Value-based Orientation Study On The Formation Mechanism Of Saving In The Global Budget Of Medical Insurance In County Medical Community

[Purpose]Taking the value-based orientation and incentive effect of medical insurance payment on supplier service behavior as the breaking point,and the formation of saving as the standing factor,this study established a theoretic model of value-based oriented action mechanism for the saving of global budget of county medical community.Revealed the impact path of global budget scheme design,medical community management measures and medical staff service behavior factors on the formation of saving through empirical research,and revealed the action mechanism of the payment strategy of "global budget,saving retention".It was provide research support for the reform of the global budget for County medical community.[Methods]1.Data collection method(1)Literature collection: collect periodical literature,policy texts and other materials by searching domestic and foreign literature and visiting the official websites of relevant government departments.(2)Empirical research data collection: typical sampling combined with feasibility,five counties in Fujian Province and Hubei Province were selected to carry out on-site investigation,investigated the saving promotion behavior,behavior willingness and influencing factors of medical personnel,and collect relevant policies and data on the reform of medical community in the sample area.2 Data sorting and analysis method(1)Literature research: carry out content analysis of policy texts,journal articles and other literature,clarify the policy orientation of saving formation,analyze the connotation and action mechanism of value orientation,and systematically summarize the influencing factors of saving formation.(2)Theoretical analysis: the cost-benefit theory is used to analyze the process of saving formation and the attribute of saving in global budget;Using the incentive theory,this paper analyzes the incentive transmission process of the payment strategy of "global budget and saving retention";The incentive compatibility theory is used to construct the analysis standard of incentive effect of global budget scheme design;Using the theory of planned behavior,this paper constructs the influencing factor model of medical staff’s willingness to promote behavior.(3)Empirical analysis: using the method of case comparative analysis,this paper compares the incentive effect of global budget scheme design in sample areas from four dimensions;The entropy weight TOPSIS method was used to comprehensively evaluate the effectiveness of the management mechanism of medical community in the region;Descriptive analysis,variance test and confirmatory factor analysis were used to reveal the willingness of medical staff to promote saving and its influencing factors;Descriptive analysis and chi square test were used to reveal the changes and influencing factors of service behavior of medical community member institutions in sample areas before and after the reform of "global budget and saving retention";Fuzzy set qualitative comparative analysis is used to reveal the influencing factors and action path of saving.[Results]1 Results of literature research and theoretical analysis(1)The analysis of policy text showed that: 79.16% of local policies did not specify the distribution mode of surplus funds;the cost overrun risk sharing design was mainly based on reasonable cost overrun sharing(70.8%);the orientation of relevant policies was to guide the medical community to do a good job in preventive health care,health management and medical prevention integration in the service process through "global budget and saving retention",promote the formation of reasonable diagnosis and treatment order,standardize service behavior and cost or cost control.(2)Literature and theoretical analysis showed that: the attribute of the saving fund in the global budget was the saving of business income and expenditure rather than the saving of medical insurance fund;value orientation was that the medical insurance handling department guides the medical community to take measures of cost control,service code of conduct,management and control of medical order and strengthening health management services through "global budget and saving retention",so as to control medical costs and improve medical quality,medical effect,health results of patients and patient experience;the formation of the saving was the process that the incentive effect of the county medical community’s total medical insurance prepayment scheme is effectively transmitted between the "medical insurance handling department-medical community-medical personnel",so as to improve the efficiency of the use of global budget funds.It was affected by global budget scheme design,medical community management mechanism and supplier service behavior.2 Empirical research results(1)The comparison of global budget scheme design of the sample areas showed that the incentive effect of the global budget design was weak if the global budget fund was determined according to the historical compensation standard,annual cost control index or budget index,the compensation scope did not include outpatient and extraterritorial inpatient services;the global budget fund management measures have a strong incentive and restraint effect on the service behavior of medical personnel if the member institutions of the medical community paid by the single disease fixed payment or DRG settlement method,and the part exceeding the fixed standard shall be borne by the medical institutions themselves.(2)The evaluation and Analysis on the effectiveness of the management mechanism of county medical community showed that: the management mechanism of county B(Ci =0.7512),District D(Ci = 0.7339)and city A(Ci = 0.7144)was more effective;the management mechanism of City C(Ci = 0.5788)was generally effective;the effectiveness of the management mechanism of city E(Ci= 0.3343)and county F(Ci = 0.1073)needs to be improve.(3)Mathematical statistical analysis showed that: the saving promotion behavior intention of 1725 medical staff in the sample area was affected by saving promotion behavior attitude(0.207),subjective norm(0.540)and behavior control(0.210)(P < 0.05),and subjective norm indirectly affected saving promotion behavior intention by influencing behavior attitude(0.924)and behavior control(0.455)(P < 0.001);the service behavior of medical communities in the sample areas showed different trends,and the factors of behavior also had regional differences(P < 0.05).(4)The qualitative comparative analysis of fuzzy sets showed that: the factors of the three dimensions of total saving formation,prepayment scheme design,medical community management mechanism and supplier service behavior can not have a dominant impact on the formation of saving in the form of single factor(the consistency index value is less than0.9),but jointly affect the formation of saving in the form of four non exclusive combinations.[Conclusions]According to the theoretical model,the formation mechanism of the saving is the process in which the value orientation and incentive effect of the global budget method are transmitted between the "medical insurance handling department(system level)-medical community(management level)-medical personnel(operation level)",so as to reduce the service quantity and cost level,improve the county medical order and improve the use efficiency of the global budget fund.The empirical study found that(1)under the joint incentive of scientific global budget mode design and effective medical community management mechanism,medical personnel will change their service behavior and control the number of hospitalizations and hospitalization expenses,so as to form the balance of global budget funds,such as path 1 and path 3;(2)The effective management mechanism of medical community has changed the service behavior of medical staff of medical community,reduced the number of inpatients in the county or outside the county,and formed the saving of total prepaid funds,such as path 2 and path 4.It can be seen that the formation mechanism of the saving can be the value orientation and incentive effect of the global budget scheme,which can be conducted at the "system layer-management layer-operation layer" layer by layer,effectively encourage and restrict the service behavior of medical personnel,and then reduce the global budget capital expenditure;It can also be an effective medical community management mechanism of the "management" to encourage and restrict the service behavior of the "operation" medical staff,so as to reduce the total prepaid capital expenditure.Therefore,Scientific global budget scheme design is the external incentive factor for the formation of saving,the transformation of medical staff’s service behavior in medical community is the intervention foothold to promote the formation of saving,and the key to the formation of saving is to adopt effective County medical community management mechanism.[Innovation and Deficiency]The innovation of the dissertation as follow:(1)Taking the value orientation and incentive effect of medical insurance payment on supplier service behavior as the starting point and the formation of saving as the foothold,this paper studies the incentive and restraint mechanism of the payment strategy of "global budget and saving retention" of county medical community,and puts forward some suggestions on optimizing the design of global budget scheme and the construction of county medical community;(2)This paper constructs a value oriented theoretical model of the saving formation mechanism in the global budget of medical insurance in County medical community,defines the attribute of the saving,and has some theoretical application innovation;(3)Fuzzy set qualitative comparative analysis was used to analyze the causal relationship between global budget scheme design,medical community management mechanism,supplier service behavior and saving formation,and reveal the action path of influencing factors of saving formation,which is innovative in method application.The innovation of the dissertation as follow:(1)Due to the lag of policy effect,the current empirical research can not fully demonstrate the theoretical model of saving formation;(2)The research sample contains the statistical data of medical and health services in 2020,which may affect the representative of the research conclusions;(3)Some statistical data are missing,which affects the consistency of data.