Research On The Operation Mechanism Of American Healthcare System And Its Implications For The Healthcare Reform In China

In face of the cost, quality and access problems of health care system, China launched the new round of health care reform in 2009. However, for the resolution failed to specify the reform plan of operation mechanism, the reform had undergone considerable difficulties in the implementation process, with the stakeholders wrestling with each other. Against such a condition, the dissertation analyses the operation mechanism of U.S. health care system systematically, based on the conceptual model of third party management, and discusses its implications for the health care reform in China.It is asserted that the core feature of U.S. health care system is the third party management mechanism led by private health plans. By intervening into each pair of stakeholders and implement certain kinds of contractual arrangements and management tools, the health plan alter the original relationships into new relationships between health plans and each stakeholders (called the Third Party Relationships by the author), namely, Insurer-Provider Relationship, Insurer-Patient Relationaship and the Insurer-Government Relationship, within each of which the insurer leverage series of contractual arrangements and management tools to overcome the market failures and solve the cost and quality problem of health care system. The Insurer-Provider Relationahip is represented by the Integrated Delivery System, innovative payment schems and medical management; the Insurer-Patient Relationship is represented by the indirect impact on patients of the Insurer-Provider Relationship, and health management to patients; while the Insuer-Government Relationship is represented by the contractual administration of public health programs. The major problem faced by the health care system of China is the lack of Third Party Management mechanism. In order to better implement the health care reform, and hence alleviate the cost, quality and access problems, we should learn from the Third Party Management mechanism, and improve the health care operation mechanism of China.The dissertation is organized as follows:after introduction and literature review, chapter 3 introduces the structure and operation mechanism of US health care system, so as to pave the realistic basis for theoretical analysis. Chapter 4 establishes the conceptual model of third party management, and dives into each of the third party relationships, analyzing how the health insurers leverage contractual arrangement and management tools to overcome the market failure and improve cost and quality problems based on formal theoretical models. Chapter 5 conducts case studies into Blue Cross Blue Shield system, Kaiser Permanente and Veteran Health Administration to provide empirical evidences for the theory. Chapter 6 makes comparative research into the health care systems of U.S. and China, in which the author explores the major problems and gaps faced by health care system of China, and puts forward some policy suggestions in improving its health care operation system.The dissertation innovates in the following aspects:firstly, the author puts forward the conceptual model of third party management of US health care system, which is a whole new theory as well as a whole new perspective. Secondly, within the theoretical framework of third party management there contains a group of theoretical models for every contractual arrangements or management tools, which relate with each other while keeping necessary indepence nature. Some of the models are created by the author, while some others are developed based on pioneers’work. Thirdly, the author take the first move of comparative research into the operation mechanisms of US and China health care system, and puts forward the new idea that the major problem faced by China health care system is the lack of third party management mechanism.