbursement method from the publicly administered New Cooperative Medical Scheme (NCMS) from fee‐for‐service to global budget. We interacted measures of hospital autonomy over surplus, hiring, and procurement (drugs, consumables, equipment, and overall index) with the difference‐in‐difference estimator to examine how autonomy moderated the intervention's effect. Results Autonomy over surplus (p 0.05). Post hoc analysis suggests that hospitals with surplus autonomy had higher OOP per admission (p