| 1. The significance and background of the research1.1 The tripartite intensification of conflicts between the health care organizers, the provider, and people receiving careCurrently, as consumers of health care, people have strong reactions mainly to seven aspects; including expensive medical care, difficulty to see a doctor, artificially high pricing of medication, unnecessary prescription of drugs, and widening range of lab tests, etc. In the mean time, negative media reports undoubtedly played a role in fueling the gradual equivalence between doctors and "White Wolf. As the result, (1) the social opinion of the health care provider and medical staff are lowered. (2) The level of trust between the medical staff and the people decline. (3) Doctor-patient conflicts and disputes are frequent. (4) Medical staff is concerned regarding declining the social status of their profession. Public health system in China plays a huge role in Chinese people’s health and wellbeing. In theory, the health care provider feels very respectable as a huge asset to society, however, in recent years, the recognition has deteriorated; medical institutions feel undervalued - mainly due to the distortions caused by government involvement and responsibilities of the government. The government finances have always been inadequate, medical and labor charge did not reflect the value of the work. General charges are unreasonable. In the health care system, organizer, provider and people receiving the health care, tripartite status is currently in an unbalanced state. The intensification of conflicts intensified, medical and healthcare issues such as expensive and hard to get health care has risen to the point of view that CPC Central Committee has included this unbalanced state into their policy agenda.1.2 Relieve the key issues and contradiction, toward a balanced system is a priorityTo solve the problem, eliminate of grievances, medical services requires from the imbalance towards a balanced tripartite has become a top priority. In the 1990s, the research group has demonstrated the cause and the formation mechanism of this problem using qualitative derivation and quantitative, this view was later widely recognized in China and the world, the issue due to its unreasonable compensation mechanism. When China entered the market economy, the shrinking of government financial assistance to public hospitals has resulted in emphasizing and encouraging public hospitals to be "self-financing", "self-supporting". However, standard charges determined by revenue (no or very low labor charges; income over expenditure of general service; income much greater than expenditure charges for the high-tech services; medicines allowed to be charged up to 15% increase from purchase price) has led medical institutions facing survival and development difficulty if they focus on general services. In the event of insufficient supervision, medical institutions encourage their medical staff to use high-tech drugs and high-tech services regardless of necessity. As excessive growth of medical costs becomes a reality, expensive medical care is natural.Based on the results of the qualitative and quantitative proof from the previous research, the study will continue to maximize the goal of the CPC Central Committee’s entire health care system; explore the complex contradictory relationship between health care organizer, the provider and the people receiving the care (consumer) to clarify the balance point of the system and the requirement for proper conduct of each party. Then the study will identify the gap between unbalanced state to balanced state and discuss the key strategies for minimising the gap; at the end the study will suggest the methods, solutions, policies which led to the unbalanced state to balanced state. All of above based on Game Theory.1.3 The desire to fill the vacuum of research in China and the world1.3.1 The health care system needs to resolve the conflicts from the perspective of Game EquilibriumPreliminary research shows that China’s health care system, government financial funding, commodity prices, hospitals, people interests are intertwined and complex. Game Theory with its analysis of the advantages of multi-complex relationships in many fields will be the guidance of this study, through from the imbalance to a balanced state.Game Theory is divided into qualitative and quantitative studies. Qualitative research is already quite mature, are reasoning-based, drawing on the knowledge of Game Theory, defined from the stakeholder relations perspective to the game power, resistance, direct countermeasures. This is uncommon in the field of health care services research. For quantitative research, this can be subdivided based on the classic Nash equilibrium of semi-quantitative and quantitative study of the mathematical model of Equilibrium. Game model of semi-quantitative reasoning behavior patterns by analysis of the relevant parties in the game, building the game tree diagram and the game matrix. In the field of Medical service research, the classic pattern of behavior of Gudong Hui (2006) in the "doctor-patient game," suggests that analysis of Game Theory must identify the game participants, information, actions and strategies. However, pure quantitative research in the health care field is yet to come, as the system solution process is rigorous and precise, but the process is very complex, and the derivation of the equilibrium solution involves the field of definition and theorem application. Therefore, this study applies the generalized Nash equilibrium method to determine the presence of the equilibrium value, and quantify the expression, then with the other auxiliary calculation of mathematical modeling methods. Cross-view at China and overseas about the application of Game Theory to the field of health care, the majority of existing studies stay in the level of the reasoning, and lack of valid data to support the idea of specific strategies. This study aims to develop the quantitative calculation and provides further excavation.1.3.2 Equilibrium is not a single mathematical methodsSimultaneous equations model has advantage to handle the timing data and panel data, etc. It is not only used in the field of economics, but has also been extended to the engineering field. Although the medical services field does not have prior research to apply the simultaneous equation modeling approach, but more research tips shows it will be a good interpretation if,study of the complex casual relationship between the input and the role of object associated simultaneous equations model, not limited to economic variables, but also establishes the fundamental basis to analysis the complex relationship between the Government funding for health care system and the growth of medical costs. This is based on fully considering the suitability for analysis.1.3.3 The optimization strategy requires a dynamic simulation systemSystems dynamics in a number of areas of practice, can dynamically show the interaction between each module, and has been included in the model test of the effect of policy interventions as a variable, the similar study which apply policy into the model has provided the theoretical support to the value of this study.2. Materials and MethodsGame theory guidance throughout the study, and simultaneous equations model, the panel data model and system dynamics model are for the Equilibrium and simulation and prediction of the specific methods. Game Theory guide the core of players of organizer, medical services provider, consumer, to analyze the policy; Simultaneous equations model is mainly used for scientific calculations of the quantitative relationship between medical costs and pharmacy, high-tech, hospitals, financial and price and other factors, suggesting that the grasp of the relationship between net income and gross income of medical institutions to influence the Chinese medical reform from an economic point of view. In particular, the solution to high medical expense, to start the redevelopment of key elements from a scientific basis of the strategies and measures developed from the imbalance to a balanced state; panel data modeling is mainly applied to the solution process of equilibrium value of the overall financing of the parties funding the solution process; system dynamics can achieve the dynamic simulation of the parties to the game, so this study is an intervention in the simulation of equilibrium strategies of the health care system in China, after the introduction of tools to verify the game analysis of the scientific feasibility and rationality of the proceeds of the strategies ideas.The sources of information of the study are mainly from the China Statistics Yearbook, the China Health Statistics Yearbook and China’s financial annual report. The study established Excel 2010 entry library, data entry and sorting; to use SPSS 17, established analytical library for data statistical analysis. The application of system dynamics simulation of the use of Vensim DSS.3. Results3.1 Qualitative and quantitative expression of China’s medical services in balanced Game SystemDue to the focus of conflicts of medical services of the parties to the game system expensive medical treatment and other issues have been confirmed during a series of studies. Therefore, this study directly dives into a balance of parties within the system, under the guidance of the equilibrium theory. First define the balanced qualitative connotation to ensure that it achieves the balance of China’s medical services system:As a public field, the balance of the system of health care reform and the implementation of the public interest are closely related. On the basis of the coordination of government (the organizers), medical institutions (suppliers), and the people (consumers) and other key interest groups to achieve the fundamental interests of the state and society, to resolve the problem; to protect each party’s interest, to coordinated with each other’s behavior for harmonious development.Based on the generalized Nash equilibrium theory, clarify interests of all parties, the set policy and the parties to payoff function, analysis of the mutual influence and constraints of the policy choice between the parties, clarify the inevitable choice of the equilibrium behavior of the parties through the Game Matrix. Medical institutions and government Game Theory, for example, two of the Government’s fiscal strategy options: financial investment and or not; the behavior of the corresponding medical institutions is also divided into the emphasis on social welfare (a reasonable income-based) and by the pursuit of induction services the pursuit of profit, induced services (the pursuit of irrational revenue of the epitaxial growth). Medical institutions, because it provides the basic functions of social and public services, its rate of return should not exceed goods retail thus medical institutions chose induced services over induction services. The Government’s financial investment on the health sector should at least meet the basic needs of the development of medical and health services; subsequently Government has put most effective investment. Together 支付函数with 制度均衡 definition, approach best interest to balanced system overall (government spending, did not induce the service). Furthermore, it can be derived an equilibrated performance indicator of supply-and-demand: a reasonable proportion of government funding, medical institutions in normal rate of return, reference to the articles about medical institutions should enjoy the concept of medical field average profit to determine its value equal or greater than 7.5%, the proportion of Government funding to be 40.0% of total costs for the health, which is based on WHO recognized indicators and the third key technologies.3.2 A balanced-oriented, looking for the reform of a breakthrough from the system imbalance and impact issuesBy finding of policy documents and literature review, summarizing preliminary studies and research advances in domestic or overseas, it is known the issue of expensive health care can be divided into two categories, the First is inadequate governmental compensation to the supply of medical institutions, which causes over-necessary-dose prescription waste behavior, highlighting uneven government investment to health care development; the second is lack of health insurance and pooling mechanism, health care and medical fairness is not balanced. On qualitative basis for justifying control the behavior of the parties to a balanced and its expression indicators, access to an unbalanced state, the relevant data and accurate calculation of the index value of the imbalance. Compare the expression of equilibrium behavior of the state and its index value, analyze the gap between the index values of non-equilibrium and equilibrium to complete the quantitative definition of the imbalance.From the supply-side perspective, the medical institutions in practice does not fully fulfill their own responsibilities, manifestation of functional absence:induction service, in addition to the provision of social necessary medical services, such as expensive drugs, unnecessary high-tech item examination; while the public welfare gradually diluted. For example, increase rise growth rate, representing behavior indicators, of income in medical institutions is over GDP growth for many years, and with no trend to change in recent years, except for 1994 and four years in 2005-2007. The business income of the medical institutions have shown beyond GDP growth imbalance.From the administration perspective, firstly fund-raising functions of the government’s year by year retreat in 1991 to 2002. The function of the government has gone up and the proportion of government funding to health care rebounded after the SARS outbreak in 2003, but still away from the balanced target of 40.0% lag far behind. Secondly, due to medical institutions as a self-supporting economic entity, for consequent development of medical institutions, the rate of return not below the social average profit level of the lower limit (medical field average profit margin of 7.50%). In fact, the rate of return in medical institutions is not yet up to the nationwide average profit level since 1993, especially in 2007 that the gap of imbalance to the equilibrium reached 2.70 percent, which further demonstrated reality of medical institutions to waste compensation mechanism.From the demand-side perspective, the general merchandise market economy, the principle of utility maximization will become a decisive indicator of affect demand. The reality, however, "your doctor" feeling strong, and even bring some "difficult". Personal cash expenditures proportion of total health expenditure, China’s personal expenses from 1991 to 2001 show a growth trend, then at about 50.0% in more than ten years after the reach to its peak. Although it has dropped slightly in recent years, but still much higher than 30.0 percent as for the equilibrium state, and the burden of personal medical care has been to maintain at higher level.Demand, supply and administration tripartite imbalance and formation mechanism clearly reveals that the withdrawal of fund-raising of administrative functions, induced services by supply-side to increase health care costs excessive growth led to the increase in the burden of medical costs on the demand side are closely linked. While, in light of a balanced system, what should be the overall funding, how to develop; how to adjust financing ratio between parties in the medical services within the game system, those issues become a bottleneck obstructing our medical service system to reach from the imbalance to a balanced. To solve those issues becomes main purpose of this study to develop the three key technologies.4. Innovations and shortcomings4.1 Theory innovation-paving for medical reform in China4.1.1 To define social balance state of medical reform in China with qualitative and quantitative approaches for the first timeThe study use specific approaches such as documentary analysis, linear regression, contrast analysis and the Panel data mathematical model on the basis of game theory and balance theory. The study defines the state point of social balance of medical reform in China, which points out scientific direction of slowly developing medical reform. Meanwhile, the quantified parties’ balance states will provide quantified and operable behavior standard to coordinate all parties and conciliate principle contradiction for the practice of medical reform.4.1.1 Comparing to unbalance, to define unbalance state of medical reform in ChinaFirst of a clear qualitative medical reform imbalance of our country, and we fill in the status of the study of gaps imbalance; qualitative clear imbalance the conduct of parties, measure accurately imbalance of conduct and even the quantitative gap between developed and the relevant policy measures for the conduct of parties to compensate for gaps in our country to balance scientific imbalance provides the basis of; At the same time, to the existing policies or measures medical reform whether to make the gap between the parties, prompted to action coordination of balance state provides a measure of assessment based on the operation.4.2 Integration innovation-finding new methods4.2.1 Integrating various mathematical modeling methods to solve balance conducted by Game TheoryThe construction of simultaneous equation model scientifically calculate the quantitative relation between medical expenses and medical treatment, drugs, advanced technology, hospital, finance and price. It reveals that all the measures which could effectively improve the net income of medical institution can significantly reduce the medical expenses(1:4.03) such as shrinking financial investment or changing charging standard if scientifically dealing with relationship between net and gross income of medical institutions in economical perspective. Therefore China’s medical reform can be out of unbalance to normal.The clarification of total medical expense in government, individual and population answers the key technological problems to be solved urgently in study and practice of medical reform theory. How much the government should invest to solve the prominent problem in medical reform? How much the common people should pay not to feel high price of doctor? These provide scientific evidence for China’s medical reform practice especially developing balance strategy to long-term maintenance mechanism and making clear respective responsibility among individual, society and government.The mathematical model between total medical expenses and influencing factor such as economic development, health condition and government financing scientifically indicates the appropriate proportion of total medical expenses living up to China’s actual conditions in GDP and answers the key technological problems to be solved urgently in study and practice of medical reform theory. What is the total medical expenses and its increment living up to China’s actual condition in medical reform practice? How is the balance situation between healthcare and social economic development? These provide scientific evidence for China’s medical reform practice especially developing balance strategy to long-term maintenance mechanism and scientifically dealing with the relationship between social economic development and healthcare cause.4.2.2 System dynamics integrates various key technological theory and dynamically demonstrating the process of unbalance to balance.It is the first time by system dynamics modeling to realize the realistic dynamical simulation of unbalance of China’s medical reform and the evolution of each behavior, quantizing the natural evolution process of unbalance and its developing trend. These provide solid theory foundation for policymakers and researcher to deeply analyze the current prominent problems and game relations and develop strategy intervening models.4.3 Practice innovation-theory serving for practiceThe strategy approach of the research is to solve current prominent problems. The objective of the study is to straighten out the mechanism of the game and eliminate the principal contradiction. The study will provide scientific theory for the break of slowly improving medical innovation in China, and offer initial medical reform policy reference to realize the goal of medical innovation-to establish basic medical service system.4.4 Shortcomings and solving waysThe research is obedient to scientific research pattern, rational research methods and data sources, and accurate analysis and measuring. Additionally, we try the best to combined qualitative research with quantitative research, integrate thoughts of researchers, organizers and providers to ensure feasibility, reliability and operability of the study process and consequence. However, on account of limit time, there exists deficiency as following. Firstly, although we had system dynamic simulation for the intervention effects of our policy, but haven’t carry out strategic manageable practice. If time permits, we can develop into operable scheme of the strategy. Secondly, we haven’t introduced more indexes related to medical insurance and pharmaceuticals because of availability of current data in the process of balance solution. If we have introduced more generally accepted indexes into our balance system of health service in China, we’11 receive more credible measuring results. These defects will be study direction of us and colleagues at home and abroad. |
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