| BackgroundWith the establishment and perfection of the socialist market economic system in our country, public hospitals adapt to the development of market economy gradually and become market operating economic organizations with social public benefit nature. Shandong province launched the first comprehensive reform of county-level public hospitals on January 1,2013. It has been more than two years since the comprehensive reform began. What changes have happened to the operating efficiency of the pilot hospitals after the reform? What influence has the reform brought to the pilot hospitals? And what is the influencing mechanism? These are the present focuses of health administrators and health policy researchers. They are also the basic questions to be answered in this study.The current researches on hospital efficiency, from the research content, are mainly focused on three aspects:hospital efficiency, efficiency measuring methods and the factors influencing hospital efficiency. From the research data, most researches applied cross section data or mixed cross section data while only a few researches used the panel data. From the research period, most researches were one-year study on hospital efficiency and researches of continuous multiple years were not much. From the research method, most researches applied data envelopment analysis (DEA), stochastic frontier analysis (SFA) and comprehensive evaluation to analyze hospital efficiency and they mainly used descriptive analysis. A few researches adopted more rigorous empirical models and analyzing methods to analyze hospital efficiency, such as Tobit regression model and two stage model, etc. After reviewing the present researches, we find that although researches on hospital efficiency were very rich, there are still some gaps in the existing researches. For example, there are few researches on the influence of health reform policy factors on hospital efficiency and the influencing mechanism while fewer researches were on specific reform measures, especially in domestic researches.The health field has the characteristic of resource scarcity. How to allocate resources reasonably under the existing conditions and make full use of them is the key to solve the problem of scarcity. And it is efficiency focused in this study. In the health field, due to the scarcity of resource, efficiency has become the focus of health policy makers and hospital managers while it is also an important standard for the evaluation of health policy implementation. Meanwhile, it has been more than two years since the comprehensive reform began. It is very urgent and necessary to analyze the operating efficiency of the pilot hospitals after the reform and discuss the influence of reform measures. Therefore, this study will answer the following questions:What extent has the comprehensive reform processed to? What is the operating efficiency of the pilot hospitals before and after the reform? What influence has the reform brought to the pilot hospitals? And what is the influencing mechanism?To answer the above questions, this study will evaluate the changes of the operating efficiency of the pilot hospitals before and after the reform (from 2012 to 2014) systematically based on the operation and operating efficiency of the pilot hospitals. Then this study will analyze the influence of comprehensive reform on the operating efficiency of the pilot hospitals and provide useful references for improving hospital operating efficiency and perfecting the comprehensive reform measures.ObjectivesThe general purpose is to evaluate the operation and operating efficiency of the pilot hospitals before and after the comprehensive reform systematically and analyze the influence of comprehensive reform on the operating efficiency of the pilot hospitals and influencing mechanism and provide scientific references for improving hospital operating efficiency and perfecting the comprehensive reform measures.Specific objectives include:to establish the input and output indicator system for the operating efficiency of county-level public hospital; to analyze the operation and operating efficiency of the pilot hospitals before and after the comprehensive reform; to discuss the influence of comprehensive reform on the operating efficiency of the pilot hospitals and influencing mechanism; to provide policy recommendations for improving hospital operating efficiency and perfecting the comprehensive reform measures.MethodsIn this study, we chose 34 comprehensive hospitals and 19 traditional Chinese medicine (TCM) hospitals participating comprehensive reform as our objects. Data mainly came from the following sources:Shandong Provincial Health Statistics Yearbook; progress monitoring system of comprehensive reform of county-level public hospitals in Shandong Province; field investigation.In this study, we used black box model as the measuring framework for hospital efficiency. Under the guidance of indicator selecting principles of DEA, we used literature selection, clustering analysis, correlation analysis and expert consultation to select the final input and output indicators. Then we applied DEA and its related methods to measure and evaluate the operating efficiency of the pilot hospitals. Statistical analysis methods include descriptive statistical analysis, univariate statistical analysis and Tobit regression analysis. Descriptive statistical analysis was applied to analyze the comprehensive reform process and operating efficiency of the pilot hospitals. T test was used to analyze whether there is a statistical difference between the operating efficiency of the pilot hospitals before and after the comprehensive reform. Chi-square test was applied to analyze whether there is a statistical difference between the DEA efficient rate of the pilot hospitals before and after the comprehensive reform. And we used Tobit regression to discuss the influence of comprehensive reform policies on the operating efficiency of the pilot hospitals. Besides, we applied qualitative methods to interview the personnel in the pilot hospitals.Results1. After the implementation of comprehensive reform, the pilot hospitals overall operate well. The personnel, beds, services, incomes and expenditures have growed at different rates. It is worth noting that, the ratio of doctors and nurses of comprehensive hospitals has decreased from 1:1.36 of 2012 to 1:1.40 while TCM hospitals from 1:1.18 to 1:1.20. And the health material income proportion and examining income proportion have increased from 6.64% and 10.41% of 2012 to 10.40% and 12.33% of 2014 while TCM hospitals from 3.63% and 9.01% to 6.06% and 10.52%.2. The operating efficiency of comprehensive hospitals has increased from 0.884 of 2012 to 0.887 of 2014 while TCM hospitals from 0.918 to 0.933. However, the change is not significant. Meanwhile, the total factor productivity change index of comprehensive hospitals was 0.978 with a 2.20% fall averagely while the index of TCM hospitals was 1.022 with a 2.20% rise averagely.3. The Tobit regression equation of the operating efficiency of comprehensive hospitals included 24 policy variables. Coefficient of determination R2 was 0.8209 and the goodness of fit of the model was good.14 policy variables have influence on the operating efficiency of comprehensive hospitals and it is significant (P<0.05).Specifically, the amount of financial assistance received per actual bed, the amount of compensation obtained by the medical service price adjustment for each diagnosis and treatment, the number of diseases paid by disease, the number of medical insurance payments implemented, implementing full employment and job management, establishing corporate governance structure, implementing the director responsibility system, implementing the assessment system of the target responsibility of the presidency, implementing the appointment of the director, implementing general accountant system, implementing logistics service outsourcing and the number of clinical pathway diseases have positive influence on the operating efficiency of comprehensive hospitals; implementing the director’s right to operate independently and number of medical associations have negative influence on the operating efficiency of comprehensive hospitals.4. The Tobit regression equation of the operating efficiency of TCM hospitals included 12 policy variables. Coefficient of determination R2 was 0.9020 and the goodness of fit of the model was good.11 policy variables have influence on the operating efficiency of TCM hospitals and it is significant (P<0.05).Specifically, the amount of financial assistance received per actual bed, the amount of compensation obtained by the medical service price adjustment for each diagnosis and treatment, the number of diseases paid by disease, the number of medical insurance payments implemented, implementing full employment and job management, establishing corporate governance structure, implementing the appointment of the director, implementing general accountant system and the number of clinical pathway diseases have positive influence on the operating efficiency of TCM hospitals; implementing the director’s right to operate independently and number of medical associations have negative influence on the operating efficiency of TCM hospitals.Conclusions and Policy RecommendationsIn this study, the main conclusions are as follows:1. After the implementation of comprehensive reform, the pilot hospitals overall operate well, but there are still some problemsAfter the comprehensive reform, the pilot hospitals overall operate well, but there are still some problems:although the ratio of doctors and nurses of the pilot hospitals has decreased, the ratio is still far from the objective of National Health and Family Planning Commission (1:2) and registered nurses cannot meet the actual needs of the hospitals; the health material income proportion and examining income proportion have increased at different rates.2. After the implementation of comprehensive reform, the change of the operating efficiency of the pilot hospitals is not significantThe operating efficiencies of comprehensive hospitals and TCM hospitals have both increased after the comprehensive reform, though not significantly. Specifically, the technical efficiency and scale efficiency of comprehensive hospitals have increased while the pure technical efficiency and total factor productivity have decreased; the technical efficiency, pure technical efficiency and total factor productivity of the TCM hospitals have increased while the scale efficiency has decreased.3. Most of the comprehensive reform policy measures have positive influence on the operating efficiency of the pilot hospitalsIncreasing the government financial investment and adjusting the price of medical services can influence the operating efficiency of the pilot hospitals positively; increasing the number of diseases paid by disease and medical insurance payments can improve the operating efficiency of the pilot hospitals; implementing full employment and job management can influence the operating efficiency of the pilot hospitals positively; establishing corporate governance structure and implementing general accountant system have positive influence on the operating efficiency of the pilot hospitals; increasing the number of clinical pathway diseases can also improve the operating efficiency of the pilot hospitals.4. Due to imperfect implementation a few reform measures have negative influence on the operating efficiency of the pilot hospitalsImplementing the director’s right to operate independently has negative influence on the operating efficiency of the pilot hospitals. The main reason may be that the director’s right to operate independently at the present is not the real independent right. The present medical associations are associated by structure merely not by functions, so it would have negative influence on the operating efficiency of the pilot hospitals. Therefore, the more medical associations are, the lower operating efficiency of the pilot hospitals have.According the above conclusions, it is recommended that:(1) Increase the government financial investment and adjust the price of medical services reasonably; (2) Increase the number of medical insurance payments and emphasize the way of diseases paid by disease; (3) Deepen the reform of personnel distribution system, especially implementing full employment and job management system; (4) Continue to deepen the reform of hospital management system and implement the director’s right to operate independently further; (5) Increase the number of clinical pathway diseases and build the medical associations combined organically by structure and functions. |
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