Identification And Simulation Of Hospital Output Efficiency Based On Path-Converged Design

The Drug Addition Policy in China's medical service system has stimulated the development and operation efficiency of public hospitals. However, it gradually incurs the profit-driven behavior of hospitals and challenges the equity features of public hospitals. Policies have been put forward to call for abolishing Drug Addition Policy and improving hospital compensatory mechanism since 2000. And "The Guidance on Reform Experiment of Public Hospital" was officially issued to push the health care reform on February 2th 2010, of which the core is to increase governmental fiscal subsidies and to set pharmaceutical additional service fee for abolishing Drug Addition Policy so as to make public hospitals return to equity. Therefore, the research on identification of output efficiency, equity and the integration of efficiency and equity is of great practical significance.However, existed researches on hospital efficiency and on governmental price regulation have failures in both contents and approaches. First, from the perspective of research contents, isolated researches on hospital efficiency and on governmental price regulation are presented rather than the exploration of hospital operation mechanism with integration of efficiency and equity. Second, from the perspective of research approaches, DEA model and SFA model with the objective functions to maximize output with given inputs or to minimize inputs with given outputs are mainly applied to assess the hospital output efficiency rather than the public welfare efficiency. As commonweal institution, public hospitals should pursue not only itself economic efficiency but also the equal social efficiency. Different from existed researches, the thesis integrates the perspectives of efficiency and equity for the first time and determines its theme as the identification and simulation of output efficiency of public hospital based on the reform backgrounds of abolishing Drug Addition Policy and improving hospital output efficiency. Semi-parametric counterfactual approach, nonparametric path converged design, nonparametric environmental interaction model and simulation design approach are established besides classic DEA approach with application to provincial hospitals in Zhejiang province to explore how to achieve the public conversion from drug revenues to governmental fiscal subsidies and pharmaceutical additional service fee revenues, which aims to make theoretical contributions to current major issues in health care reform. Moreover, the thesis obtains following conclusions.Identification. First, DEA approach is applied to identify output efficiency of 14 provincial hospitals in Zhejiang province in 2007. Integrating the variable profit levels, the identification classifies the 14 provincial hospitals into efficient class hospital (Group 1) and inefficient class hospital (Group2). Group 1 class hospitals include H1, H2, H4, H6, H7, H12 and H13. Group2 class hospitals include H3, H5, H8, H9, H10, H11 and H14.Second, semi-parametric counterfactual kernel density distribution under Logistic model is established with application to identify the formation mechanism of the hospital drug balances. The identification illustrates the major change of drug balance distribution during 2004-2008 can be explained by the number change of outpatients and discharged inpatients rather than the number change of drug prescriptions, which provides the basis of setting pharmaceutical additional service fee with the abolishment of Drug Addition Policy.Finally, nonparametric drug converged path model and environment interaction model are established to identify the driven factor and transmission mechanism of hospital output efficiency.1. The main driven factor of Group 1 hospitals is capital, which is consists of acquisition and maintain fee of fixed assets and special material fees. The main driven factor of Group2 hospitals is labor, which is consists of the number of outpatient and emergency visits and the number of discharged inpatients.2. The drug path majorly exerts its role on hospital output efficiency through labor in Group 1 hospitals while through capital in Group 2 hospitals. The difference of transmission mechanism in two groups indicates Drug Addition Policy crowds out the treatment volume of Group2 hospitals and crowds in the one of Group 1 hospitals and implies the public is more inclined to go to efficient hospitals for treatment.3. The environmental factors such as governmental fiscal subsidies might shift the transmission mechanism in different hospitals.Simulation. First, simulate the operation strategies of inefficient hospitals with DEA identification for the next period. Different from previous DEA models that pursue maximum outputs with given inputs, minimum inputs with given outputs or both decrease in inputs and increase in outputs for efficiency promotion, the thesis designs a feasible strategy with simultaneously increasing inputs and outputs for promoting inefficient hospitals to efficient ones. The simulation on Group2 hospitals through determining the theoretical added value, searching the ideal output with given inputs, and determining ideal inputs and ideal outputs for inefficient hospitals confirms the simulation program can enhance hospital efficiencies of Group2 hospitals under the premise of ensuring the efficiencies of other hospitals do not deteriorate, which can provide strong decision support for the inefficient DMU during next period.Second, simulate on how to fill the output gap with abolishment of Drug Addition Policies with application of new established path environmental model from the perspective of production efficiency. Different from previous researches on keep total output Y unchanged, the thesis focuses on keeping the driven roles of factor K and L under drug path unchanged, and furthermore determines which factor (K or L) can be applied to compensate the output gap with abolishment of Drug Addition Policies based on transmission mechanism. Empirically, simulations on increasing governmental fiscal subsidies to compensate the output gap with abolishment of Drug Addition Policy are carried out for hospital H2 and H8 through enhancing the transmission mechanism of capital and labor respectively; and simulation on simultaneously setting pharmaceutical additional service fee and increasing governmental fiscal subsidies to compensate the output gap with abolishment of Drug Addition Policy is carried out for hospital H4 through enhancing the transmission mechanism of capital. The simulations indicate that different policies on increasing governmental fiscal subsidies and setting pharmaceutical additional service fee should be put forward for different hospitals in reform experiment of public hospitals.The thesis contains three innovations. First, it creatively integrates the efficiency and equity under the framework of nonparametric path converged design. Different from existed isolated researches, the thesis realizes the exploration on involved resource allocation issues in medical care reform such as the abolishment of Drug Addition Policy, the increase in governmental fiscal subsidies and the set of pharmaceutical additional service fee through establishing a benchmark model that reflects equity, path model that reflects efficiency, and path converged design that integrates efficiency and equity. Second, the thesis identifies driven effect of Drug Addition Policy on hospital output efficiency. Different from the superficial study on the output gap due to the abolishment of Drug Addition Policy, the thesis explores the driven mode and transmission mechanism of Drug Addition Policy on hospital output efficiency with application of semi-parametric counterfactual approach and path converged design approach. Third, the thesis presents a brand-new exploratory simulation with design on realization of public conversion from drug revenues to governmental fiscal subsidies and pharmaceutical additional service fee revenues.