Does integrated care reshape service utilization patterns? Evidence from China's compact county-level medical community on utilization, cost, and equity

Promoting equitable service utilization is central to realizing the "Healthy China" strategy. Since 2019, China has vigorously advanced the construction of compact county-level medical community (CCMC), aiming to restructure the primary healthcare delivery system through organizational integration and medical insurance payment reform. However, whether this integrated care model can strengthen equitable service utilization and optimize the pattern of service utilization lacks sufficient empirical testing. Based on full-sample urban and rural resident medical insurance data from Zhangjiagang City, Jiangsu Province (2020-2024), this study employs a propensity score matching-difference-in-differences (PSM-DID) approach to systematically evaluate the impact of CCMC on medical service utilization, cost structure, and equitable service utilization. The findings show that CCMC construction significantly altered the pattern of service utilization within the county: primary-level inpatient volumes increased in the first year, while primary-level outpatient volumes declined-indicating an asymmetric pattern of service restructuring rather than a uniform shift toward primary care. Average outpatient costs per visit decreased overall, but inpatient cost control remained unstable. Per capita pooled fund payments increased at the primary level, reflecting an optimized allocation of medical insurance resources. However, further equitable service utilization analysis reveals that vulnerable groups-those in townships with higher aging rates and those farther from county hospitals-did not experience significantly greater improvements in service utilization than other groups, suggesting that the CCMC's role in strengthening equitable service utilization remains limited.The observed patterns are consistent with theoretical predictions regarding global budgeting incentives, chronic disease decentralization, and organizational integration. However, a structural characteristic of "emphasizing service decentralization while neglecting cost reduction" persists, and no significant improvement has been observed in patients'out-of-pocket expenses. This study provides new empirical evidence for understanding the relationship between integrated care and equitable service utilization, and offers policy implications for comprehensively advancing CCMC construction nationwide.