The Hierarchical Medical System’s Strategy Research In China Based On The Division Of Labor In Society

[Purpose] The health care system is a very complex system. The best way to improve the overall efficiency of the health care system and protect the health of patients is set up a well-organized and high efficient hierarchical medical system. So that the distribution and usage of regional medical resources can be effectively optimized. And the homogeneity, coordination, continuity of medical services are improved, as well as the functional orientation efficiency of all kinds and levels of medical institutions.This research is based on the theory of division of labor in society and combined with the chain theory, incentive theory and systems theory to discuss the mechanism of the division and cooperation inside the medical services system in China. By using the stakeholder theory, the interaction and the behavior of all stakeholders in the health care systems can be analyzed. And the conceptual framework of the division of the medical services system can be build. The current status of Chinese hierarchical medical system is sorted through the current division of labor model of health care systems in China and its internal and external environment. By clarify the key factors which affect the hierarchization of services and the existing difficulties, suggestions can be provided to achieve hierarchical medical system. And it can also serve as the theoretical and empirical basis to build a continuous and effective hierarchical medical system which is suitable to China.[Methods]Based on analysis of literature on hierarchical medical system, relative theories and health policy was sorted and analyzed. Within stakeholder analysis and vertical strategy interaction theory method, the roles and the relationship among stakeholders and behavioral characteristics of stakeholders in hierarchical medical system were analyzed. Comparison of healthcare resourses layout among different regions was carried out by using structural similarity coefficient analysis. Under the mechanism of division and cooperation among medical service institution, and DEA model was applied comprehensively to compare the efficiency of public hospitals in different regions. Some questionnaire surveys, in-depth interview, Delphi method for knowledegeable informants and advanced SWOT analysis were utlized to assessed the current situation, problems and potential determinants of implementation of hierarchical medical system’s construction and two-way referral. Epidata3.1and SPSS19.0were used to manage data and for statistical analysis. Statistical analysis includes descriptive analysis, chi-square test, nonparametric test, correspondence analysis, cluster analysis, and ordinal logistic regression analysis. Qualitative information were sorted and analyzed by using typical case study. Some sources of this dissertation is from the project named ’the strategy study on strengthening regulation on medical services agencies’, which authorized by National Health and Family Planning Commission.[Results]I. Theoretical study of the hierarchical medical systemBy the combination of literature analysis and theoretical study, the core concept were defined, including hierarchical medical system, two-way referral and division and cooperation in medical services system. On this basis, the application and contribution of social division of labor theory, systems theory, incentive theory and chain theory to the building of hierarchical medical system are discussed.This article uses stakeholder group analysis method to clarify the major interest groups in building hierarchical medical system. They are government, medical insurance institutions, higher public hospitals, primary health care service institutions, health care professionals and patients. The results show that all the interest group will benefit from the building of hierarchical medical services and two-way referral. And among the interest group, higher public hospitals and doctors stay neutral to this considering their own interests.II. Researches on the conceptual model of the division of the medical service systemBased on the realistic background and difficulties of the health care systems in China, the necessity of achieving the division of labor in health care systems is proposed. Summarizing the current sophisticated hierarchical structure of the health care systems around the world, the common stratification criteria are basic medical services, second level medical services and third level medical services. The basic medical services are the main content. And it clears the non-overlapping of the functional orientation and services of all levels health care providers inside the system.By the integrated use of social division of labor theory and selecting the basic theories to achieve hierarchical division of the health care system, the basic conceptual model of the health care system division is formed from four division dimensions to provide the theoretical foundation to improve the planning and construction of regional hierarchical health care services.III. The current situation of building hierarchical medical system in ChinaIn this part, the division of labor in medical resources, the amount of medical services, medical expenses and medical insurance cost of all levels of medical service providers inside county health care systems are analyzed and compared based on the current distribution of county health care systems in China. The results show that medical human resources, the number of beds, health insurance fund are mainly focused in county-level medical institutions. The resources in town hospitals and community health service institutions are significantly inadequate. The amount of outpatient and emergency services mainly distributes in village-level health room. The county public hospitals bear a large number of inpatient services. The proportional cost of health insurance outside the county is around30%. It indicates a significant outflow of the health insurance fund. Also, the amount of services are different in regions. By the integrated use of structural similarity coefficient, the trends of division structure in three years of the sample county are analyzed and the structural similarity in different regions are compared.From the point of view in policy level, interest level and the level of technical collaboration, the division of labor in all levels of medical institutions in the sample regions (urban and rural area) are summarized. It is considered that a close interests collaboration and division relationship shall be build from the point view in shared interests while taking into account the concept of incentive compatibility.IV. Cognitive appraisal on hierarchical medical system in ChinaThis research uses the doctors in the higher and primary medical service institutions as the study targets to evaluate the current building of hierarchical medical system. Thus the grading medical and two-way referral can be known. The results show that75.7%of the doctors consider it is necessary to build the grading medical services. And84.8%of the doctors consider the medical insurance and reimbursement system are the key factors which effectively help the division of patients and grading treatment. However, the current two way referral is not satisfied. The mistrust of the people to the primary medical services is the main limit to two way referral. And the implementation of two-way referral is related with the medical institutions’ publicity management and the level of implement.When using referral patients as the study targets, the results show that82.7%of the patients agree that the first diagnosis of disease shall be taken at the primary medical institutions. However the patients do not have strong trust in these institutions. From the point view of the patients, the main factors that affect their decisions are the service level and reimbursement of medical expenses in the primary medical institutions. The satisfaction of referral system between medical institutions is influenced by regions, age, convenience and so on.The health care managers play important roles in the policy development, practice and improvement of building hierarchical medical systems. Based on the SWOT analysis of the factors which affect the current hierarchical medical systems, and combined with expert consultation method and AHP, it can be concluded that the hierarchical medical systems in China are in the ST environment.V. The analysis of internal efficiency of medical service system in ChinaFor the county regions, the medical institutions are divided into two groups based on the division and cooperation of labor inside the medical service system. And the efficiency of different medical institutions with or without division of labor cooperation mechanism is studied. By the using DEA-CCR model, DEA-BCC model and DEA-Malmquist exponential model comprehensively, the efficiencies of29county public hospitals from2011to2013are analyzed. The results show that the overall efficiency, pure technical efficiency and scale efficiency are higher in medical institutions with division of labor cooperation mechanism. And only the technical efficiency drops with the time. All others have been fully released. The result using Malmquist exponential model shows that technical efficiency drops of medical institutions are affected by the change in technologies in both groups.The other analysis of internal efficiency of6sample city hospitals and6primary medical institutions shows that, from2011to2012in which the division of labor cooperation mechanism is built, the overall efficiency and pure technical efficiency increases and the scale efficiency drops. This indicates the scale is unreasonable. The overall efficiency of primary medical institutions increases. However, the scale efficiency is not desirable. It means the scale is not reasonable under the current technology level. The development of scale in primary medical institutions shall be collaborative with the business scope.VI. Difficulties and strategies in building hierarchical medical systemBy empirical analysis, case studies and key informant interviews, the current difficulties in building hierarchical medical system in China can be studied. Utilization of the dynamic Game on main suppliers in medical service system found that, when the higher medical institution decentralizing medical services and primary care institutions remaining moderate service strategy would achieve the medical social cost optimization. At the mean time, for the medical services’ suppliers of two levels who have set up connections, they should avoid choosing opportunistic behaviors based on the vertical interactive to achieve long-term maximization of benefits. At last, based on the international experience and China’s current situation, corresponding countermeasures on how to build a proper hierarchical medical system is put forward from four dimensions among the system, organization, individual and security.VII. Case studies on the typical hierarchical models of health care servicesAccording to the theory described and investigation of sample areas, several typical cases were selected to carry out an in-depth analysis on the establishment and development of hierarchical medical system. Case one is the direct supervision model between F Hospital and community health service agencies. The major organizing method was summarized based on the study of organization structure, function, technical collaboration, human resources management and financial management. The efficiencies before and after the reformation were compared.Case two is to study the model established in the H District of Wuhan City. In this model, the construction of medical group is combined with the payment reform of the new rural cooperative medical system. The operability and efficiency were studied through an analysis of the medical group’s total hospitalization expenses control, the protection mechanism of the payment reform, process management and capital regulation. The result shows that payment reform played a significant role on the cost control. To achieve the optimizing fund usage, it also promoted incentive compatibility and profit sharing between both agencies of the collaboration.[Conclusions]I. The health care system is a structural and functional system. To achieve the optimization of the overall efficiency and system balance, it is necessary to build a rational division of labor inside the system.II. The building of hierarchical medical system should use primary medical service, second level medical service and third lever medical service as the basic grading standard.III. The medical system distribution and the flow patient visits is not reasonable. The patient visits inside county are mainly in the county level medical institutions. The cognitive of doctors to the two-way referral in the hierarchical medical system is not adequate. And there is misunderstanding in patients to the hierarchical health care.IV. In both cities and counties, the medical institutions with division of labor all have higher overall efficiency, pure technology efficiency and scale efficiency.V. The reasonable design of the tight medical groups and medical insurance will help the building of grade health care systems. And division of interests and incentive compatibility should be considered as the necessary parts in building hierarchical medical systemVI. The proper decentralizing of the higher medical institutions and the modest service in the primary medical institutions are the two requirements to optimize the medical social costs. On the basis of two level medical suppliers with vertical interactive, the opportunism behavior should be avoided to optimize the long-term interests in the medical institutions.VII. For the purpose of avoiding excessive use of resources and achieving reasonable diversion of patients, the disease classification should be used as basic standards.. Therefore the costs of patients in different levels can be shared.[Creativity and inadequate]I.Theoretical creativityBy the integrated use of social division of labor theory, stakeholder theory, industrial chain theory and incentive theory, the relations in the main body of interests of hierarchical medical system are sorted and analyzed. And a concept model of building health care system is developed.II.Mathematical creativityStakeholders and vertical strategic interaction game theory are used to discuss the selection of the vertical interaction in all levels medical institutions. The division structure similarity coefficient are used to analyze the distribution of regional medical services in China, And DEA model is used to analyze the influence of division of labor cooperation mechanism to the medical institutions. Advanced SWOT is used to clarify the main factors and background of building hierarchical medical system in China. Suggestions are provided based on the level control characteristic theory to reform the current medical insurance system.Ⅲ.Political valueThis research is based on the current situation in China and combined the relevant theories. The current status, mechanism, results and difficulties in hierarchical medical system are well discussed. And suggestions are provided for the difficulties.However, due to the time limitation and costs of the research, there are some further works need to be done in the future.I. The research in the building of health care systems in citiesⅡ. The practical operability of division of labor model need to be strengthen.Ⅲ. The analysis of disease in the hierarchical medical system should be taken into consideration in the future.