The Incentive Mechanism Of The Cooperation Between Hospitals Involving The Mutual Referral By Hospitals' Governance

The referral between different-level hospitals widely exists in the health care systems of various countries.Different from the one-stream referral from the gatekeeper to the secondary care providers,China adopts the mutual referral between the hospital with high treatment level,such as tertiary referral hospital,and the hospital with low treatment level,such as the primary health care institution.The mutual referral between hospitals with different treatment levels is the part of establishing the hierarchical diagnosis and treatment mechanism,critically contributing to the reasonable allocation of medical resources and the equalization of health care services.Based on the status of the medical treatment and health care policy in China,we focus on the relationship between hospitals with different treatment levels and the public insurance,and illustrate the cooperation and incentive schemes between the hospitals,as well as the regulation schemes given by the government to regulate the supple-side and the demand-side of medical service.The main contents in this dissertation are as follows.1)Based on queuing theory,the referral process between hospitals with different levels is established and the optimal referral strategy is derived in the subordination relationship.A health care system involving a city hospital with higher treatment level and a community hospital with lower treatment level is abstracted to model the mutual referral.Based on the classical queueing theory and the square-root staffing rule,we consider the two hospitals as a queueing network from the prospect of business process re-engineering,and derive the optimal referral thresholds and the corresponding referral strategies of the small-scale health care system and the large-scale health care system by minimizing the total operating costs,respectively,which provides the reference of establishing the mutual referral process between the hospitals under the relationship of subordination.2)Based on the square-root staffing rule,the dissertation investigates the approach to prompt the cooperation between the city hospital and the community hospital in the decentralized system.In the health care system with different scales,the dominated city hospital and the followed community hospital are operated independently,where the city hospital designs the contracts to motivate the community hospital to select the optimal referral threshold derived in the centralized situation,in order to coordinate the health care system.From the analysis of non-coordination scene and the coordinatability of two complex contracts and four simple contracts,we can obtain the results are as follows: FFS-CS and P4P-CS can coordinate the health care systems of large-scale and small-scale by satisfying the coordination conditions,but four simple contracts,i.e.,FFS-NCS,FFS-TCS,P4P-NCS,and P4P-TCS,are inferior in coordinating the large-scale health care system for lack of risk sharing scheme.Among them,FFS-NCS,FFS-TCS and P4P-TCS only can coordinate a small-scale health care system,yet P4P-NCS fails to coordinate the health care system of any scale.3)Without the square-root staffing rule,the dissertation discusses the coordination issue of the health care system without the square-root staffing rule.Given the conclusions of coordinating the health care system with the staffing rule,we extend two complex and four simple contracts to the same-scale health care system without the square-root staffing rule,verify the coordinatability and the application of the six contracts above,and further reveal their advantages and the disadvantages.The dissertation explores the optimal referral threshold between the hospitals who are in the relationship of subordination,and discusses the coordinatability of the above contracts given that the hospitals are in the relationship of subcontracting.The conclusions suggest FFS-CS and P4P-CS still can coordinate the health care system with the samescale,and should be the best option for the hospitals in the relationship of subcontracting.As the simple contracts,FFS-NCS,FFS-TCS and P4P-TCS can coordinate the health care system,but P4P-NCS fails to coordinate at all.4)The design of incentive mechanism in regulating the supply-side and demandside of treatment service under the asymmetric information is studied.With the schemes of the supply-side cost sharing and the demand-side cost sharing,a three-tier model is established to inspire the optimal strategies involving the government,the city hospital and the community hospital in the symmetric information case(where the community hospital's cost reduction effort is observable and verifiable)and the asymmetric information case(where the community hospital's cost reduction effort is unobservable and unverifiable),respectively.The government's optimal strategies through two cost sharing schemes in the symmetric and asymmetric information cases are compared to illustrate the optimal cost sharing scheme which should be adopted by the government to motivate the community hospital to reduce the treatment cost and maximize the social welfare.The comparative results show that the supply-side cost sharing scheme is superior to the demand-side cost sharing scheme in the symmetric information case as well as in the asymmetric information case,and should be the first choice for the government to regulate.Furthermore,the mutual referral strategy is always beneficial for the city hospital,and the community hospital is prone to make the first-best effort to reduce the treatment cost with the government's reasonable regulation.