A Research On Doctor-Patient Relationship Under Administrative Contracting

Considering the long-lasting conflicts between the doctors and patients in current Chinese society,many researchers have pointed out that the root causes of the intensification of these conflicts lie in the serious imbalance in the allocation of medical resources,the over-concentration of quality medical resources,and the preference of a large number of patients for well-known and large hospitals.The long waiting of registrations for doctors,the brief diagnosis and treatment,the serious lack of communication between doctors and patients,and other unpleasant treatment experiences have directly led to serious doctor-patient conflicts.The focus of this dissertation is to conceptualize and solidify the idea of the differentiated and vague medical system,so that we can conduct in-depth academic discussions on the causes of the conflicts between doctors and patients.From the perspective of government's administration model,this dissertation draws on the concept of "administrative subcontracting" put forward by Zhou Li'an to summarize the government's management model of public hospitals.Under the premise of ensuring the public hospital's goal to maintain public welfare,the government has taken the model of administrative subcontracting when managing public hospitals,in order to solve the problems that are caused by the large number of public hospitals:insufficient budget,high information cost,and heavy managerial load.The act of the government taking administrative subcontracting to manage public hospitals is the core characteristic of China's medical system.Administrative subcontracting is the mixed form of the traditional administrative management mode and the marketed governance mode.It is embodied in three aspects:the distribution of administrative power,the allocation of financial power and budget control,as well as the assessment,supervision,and incentives of people.In actuality,administrative subcontracting is introducing the financial contract system to the daily operation of public hospitals.Administrative subcontracting includes strong incentives,a characteristic that leads to the incentive distortion of public hospitals.The difficulty,high cost,and potential conflicts of getting medical help is the concrete manifestation and result of such incentive distortion.At the same time,the accountability and assessment under administrative subcontracting is personalized and result-oriented.It is difficult for the government to grasp the real and specific information of public hospitals;therefore,there is a lack of an effective mechanism to solve conflicts between doctors and patients.In this dissertation,the concept of administrative subcontracting is revised and expanded.Based on the public hospital governance model,the dissertation strengthens the "administrative" mechanism in the concept of administrative subcontracting.To be specific,the connotations of "administrative" in administrative subcontracting include:first,administrative subcontracting allows the government to allocate medical resources according to the administration hierarchy and grants public hospitals the bureaucratic powers equivalent to the government's.By doing so,the government ensures that public hospitals are in a two-way dominant position when bargaining with pharmaceutical manufacturers and patient,so that the revenues and profits of public hospitals are protected by policies.Second,the state's control on medical behaviors has reduced doctors' autonomy and their control on clinical performances.Due to the hospital organizational system,doctors are constrained when it comes to where to work;they cannot practice medicine freely,resulting in their dependence on the hospital organizations."Administrative" mechanism has led to doctors' failure to play a fundamental role in the medical system,despite of their professional authority.Such situation,on the contrary,has driven doctors to pursue profits for the sake of the hospitals and their own good with the use of their professional knowledge.This dissertation puts forward three propositions according to the characteristics of administrative subcontracting:first,administrative subcontracting has brought about incentive distortion of hospitals and doctors,which means that the administrators of public hospitals tend to pursue excessive economic interests and expansion at the advantage of the surplus and retention policy;second,administrative subcontracting is the root cause of the conflict between doctors and patients.Under this idea,doctors convert their professional knowledge to economic interests,causing damage to their professional authority;moreover,doctors have become the scapegoat for administrative subcontracting and the buffer between the state and patients.Third,to free the hospitals and doctors from the distorted incentives due to the administrative subcontracting,the reform of the medical system should be an adjustment of the policy design of administrative subcontracting.By transforming the government's role and functions,the agency mechanism among government-hospital-patient should be reshaped and the autonomy of hospitals to operate should be confirmed.Therefore,the cost of getting medical treatment will be lowered,the difficulty of obtaining medical help will be reduced,and the relationship between doctors and patients will be improved.Next,the dissertation revels the meanings of the above propositions through the Shenzhen public hospital governance model and the empirical research of the doctor-patient relationship.This dissertation first conducts a questionnaire survey on the relationship between doctors and patients in Shenzhen,and then focuses its analysis on the main problems concerning the doctor-patient relationship after describing the basic characteristics and factors of it.According to the results of the questionnaire survey,doctors in Shenzhen public hospitals generally face the challenges of long working shifts,large intensity of giving diagnoses and treatments,worsened practice environment,consistent conflicts with patients,and declining social status.Doctors are concerned with whether the hospitals they work for are competitive and advanced,but they are most dissatisfied when it comes to the fairness of their salary and compensation.Doctors are the central pillars of medical practices and the core resources of hospital competition.Under administrative subcontracting,hospitals take on strong incentive methods to inspire doctors;doctors work at an overload rate;yet the medical services provided can hardly meet the growing needs of patients.It can be drawn from the results that the key to relieving the tension between doctors and patient is to establish reasonable compensation mechanism for doctors.Later,the author analyzes the allocation of medical resources in Shenzhen as well as the management model of public hospitals and doctor-patient relationship separately in the following chapters.In Shenzhen,administrative subcontracting has the following characteristics:the distribution of medical resources is imbalanced and unfair;medical resources mostly concentrate in administrative center districts,leading to both excessive waste and deprivation of medical resources;patients can hardly reach doctors.Due to the fact that public hospitals in Shenzhen have a monopoly of quality medical resources and the public has little knowledge about health and medicine,Shenzhen has not yet formed an orderly medical treatment pattern and patients of Shenzhen have a hard time going to the right hospitals for medical help.Moreover,the cost of getting medical help is increasing at a rate faster than the inflation of prices year after year,a problem that still needs to be solved by the Shenzhen government.In the analysis of the relationship between public hospital management model and doctor-patient relationship,this paper takes the Shenzhen C District People's Hospital as an example,to explore the relationship between doctors and patients in the concrete operation process of public hospital from the perspective of administrative subcontracting theory.C District People's Hospital case study shows that the discretionary power gain from administrative subcontract system has given public hospitals flexible operating space.Under the pressure of economic incentives,medical personnel have become the main force of income.Medical practices of medical personnel are distorted as skimping work,inducing and deceiving patients when medical personnel practice medicine in the pursuit of overloaded workloads and high performance bonuses.Their pursuit of personal self-interest exceeds their pursuit of patient-based doctor's professional ethics that leads to the patients' open dissatisfaction,blame,anger and even violence.The case analysis also reveals the information blockade and formalism coping of public hospitals under administrative subcontracting system.Then,the paper takes the graded diagnosis and treatment conducted in Shenzhen Luohu District as a sample to analyze the model of doctor-patient relationship reform under administrative subcontracting.The biggest highlight of Luohu health care reform is,by transforming the government's role and functions and confirming the hospitals'autonomy to operate,to achieve the diversion of patients,increase the district government's investment in community health care institutions,and establish the "total revenue management,balance for bonus" health insurance cost system to chance the incentive mechanism for public hospitals and doctors.This case reveals the biggest and most urgent concern is to free the hospitals and doctors from the distorted incentives caused by administrative subcontracting,so that the relationship between doctors and patients will be improved.Meanwhile,by redesigning the incentive mechanism of medical service system,transforming the government's role and functions and confirming the hospital's role and functions to operate,we can introduce a new incentive mechanism which will benefit everyone and improve the performance of the medical service system.The conclusion and discussion part summarizes the whole text.First,it summarizes the distortions of incentive in the medical service delivery system,which makes the public hospital deviate from the patient-centered service purpose.Then it clarifies the profound influence of the irrational incentive mechanism on the doctor-patient relationship and put forward the idea of redesigning the incentive mechanism in the medical service system,which includes the division of responsibilities between the government and the hospital,the establishment of reasonable and effective hospital compensation mechanism,and the rationalization of the doctors' incentive mechanism.Finally,the paper analyzes the optimization measures of conducting graded diagnosis and treatment reform.