| [Purpose]To integrate the fragmented policies into a whole,and to promote healthcare reform through the coordinative adjustments of multi-systems,multi-sectors and multi-agents is the primary idea for China's health policy research and development.This paper focused on the synergetic development and reform of medical service delivery system and basic medical insurance system,the two core subsystems of health macro system.By referencing to the theory of synergy,this paper aimed to analyze the connotation of synergetic management and develop a Medical Service-Insurance Synergetic Management Model.By taking the model as research framework,this paper tried to analyze the synergy degree of China's medical service-insurance system,explore some key mechanisms in the process of synergetic management of medical service-insurance system,and to propose policy recommendations for medical service-insurance system reform from the perspective of cross-system synergetic management.[Methods]According to the research contents of each part,this paper used the corresponding qualitative and quantitative analysis method to conduct the research.Firstly,through the literature analysis,this paper generalized previous theories and models that related to synergetic management model,and proposed a series of important inferences for the construction of Medical Service-Insurance Synergetic Management Model.Through contextualization and operation,this paper put forward the Medical Service-Insurance Synergetic Management Model.Secondly,this paper constructed the synergy degree model of medical service-insurance complex system according to the idea of Synergy Theory,assessed the time series characteristics of synergy degree of Chinese medical service-insurance complex system during 1996-2015,and proposed a set of objective parameters for synergetic management of medical service-insurance system.Thirdly,the researcher guided Dangyang city of Hubei province to conduct medical service-insurance system synergetic reform of stage 3 hypertension based on the Medical Service-Insurance Synergetic Management Model.Zhijiang city was enrolled into the quasi-experimental comparative assessment as control group.By using Propensity Score Matching(PSM)method and Difference-in-Differences(DID)model,the assessment obtained homogeneous objects to determine the intervention effects and to reveal some key mechanisms in the synergetic management process.Finally,through normative analysis,this paper proposed policy recommendations for medical service-insurance system reform from the perspective of cross-system synergetic management.[Results](1)Medical Service-Insurance Synergetic Management Model:medical service-insurance system synergetic management had a system-organization-individual hierarchical characteristic.Medical Service-Insurance Synergetic Management Model comprised ten critical links:to determine the sequence parameters of medical service system and medical insurance system,to diagnose inter-system synergy,to define target sequence parameters for synergetic management,to authorize synergistic process leadership to the medical insurance management departments,to seek cooperative projects,to start negotiations,to reach a consensus,to sign a project agreement,to execute synergetic reform projects,to evaluate the of synergistic effects.(2)Chinese medical service-insurance system synergy analysis(1996-2015):during 1996-2020,the order degrees of China's medical service delivery system and medical insurance system increased exponentially.The order degree of medical service delivery system showed a slow upward trend between 1996 and 2002,and showed a rapid growth after 2002;the order degree of medical insurance system showed a slow upward trend between 1996 and 2004,and showed a rapid growth after 2004.Medical insurance system coming into orderly development stage had a clear time lag compared with medical service delivery system.The "reaction period" was about 2 years.Medical service-insurance system development was in a low-level synergetic state in the past 20 years.The highest synergy degree of the medical service-insurance synergy system was 0.12(2007),and the lowest was-0.07(2001);during 1996-2002,the synergy degree was zero or negative,and the synergy gradually increased and stabilized at a low level of 0.1 or so after 2002.The highest synergy degree of the complex system had a significant negative correlation with the proportion of resident personal health expenses in total health expenditure(r=-0.798,P<0.05).During 1996-2001,the development of medical service delivery system was faster than that of medical insurance system.The proportion of resident personal health expenses in total health expenditure increased significantly.After 2002,the medical insurance system developed faster than medical service delivery system,and the proportion of resident personal health expenses in total health expenditure declined.(3)Medical service-insurance synergetic management mechanism:the synergetic management mechanisms of synergetic management of medical insurance inpatients and medical insurance fund expenditure included:service gateway forward mechanism,incentive mechanism for the doctors signed in the project,medical service supply and demand constraint mechanism,the medical insurance management departmental regulatory mechanism,the integrated payment mechanism for the three-stage medical services,the negotiation mechanism,the dynamic adjustment mechanism,the equilibrium mechanism.(4)Medical service-insurance synergetic management policy net effect(processed by PSM + DID):Outpatient:outpatient visits of the intervention group increased 3.3 times/capita·year(P=0.008),of which the village outpatient visits increased 0.249 times/capita·year(P=0.039),the township hospitals outpatient visits increased 1.932 times/capita·year(P=0.001),the county outpatient visits increased 1.085 times/capita-year(P=0.028);there was no significant difference in tertiary outpatient visits(P=0.401);the comparison between the baseline and follow-up of the intervention showed that the proportion of the village outpatient visits decreased by 1.4%(?2=6.188,P=0.09);the proportion of the township hospitals outpatient visits increased by 14.8%(?2=389.506,P=0.000),and the proportion of the county hospital outpatient visits decreased by 13.2%(?2=426.264,P=0.000);the change of the proportion of tertiary institution outpatient visits was not statistically significant(?2=0.276,P=0.599).Inpatient:inpatients of the intervention group decreased 0.075 times/capita-year(P=0.000),of which the county hospital inpatients visits decreased 0.042 times/capita-year(-64.6%,P=0.033),the tertiary hospital inpatients visits decreased 0.015 times/capita-year(-83.3%,P=0.001),there was no significant difference in township hospital inpatients(P=0.271);the comparison between the baseline and follow-up of the intervention showed that county hospitals were the primary institutions for hospitalization,accounting for no significant difference(?2=0.336,P=0.562);tertiary hospital hospitalization decreased by 7.7%(?2=4.225,P=0.040);total visits(inpatient + outpatient):patient total visits of the intervention group increased 3.225 times/capita-year(P=0.001);OIR(outpatient/inpatient):the synergetic project significantly increased the OIR;the estimated OIR was 15.29 if the project was not implemented,while the actual OIR was 99.36;Expenditures:total medical expenditure of the intervention group decreased 394.2 yuan/capita"year(P=0.013),of which outpatient expenditure of the intervention group increased 81.2 yuan/capita·year(P=0.048),and the inpatient expenditure decreased 475.4 yuan/capita·year(P=0.027);Health outcome:The prevalence of complications of the control group did not changed statistically significantly before and after the project(?2=0.737,P=0.391);the average hospital stay decreased 0.45 days/capita·year,the variation range was-39.1%(P=0.O11);the mean diastolic blood pressure decreased 2.9 mmHg(P=0.011)and the change of the systolic blood pressure was not statistically significant(P=0.508).[Conclusions]Medical service-insurance system,the two core subsystems of health macro system,had long been in the state of development division in the past 20 years,and the health policies lacked the top-level design of the two systems.In China's future healthcare reform,to speed up the development of medical insurance system,and to inhibit or control the scale expansion of medical service delivery system will be critical dual policy paths to further reduce the proportion of resident personal health expenses in total health expenditure.Under the premise of medical expenses co-payment system,through the establishment of medical service-insurance synergetic management mechanisms,Chinese healthcare reform will achieve synergistic effects including:a total reduction in the total expenditure of health care funds,a greater proportion of medical insurance funds allocated into primary health care institutions,primary health care institutions(including the signed doctors)benefitted more,more reasonable OIR,and significant reduction of patient personal medical expenses with health outcome improvement.[Advantages](1)This paper applied the thought and measurement model of synergetic theory to medical service-insurance systems,which expanded the application scope of Synergy Theory and enriched the theoretical basis of health policy and management discipline;(2)Medical service-insurance complex system synergy degree model provided a quantitative measurement tool for the analysis of synergy between medical service system and medical insurance system.At the same time,the medical service-insurance synergetic management model could provide universal guidance to policymakers in different regions on the synergetic management of medical service-insurance systems.(3)Empirical study used the quasi-experimental evaluation with non-disturbing advantages,in addition,PSM +DID was effective in controlling of the mixed factors on the net effect of policy.[Limitations](1)Evaluation index systems of medical service-insurance systems needed to be optimized;(2)Mechanisms for synergistic effects were not elaborated comprehensively,and more similar empirical researches were needed to clarify other potential mechanisms. |
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