| Background:The public hospital reform is the key to the health delivery system reform in China.The realization of public-interest nature is the core of public hospital reform,which is directly influenced by the reasonable medical expenses.However,since the pilot public hospital reform in 2010 and the public hospital reform on all public hospitals in 2017,there haven't been significant effects on the public-interest nature of public hospitals.On the contrary,the unreasonable increase in medical expenses deteriorated the satisfaction of patients on the public-interest nature of public hospitals.Therefore,the promote of the public-interest nature of public hospitals will control the unreasonable increase in medical expenses,which means the equal,accessible,appropriate,efficient and good-quality access to health care services in China.Currently,there is an extreme lack of studies on the relationship and incluencing mechanism between public-interest nature and medical expenses.Most studies on publicinterest nature of public hospitals in China are qualitative research and quantitative research limited to a single agent rather than empirical research in the view of various agents.Researches on the control of unreasonable growth of medical expenses are limited to qualitative research and quantitative research on a certain disease,and lack research from the perspective of complex system modeling.Therefore,it is of great theoretical and realistic significance for the improvement of public-interest nature and the control of unreasonable growth of medical expenses when conducting empirical and multi-agent system modeling research from various related agents based on their relationship.This research is a sub-project of the key project of National Natural Science Foundation,named of "Research on the Public Hospital Reform by Evidence-informed Decision-making Based on Multiple CAS Modeling of Public Welfare"(No.71233008).Objectives:(1)We conducted a scientific theory research on public-interest nature of public hospitals and the unreasonable growth of medical expenses,which could determine the connotation and characteristics of public-interest nature,the relationship among publicinterest nature,profit-seeking practices and medical expenses.(2)We conducted an investigation study on the current status of public-interest nature of fifteen public hospitals in Shanghai from the perspectives of suppliers and demanders of health care services,which could understand the situation of public-interest nature and the unreasonable growth of medical expenses in Shanghai public hospitals,the influencing factors of the public-interest nature,and the relationship between public-interest nature and medical expenses.This could provide data and logic for the research on public-interest nature and medical expenses.(3)We established a multi-agent system model of the control of unreasonable growth of medical expenses based on complex adaptive system theory,multi-agent system modeling and system dynamics modeling.This model paid special attention to the behavioral characteristics and interactions of different agents and the interaction between different agents' public-interest behaviors and the environment,which could analyze the mechanism of unreasonable growth of medical expenses from the view of various agents.(4)We designed and conducted the intervention experiments on behaviors of patients,physicians and the government,which could predict and evaluate the effects of different intervention proposals,and provide objective and quantitative evidence for the control of unreasonable growth of medical expenses.(5)We provided effective policy suggestions on the realization of public-interest nature and the control of unreasonable growth of medical expenses based on the results of the theory research,investigation analysis and modeling.Significance:(1)This study firstly explored and screened the influencing factors and reasons of the lack of public-interest nature of public hospitals in Shanghai from multiple agents.This would promote the transformation of behavors of different agents,which would control the unreasonable growth of medical expenses and accelerate the realization of public-interest nature of public hospitals.(2)This study firstly established a multi-agent model of the control of unreasonable growth of medical expenses,which would simulate the changing trend of medical expenses,the interaction between agents' behaviros and environment.Based on policy intervention experiments,it could evaluate the effects of the policy on the control of nreasonable growth of medical expenses,which would provide quantitative evidence for policy-making decisions.(3)According to the investigation,modeling and policy intervention experiments,this study firstly prompted suggestions on how to control the unreasonable growth of medical expenses,which meaned a lot for the effective implementation of public hospital reform and dealing with the problem of “difficult and expensive of medical services”.Methods:The on-site survey,literature induction,expert consultation,statistical analysis,complex adaptive system theory,multi-agent system modeling and system dynamics modeling were used in this research.The literature induction and expert consultation could help conduct qualitative analysis and theoretical research on public-interest nature of public hospitals and medical expenses.On-site survey,statistical analysis,literature induction and expert consultation were used to conduct empirical analysis.Complex adaptive system theory,multi-agent system modeling and system dynamics modeling were employed to analyze of unreasonable growth of medical expenses,divide agents,establish the individual agent model and multi-agent system model.The AnyLogic software was used for the model simulation and intervention experiments.Results:(1)Theoretical analysis of the public-interest nature of public hospitals.Based on the viewpoints of various schools at home and abroad,the public-interest nature was defined as the essential attribute of public hospitals from the perspectives of concept,connotation and extension.The public-interest nature was a relative characteristic of profit-seeking practices,and required public hospitals to provide equal,accessible,appropriate,efficient and goodquality health care services to the whole society.Public-interest nature was the social attribute,while profit-seeking practice was is its natural attribute,and the rationality of medical expenses was closely related to these two attributes.The profit-seeking practices based on the public-interest nature would promote the efficiency and quality,which could accelerate the realization of the public-interest nature.The realization of the public-interest nature could promote the rationality of medical expenses,which in turn would reflect the public-interest nature.The reasonable performance of profit-seeking practices could lead to reasonable medical expenses.Compared with public hospitals in the United Kingdom,the United States and Germany,the attention of public hospital reform in China should be paid to optimize the fiscal revenue structure of public hospitals,decrease medical expenses,and diverting patients rationally.(2)Empirical research on public-interest nature and medical expenses in public hospitals in Shanghai.Based on the investigation on 2811 patients and medical staff in 15 public hospitals in Shanghai: 1)According to the analysis on the 977 samples of patients' cognition and evaluation of the public-interest nature and medical expenses in public hospitals,it was found that patients made a moderate evaluation on the degree of the realization of the public-interest nature.In the view of patients,strengthening doctors' behaviors on rational prescription would accelerate the realization of public-interest nature of public hospitals.However,the reasonable medical-seeking behaviors of patents would influence medicl expenses,which then affected public-interest nature.2)Through the analysis on the 1129 samples of medical staff's cognition and evaluation of the connotation of public-interest nature and profit-seeking practices and the degree of the realization of public-interest nature,it suggested that most medical staff made a moderate evaluation on the degree of the realization of the public-interest nature.To promote the realization of public-interest nature to keep the reasonable growth of medical expenses,?)medical staff should prescribe medicine and physical examination rationally;?)public hospitals should undertake more social responsibilities,and keep the health relationship between publicinterest nature and medical expenses;?)the government should reform the operation system,balance the development of various public hospitals,and alleviate the economic burdens of patients.3)Based on the analysis on the 705 samples of extension and the degree of the realization of public-interest nature,to promote the realization of public-interest nature,it prompted that medical staff's public-interest behaviors were influenced by their incomes.Public hospitals should improve the equality,accessibility and quality,accelerate the reasonability of medical expenses,and promote the protection of patients' privacy.4)The analyses on the reasonability and tendency of medical expenses in public hospitals showed that the outpatient and inpatient medical expenses and physical examination expenses kept increasing,and the increasing rate was rising.The outpatient and inpatient medicine expenses kept increasing,but the changing rate showed a decreasing trend.The proportions of outpatient and inpatient medicine expenses kept reducing,outpatient and inpatient physical examination expenses fluctuated.The proportions of outpatient physical examination expenses increased with a fluctuating trend,while inpatient physical examination expenses did not show significant changes.In summary,the medical expenses need to be reduced,and the increasing trend should be more reasonable.(3)Multi-agent system modeling research on the control of unreasonable growth of medical expenses in public hospitals.Based on the theoretical analysis and empirical research mentioned above,it was found that the unreasonable growth of medical expenses was an important factor impeding the realization of public-interest nature in public hospitals,and the public-interest behaviors of different agents played an important role for the reasonable medical expenses.Based on the complex adaptive system theory,the analysis of the control of unreasonable growth of medical expenses involved multiple agents,that were patients,health institutions,medical staff,government and medical insurance department.Such a multi-agent system was a typical multi-agent complex adaptive system.According to the design of a multi-agent system model,it included 5 agents,that were patients,doctors,health institutions,government and medical insurance department.Based on the behavior rules of these five agents and their interaction rules with the environment,we could clarify the logic of the constitution and influencing mechanism of medical expenses,and establish an individual agent model.We could then combine the five individual agent models to establish the multi-agent model based on the perception and effect among the five agents.(4)The simulation and intervention experiment on the control of unreasonable growth of medical expenses in public hospitals.The goal of the system was to effectively control the unreasonable growth of medical expenses in public hospitals and to promote the realization of public-interest nature.We used AnyLogic software to testify the reliability and reasonability of this model.The simulation results showed that the current medical expenses increased with a mild increase tendency,but the value was too high.The proportion of medicine and physical examination expenses were not appropriate.The financial investment of the government was extremely insufficient.The medical-seeking behaviors of patients were irrational.The public-interest behaviors of doctors were weak.Based on the empirical research results,we screened the policy interventions and conducted the intervention experiments on behaviors of patients,doctors and the government.Results suggested that expanding the promotion and application of community's first consultation system to 1.5 times of the current level,increasing doctors' incomes to 2 times of the current incomes and decreasing workloads to 75% of the current level,and increasing the financial investment from the government to the community to 175% of the current level,could realize the best effects on controlling the unreasonable growth of medical expenses.Conclusions:We proposed six suggestions on maximize the public-interest nature and rationalize medical expenses of public hospitals.First,strengthening public hospitals' and medical staff's understandings of public-interest nature,profit-seeking practices and medical expenses.Second,promoting public hospitals undertake public-interest responsibilities.Third,improving medical staff's incomes and reducing their workload.Fourth,increasing the government's financial investment to public hospitals.Fifth,optimizing patients' medical-seeking preferences.Sixth,transforming the public-interest behaviors of suppliers and demanders of health care services simultaneously.This study was the first theoretical,empirical and modeling study on the public-interest nature and unreasonable growth of medical expenses in public hospitals from the perspective of multi-agent system research.Because public hospital reform involved a wide range of issues,many influencing factors,and complicated mutual relationships,and there was a lack of relevant researches,the model in this article needed to be polished up in the next step to provide better methodologies and research platform for policy research. |
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