The Economic Impact of National Essential Public Health Service Package for Hypertension and Type-2 Diabetes: A Retrospective Province-wide Study in China

doi:10.21203/rs.3.rs-8180914/v1

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Research Article

The Economic Impact of National Essential Public Health Service Package for Hypertension and Type-2 Diabetes: A Retrospective Province-wide Study in China

https://doi.org/10.21203/rs.3.rs-8180914/v1

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Background

Hypertension (HTN) and type-2 diabetes mellitus (T2DM) present a substantial economic burden of disease in China. The National Essential Public Health Service Package (NEPHSP) is a Chinese government initiative to provide a suite of basic public health services to all residents for free, with the aim to shift the focus of the healthcare system towards prevention and community-based primary health care. However, evidence is scarce regarding its economic impact.

Methods

A retrospective, province-wide study was designed to extract 5,456,854 electronic medical records from 339 institutions in Henan province from January 1, 2022 to December 31, 2024, using stratified cluster sampling. Patients with HTN or T2DM managed under the NEPHSP were identified by linking medical records to the NEPHSP management registry. Based on the International Health Partnership+ (IHP+) common monitoring and evaluation (M&E) framework, we assessed medical costs as the primary outcome. Propensity score matching was used to create comparable cohorts of NEPHSP-managed and non-managed patients. The difference in mean annual total medical costs per capita was analysed using a two-sample Z-test.

Results

NEPHSP-managed patients had lower mean annual total medical costs across all years for both HTN and T2DM, with the largest cost difference observed in 2023 (up to CNY 713.57). When stratified by types of medical costs, we found NEPHSP-managed patients had lower average costs for general medical services, diagnostics, treatment, and western medicine compared to non-managed patients. The cost savings associated with NEPHSP-managed were most pronounced in males, older patients (≥ 65 years), and those with three or more comorbidities.

Conclusions

Community-based public health management of HTN and T2DM through China’s NEPHSP is associated with substantial medical cost savings, particularly for high-risk demographic groups. Our findings provide real-world evidence supporting national policies that prioritise prevention and community health services. Continued investment in NEPHSP is a highly effective strategy for mitigating the economic burden of chronic disease in China and similar settings.

Hypertension

Type 2 diabetes

Essential public health services

Medical costs

China

This study provides the first large-scale, real-world evidence that managing hypertension and diabetes through China’s public health program significantly reduces medical costs, filling a critical knowledge gap on its economic impact.
It identifies which patient groups—specifically men, older adults, and those with multiple comorbidities—benefit most from the program, offering clear guidance for targeted healthcare efforts.
The findings strongly support the cost-effectiveness of investing in primary care and prevention, providing a practical model for other countries facing similar chronic disease challenges.

Evidence before this study

Although China’s National Essential Public Health Service Package (NEPHSP) was launched in 2009 to manage the escalating disease burden of hypertension (HTN) and type-2 diabetes (T2DM), little is known about its real-world impact of medical costs. We searched PubMed, Web of science and China National Knowledge Infrastructure (CNKI) for studies published up to 30 July 2025, with terms including “essential public health services”, “hypertension”, “diabetes”, and “medical costs” or “economic burden”. Existing evidence has largely focused on NEPHSP’s clinical effectiveness, implementation factors, and equity in service use, with little evidence on its economic outcomes. While the cost estimation model and an economic evaluation model for NEPHSP have been developed, only one small-scale study (n=369), using data from 2013 to 2015, assessed the cost saving effect of NEPHSP for HTN. Findings from large-scale population-wide studies are needed to examine the economic impact for NEPHSP management of both HTN and T2DM.

Added value of this study

This study provides the first large-scale, real-world evaluation of the economic impact of NEPHSP-based chronic disease management, using data of over 5.4 million medical records from 339 institutions across 11 counties/districts in Henan province, China (2022-2024). The direct medical cost savings attributable to NEPHSP management for HTN and T2DM were quantified, demonstrating a substantial reduction in expenditures for NEPHSP-managed group. By employing propensity score matching, we controlled key confounders, strengthening the causal interpretation. Our analyses also identified high-risk demographic groups, including males, older patients (≥65 years), and patients with multiple comorbidities (≥3 conditions), providing evidence for targeted resource allocation.

Implications of all the available evidence

Our findings provide empirical support for the economic justification for China’s prevention-first strategy (e.g., Healthy China 2030), demonstrating that sustained investment in primary care-led chronic disease management yields substantial financial returns. The pronounced cost saving in high-risk groups suggests a clear policy imperative to prioritise these populations for management and design intensified management protocols to maximise the NEPHSP’s value. NEPHSP serves as a powerful platform to advance health equity by reducing the economic burden of chronic disease. This study also offers a tangible, evidence-based model for other low- and middle-income countries, showing that investment in community-based public health is an effective strategy to combat the dual health and economic threats of chronic diseases. Further work is needed to explore the long-term clinical and economic outcomes and the specific programmatic components driving these cost savings, providing the evidence needed to refine and scale this successful public health model nationally and globally.

Hypertension (HTN) and type-2 diabetes mellitus (T2DM) represent a significant public health challenge, imposing as substantial economic burden in China and globally.^1,2 According to the 2021 Global Burden of Disease data,³ among the five leading metabolic diseases, HTN accounts for the greatest economic burden while T2DM is associated with severe complications, particularly in populous countries such as China, where the burden of both conditions is among the highest globally. Primary healthcare serves as the frontline for chronic disease control. Investing in primary healthcare can significantly reduce disease-related hospitalization rates, improve chronic disease management outcomes, and promote health equity.⁴

To confront the crisis for HTN and T2DM, China launched the National Essential Public Health Service Package (NEPHSP) in 2009, delivering a suite of basic public health services for all residents free of charge.⁵ Within the NEPHSP, individuals aged 35 years and older with HTN or T2DM receive long-term management, including systematic screening, regular follow-ups, and health monitoring. Beyond its focus on HTN and T2DM, the NEPHSP also integrates core public health modules for establishing public health service records, delivering health education for the general population, and offering maternal and child health services, elderly care, and immunization services (see Supplementary Table 1)⁶. This national public health initiative is underpinned by substantial and growing government investment, with all funding borne by the Chinese government and channelled into primary healthcare institutions, which deliver these services free of charge to all residents⁷. The Chinese government places high priority on and continuously reinforces investment in this program, with the per capita funding subsidy increasing from ¥15 to ¥99 per person between 2019 and 2025.^8,9

There is emerging evidence regarding the clinical effectiveness, implementation factors, and equity in service use in China’s NEPHSP regarding HTN and T2DM.^7,10,11 Xiong et al¹⁰ found that, among 149,176 HTN patients and 50,828 T2DM patients managed in the NEPHSP program, treatment rates reached 70.8% for HTN and 82.2% for T2DM, with high rates of disease control in those receiving care. Xiong et al¹¹ also identified several key barriers to implementing NEPHSP for HTN and T2DM management in China's primary care system, such as staff shortages, insufficient training, and inadequate medical supplies. Liu et al⁷ found equity gaps in access to health management services for patients with HTN and T2DM across three provinces in China, reflecting disparities where services were only accessible to certain populations (e.g., living in urban areas) but limited for others due to uneven resource distribution and administrative quotas.

By mitigating disease progression and reducing costly complications, primary healthcare efforts may translate into economic benefits. However, empirical evidence is scarce regarding the economic impact. Xiong et al¹² proposed an economic evaluation to assess the impact of improved HTN/T2DM management on cardiovascular risk and QALYs, but the results remain unknown. Yin et al¹³ developed the NEPHSP cost estimation model and estimated that, the per capita cost of NEPHSP was $7.95 in Beijing in 2010 — nearly double the actual government subsidy of $3.97 per capita — highlighting a substantial funding gap. Xue et al.¹⁴ conducted a study that examined the impact of increased NEPHSP subsidies on HTN-related costs in China, showing that higher subsidies were associated with reduced hospitalization expenses for HTN. However, Xue et al’s conclusion is constrained by its small sample size (n = 369) and outdated data (2013–2015), limiting its generalizability. A crucial evidence gap has precluded the evaluation of the NEPHSP’s economic value. To our knowledge, there have been no large-scale population-wide studies that compare the direct medical costs of HTN or T2DM patients managed within the NEPHSP program versus those who are not.

This study aimed to use a three-year (2022–2024) province-wide dataset of 5.4 million medical records from Henan province to quantify the medical costs associated with NEPHSP management. Specifically, we estimated the magnitude of medical cost savings through NEPHSP management and identified the patient subgroups who might benefit most, providing empirical evidence to guide future investment and policy for chronic disease management in China and similar settings.

Applied conceptual framework

This study applied the International Health Partnership+ (IHP+) common monitoring and evaluation (M&E) framework, developed by the World Health Organization (WHO),¹⁵ to structure the evaluation of the NEPHSP on HTN and T2DM management (see Fig. 1). The IHP + framework offers a logical result chain that connects health system inputs and processes to outputs, outcomes, and ultimate impacts, facilitating a comprehensive assessment of policy effectiveness¹⁶. Several studies have used this framework to evaluate the impact of health policies¹⁷. The IHP + common M&E framework illustrates how systemic inputs—such as financial resources and physical infrastructure — along with operational processes, including policy execution and support mechanisms, lead to measurable outputs like the provision of health services and interventions. These outputs subsequently contribute to intermediate outcomes, for instance, increased intervention coverage and higher service utilization rates, and ultimately to long-term impacts, such as enhanced health status and strengthened financial risk protection. Arrows used in the framework denote the sequential and causal linkages between these indicators .

In this study, the “inputs and process” refer to the operational implementation of the NEPHSP across primary healthcare institutions. The “outputs” encompass direct service delivery indicators, such as hypertension and diabetes management rates, control rates, and medication adherence. The “outcomes” include intermediate effects such as increased utilisation of essential health services and improved patient compliance with follow-up protocols. The ultimate “impact” is measured by the change in mean annual total medical costs per capita, which reflects both financial risk protection and health system efficiency. By situating the evaluation within this structured framework, the study moves beyond intermediate process indicators to assess the program’s effectiveness in reducing economic burden — core goals of universal health coverage.

Study setting

We conducted a retrospective, province-wide study using electronic medical record data from Henan province (population: 97.9 million; area 167,000 km²), China. Henan has fully implemented NEPHSP and established 23 national demonstration zones for chronic disease prevention and control,¹⁸ providing a highly relevant context for evaluating cost-saving effects of NEPHSP management. We selected 11 counties/districts (see Fig. 2) across five distinct regions based on a stratified random sampling strategy: eastern (Zhecheng, Qixian), western (Mianchi, Yiyang), southern (Xinye, Luoshan), northern (Xun, Neihuang, Wen), and central (Jiaxian, Linying). Within these sites, a total of 339 healthcare institutions including community health centers/township health centers, Western medicine hospitals, and traditional Chinese medicine hospitals were recruited to extract medical record data.

Data sources and linkage

We extracted data from the front-page electronic medical record for the period from 339 healthcare institutions between January 1, 2022 and December 31, 2024. These records were sourced from the Henan Provincial Health Commission’s centralized database and included patients’ demographics (name, sex, date of birth), admission and discharge information, clinical diagnoses, and itemised cost data. The final dataset comprised 5,456,854 records from 339 healthcare institutions across the 11 selected counties and districts (see Supplementary Table 2).

We combined potential duplicate records for the same patient across multiple healthcare institutions and performed deterministic linkage between the medical record database and official NEPHSP registries using patient name, sex, and date of birth. Successfully matched individuals were classified as NEPHSP-managed, whereas all others formed the non-managed comparison group. Data underwent rigorous two-stage quality control: (1) Hospitals performed internal checks for completeness and accuracy, specifically excluding records lacking diagnoses or cost data before submission; (2) and the Provincial Health Commission conducted secondary quality control to ensure proper upload compliance. Records were included only if they contained complete demographic data (name, sex, date of birth with age > = 35).

In cases where a patient might have more than one record from different healthcare institutions, we consolidated records for the identical patient and finally identified 133,724, 163,989, and 161,911 HTN patients and 64,225, 77,765, and 79,053 T2DM patients in 2022, 2023, and 2024, respectively. We also found the number of patients diagnosed with both conditions was 34,208, 41,793, and 42,989 in each year. To identify patients managed under the NEPHSP, we performed a deterministic linkage between the medical record database and the official NEPHSP management registries from 11 districts/counties. The linkage was done based on a combination of patient name, sex, and date of birth. Individuals with a successful match were classified as the NEPHSP-managed group, while those without a match formed the non-managed comparison group. Post-linkage, the NEPHSP-managed group comprised 23,522, 29,680, and 29,871 HTN patients; 11,060, 13,452, and 13,833 T2DM patients; and 6,471, 7,997, and 8,242 patients with both conditions in 2022, 2023, and 2024, respectively. The participant flowchart can see Supplementary Fig. 1.

Definition of Disease and Outcomes

The primary diagnosis of HTN or T2DM was determined using an algorithm that combined ICD-10 codes with text mining of diagnosis fields from medical record front pages for relevant keywords (Supplementary Table 3). Comorbidities, identified from the same source using a predefined list of conditions based on clinical guidelines and expert consultation (Supplementary Table 4), were mapped to ICD-10 codes, and the total number per patient was calculated.

The primary outcome was the mean annual total medical cost per capita. For subgroup analysis, costs were disaggregated into eight mutually exclusive categories based on the nationally standardised expense classification system: (1) General Medical Services (basic care, therapeutic procedures, nursing, miscellaneous fees); (2) Diagnostics (pathology, laboratory, imaging, clinical assessments); (3) Treatments (non-surgical/surgical interventions); (4) Rehabilitation; (5) Traditional Chinese Medicine Therapies; (6) Western Medications; (7) Chinese Herbal Medicines (proprietary formulations/raw herbs); and (8) Blood Products (whole blood, albumin, globulin).

Statistical analysis

Population characteristics were summarised using proportions for categorical variables and means ± standard deviations for continuous variables. Group comparisons were conducted using Chi-square tests. To control for confounding, 1:1 propensity score matching (PSM) was performed via logistic regression based on age, sex, and number of comorbidities. After matching, the analysis included 23,515 to 29,853 matched pairs for HTN and 11,048 to 13,819 for T2DM per year from 2022 to 2024, with 6,471 to 8,242 patients having both conditions (see Supplementary Fig. 1). Covariate balance was assessed post-matching. Mean total medical costs were compared using a two-sample Z-test. Subgroup analyses were conducted by sex, age group, and number of comorbidities. Due to substantial missing data in insurance type and occupation, a sensitivity analysis was also conducted using a subset of the population with PSM controlling for sex, age, number of comorbidities, insurance type, and occupation to assess socioeconomic influences (Supplementary Table 5). All analyses were two-sided (p < 0.05) and performed using Python 3.14, R 4.3.2, and ArcGIS 10.8.1.

Characteristics of Patients with HTN and T2DM

Characteristics of patients with HTN and T2DM are presented in Table 1. Distributions of sex, age, and the number of comorbidities differed significantly between NEPHSP-managed patients and those not managed for HTN, T2DM, as well as for patients with both conditions across three years (all P < 0.001).

Table 1
Basic characteristics of Hypertension and Type-2 diabetes mellitus patients in Henan Province, China (2022–2024)
Year	Feature	Hypertension					Type-2 diabetes mellitus					Both conditions
Year	Feature	Total	NEPHSP^*	Non-NEPHSP	Chi-square	P	Total	NEPHSP	Non-NEPHSP	Chi-square	P	Total	NEPHSP	Non-NEPHSP	Chi-square	P
2022	Total	133,724	23,522(17.59)	110202(82.41)			64,225	11060(17.22)	53165(82.78)			34,208	6471(18.92)	27737(81.08)
	Sex
	Male	65,740	10,558(16.06)	55182(83.94)	209.613	<0.001	28,870	4578(15.86)	24292(84.14)	68.820	<0.001	15,345	2535(16.52)	12810(83.48)	105.155	<0.001
	Female	67,960	12,964(19.08)	54996(80.92)	209.613	<0.001	35,339	6482(18.34)	28857(81.66)	68.820	<0.001	18,858	3936(20.87)	14922(79.13)	105.155	<0.001
	Age
	35–45	9,428	189(2.00)	9239(98.00)	4817.156	<0.001	8,001	160(2.00)	7,841(98.00)	2575.754	<0.001	2,168	62(2.86)	2106(97.14)	969.867	<0.001
	45–55	16,804	1,365(8.12)	15439(91.88)			8,764	928(10.59)	7836(89.41)			3,993	444(11.12)	3549(88.88)
	55–65	28,437	3,809(13.39)	24628(86.61)			14,756	2370(16.06)	12386(83.94)			7,959	1291(16.22)	6668(83.78)
	65–75	45,029	11,058(24.56)	33,971(75.44)			20,506	5,139(25.06)	15367(74.94)			12,433	3121(25.1)	9312(74.9)
	≥ 75	32,672	7,100(21.73)	25,572(78.27)			11,654	2,463(21.13)	9191(78.87)			7,334	1553(21.18)	5781(78.82)
	Comorbidities*
	0	44,890	6,326(14.09)	38,564(85.91)	673.861	<0.001	20,319	2,784(13.70)	17,535(86.30)	283.005	<0.001	6,941	1197(17.25)	5744(82.75)	38.457	<0.001
	1	29,846	5,243(17.57)	24,603(82.43)			15,958	2,824(17.70)	13,134(82.30)			7,690	1370(17.82)	6320(82.18)
	2	33,746	6,914(20.49)	26,832(79.51)			14,932	2,937(19.67)	11,995(80.33)			9,283	1920(20.68)	7363(79.32)
	≥ 3	25,218	5,039(19.98)	20,179(80.02)			13,000	2,515(19.35)	10,485(80.65)			10,294	1984(19.27)	8310(80.73)
2023	Total	163,989	29,680(18.10)	134,309(81.90)			77,765	13,452(17.3)	64,313(82.70)			41,793	7997(19.13)	33796(80.87)
	Sex
	Male	79,826	13,072(16.38)	66,754(83.62)	311.847	<0.001	35,239	5,498(15.60)	29,741(84.40)	129.635	<0.001	18,829	3109(16.51)	15720(83.49)	152.371	<0.001
	Female	84,156	16,608(19.73)	67,548(80.27)	311.847	<0.001	42,525	7,954(18.70)	34,571(81.30)	129.635	<0.001	22,964	4888(21.29)	18076(78.71)	152.371	<0.001
	Age
	35–45	8,378	240(2.86)	8,138(97.14)	5283.817	<0.001	7,791	182(2.34)	7,609(97.66)	2591.909	<0.001	1,678	75(4.47)	1603(95.53)	770.823	<0.001
	45–55	20,943	1,765(8.43)	19,178(91.57)			11,064	1,168(10.56)	9,896(89.44)			5,117	581(11.35)	4536(88.65)
	55–65	37,387	5,029(13.45)	32,358(86.55)			19,040	2,993(15.72)	16,047(84.28)			10,431	1732(16.6)	8699(83.4)
	65–75	57,029	14,352(25.17)	42,677(74.83)			25,778	6,300(24.44)	19,478(75.56)			15,594	3820(24.5)	11774(75.5)
	≥ 75	39,929	8,294(20.77)	31,635(79.23)			14,074	2,809(19.96)	11,265(80.04)			8,970	1789(19.94)	7181(80.06)
	Comorbidities
	0	56,819	8,957(15.76)	47,862(84.24)	721.048	<0.001	25,199	3,507(13.92)	21,692(86.08)	363.231	<0.001	9,145	1517(16.59)	7628(83.41)	131.784	<0.001
	1	37,182	6,137(16.51)	31,045(83.49)			19,892	3,449(17.34)	16,443(82.66)			9,624	1686(17.52)	7938(82.48)
	2	40,824	8,993(22.03)	31,831(77.97)			17,682	3,620(20.47)	14,062(79.53)			11,108	2489(22.41)	8619(77.59)
	≥ 3	29,157	5,593(19.18)	23,564(80.82)			14,991	2,876(19.18)	12,115(80.82)			11,916	2305(19.34)	9611(80.66)
2024	Total	161,911	29,871(18.45)	132,040(81.55)			79,053	13,833(17.50)	65,220(82.50)			42,989	8242(19.17)	34747(80.83)
	Sex
	Male	78,835	13,092(16.61)	65,743(83.39)	346.868	<0.001	35,397	5,707(16.12)	29,690(83.88)	84.065	<0.001	19,341	3308(17.1)	16033(82.9)	97.666	<0.001
	Female	83,069	16,779(20.20)	66,290(79.80)	346.868	<0.001	43,654	8,126(18.61)	35,528(81.39)	84.065	<0.001	23,646	4934(20.87)	18712(79.13)	97.666	<0.001
	Age
	35–45	8,591	168(1.96)	8,423(98.04)	6372.235	<0.001	8,882	157(1.77)	8,725(98.23)	3276.761	<0.001	1,893	66(3.49)	1827(96.51)	1010.486	<0.001
	45–55	19,393	1,458(7.52)	17,935(92.48)			10,548	1,023(9.70)	9,525(90.30)			4,969	504(10.14)	4465(89.86)
	55–65	38,114	4,870(12.78)	33,244(87.22)			19,470	3,039(15.61)	16,431(84.39)			10,827	1720(15.89)	9107(84.11)
	65–75	55,031	14,283(25.95)	40,748(74.05)			25,463	6,474(25.43)	18,989(74.57)			15,696	3935(25.07)	11761(74.93)
	≥ 75	40,745	9,092(22.31)	31,653(77.69)			14,684	3,140(21.38)	11,544(78.62)			9,604	2017(21)	7587(79)
	Comorbidities
	0	54,891	8,961(16.33)	45,930(83.67)	532.596	<0.001	25,564	3,629(14.20)	21,935(85.80)	348.576	<0.001	9,117	1542(16.91)	7575(83.09)	79.443	<0.001
	1	37,119	6,271(16.89)	30,848(83.11)			20,015	3,481(17.39)	16,534(82.61)			9,947	1765(17.74)	8182(82.26)
	2	39,456	8,486(21.51)	30,970(78.49)			17,649	3,534(20.02)	14,115(79.98)			11,237	2376(21.14)	8861(78.86)
	≥ 3	30,438	6,153(20.21)	24,285(79.79)			15,823	3,189(20.15)	12,634(79.85)			12,688	2559(20.17)	10129(79.83)
* NEPHSP: Population managed under the National Essential Public Health Service Program (NEPHSP).
Comorbidities were identified using a predefined list of conditions based on established clinical guidelines and expert consultation, which were then mapped to ICD-10 codes. The total number of comorbidities for each patient was calculated.

Medical costs

Based on PSM analysis, annual medical costs per capita for both managed and non-managed patients with HTN, T2DM and both conditions showed a consistent downward trend from 2022 to 2024 (Tables 2–4). T2DM patients had higher costs than HTN patients across all years. The average costs for patients with HTN, T2DM and both conditions in the NEPHSP managed group were significantly lower than those for non-managed patients. The largest cost differences between groups were observed in 2023: CNY 647.35 ± 59.99 (Z = 10.791, P < 0.001) for HTN and CNY 668.79 ± 82.02 (Z = 8.154, P < 0.001) for T2DM, and CNY 713.57 ± 114.55 (Z = 6.229, P < 0.001) for patients with both conditions.

Table 2
Comparison of medical costs between managed and non-managed groups receiving NEPHSP for Hypertension in Henan Province, China (2022–2024)
Year	Cost Type	Sample	Managed (Mean)	SD*	Non-managed (Mean)	SD	Z	P	Mean Difference	SE Difference	95%CI Upper	95%CI Lower
2022	Per Capita Inpatient	23,515	6177.63	7071.82	6591.45	9205.70	5.465	<0.001	413.82	75.72	265.41	562.22
	Comprehensive Medical Services		805.90	1448.06	1075.26	1842.87	17.417	<0.001	269.36	15.47	239.05	299.67
	Diagnostic Services		883.77	754.65	1071.97	1022.77	21.034	<0.001	188.21	8.95	170.67	205.75
	Treatment Services		951.99	1445.98	1058.53	1803.40	5.110	<0.001	106.54	20.85	65.67	147.41
	Rehabilitation		410.77	1041.76	331.37	815.01	-3.181	0.001	-79.40	24.96	-128.32	-30.47
	TCM Treatment		247.39	297.85	520.89	957.98	3.322	0.001	273.50	82.33	112.07	434.93
	Western Medicine		1223.81	1651.29	1492.64	1991.45	15.662	<0.001	268.84	17.17	235.19	302.48
	TCM Medicine		640.02	637.23	483.79	597.12	-23.763	<0.001	-156.22	6.57	-169.11	-143.34
	Blood & Blood Products		1091.32	1146.18	677.15	906.72	-6.139	<0.001	-414.17	67.47	-546.56	-281.78
2023	Per Capita Inpatient	29,676	5398.14	6425.28	6045.48	8092.97	10.791	<0.001	647.35	59.99	529.77	764.92
	Comprehensive Medical Services		566.92	898.01	904.27	1667.69	30.642	<0.001	337.35	11.01	315.78	358.93
	Diagnostic Services		847.72	697.35	951.85	883.16	15.580	<0.001	104.13	6.68	91.03	117.23
	Treament Services		875.90	1418.77	1079.99	1765.72	11.123	<0.001	204.08	18.35	168.12	240.04
	Rehabilitation		359.83	780.46	287.75	883.94	-3.351	0.001	-72.08	21.51	-114.24	-29.92
	TCM Treatment		268.69	320.28	548.62	935.32	10.425	<0.001	279.94	26.85	227.30	332.57
	Western Medicine		872.53	1049.34	1196.19	1540.54	29.667	<0.001	323.66	10.91	302.28	345.05
	TCM Medicine		579.52	594.20	485.79	595.46	-17.072	<0.001	-93.73	5.49	-104.49	-82.97
	Blood & Blood Products		954.16	849.02	744.97	785.82	-3.762	<0.001	-209.20	55.60	-318.32	-100.07
2024	Per Capita Inpatient	29,853	4879.71	5093.74	5569.49	7310.54	13.375	<0.001	689.78	51.57	588.69	790.86
	Comprehensive Medical Services		490.02	873.05	949.67	1996.39	36.384	<0.001	459.65	12.63	434.89	484.41
	Diagnostic Services		772.50	597.96	884.02	798.79	19.058	<0.001	111.52	5.85	100.05	122.99
	Treament Services		842.46	1423.58	1162.91	1811.41	17.481	<0.001	320.46	18.33	284.53	356.39
	Rehabilitation		291.62	521.92	278.79	862.00	-0.643	0.520	-12.83	19.95	-51.94	26.29
	TCM Treatment		262.71	287.80	522.78	837.29	10.667	<0.001	260.07	24.38	212.27	307.86
	Western Medicine		682.21	840.53	958.04	1344.94	29.890	<0.001	275.83	9.23	257.75	293.92
	TCM Medicine		511.82	509.68	406.57	491.53	-22.741	<0.001	-105.25	4.63	-114.32	-96.18
	Blood & Blood Products		907.65	652.44	743.29	1128.01	-2.227	0.026	-164.35	73.80	-309.16	-19.54
*SD (Standard Deviation) measures the dispersion, variability, or spread of a set of data points relative to their mean (average).

Table 3
Comparison of medical costs between managed and non-managed groups receiving NEPHSP for Type-2 diabetes mellitus in Henan Province, China (2022–2024)
Year	Cost Type	Sample	Managed (Mean)	SD	Non-managed (Mean)	SD	Z	P	Mean Difference	SE Difference	95%CI Upper	95%CI Lower
2022	Per Capita Inpatient	11,048	6298.78	6848.09	6806.13	9179.81	4.654	<0.001	507.36	109.01	293.70	721.02
	Comprehensive Medical Services		823.90	1376.25	1126.74	1807.73	13.875	<0.001	302.84	21.83	260.06	345.62
	Diagnostic Services		915.49	768.05	1160.85	1231.35	16.611	<0.001	245.36	14.77	216.40	274.31
	Treament Services		977.76	1535.21	1092.64	1801.38	3.645	<0.001	114.88	31.51	53.10	176.65
	Rehabilitation		353.65	836.23	268.91	625.09	-2.830	0.005	-84.74	29.94	-143.45	-26.03
	TCM Treatment		375.21	473.41	460.15	792.90	0.575	0.566	84.94	147.79	-204.95	374.83
	Western Medicine		1230.74	1559.19	1572.57	2126.55	13.496	<0.001	341.83	25.33	292.18	391.47
	TCM Medicine		629.96	628.94	448.09	583.21	-19.067	<0.001	-181.87	9.54	-200.57	-163.18
	Blood & Blood Products		1087.22	1253.62	573.15	842.30	-6.010	<0.001	-514.07	85.54	-682.03	-346.11
2023	Per Capita Inpatient	13,449	5609.24	6031.31	6278.03	7353.89	8.154	<0.001	668.79	82.02	508.04	829.54
	Comprehensive Medical Services		571.89	843.75	954.41	1705.62	23.292	<0.001	382.52	16.42	350.33	414.70
	Diagnostic Services		879.28	697.06	1045.61	1015.26	15.327	<0.001	166.33	10.85	145.06	187.60
	Treament Services		869.64	1377.72	1049.16	1723.68	7.021	<0.001	179.52	25.57	129.40	229.64
	Rehabilitation		343.40	731.07	245.34	669.40	-3.579	<0.001	-98.06	27.40	-151.78	-44.34
	TCM Treatment		321.91	415.01	509.69	993.10	2.687	0.007	187.78	69.87	50.75	324.81
	Western Medicine		918.87	1048.17	1257.62	1548.36	20.853	<0.001	338.75	16.24	306.91	370.59
	TCM Medicine		568.83	573.10	458.76	568.09	-13.981	<0.001	-110.06	7.87	-125.49	-94.63
	Blood & Blood Products		960.66	940.17	837.18	951.32	-1.462	0.144	-123.48	84.49	-289.43	42.47
2024	Per Capita Inpatient	13,819	5067.17	4944.96	5580.01	6902.27	7.100	<0.001	512.84	72.23	371.26	654.41
	Comprehensive Medical Services		482.22	782.05	953.80	1994.17	25.809	<0.001	471.58	18.27	435.76	507.39
	Diagnostic Services		775.42	600.50	933.17	831.74	17.828	<0.001	157.76	8.85	140.41	175.10
	Treament Services		826.47	1378.46	1089.76	1662.83	10.691	<0.001	263.28	24.63	215.01	311.55
	Rehabilitation		312.30	577.50	279.06	940.64	-0.990	0.322	-33.24	33.57	-99.07	32.58
	TCM Treatment		266.25	306.69	523.94	782.53	4.627	<0.001	257.69	55.69	148.50	366.89
	Western Medicine		717.62	816.29	981.77	1407.08	19.003	<0.001	264.15	13.90	236.90	291.39
	TCM Medicine		501.15	494.96	389.57	486.37	-16.733	<0.001	-111.58	6.67	-124.65	-98.51
	Blood & Blood Products		930.77	680.44	732.82	1259.72	-1.914	0.056	-197.95	103.41	-401.07	5.17

Table 4
Comparison of medical costs between managed and non-managed groups receiving NEPHSP for Both Conditions in Henan Province, China (2022–2024)
Year	Cost Type	Sample	Managed (Mean)	SD	Non-managed (Mean)	SD	Z	P	Mean Difference	SE Difference	95%CI Upper	95%CI Lower
2022	Per Capita Inpatient	6,471	6,402.57	6,685.98	6,759.77	8,365.05	2.683	0.007	357.20	133.12	618.14	96.26
	Comprehensive Medical Services		816.25	1,298.58	1,045.73	1,732.42	8.526	<0.001	229.48	26.91	282.24	176.72
	Diagnostic Services		797.07	768.78	993.83	1,044.20	12.206	<0.001	196.76	16.12	228.36	165.16
	Treament Services		520.81	1,168.05	486.67	1,219.25	-1.626	0.104	-34.14	20.99	7.00	-75.28
	Rehabilitation		29.43	275.03	51.71	342.36	4.080	<0.001	22.27	5.46	32.97	11.57
	TCM Treatment		0.00	0.00	64.85	393.80	13.248	<0.001	64.85	4.90	74.45	55.26
	Western Medicine		1,233.41	1,619.19	1,546.70	2,077.33	9.569	<0.001	313.29	32.74	377.47	249.11
	TCM Medicine		593.74	634.88	358.91	592.64	-21.751	<0.001	-234.84	10.80	-213.67	-256.00
	Blood & Blood Products		15.87	215.48	18.71	159.68	0.854	0.393	2.85	3.33	9.38	-3.69
2023	Per Capita Inpatient	7,997	5,878.09	6,688.67	6,591.66	7,758.98	6.229	<0.001	713.57	114.55	938.10	489.03
	Comprehensive Medical Services		573.22	836.93	921.23	1,558.57	17.592	<0.001	348.00	19.78	386.78	309.23
	Diagnostic Services		877.36	733.56	990.78	900.76	8.731	<0.001	113.42	12.99	138.88	87.96
	Treament Services		516.81	1,178.40	533.26	1,329.77	0.828	0.408	16.45	19.87	55.39	-22.50
	Rehabilitation		28.94	240.90	45.75	309.93	3.830	<0.001	16.81	4.39	25.41	8.21
	TCM Treatment		0.28	10.38	73.19	469.97	13.868	<0.001	72.90	5.26	83.21	62.60
	Western Medicine		933.55	1,075.22	1,248.06	1,518.04	15.119	<0.001	314.51	20.80	355.28	273.73
	TCM Medicine		571.65	601.04	392.30	593.07	-18.995	<0.001	-179.35	9.44	-160.85	-197.86
	Blood & Blood Products		10.71	116.29	16.91	172.40	2.665	0.008	6.20	2.33	10.76	1.64
2024	Per Capita Inpatient	8,242	5,270.78	5,220.04	5,692.28	6,173.98	4.733	<0.001	421.50	89.06	596.06	246.94
	Comprehensive Medical Services		473.83	874.70	906.58	1,365.26	24.231	<0.001	432.76	17.86	467.77	397.75
	Diagnostic Services		791.05	616.15	911.32	777.50	11.007	<0.001	120.28	10.93	141.69	98.86
	Treament Services		506.90	1,165.66	522.42	1,282.27	0.813	0.416	15.52	19.09	52.94	-21.89
	Rehabilitation		25.26	194.51	46.42	318.70	5.146	<0.001	21.16	4.11	29.22	13.10
	TCM Treatment		0.23	11.01	81.77	366.07	20.215	<0.001	81.55	4.03	89.46	73.64
	Western Medicine		735.41	855.69	955.45	1,177.94	13.721	<0.001	220.04	16.04	251.47	188.60
	TCM Medicine		500.55	510.20	315.52	467.48	-24.275	<0.001	-185.03	7.62	-170.09	-199.97
	Blood & Blood Products		8.70	107.08	19.81	293.29	3.230	0.001	11.11	3.44	17.85	4.37

When stratified by types of medical costs (Table 2–4), we found that NEPHSP-managed patients had lower average costs for general medical services, diagnostics, treatment, and western medicine compared to non-managed patients. Conversely, costs for other categories, including rehabilitation, traditional Chinese medicine, and blood products, were consistently lower in the non-managed group. For example, in 2024, managed HTN patients had CNY 459.65 ± 12.63 lower costs for general medical services than non-managed patients (Z = 36.384, P < 0.001), but CNY 105.25 ± 4.63 higher costs for TCM (Z=-22.741, P < 0.001).

Medical costs by sex, age, and number of comorbidities

We also compared medical costs for patients with HTN, T2DM and both conditions between those managed in the NEPHSP (managed) and those not managed (non-managed) in terms of sex, age, and the number of comorbidities (Tables 5–7).

Table 5
Stratified comparison of medical costs by category between managed and non-managed groups receiving NEPHSP for Hypertension in Henan Province, China (2022–2024)
Year	Feature	Sample	Managed (Mean)	SD	Non-managed (Mean)	SD	Z	P	Mean Difference	SE Difference	95%CI Upper	95%CI Lower
2022	Sex
	Male	10,557	6,308.45	7210.52	6,784.52	8918.21	4.264	<0.001	476.07	111.64	257.25	694.88
	Female	12,958	6,071.05	6955.24	6,434.06	9430.98	3.526	<0.001	363.01	102.97	161.19	564.83
	Age
	35–45	189	5,591.16	4522.88	6,803.00	7552.11	1.893	0.059	1211.84	640.32	-47.21	2470.89
	45–55	1,364	5,941.26	7754.00	6,143.30	8550.29	0.646	0.518	202.04	312.53	-410.79	814.87
	55–65	3,809	6,126.01	6869.97	6,356.30	9831.92	1.185	0.236	230.29	194.36	-150.71	611.29
	65–75	11,058	6,238.40	6917.64	6,802.94	10044.98	4.866	<0.001	564.54	116.01	337.16	791.93
	≥ 75	7,095	6,171.69	7329.67	6,468.77	7485.02	2.388	0.017	297.08	124.41	53.21	540.94
	Comorbidities
	0	6,326	6,256.67	8143.82	6,084.93	8684.88	-1.147	0.251	-171.73	149.70	-465.17	121.71
	1	5242	6,604.35	7970.95	6,661.16	8108.81	0.362	0.718	56.82	157.06	-251.05	364.69
	2	6,914	5,913.96	6319.16	6,767.33	10011.24	5.993	<0.001	853.37	142.40	574.24	1132.49
	≥ 3	5,033	5,996.06	5382.50	6,914.79	9725.53	5.862	<0.001	918.73	156.73	611.51	1225.95
2023	Sex
	Male	13,071	5,509.45	6095.28	6,368.95	8801.38	9.178	<0.001	859.50	93.64	675.95	1043.05
	Female	16,605	5,310.51	6672.45	5,790.86	7478.76	6.175	<0.001	480.34	77.78	327.89	632.80
	Age
	35–45	240	5,595.35	5848.68	5,464.43	5059.48	-0.262	0.793	-130.92	499.19	-1111.80	849.95
	45–55	1,765	4,962.36	4698.72	5,148.51	5619.43	1.068	0.286	186.15	174.38	-155.74	528.04
	55–65	5,029	5,378.93	8049.57	5,471.87	6726.04	0.628	0.530	92.94	147.92	-197.01	382.89
	65–75	14,352	5,486.56	6654.38	6,336.58	9155.87	8.996	<0.001	850.01	94.48	664.82	1035.20
	≥ 75	8,290	5,343.76	5107.57	6,097.31	7342.57	7.671	<0.001	753.54	98.24	560.99	946.10
	Comorbidities
	0	8,957	5,078.39	6376.18	5,619.99	7859.33	5.064	<0.001	541.59	106.94	331.98	751.21
	1	6,136	5,939.27	7517.27	6,211.62	7874.54	1.960	0.050	272.36	138.98	-0.06	544.78
	2	8,991	5,195.36	5731.95	6,070.13	8611.23	8.018	<0.001	874.77	109.10	660.92	1088.61
	≥ 3	5,592	5,642.54	6208.76	6,505.04	7802.39	6.468	<0.001	862.50	133.35	601.12	1123.89
2024	Sex
	Male	13,089	5,037.63	5345.45	5,788.44	7856.41	9.039	<0.001	750.81	83.06	588.00	913.62
	Female	16,764	4,756.43	4884.87	5,398.50	6849.46	9.881	<0.001	642.07	64.98	514.71	769.43
	Age
	35–45	167	4,632.26	3176.71	5,449.68	6048.57	1.546	0.123	817.42	528.68	-222.56	1857.41
	45–55	1,458	4,721.61	4359.98	5,055.00	5675.99	1.778	0.075	333.40	187.47	-34.18	700.98
	55–65	4,867	4,795.46	5015.21	5,176.08	6742.08	3.160	0.002	380.62	120.45	144.52	616.72
	65–75	14,277	4,961.88	5451.14	5,710.94	7718.11	9.472	<0.001	749.07	79.08	594.06	904.08
	≥ 75	9,084	4,825.66	4673.28	5,642.69	7188.09	9.082	<0.001	817.04	89.96	640.70	993.37
	Comorbidities
	0	8,959	4,818.59	5508.71	5,186.11	6525.23	4.073	<0.001	367.52	90.23	190.66	544.38
	1	6,269	5,326.64	5984.06	5,724.63	7745.90	3.219	0.001	398.00	123.63	155.67	640.33
	2	8,482	4,622.86	4669.50	5,629.48	7742.36	10.253	<0.001	1006.62	98.18	814.18	1199.07
	≥ 3	6,143	4,867.35	3859.70	5,887.50	7301.35	9.681	<0.001	1020.15	105.37	813.60	1226.69

Table 6
Stratified comparison of medical costs by category between managed and non-managed groups receiving NEPHSP for Type-2 diabetes mellitus in Henan Province, China (2022–2024)
Year	Feature	Sample	Managed (Mean)	SD	Non-managed (Mean)	SD	Z	P	Mean Difference	SE Difference	95%CI Upper	95%CI Lower
2022	Sex
	Male	4,577	6,399.94	7,207.06	6,909.35	8,711.28	3.047	0.002	509.41	167.18	181.69	837.13
	Female	6,471	6,227.22	6,582.01	6,733.08	9,497.46	3.520	<0.001	505.86	143.71	224.17	787.55
	Age
	35–45	159	5,480.93	4,787.23	6,494.70	7,188.60	1.479	0.140	1013.78	685.60	-335.16	2362.71
	45–55	927	5,942.35	7,779.63	6,766.93	10,674.13	1.900	0.058	824.58	433.90	-26.41	1675.56
	55–65	2,370	6,077.26	6,064.67	6,411.23	8,176.03	1.597	0.110	333.97	209.17	-76.10	744.04
	65–75	5,139	6,359.51	6,864.88	6,879.52	9,544.13	3.170	0.002	520.02	164.06	198.43	841.60
	≥ 75	2,453	6,573.28	7,241.64	7,069.44	8,807.89	2.154	0.031	496.16	230.40	44.48	947.85
	Comorbidities
	0	2,783	6,329.94	7,524.06	6,336.21	8,896.16	0.028	0.977	6.28	221.03	-427.02	439.58
	1	2,822	6,418.62	7,380.78	6,440.03	7,396.56	0.109	0.913	21.41	196.75	-364.30	407.12
	2	2,937	6,229.24	6,709.38	7,032.58	10,353.46	3.528	<0.001	803.34	227.70	356.97	1249.71
	≥ 3	2,506	6,210.71	5,458.99	7,475.33	9,777.69	5.651	<0.001	1264.62	223.80	825.88	1703.36
2023	Sex
	Male	5,496	5,579.90	5,213.53	6,320.28	7,380.59	6.074	<0.001	740.38	121.89	501.45	979.31
	Female	7,953	5,629.52	6,537.18	6,248.83	7,335.70	5.621	<0.001	619.32	110.19	403.34	835.29
	Age
	35–45	182	4,840.20	4,004.44	5,354.75	5,068.78	1.075	0.283	514.55	478.83	-427.08	1456.18
	45–55	1,167	5,121.51	4,261.46	5,400.58	6,021.50	1.292	0.196	279.07	215.94	-144.39	702.53
	55–65	2,992	5,561.41	7,546.31	5,842.95	6,142.03	1.583	0.114	281.54	177.88	-67.17	630.25
	65–75	6,300	5,688.79	5,942.22	6,499.43	7,885.88	6.516	<0.001	810.64	124.41	566.79	1054.49
	≥ 75	2,808	5,734.27	5,060.93	6,669.75	7,860.78	5.302	<0.001	935.48	176.45	589.58	1281.39
	Comorbidities
	0	3,507	5,556.34	6,295.05	5,969.27	7,952.33	2.411	0.016	412.93	171.28	77.18	748.68
	1	3,449	5,622.85	7,028.32	6,209.94	7,418.61	3.374	0.001	587.09	174.01	245.98	928.20
	2	3,620	5,572.06	4,554.23	6,425.05	7,225.69	6.008	<0.001	852.99	141.96	574.70	1131.28
	≥ 3	2,873	5,704.33	6,041.70	6,551.46	6,628.49	5.062	<0.001	847.13	167.34	519.08	1175.18
2024	Sex
	Male	5,705	5,205.83	5,257.44	5,683.39	6625.38	4.265	<0.001	477.57	111.98	258.06	697.07
	Female	8,114	4,969.68	4,710.76	5,507.30	7090.02	5.689	<0.001	537.62	94.51	352.38	722.86
	Age
	35–45	154	5,330.94	6,852.53	5,342.45	6655.24	0.015	0.988	11.51	769.76	-1503.18	1526.20
	45–55	1,023	4,796.97	3,582.64	4,823.31	4146.77	0.154	0.878	26.34	171.34	-309.67	362.35
	55–65	3,037	4,938.63	4,375.01	5,418.56	6842.22	3.257	0.001	479.93	147.37	191.04	768.83
	65–75	6,468	5,134.32	5,379.93	5,707.09	7460.16	5.008	<0.001	572.77	114.37	348.59	796.95
	≥ 75	3,137	5,128.32	4,795.51	5,732.88	6464.75	4.206	<0.001	604.55	143.73	322.79	886.31
	Comorbidities
	0	3,629	5,246.61	5,453.53	5,305.14	5877.01	0.440	0.660	58.53	133.11	-202.40	319.46
	1	3,481	5,155.38	5,731.69	5,418.52	7899.54	1.591	0.112	263.14	165.43	-61.15	587.44
	2	3,534	4,959.58	4,315.46	5,719.63	6519.83	5.779	<0.001	760.05	131.53	502.22	1017.89
	≥ 3	3,175	4,885.12	3,952.08	5,915.63	7206.75	7.065	<0.001	1030.51	145.87	744.56	1316.46

Table 7
Stratified comparison of medical costs by category between managed and non-managed groups receiving NEPHSP for Both Conditions in Henan Province, China (2022–2024)
Year	Feature	Sample	Managed (Mean)	SD	Non-managed (Mean)	SD	Z	P	Mean Difference	SE Difference	95%CI Upper	95%CI Lower
2022	Sex
	Male	2,535	6,393.83	6,352.51	6,797.87	8,348.17	1.939	0.053	404.05	208.35	812.51	-4.42
	Female	3,936	6,408.21	6,893.00	6,735.23	8,376.87	1.891	0.059	327.03	172.92	665.99	-11.93
	Age
	35–45	62	6,116.02	5,755.78	6,945.46	6,161.15	0.775	0.440	829.43	1,070.79	2,949.17	-1,290.30
	45–55	444	6,099.72	5,554.90	5,938.66	6,927.88	-0.382	0.702	-161.05	421.42	666.05	-988.15
	55–65	1,291	6,345.62	6,448.50	6,440.73	7,310.77	0.351	0.726	95.11	271.31	627.12	-436.90
	65–75	3,121	6,443.82	6,914.70	6,964.71	9,240.92	2.521	0.012	520.89	206.59	925.89	115.90
	≥ 75	1,553	6,465.05	6,747.15	6,840.46	7,749.39	1.440	0.150	375.42	260.73	886.65	-135.81
	Comorbidities
	0	1,197	6,633.85	6,819.13	6,469.52	7,820.55	-0.548	0.584	-164.32	299.90	423.78	-752.42
	1	1,370	6,524.98	7,564.91	6,368.84	7,487.62	-0.543	0.587	-156.13	287.57	407.74	-720.00
	2	1,920	6,309.69	6,744.90	6,699.51	8,615.98	1.561	0.119	389.82	249.72	879.41	-99.77
	≥ 3	1,984	6,268.41	5,848.37	7,263.15	8,970.02	4.138	<0.001	994.74	240.41	1,466.07	523.41
2023	Sex
	Male	3,109	5,771.35	5,160.08	6,678.02	7,821.76	5.395	<0.001	906.67	168.06	1,236.12	577.22
	Female	4,888	5,945.99	7,500.28	6,536.73	7,719.09	3.837	<0.001	590.74	153.94	892.50	288.98
	Age
	35–45	75	5,529.87	5,590.49	5,069.96	3,641.03	-0.597	0.551	-459.90	770.37	1,062.45	-1,982.25
	45–55	581	5,368.08	4,316.83	6,190.41	8,633.33	2.054	0.040	822.33	400.45	1,608.02	36.64
	55–65	1,732	5,811.98	8,928.68	5,983.67	5,920.50	0.667	0.505	171.69	257.42	676.41	-333.03
	65–75	3,820	5,977.47	6,490.99	6,901.97	8,450.22	5.362	<0.001	924.50	172.40	1,262.46	586.55
	≥ 75	1,789	5,910.14	5,044.31	6,711.78	7,570.90	3.727	<0.001	801.65	215.09	1,223.35	379.94
	Comorbidities
	0	1,517	6,192.83	6,814.72	6,455.80	7,741.44	0.993	0.321	262.97	264.80	782.18	-256.23
	1	1,686	6,060.47	8,882.52	6,812.77	8,493.86	2.513	0.012	752.31	299.31	1,339.16	165.46
	2	2,489	5,621.93	4,765.32	6,426.96	7,723.59	4.426	<0.001	805.04	181.91	1,161.66	448.42
	≥ 3	2,305	5,814.18	6,505.26	6,697.19	7,226.86	4.360	<0.001	883.01	202.53	1,280.06	485.95
2024	Sex
	Male	3,308	5,442.83	5,732.88	5,843.52	6,603.59	2.635	0.008	400.69	152.04	698.74	102.63
	Female	4,934	5,155.44	4,843.09	5,590.89	5,866.88	4.021	<0.001	435.45	108.31	647.75	223.15
	Age
	35–45	66	5,286.79	3,181.54	6,002.62	6,644.97	0.789	0.431	715.83	906.86	2,509.94	-1,078.28
	45–55	504	5,288.31	4,127.30	5,126.66	4,456.19	-0.597	0.550	-161.65	270.55	369.27	-692.56
	55–65	1,720	5,300.93	4,884.54	5,538.83	6,092.96	1.263	0.207	237.90	188.30	607.08	-131.28
	65–75	3,935	5,311.14	5,702.91	5,816.76	6,444.77	3.686	<0.001	505.62	137.19	774.55	236.70
	≥ 75	2,017	5,161.44	4,794.34	5,711.46	6,049.86	3.200	0.001	550.02	171.88	887.00	213.04
	Comorbidities
	0	1,542	5,988.53	5,847.39	5,781.28	6,325.11	-0.945	0.345	-207.25	219.36	222.86	-637.35
	1	1,765	5,535.67	6,726.68	5,870.86	6,597.87	1.495	0.135	335.19	224.28	774.91	-104.54
	2	2,376	4,993.71	4,617.37	5,564.79	6,087.10	3.643	<0.001	571.08	156.74	878.36	263.79
	≥ 3	2,559	4,912.85	3,953.69	5,633.86	5,851.08	5.165	<0.001	721.01	139.60	994.68	447.34

Stratification by sex

Among both managed and non-managed groups, male HTN patients incurred significantly higher medical costs than females (P < 0.05). NEPHSP-managed patients had significantly lower costs than non-managed patients across all disease and sex subgroups (all P < 0.05). In 2023, the per capita cost savings for managed patients were most substantial: male HTN patients saved CNY 859.50 ± 93.64 (Z = 9.178, P < 0.001), and male T2DM patients saved CNY 740.38 ± 121.89 (Z = 6.074, P < 0.001). Female HTN and T2DM patients saved CNY 642.07 ± 64.98 and CNY 619.32 ± 110.19, respectively (both P < 0.001). Similarly, patients with both conditions showed significant savings, particularly males (CNY 906.67 ± 168.06, P < 0.001). Notably, the sex-based cost difference among HTN patients narrowed significantly under NEPHSP management. In 2023, the cost gap between males and females was reduced from CNY 578.09 ± 94.57 in the non-managed group to CNY 198.94 ± 75.12 in the managed group (P = 0.008).

Stratification by age group

Analysis by age group revealed that the peak per capita medical cost for HTN and patients with both conditions occurred in the 65–75 years age group, while for T2DM patients, the peak occurred in the ≥ 75 years age group. The cost-saving effect of NEPHSP management was significant among older patients (65–75 years and ≥ 75 years) (all P < 0.05). Taking 2023 as an example, managed HTN, T2DM and patients with both conditions aged 65–75 years had per capita medical costs lower by CNY 850.01 ± 94.48 (Z = 8.996, P < 0.001), CNY 810.64 ± 124.41 (Z = 6.516, P < 0.001) and CNY 924.50 ± 172.40 (Z = 6.516, P < 0.001), respectively, compared to non-managed patients. Managed HTN, T2DM and patients with both conditions aged ≥ 75 years had per capita medical costs lower by CNY 753.54 ± 98.24 (Z = 7.671, P < 0.001), CNY 935.48 ± 176.45 (Z = 5.302, P < 0.001) and CNY 801.65 ± 215.09 (Z = 5.302, P < 0.001), respectively, compared to non-managed patients.

Stratification by the number of comorbidities

For HTN, T2DM and both conditions, when the number of comorbidities was ≥ 2, the per capita medical costs of those managed in the NEPHSP were significantly lower than those of non-managed patients (all P < 0.001). Furthermore, the per capita cost savings were greater when the number of comorbidities was ≥ 3. Taking 2024 as an example, for HTN patients with ≥ 3 comorbidities, managed patients had per capita medical costs lower by 1020.15 ± 105.37 RMB (Z = 9.681, P < 0.001) compared to non-managed patients; for T2DM patients with ≥ 3 comorbidities, managed patients had costs lower by 1030.51 ± 145.87 RMB (Z = 7.065, P < 0.001) compared to non-managed patients and for patients with both conditions with ≥ 3 comorbidities, managed patients had costs lower by 721.01 ± 139.60 RMB (Z = 5.165, P < 0.001) compared to non-managed patients.

Sensitivity analysis including socioeconomic indicators

When considering socioeconomic indicators (insurance type and occupation) in the PSM, we found similar results showing that NEPHSP managed groups had lower annual medical costs per capita than non-managed groups (see Supplementary Tables 6–8).

This is the first large-scale real-world study to quantify the economic savings attributable to China’s NEPHSP for the management of HTN and T2DM patients. Our findings highlight that NEPHSP management is associated with substantial reductions in direct medical costs. This cost-saving effect remained robust throughout the entire three-year observation period, with the largest cost difference observed in 2023. This effect was most pronounced in males, older patients (≥ 65 years), and those with three or more comorbidities.

We found that annual per capita medical costs consistently decreased from 2022 to 2024 among all patients, regardless of NEPHSP management groups. This trend may be attributed to China’s implementation of the Diagnosis-Intervention Packet (DIP) payment system. Since 2022, Henan Province has fully adopted the DIP payment model, and existing evidence supports its effectiveness in reducing medical expenditures^19,20.

Our findings show that NEPHSP significantly reduced medical expenditures for HTN and T2DM. While prior research has found the effectiveness of NEPHSP in improving treatment and control rates,²¹ the present study extends existing evidence by demonstrating that enhanced disease management translates into substantial medical cost savings. China’s current health policy emphasises prevention, shifting from a “treatment-centred” to a “health-centred” approach, implementing a health-prioritised development strategy that integrates health into all policies.²² Our findings provide empirical support for the hypothesis that “prevention/management investments yield long-term economic returns.” As highlighted in a recent WHO report,²³ every USD 1 invested in scaling up cost-effective NCD interventions could yield a return of up to USD 7, potentially generating USD 230 billion in total economic benefits by 2030. Cost-effectiveness studies on chronic disease management programs elsewhere also reveal economic benefits,²⁴ aligning with our findings and underscoring the value of primary healthcare initiatives like NEPHSP in controlling chronic disease costs.

The cost savings were primarily driven by reductions in core expenditure categories: comprehensive medical services, diagnostics, treatments, and Western medicines. The slightly higher costs observed in the management group for rehabilitation, traditional Chinese medicine, and blood products may reflect greater utilisation needs in these areas.²⁵ The cost-saving mechanism likely involves early intervention and complication prevention. Routine screening and follow-up under NEPHSP facilitate earlier disease detection, timely treatment adjustments, and enhanced patient self-management, thereby effectively preventing or delaying severe complications—major drivers of high hospitalisation and emergency costs.²⁶ Regular provider contact and health management may also improve medication adherence and treatment standardisation, reducing unnecessary tests and inappropriate prescribing. The observed reductions in costs for comprehensive services, diagnostics, treatments, and Western medicines support this explanation.

Stratified analyses revealed greater cost savings among male patients. NEPHSP management significantly narrowed the gender-based expenditure gap, highlighting its potential to improve health equity. Males typically bear a higher disease burden, incur greater medical costs, and present greater management challenges.²⁷ The structured management of NEPHSP (e.g., regular follow-ups, intensive monitoring, timely interventions) is likely to play a more critical role in curbing cost escalation in this vulnerable group. The narrowing of gender disparities reflects the program’s potential to promote health equity. Age-stratified analysis showed optimal cost-saving effects in the high-expenditure over 65-year-old group. This validates the effectiveness of NEPHSP management for older adults, aiding in addressing the chronic disease burden associated with aging.^28,29 The cost-saving effect intensified significantly with the increasing number of comorbidities, indicating that NEPHSP yields the most substantial benefit for high-risk populations. Management markedly buffered the cost surge associated with the rising number of comorbidities. This pattern is likely attributable to the program’s coordinated care approach, which may facilitate early intervention, reduce redundant treatments, prevent complications, and optimise resource utilisation for patients with complex health needs.

Our findings suggest a proportionate universalism approach within the NEPHSP. This entails maintaining universal coverage while directing additional resources towards male, elderly, and multi-comorbid HTN/T2DM patients. These subgroups may benefit more from the NEPHSP management, offering the highest return on investment. Investment in primary healthcare can effectively reduce the long-term economic burden of disease at both national and individual levels, demonstrating significant cost-saving benefits. The Chinese government recently issued the “Notice on Effectively Implementing Essential Public Health Services in 2025”³⁰, which strengthens continuous primary care services for patients with HTN or T2DM. This involves implementing tiered and continuous care: increasing follow-up frequency for patients with unstable chronic conditions, facilitating timely referrals to higher-level medical institutions based on clinical need, and ensuring referral tracking.

Despite substantial government investment in the primary healthcare system through China’s NEPHSP, the program faces several challenges.³¹ First, primary care providers often lack sufficient capacity, exhibiting deficiencies in core competencies such as chronic disease diagnosis/treatment and patient communication. Second, the quality of service and the evaluation mechanism are suboptimal; the current performance assessment overemphasises service volume metrics (e.g., number of records established, follow-up visits) while neglecting service quality and actual health outcomes. These limitations erode public trust in and utilisation of primary care services, leading patients to bypass primary care institutions in favour of seeking care at higher-level hospitals. The present study, however, reveals the significant cost-saving effect achieved by investing in essential public health services. Future research should further investigate the long-term effects and specific mechanisms of action of the NEPHSP to provide a foundation for refining chronic disease prevention and control strategies.

Strengths and limitations

This study is the first in China to utilise large-scale real-world data to quantitatively evaluate the cost-saving effect of the NEPHSP on direct medical expenditures for HTN and T2DM patients. It addresses a critical gap in previous research focusing on process indicators (e.g., treatment rates, control rates). The application of PSM effectively controlled for selection bias, enhancing the causal interpretability of the results. Furthermore, the in-depth analysis of cost-saving variations across different subpopulations (by gender, age, comorbidities) provides crucial evidence for precise resource allocation optimisation and policy refinement.

However, there were several limitations. First, as the analysis relied primarily on medical record homepage data, which emphasises inpatient costs, outpatient and medication expenses were not fully captured, potentially underestimating total cost savings. Second, the NEPHSP only covers individuals aged 35 and older with HTN or T2DM, limiting generalisability to younger patients. Third, although based on representative data from Henan, regional variations across China may affect the nationwide generalisability. Finally, despite using PSM, residual confounding may persist due to the observational design, and causal inferences should be made cautiously. We controlled for socioeconomic status using PSM for a small group of patients due to data availability, however results are similar, indicating the robustness of our findings.

In conclusion, this study provides large-scale province-wide evidence from Henan that China’s investment in community-based management of HTN and T2DM through the NEPHSP yields substantial economic returns. This financial benefit is most pronounced in high-risk groups, including among males, older adults, and those with multiple comorbidities. These findings present a compelling case for policymakers to sustain and increase investment in NEPHSP, with targeted resource allocation to maximise its value among those who benefit most. Further work is needed to explore the long-term clinical and economic outcomes and the specific programmatic components driving these savings, providing the evidence needed to refine and scale this successful public health model nationally and globally.

HTN

Hypertension

T2DM

Type-2 diabetes mellitus

NEPHSP

National Essential Public Health Service Package

IHP+

International Health Partnership+

M&E

Monitoring and Evaluation

CNKI

China National Knowledge Infrastructure

WHO

World Health Organization

PSM

Propensity score matching

DIP

Diagnosis-Intervention Packet

Ethics approval and consent to participate

This study was conducted in accordance with the principles of the Declaration of Helsinki. The study protocol and the waiver of informed consent were approved by the Medical Ethics Committee of Fuwai Central China Cardiovascular Hospital (Approval No: #202485). Due to the retrospective nature of the study and the use of anonymized patient data, the requirement for individual informed consent was waived by the ethics committee.

Consent for publication

Not Applicable.

Availability of data and materials

The request for dataset is available from the corresponding authors at Neng-Guang Dai and Zhi-Ping Guo, [email protected] & [email protected].

Competing interests

All authors declare no competing interests.

Funding

Henan Provincial Major Science and Technology Project (241100310300); Henan Cardiovascular Disease Center (Central China Subcenter of National Center for Cardiovascular Diseases; 2023-FZX15). The funders had no involvement in study design, data collection, analysis, interpretation, or manuscript preparation.

Authors’ contributions

RL and ML conceived and designed the study. ML and YL designed and performed the data analysis strategy. QW, TJ, YM, QZ, JF, YM and TC managed the program’s operations and oversaw the quality of work performed by local hospitals. ML analyzed the data. SG validated the data analyses. ND and ZG supervised the data analyses. RL, ML, QW and SG interpreted the data. ML drafted the manuscript. All authors revised the manuscript and had final responsibility for the decision to submit for publication.

Acknowledgments

This study was supported by the Henan Provincial Major Science and Technology Project (Grant No. 241100310300) and the Henan Cardiovascular Disease Center (Central China Subcenter of the National Center for Cardiovascular Diseases; Grant No. 2023-FZX15). The funding was awarded to Rongmei Liu, Nengguang Dai, and Zhiping Guo

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The Economic Impact of National Essential Public Health Service Package for Hypertension and Type-2 Diabetes: A Retrospective Province-wide Study in China

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Introduction

Methods

Applied conceptual framework

Study setting

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Definition of Disease and Outcomes

Statistical analysis

Results

Characteristics of Patients with HTN and T2DM

Medical costs

Medical costs by sex, age, and number of comorbidities

Stratification by sex

Stratification by age group

Stratification by the number of comorbidities

Sensitivity analysis including socioeconomic indicators

Discussion

Strengths and limitations

Conclusions and implications

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