Research On The Salary Regulation Of Public Hospitals Based On The Relative Value Of Medical Services

The salary system reform of public hospitals is the core task of medical reform,aiming at establishing a clear salary incentive mechanism and ensuring the reasonable salary level of medical staff.For a long time,China's public hospitals have gradually formed an economic benefits-oriented salary system,which takes departments as economic accounting units and implements the practice of revenue reduction and proportional commission.The total salary of hospitals and the per capita level are not restricted.The salary of medical personnel is linked to the economic income generated by the hospitals,departments and even individuals,and the economic benefit is affected by both medical behaviors and government regulations.As a result,the salary distribution is difficult to reflect the value of medical services,which drives doctors to go to higher-paid specialties,exacerbates the shortage of doctors in lower-paid specialties such as emergency department and pediatrics,and leads to more uneven allocation of doctor resources among specialties,which also leads to unreasonable growth of medical expenses.In this regard,the medical reform requires the establishment of a public hospital salary system that embodies the value of public welfare and medical services,and the elimination of the profit-seeking mechanism.Although there have been frequent reforms in recent years,most of them are limited to the change of the internal salary formula of the hospital,which cuts off the correlation between salary and economic benefits and introduces non-economic factors,while the reform at the external policy level lags behind.The total salary regulation explored in some regions is still linked to economic indicators,and the external regulatory environment leading hospitals to form profit-driven compensation system has not changed.The salary difference between hospitals is still related to economic benefits,and the value of medical services has not been taken seriously.Existing research based on the external macro policy of hospital and the hospital internal distribution of the micro level,or the analysis of the effect of single regulation of hospital compensation,or demonstrating the inadequate reflection of the value of medical services in public hospitals in China from the salary distribution system,level and structure.It lacks the research results of establishing the salary regulation of public hospitals based on the value of medical services from the perspective of the institutional management of public hospitals.The research in this paper focuses on three issues:(1)What is the current state of salary regulation in public hospitals,and how does it affect public hospitals' salary?(2)How to reasonably measure the value of medical services is reasonable reflected in the level of remuneration at the institutional level of public hospitals.(3)How to build a salary regulation model framework for public hospitals that is disconnected from economic operating benefits and linked to the value of medical services,so as to eliminate profit-seeking without damaging the output efficiency of medical services.The purpose of the research is to analyze the existing pay regulation effects and the issue of medical service value from the mesoscale perspective of public hospital institution managers around the goals of public hospital salary reform.Based on the reasonable measurement and manifestation of medical service value,the public hospital pay regulation is proposed.The research methods mainly include the use of literature research methods to compare major domestic and foreign models of pay regulation and medical service value measurement methods,the construction of regression models to analyze the effects of pay regulation,and the use of DEA input-output models to study the manifestation of the value of medical services in hospitals.The theoretical analysis method proposes and demonstrates the framework of salary regulation model.The empirical research uses the actual data of institutional business and economic operations of 30 tertiary public hospitals belonging to a certain province(city)in the east from 2008 to 2018.The data sources are national statutory statements and hospital information systems.Main research contents:(1)Theoretical basis.Focusing on research issues and ideas,we will focus on reviewing pay-related theories,regulatory economic theories,ruler competition theories,and production frontier theories.(2)Analysis of the status quo.Review the historical evolution of salary regulation in public hospitals in China,summarize and compare the major models of salary regulation in public hospitals in the new medical reform period,and analyze the experience of salary regulation in typical national public hospitals.(3)Analysis of salary regulation effect.Using the panel data of the sample hospital to build a regression model,combined with theoretical derivation,analyze the extent and path of public hospital salary regulation affecting hospital salary.(4)Analysis of salary input and medical service value output of public hospitals.Through comparative research,a medical service value measurement method that meets the needs of medical reform and salary regulation is proposed.The sample hospital data is used to measure,and from the perspective of input and output,it is evaluated whether the hospital salary and its medical service value output match.(5)Establish a framework for salary regulation based on the relative value of medical services,and demonstrate the model from the perspective of theoretical derivation and empirical simulation.(6)Summarize the main conclusions and make policy recommendations.The main research conclusions are as follows:Firstly,public hospitals' salary regulations lack clear guidance,aggregate constraints,and competition mechanisms.The salary regulation of public hospitals in China has gone through the process of regulation,deregulation,and re-regulation.From public welfare to profit-seeking,it has formed excessive operating autonomy and profit-seeking,and then returns to public welfare.Reregulation is not to return to the planned economy,but to establish relevant incentive regulations through the regulation of total pay,integration of medical price regulations,fiscal investment policies,and operating income and expenditure balances.From the perspective of the current reform,the four modes of income coefficient,expenditure ratio,balance reward,and increase approval formed by the total salary verification of public hospitals are all different from the expected reform: the total salary verification is still related to the hospital's economic benefits to varying degrees;The salary regulation in some regions is not strong in binding on total salary,and lacks supporting policies such as medical insurance payment and medical fee control.The internal competition mechanism among public hospital peers has not been established.The total salary of each hospital depends on its own performance.The improvement of performance will not cause the total salary to decrease,and it is difficult to motivate the hospital to increase the value of medical services under the given input.From international experience,despite different national conditions and systems,the salaries of medical staff in public hospitals in developed countries such as the United Kingdom,Germany,and the United States are regulated by the government,and the direction of reform is approaching the same: First,pay is decoupled from medical services as much as possible;second,regulation and competition In combination,market-led countries build managed competition and introduce regulations to strengthen constraints,while government-led countries build internal competition markets to introduce competition and enhance incentives.The third is to focus on the overall synergy of regulation and implement the wage system.We have implemented a comprehensive payment system and sufficient labor market competition to achieve salary regulation.Secondly,total salary regulation and medical service price regulation significantly affect the salary level through intervention in the hospital's economic operations,but the balance of operating income and expenditure and fiscal investment policies have no significant impact.Hospital compensation is closely related to economic operation benefits.Empirical analysis shows that the total salary regulation has a significant positive impact on the salary level of the sample hospitals.Among the related regulations of the medical service product market,diagnosis and treatment services(technical and labor-based medical services such as diagnosis,nursing,treatment,and surgery),inspection and testing,and drug prices The impact of regulation on salary levels reaching a significant level of 1%,with regression coefficients of 0.589,0.470,and 0.084 respectively;the regulation of total wages effectively reduced the impact of price regulation on hospital salaries,but hospital salaries and economic operating benefits were not completely Decoupling;the balance of operating income and expenditure and the impact of fiscal investment policies are not significant,indicating a lack of synergy between regulations.From the perspective of impact,salary regulation affects the formation of total salary in hospitals through four methods: total salary regulation,medical price regulation,fiscal investment policy,and operating income and expenditure balance,which then affect its internal distribution.Hospitals,hospital managers,and medical staff are relevant stakeholders,and they each face the constraints of operating income and expenditure balance,determining the total amount of salary distribution,and providing appropriate diagnosis and treatment services: When determining the total amount of salary distribution,managers are subject to the operating income balance and the total salary Constraints on measurement and regulation;the mechanism for determining the total amount of salary distribution affects the hospital's internal distribution and also affects the diagnosis and treatment behavior;the diagnosis and treatment behavior affects the hospital's economic operation under the regulation of medical price regulation and other regulations.Thirdly,measuring the relative value of medical services based on the average cost of the industry is more suitable for salary regulation needs.Comparative analysis shows that: from the perspective of the measurement object,the medical service project reflects the efficiency of medical service production and can cover all medical service activities.It has high segmentation,comparability,and high homogeneity,which is consistent with the current collection and payment system.Because the adjustment of medical service prices lags behind the actual cost changes,and it is necessary to consider factors such as the patient's cost burden,medical insurance payments,and price levels,it is difficult to truly reflect the difference in the supply costs of medical service items.Cost should be used as the measurement basis;from the measurement scale,choose Relative value can avoid the problem that the absolute amount of value is difficult to measure.International experience also shows that related reforms based on relative value can better generate incentive guidance and help curb excessive medical treatment.From the perspective of sample hospitals,the relative value of medical services based on the average cost of the industry is significantly different from the results measured by the prices of medical services.If the salary regulation uses the value of medical services as a measure of price,hospitals will tend to avoid high-cost and low-priced medical services.However,high-cost medical projects in the industry are often difficult,high-risk,and expensive,or there are fewer developments in the industry.On the contrary,the actual cost of the industry as a "shadow price" to measure the value can guide hospitals to increase the supply of such medical services.For the medical services that can be generally carried out,competition in the industry will cause the cost of the industry has decreased,and the relative value of medical services has also been reduced accordingly.Fourthly,the public hospital's salary input and the relative value output of medical services are seriously divergent.From the input and output analysis results of the sample hospitals,in terms of average industry efficiency,the comprehensive technical efficiency value of the model that uses the relative value of medical services as an output is 0.72,which is significantly lower than the efficiency value of the operating income output model(0.88).The same goes for the pure technical efficiency value and the scale efficiency value.The sample hospitals adjusted their operations to the state of optimal operating income output,but deviated from the value output of medical services.In terms of individual hospital efficiency,whether the relative value of medical services is the output,it still takes the revenue from diagnosis and treatment services,operating income,and comprehensive service volume as outputs.All of them have clearly deviated from the frontier of production,there are redundant inputs,and the efficiency difference between hospitals is obvious,which constitutes the necessity of salary regulation.Fifth,the regulation of total salary based on the relative value of medical services is the core of the salary regulation framework.While implementing total salary regulations,integrating relevant regulations for the medical service product market can achieve the regulatory goals of linking hospital salaries to medical service value and decoupling economic operation benefits.The mechanisms include: Relative value input-output efficiency directly restricts total pay;the second is to adjust medical price regulations and financial input policies for the medical service market,interfering with the input and output efficiency of hospitals,and indirectly affects total pay regulation;the third is to use the balance of operating income and expenses to restrict the payment of hospital salaries.Under the salary regulation,public hospitals have the internal power to restrain profit-seeking,and no longer expand the total compensation and medical scale indefinitely,and the medical behavior changes.Theoretical analysis shows that the implementation of salary regulation by measuring the relative value of medical services with the average industry cost can artificially construct the internal competitive market,form an incentive mechanism,and alleviate the information asymmetry.In particular,when the medical price cannot dynamically reflect the actual cost,the performance evaluation of public hospitals can be returned to its value.The proportion of the total target investment in the total compensation of each hospital in the industry obtained by DEA model can have a positive incentive effect on the total compensation reduction and increase of redundant and efficient hospitals,respectively.Based on the above conclusions,it is suggested that the hospital salary should be linked to the value of medical service through the regulation of total compensation,and the price of medical service should be adjusted dynamically based on the actual cost,and the financial input should be linked to the output of medical service.Possible innovations:(1)Attempt to put forward "directly for approval in accordance with the input and output efficiency wages,indirectly control the total compensation on both sides from the input and output,with operating balance constraints,the total compensation issue" of public hospital compensation model framework of rules and regulations,implement the integration of total salary regulation and relevant government regulation,to solve the existing mode of hospital compensation and economic benefit of business operation,some problems such as induced medical service motivation.On the one hand,the total salary is verified based on the output efficiency of the relative value of medical services,so as to decouple the hospital salary from the economic operating benefit.On the other hand,the total salary is recognized by regulatory authorities and supported by relevant regulations.Meanwhile,the hospital pays the salary according to the relative value output of doctors' medical services,so as to form an incentive orientation consistent with the value of medical services within and outside the hospital.(2)Based on the study,the relative value of cost measurement in the medical service project industry is more suitable for the demand of salary regulation.According to the characteristics of medical market and the target of public hospital compensation system reform,using relative value concept and reform experience,put forward by the medical service project as the object,based on the cost and the relative value of the measurement method of the scale,and use the sample hospital actual business data,according to the industry average cost and the current price comparing the measurement results of two methods,feasibility validation method,from the perspective of the supplier solve the problem of the difficulty of the medical service value quantity,provides the evaluation basis for the salary regulation.(3)This paper systematically studies the compensation regulation in public hospitals from the medium perspective.The salary research of public hospitals mainly focuses on the macro influence of internal salary distribution and single regulation,but lacks the medium perspective and systematic research.This study based on the organization management level of hospital,from the perspectives of medium and define public hospital compensation regulation concept,to carry out the compensation regulation status and regulation effect,such as medical service metric value theory and empirical analysis,the related regulation and building the new compensation regulation of rewards for integration framework conclusion Suggestions,both enrich the public hospital regulation theory research,and provide reference for deepening reform,especially the salary system reform,has important practical significance.(4)Focusing on the core issues of total salary regulation,we systematically combed the evolution of salary regulation in public hospitals in China,and summarized and compared the four main modes of total salary assessment in public hospitals in China.Through model simplification and logical derivation,we systematically analyzed the advantages and disadvantages of different models.