Research On The Machanism Of Imblanced Provision Of Services By Primary Care Facilities And Its Governance

[Objective]This study aims to explore the mechanism and governance of imbalanced service supply by the primary care facilities(PCFs): 1)constructing a measurement of service supply by PCFs and describing its imbalanced status;2)analyzing the mechanism of service supply imbalance of PCFs,examining the association between service supply and patients’ choice of medical institutions,service quality,expense and reimbursement ratio;3)analyzing the effect of multi-agent system arrangement and policy supply on PCFs’ service supply,and explaining the promotion and obstacles of the balanced supply of service by PCFs,and informing the balanced service supply and its effective governance.[Method]1)Literature review.Combing the current studies and practical experience of health governance,main research frameworks and practice modes are determined.2)Interview and expert consultation.Government officials,managers and medical staff of PCFs were selected to conduct in-depth interviews to clarify key subjects and their relationship related to the service supply of PCFs.This study also carried out expert consultation and seminars in many fields such as health policy research.3)Normative analysis.From the perspective of multidisciplinary,this study analyzed the basic medical and health service attributes,supply boundary and governance mechanism.4)Cross-sectional study.The study has carried out a retrospective survey of PCFs from 36 counties/districts in 6 provinces/regions by multi-stage stratified sampling method.5)Comparative study.This study also combined with the relevant data and reports,thus enriching the theoretical interpretation and practical application value of this study.6)Statistical analysis.The quantitative and qualitative data were analyzed by using multiple regression models and thematic framework methods.[Results]1)Characteristics of "imbalance of supply and health need" and "regional variations" of service supply caused by "structural defects" such as rehabilitation,mental health and hospice care in the process of service supply of PCFs are significant.The rate of health management service for patients with severe mental disorder in PCFs was only 55.2%,the rate of health and family planning supervision and co management service was 73.6%;surgery(22.2%),pediatrics(67.4%),obstetrics(21.1%),dentistry(30.3%),home care(8.3%),family doctors(36.0%),rehabilitation(0.2%),mental health(0%),hospice care(6.6%),anesthesia(26.9%),medical examination(14.3%),medical treatment(6.6%),anesthesia(26.9%),medical examination(14.3%),medical treatment(6.6%),and medical examination and imaging(28.6%)had low rates to be supplied.The rates of basic public health service items in urban and rural PCFs is relatively high.The rates of vaccination and maternal health service in rural PCFs were significantly higher than those in urban areas.The rates of health and family planning supervision and co-management service in rural PCFs is significantly lower than that of urban PCFs.The rates of basic medical and health services in rural PCFs such as surgery,pediatrics,gynecology,obstetrics,telemedicine,Traditional Chinese Medicine,hospice care,medical imaging were significantly higher than those in urban PCFs.The rate of family physician services in urban PCFs is significantly higher than that of rural PCFs.The basic public health service projects in the eastern,central and western PCFs are more evenly carried out,the rate of health and family planning supervision and co-management service in rural PCFs is lower(27.0%),and the rate of health management services for patients with serious mental disorders is lower than 60%.The rate of TB patients’ health management service and maternal health service in the central and western PCFs is low.The rate of health and family planning supervision and co management service in the eastern PCFs is significantly lower than that of the central and western PCFs.The rates of basic medical services such as surgery,pediatrics,gynecology,obstetrics,telemedicine,Traditional Chinese Medicine,hospice care and anesthesia in the eastern PCFs is relatively low.2)There was an inverted U-shaped curve relationship between the proportion of cumulative government financial subsidies and the scope of basic medical and health services,and the extreme value was 42.5%(P = 0.023,95% CI = 11.6%-51.7%).There was also an inverted U-shaped curve relationship between the proportion of cumulative government financial investment subsidies and the basic medical service scope of PCFs,with the extreme value of 42.6%(P = 0.010,95% CI = 22.4%-50.6%).Construction of integrated delivery networks and the proportion of performance-based salaries have no significant impact on the service scope of PCFs.Compared with the inpatients in the townships where PCFs are located in interval 1 of service scope,the proportion of inpatients in PCFs increased by 10.2%,and the proportion of inpatients in county-level,municipal-level and provincial-level hospitals decreased by 6.2%,1.9% and 2.1%,respectively.The readmission rate of inpatients in the township where the PCFs are located in interval 5 of service scope is 0.45%,lower than that in the township where the PCFs are located in interval 1.The average length of stay of inpatients in the townships of interval 3 and 4 decreased by 0.44 and 0.46 days,respectively compared with those in the villages and towns of interval 1.Compared with the inpatients in the villages and townships where the PCFs are located in interval 1,the inpatients in the townships where the PCFs are located in the service scope group 5 have reduced the hospitalization expenses and out-of-pocket cost by 201.8 and 210.2 Yuan respectively,and the reimbursement ratio increased by 2.3%.3)There are some problems in the current policy supply,such as the lack of coordination,stability and strength of policy organizations and policy tools;the low degree of "incentive compatibility" between superior and subordinate governments and horizontal government functional departments has affected the ability of policy implementation,financial investment,medical insurance funds and other resources mobilization of governments at all levels,and the boundary between government and market is not clear in the process of service supply,which made PCFs to selectively complete the service projects matching with their own resources or those services with low risk and high income,leading to the imbalance of service supply and the variations of patient outcomes.[Conclusion and Implementation]Conclusion: Characteristics of "imbalance of supply and health need" and "regional variations" of service supply caused by "structural defects" such as rehabilitation,mental health and hospice care in the process of service supply of PCFs are significant.Although the government financial subsidy has successfully achieved the equalization of basic public health services in PCFs,the high proportion of financial subsidy investment in the total income of PCFs may be related to the narrowed service scope,resulting in the distortion of incentive structure of medical staff in PCFs and the insufficient utilization of health services.In addition to reducing the possibility of hospitalization in the county-level and above institutions,this study also found that improving service scope of PCFs can help reduce the length of stay,hospitalization expenses and out-of-pocket costs,and improve the reimbursement ratio.The core of the governance of the imbalanced service supply of PCFs is not only to play the main role in the institutional arrangement and policy supply through the administrative mechanism,enhance the market and social participation,playing the role of promotion and supervision and formulating basic institutional rules for the effective operation of the governance system,and paying attention to the improvement of the environment.Implementation: First,we should achieve population health need orientation,optimize the government input structure,and make up for the shortcomings of PCFs,such as hospice,mental health,rehabitation.Second,we should strengthen the services supply of PCFs,promote the utilization of services by PCFs,and take advantages of the system through the reform of incentive mechanism and salary mechanism.Third,we should strengthen the service supply of PCFs to enhance the coordination and stability of institutional arrangements and policy supply,and optimize the overall environment of service supply of PCFs.[Innovation and deficiency]Innovation: 1)this study puts forward the analytical framework of "Institution-Structure Process-Outcome" for balanced supply and effective governance of PCFs,which breaks through the limitations of previous studies under the framework of "Structure-ProcessOutcome"."Institution-Structure Process-Outcome" emphasized the importance of institutional arrangement and policy supply,which adapts to the national conditions of "big government",which responds to the urgent requirements of improving the basic medical and health system in the process of national governance modernization.2)This study reveals the "imbalance between supply and health needs" and "regional variations" of the service supply of PCFs in China,and the "inverted U" curve relationship between the proportion of financial subsidies of PCFs and its service scope,which enriches research on the health financing for PCFs;the correlation analysis of the service scope of PCFs and patient outcomes reveals the potential benefits of strengthening the service scope of PCFs,which helps to improve the service capability of PCFs,and continuously improve the governance efficiency of the basic medical and health system;3)this study fills the lack of research on the balanced supply of basic medical and health services of PCFs.The revelation of its internal path helps to explore the boundary and role of the government in the balanced supply and effective governance of basic medical and health services from the perspective of government governance and financing.Deficiency: 1)In the future research,it is necessary to collect data on the number and composition structure of service items of hospitals in the region,which represents the degree of "crowding out" of the development space of PCFs.2)Research on the complex mechanism between the financing structure and service scope,the mechanism between service supply and residents’ service utilization,cost and quality needs long-term tracking data or quasi experimental data for future evaluation.3)In the future,we should include the specific diseases,service quantity and quality of service items,detailed demographic data and disease spectrum for more micro research.We should also carry out prospective study to obtain the cost data and long-term health outcome data,thus analyzing the cost-benefit of improving the service scope of PCFs.