BACKGROUNDChina has achieved universal health insurance coverage. This study examined how patients and hospitals react to the different designs of the plans and to monitoring of patients by the local authority in the Chinese multiple health security schemes.

METHODSThe sample for analysis consisted of 1006 orthopedic inpatients who were admitted between January and December 2011 at a tertiary teaching hospital located in Beijing. We conducted general linear regression analyses to investigate whether medical expenditure and length of stay differed according to the different incentives.

RESULTSPatients under plans with lower copayment rates consumed significantly more medication compared with those under plans with higher copayment rates. Under plans with an annual ceiling for insurance coverage, patients spent significantly more in the second half of the year than in the first half of the year. The length of stay was shorter among patients when there were government monitoring and a penalty to the hospital service provider.

CONCLUSIONSOur results indicate that the different designs and monitoring of the health security systems in China cause opportunistic behavior by patients and providers. Reformation is necessary to reduce those incentives, and improve equity and efficiency in healthcare use.