China's Healthcare Costing in Times of Crisis: Conflicts, Interactions, and Hidden Agendas

This paper presents a longitudinal interpretive case study on the development of healthcare costing in China over the period 2002 to 2015. Adopting a middle-range theory lens, the study explores dynamic interactions in the use of cost information among societal institutions and organizations. It reports the successful internalization of costing systems in public hospitals in Beijing, which supports the effectiveness of a hybrid steering mechanism combining both transactional and relational features; however, such successful internalization does not indicate the success of steering the lifeworld of institutions and organizations towards change. Notably, hospitals' responses to steering alter over time, from passive absorption to active manipulation, revealing how cost information may underpin hospital beliefs in marketization. At an institutional level, the paper provides empirical evidence for relational steering among societal institutions, where a reaction of 'rebuttal' is observed. It offers insights on how accounting can be a powerful tool in legitimizing such rebuttal, while keeping political considerations as hidden agendas. The findings suggest the importance of understanding lifeworld complexity at both societal and organizational levels, and cross-institutional collaboration in using accounting as a steering mechanism. The findings have important policy implications for public sector reform, both in China and worldwide.