Blockchain-based　healthcare　IoT　technology　research　enhances　security　for　smart　healthcare　services　such　as　real-time　monitoring　and　remote　disease　diagnosis.　To　incentivize　positive　behavior　among　participants　within　a　blockchain-based　smart　healthcare　system,　existing　efforts　employ　benefit　distribution　and　reputation　assessment　methods　to　enhance　performance.　Yet,　there　remains　a　significant　gap　in　multidimensional　assessment　strategies　and　consensus　improvements　in　addressing　complex　healthcare　scenarios.　In　this　paper,　we　propose　a　blockchain　and　trusted　reputation　assessment-based　incentive　mechanism　for　healthcare　services　(BtRaI).　BtRaI　provides　a　realistic　and　comprehensive　reputation　assessment　with　feedback　to　motivate　blockchain　consensus　node　participation,　thus　effectively　defending　against　malicious　behavior　in　the　healthcare　service　system.　Specifically,　BtRaI　first　introduces　multiple　moderation　factors　for　comprehensive　multidimensional　reputation　assessment　and　credibly　records　the　assessment　results　on　the　blockchain.　Then,　we　propose　an　improved　PBFT　algorithm,　grounded　in　the　reputation　assessment,　to　augment　blockchain　consensus　efficiency.　Finally,　BtRaI　designs　a　token-based　reward　and　punishment　mechanism　to　motivate　honest　participation　in　the　blockchain,　inhibit　potential　misbehavior,　and　promote　enhanced　service　quality　in　the　healthcare　system.　Theoretical　analysis　and　simulation　experiments　conducted　across　various　scenarios　demonstrate　that　BtRaI　effectively　suppresses　malicious　attacks　in　healthcare　services,　improves　blockchain　node　fault　tolerance　rates,　and　achieves　blockchain　transaction　processing　efficiency　within　0.5　s　in　a　100-node　consortium　chain.　BtRaI＇s　reputation　assessment　and　token　incentive　mechanism,　characterized　by　realistic　differentiation　granularity　and　change　curves,　are　well-suited　for　dynamic　and　complex　healthcare　service　environments.　©　2023　Elsevier　B.V.