| 1. Study Objectives and SignificancesAt present, rising health costs make many families facing economic distress, and the difficulty of getting medical treatment becomes a prominent social problem in China. The new medical reform program is to reduce medical expense burden and solve the problem of the difficulty in seeing a doctor and the high cost of getting a treatment. But how to recognize medical expense situation, figure out the mechanism and develop the control strategies? That is an urgent issue to solve.However, current strategies and researches merely revolve around one or several issues in medical care expenditure, rather than systematic and comprehensive analysis. Most of the researches have ignored the internal contact between the structure and function of system. Thus, current policies achieve few results.Therefore, the research aims to focus on the behavior characteristics of organizations in medical care expenditure system, define the influential factors and mechanism, analyze the abnormal development tendency of medical care expenditure, propose strategies for harmonious development of health care, and provide scientific basis for further health system reform. Research methods and theories include integrated theory of complex system, modeling technique of system dynamics, health macroscopic models and stakeholder analysis.2. Materials and MethodsTheories of complex system and stakeholder analysis were used to define the relations between stakeholder's interests and issues, as well as defining the behavior characteristics of organizations in medical care expenditure system. Qualitative and quantitative mechanism models of over-increasing medical care expenditure were applied to demonstrate the formation mechanism.Modeling technique of system dynamics was utilized to construct SD model and build policy experiment platform of medical care expenditure system.Varied data-collection methods were employed in this study, including literature review, opinion survey of residents and health personnel, the second hand data collection, etc. Multiple stratified Chester sampling method was used to investigate people's views on over-increasing medical care expenditure in Shandong, Changzhou Jiangsu and Jiading Shanghai. The data used in the study was collected mainly from statistics including China Statistical Yearbook, China Population Statistics Yearbook and health accounts funding information of the year from 1991 to 2008.3. Main results(1) Define the Stakeholders and interaction of the Medical Care Expenditure system.Based on the literature and policy analysis, the research collected all the stakeholders related to medical care expenditure, such as the central and local governments, public health departments, the price department, financial department, health care providers, Food and Drug Administration, the Chinese medicine management department, development planning department, the administrative department for industry and commerce, education department, hr department, civil affairs departments, agriculture department, population and family planning department, construction department and medical institutions, pharmaceutical suppliers, medical equipment suppliers, commercial insurance company, hygienic and technical personnel, consumers, non-governmental organizations, mass media, etc.Subsequently, through Meta analysis and Mitchell score-based approach, the study demonstrated that the key stakeholders in pharmaceutical field included government departments, health departments, financial department, health care sector, Food and Drug Administration, the price department, hospital, pharmaceutical suppliers, and consumers.The demands of those interests were discussed, such as the government was concerned on the social harmony and stability;medical institutions focused on the government financial investment; medical insurance concerned on the balance of payments while worried about payments imbalances; patients paid close attention to service quality and the expense; pharmaceutical supplier cared about its own profit, etc.By methods of metrological analysis on 907 literatures and intention surveys of 3494 health personnel, the result showed that the government financial investment of medical institutions was insufficient, the price department adopted a distorted standard of prices on medical service pricing, the medical institutions depended on more prescription drugs and more medical examinations to compensate for deficit of health investment, which led to an over-increase of medical expenditure. In the absence of a social safety net, residents bear the high cost of a greater risk.Medical insurance Department suffered problems of unbalance between financing and expenditure. In such circumstances, the high cost of obtaining medical service became a focusing problem of social public concern.(2) Predict future development of medical expenses system; diagnose the problem situation and the harmfulness1) Seriously inadequate government subsidiesLack of financial investment had led to over-increasing medical care expenditure, more serious social burdens and the waste of medical resources. The analyzing results suggest that the government subsidies dropped year by year since 1978. According to the financial aid standard on 1991 level, the ideal financial input was 67.17 billion yuan, while actual financial investment was 49.33 billion yuan, so there was a 17.84 billion yuan fiscal gap in 2008. It was estimated that the fiscal gap might top 268.30 billion yuan by 2021.The study on financial investment gap in different measuring standard found that the government shall bear the liability with 6665.0-7339.0 yuan in 2015.And compared to the forecast actual financial input, there would be a 919.10-1014.30 billion yuan gap in 2020.2) The return rates of operating revenue decreased according to the price controlYields on the business income had been declined for years. The model showed the rate of return was at 7.0% to 12.5% during year 1991 to 2021 respectively. It was demanded that the operating revenue would be 1/yields times that of the financial investment atrophy. Other things being equal, the lower the yields, the more business income would be need for. Under the distorted standard of prices, the medical institutions depended on more operating revenue to compensate for deficit of health investment.3) Medical care expenditure revealed a trend of fast increase across the boardBy using the SD models, simulations suggest that medical expenses might amount to 7241.90 billion yuan by 2021, of which 1874.00 billion yuan was reasonable expense. And the rest of medical expense was 5368.00 billion yuan for deficit of health investment. According to different standards of ideal financial input, it led to an over-increasing of medical expenditure to 698.80-433.87 billion yuan from 2010 to 2021. Over the years, the medical care expenditure had experienced a continuously rapid growth which was far higher than the GDP growth rate. 4) The medical institutions depended on more prescription drugs and more medical examinationsThe simulation results showed that more medical services would create more losses since revenue was extremely low and presented negative. The revenue sources of medical institutions included the fee for diagnosis, the routine service items, and high-tech service project and prescription drugs. However, only high-tech projects and prescription drugs could be profitable. The simulation indicated that medical institutions relied on drug income to amplify their returns. Simultaneously, the research on the influencing factors was conducted in regression model, while the revenue sources were referred as dependent variables. The percentage contributions of various revenue sources to operating revenue were calculated.Regression analysis showed that the growth of revenue owed mostly to the contribution from income of drugs and medical examinations, while Service revenue had little effect. This finding reflect that the medical institutions depended on more prescription drugs and more medical examinations for deficit of health investment under the distorted standard of prices.5) Over-increasing medical care expenditure pressed too heavy an economic burden on the civic people and the equity deterioratedIn the condition that medical security system had yet to be improved, the rapid growth would have significant effects on the economic burden and impartiality of medical expenditure especially. Based on the model which calculated fiscal gap by financial aid standard on 1991 level, the economic burden would reach 0.0982 in 2015 and 0.1091 in 2020. And with regard to the lack of government subsidies, it gained an additional 0.0657-0.0809 of the burden of medical care expenditure. Catastrophic payments for health care happened in 13.16 percent of families in 2015, and that the reasonable quantity was 12.14 percent. Results stated clearly that the incidence of catastrophic health payments was far more than it should be. Thus, the economic burden and the head count of family catastrophic payments for health care were increased due to the rapid rise of medical care expenditure.(3)The Mechanism of Over-Increasing Medical Care ExpenditureSD model simulation was used to interpret the responsibility of the financial, the commodity prices and the medical institution for the excessive growth of medical expenditure. It showed that, the financial and commodity prices bore the primary responsibility due to attribution analysis, the responsibility amount to 40.0%-71.6% and 40.8%-66.7% or more separately. Medical institutions conduct "more prescription drugs, more medical examinations" to make up for the lackage of financial investment and the strict control of commodity prices.The study simulated dynamics action characteristic and mechanism of over-increasing medical care expenditure system using SD model combined with qualitative and quantitative methods. It was founded that the course of over-increasing medical care expenditure was controlled by the intrinsic properties. And the interactive mechanism among the numerous factors was complicated in the medical care expenditure system.—The central government had been giving priority to the economic development, while neglecting health care and changing the nature of welfare.—Since government subsidies dropped year by year, the medical institutions was demanded the way that funds raised by oneself. Consequently, they leant on operating revenue.—The policies of price cutting and fixing that price department always persisted in differed from the environment of macroeconomic reform and the adjustment fiscal function. They deviated from the cost of the medical services, and resulted in an abnormality in the charge standard of medical services.—It induced the health department to explore new sources of profit for hospitals.—And it stimulated the hospitals to set up more high-tech or new services, do more inspections, and over dose, etc, which became the main method for hospitals to reply the self-financing policy.—Tacit understanding between medical agencies and pharmaceutical companies helped develop the drug market chaos:too expensive drug, production structure more imbalance, production lever lower, more repeated production.—Moreover, the imperfect medical insurance with low coverage, limited access to health insurance and limited benefit package caused "overly expensive medical services" as a universal social issue.(4)Give suggestions on medical expense control and evaluate the effectsSimulation platform was build to screen policy intervention targets by system dynamics methods, using Vensim software. The experiments changed the behavior of system conditions such as government subsidies, price adjustment of the total yields, Global budget, medicare reimbursement rates and coverage, etc, in order to observe positive results. After intervention, it had been found that the change of fee per time caused by financial investment adjustment was 1.03-2.38 times more than medical insurance function, while the effect of yield change was 1.18-1.42 times as great. As the study showed, Strategies, such as increasing the government investment or bumping up business income yield could effectively control the rapid increase of the medical expense.In accordance with the game theory, the paper deduced that medical expenditure should be in proportion to the level of social and economic development, which meant social affordability. On the basis of policy intervention targets, simulations were carried out to realize economic development synchronization. At the same time, appropriate combination strategies were put forward and policy effects were analyzed as follows:?Firstly, it was possible to solve a package of the existing major problems and ensure the synchronism of medical expenditure and social economic development by increasing Government subsidies. Financial investment of medical services in 2015 was expected to 187.50 billion yuan, and 461.70 billion yuan by 2020. Compared to the financial investment under current business income growth, there would be 41.40 and 144.40 billion yuan additional investment in 2015 and 2020. And based on the standard of the government investment account for 8% in financial expenditure or takes up 40% of total health expenses, the research expected the total government subsidies to be 851.80-888.70 billion yuan in 2020.?Then, it was necessary to make some adaptations in terms of the return rates of operating revenue to compensate the loss unless increasing government subsidies. It showed that the return rates of operating revenue should rise from 0.0384-0.0525 to 0.0695-0.1060.?Furthermore, under the "fee for service" payment, the irrational price criterion needed to be improved. So as to ensure medical institutions gain reasonable compensation through regular examinations and social necessary services. Or through changing the post payment to prepayment, such as service unit payment. To pursue revenue maximization, the hospitals had to adopt the way "less prescription drugs, less expensive drugs", "less examinations, less sophisticated examinations" to increase revenues. In accordance with purchasing the lowest price drugs, replacing expensive drugs with cheap drugs within the same kind, replacing sophisticated examinations with conventional examinations.?At last, the growth of medical care expenditure would remit through optimization strategy. Total operating revenue would fall by almost a quarter compared with the same period in 2015 to 1906.90 billion. Result showed that not only operating revenue could be saved, but also 17.4 to 53.4 percent of fee per time could be saved. Besides, the implementation of the optimization strategy would lead to a decline of 8.0 percent of catastrophic payments for health care by 2021.4. Research Innovations(1) Methods InnovationsThe method of system analysis and the macro module special for health system were also employed to understand the inner laws of medical care expenditure growth.The stakeholder theory was used to analyze the stakeholders and interaction of the medical care expenditure system.The logic model and SD model of over-increasing medical care expenditure were constructed to evaluate the main variable and function relation by agent action analysis based on VENSIM software.Simulation and policy intervention research were carried out to illuminate the mechanism and put forward correlative policy suggestions by applying synthetically system dynamics and computer simulation technique.(2) Results innovationsBy using theories of system and stakeholders to analyze the interests of all stakeholders, relationship between stakeholders and the process of expenditure growth, thus suggest a kind of new thinking about how to clarify internal relations in the complicated systemUse of quantitative and qualitative methods to explain the formation of key issues, and reveal the root causes and the mechanisms by System Dynamics methods, in order to develop policy ideas for solving the problem of the difficulty in seeing a doctor and the high cost of getting a treatment.Some simulation trials with Vensim software are made, and the results prove that the model can perfectly simulate the dynamics of the medical care expenditure system. The SD model is used for the simulation and verifying platform for the whole processes. By means of predicting the future development of medical expense, results reveal the high speed growth and its damage in the absence of government intervention.The study put forward the policy suggestions of solving the focus problem by policy intervention experiment. At the same time, policy effects are analyzed. It turns out that strategies such as increasing the government investment or bumping up business income yield can effectively control the rapid increase of the medical expense. Thus, provide a reference outline for our country health system reform and the development. |
PDF Full Text Request