| [Purpose]Based on the policy background of the global budget,this study analysed the changes in the medical service supply of public general hospitals before and after the implementation of this policy,and further identified the main factors affecting the supply of medical services under the global budget system,and explored the impact mechanism.On this basis,the study explored the realization incentive compatibility of multiple stakeholders,and proposed management strategies to optimize the supply of medical services,in order to provide a reference for the formulation of hospital management strategies and related health policies.[Methods]（1）Literature review.Through searching major domestic and foreign databases,the research systematically sorted out the evaluation indicators and influencing factors of medical service supply under different medical insurance payment methods.Based on the analysis of domestic and foreign literature,the research framework and research plan were further determined.（2）Expert consultation.The study selected 16 experts engaged in research and practical work in the fields of hospital management and medical insurance,and conducted two rounds of expert consultation on the measurement indicators of the quantity,quality,and productivity of medical services.Then,the measurement indicators of the medical supply used in this study are determined.（3）Second-hand data collection.The study took Taiyuan City,Shanxi Province as the sample area,and collected data on the allocation of health resources,medical services,and operations of 46 public general hospitals in the sample area from 2013 to 2019.（4）Interrupted time series regression.The study collected 36-month observational index data before and after the implementation of the global budget,and analyzed the changes in medical service supply before and after the reform with the aid of interrupted time series regression.（5）In-depth interview and grounded theory.The study selected a total of 35interviewees,including medical insurance fund managers and health administrative managers in the sample areas,relevant responsible personnel and clinical medical staff in the sample hospitals,and conducted in-depth interviews on key factors affecting the supply of medical services in the context of global budget.Then,adopting a grounded theoretical analysis paradigm,the study performed three-level coding on the in-depth interview data to identify the influencing factors of the medical service supply under the global budget,and further constructed the corresponding theoretical framework.（6）Generalized linear mixed model.The study constructed a generalized linear mixed model before and after the global budget,and analyzed the factors that have a more significant impact on the supply of medical services after the reform.（7）System dynamics model.The study adopted the method of system dynamics modelling to analyse the impact mechanism of medical services in public general hospital under the global budget,and conducted simulation and intervention experiments.[Results]1.Changes in the supply of medical services in public general hospitals before and after global budget（1）In terms of the number of medical services,the growth trend of the number of hospital discharges has increased by 24.14 persons/month after the reform.After the reform,the number of discharged hospitals with larger budgets has increased faster（β3=34.05,p=0.002）.Regarding the number of inpatient surgeries,hospitals with larger budgets increased the number of surgeries by 3.59 person-times/month（p=0.020）after the reform of the global budget.（2）In terms of the quality of medical services,study found that the healing rate of hospitals with larger budget lines dropped by 0.05%/month（p=0.011）after the reform.However,the trend of hospital mortality has not changed significantly before and after the reform of the global budget.（3）In terms of medical service productivity,the length of stay dropped by 0.02days/month（p=0.019）after the global budget reform.The number of hospital bed turnovers increased by 0.04 times/month（p<0.001）after global budget.2.Factors affecting the supply of medical services in public general hospitals under global budgetGrounded theoretical results show that the main factors affecting the medical service supply of public general hospitals under the global budget include 9 categories,which are socio-economic environment,market environment,policy environment,human resources,material resources,financial resources,brand and technology,internal management,and diagnosis and treatment.The factors that have a more significant impact on the supply of medical services after the implementation of the global budget were that:（1）In terms of the number of medical services,the construction of the medical consortium（β=0.274,p=0.009）,the number of beds（β=0.006,p=0.008）,the proportion of hospitalized patients in December（β=0.012,p=0.003）,total control quota allocation（β=-0.427,p=0.001）,financial subsidy income ratio（β=-0.024,p=0.014）,cost-controlled performance evaluation（β=-0.008,p<0.001）and per capita outpatient expenses（β=-0.001,p=0.004）had a significant impact on the number of discharged patients.Simultaneously,the above factors have also had a more significant impact on the number of operations.（2）In terms of the quality of medical services,the number of single-disease-paid diseases（β=0.003,p=0.018）,the number of beds（β=-0.011,p=0.048）,the decomposition of the total control quota（β=-0.217,p=0.014）,and the proportion of critically ill patients（β=-0.220,p=0.001）had a more significant impact on the cure and improvement rate after the reform.The market competition intensity（β=0.247,p=0.017）,the regional medical center（β=0.093,p=0.001）,the cost-control-oriented performance appraisal（β=0.011,p=0.016）and the proportion of critically ill patients（β=0.052,p=0.009）had a significant positive impact on mortality after the reform.（3）In terms of medical service productivity,budget quota allocation（β=0.279,p=0.022）,proportion of income from medical insurance compensation（β=0.048,p=0.040）,cost-control-oriented performance appraisal（β=0.061,p<0.001）,total control quota decomposition（β=0.399,p<0.001）,the proportion of the number of beds in tertiary hospitals（β=-0.164,p=0.042）,the proportion of income from financial subsidy（β=-0.047,p=0.044）,the difference in medical insurance settlement（β=-0.271,p=0.036）and the per capita outpatient expenses（β=-0.010,p=0.029）had a significant impact on the number of bed turnover after the implementation of the global budget,and the degree of impact was further increased.The medical insurance settlement balance（β=0.554,p=0.003）,per capita outpatient expenses（β=0.006,p=0.041）,the decomposition of total control quota（β=-0.564,p<0.001）and cost-control-oriented performance evaluation（β=-0.016,p<0.001）had a more significant impact on the average length of stay after the reform.3.Influencing mechanism of medical service supply in public general hospitals under global budgetThe system dynamics modeling results show that the key influencing factors of the medical service supply of public general hospitals under global budget are as follows:the global budget directly affects the hospital’s internal performance management system,which will then affect the diagnosis and treatment service process,and ultimately bring about changes in the supply of medical services.However,external policy environment,the internal resources of the hospital and other related variables had a moderating effect.According to the simulation results,the number of discharged patients will increase from 12,778 in 2015 to 30,822 people in 2030,and the number of inpatient operations increased from 4,808 in 2015 to 23,309 in 2030.In terms of the quality of medical services,the cure rate of discharged patients has not improved significantly after 2019,and remains above 94%.The mortality rate of discharged patients will remain below 0.22%after 2022.In terms of medical service productivity,the average length of stay can be predicted to drop from 11.91 days in 2015 to 6.5 days in 2030.The number of bed turnovers will basically remain at 29-30 times/year after 2020.In terms of medical service costs,the per capita cost of discharged patients is expected to increase to 11,436 yuan by 2030.Per capita outpatient expenses are growing faster than hospital expenses.It is estimated that per capita outpatient expenses can reach 361.41 yuan in 2030.The results of the intervention trial showed that reducing the growth rate of hospital beds,increasing the proportion of medical staff with senior professional titles,increasing the number of clinical pathways,and reducing the cost of revenue of one hundred yuan have a good effect.However,adjusting the parameters of a single intervention target cannot simultaneously improve indicators of medical service quality,productivity and cost.4.Management strategy for optimizing the supply of medical services in public general hospitals under global budgetThe global budget policy lacks a sound incentive and restraint mechanism,and there is an incentive deviation for the supplier,the demander and the guarantee party.Under the global budget,the management strategy of hospital medical service supply needs to meet the principle of"incentive compatibility",specifically,（1）Optimize the top-level design of the policy to achieve the incentive compatibility between the government and the hospital;（2）Strengthen the internal management of the hospital to realize the incentive compatibility between the hospital and the doctor;（3）Establish a doctor-patient partnership to achieve the incentive compatibility between doctors and patients;（4）Manage medical treatment of insured patients to achieve the incentive compatibility between the government and patients.[Conclusions]1.After the reform of the global budget,the growth trend of the number of hospitals’medical services has increased,and the growth trend of hospitals with larger budgets is more obvious.In terms of the quality of medical services,the reform of the global budget system has slowed down the increase in the cure and improvement rate in hospitals with larger budgets.But the trend of changes in the mortality rate of discharged patients has not changed significantly before and after the reform.In terms of medical service productivity,the reform of the global budget system has accelerated the downward trend in the average length of stay and increased the upward trend in bed turnover.2.The key factors affecting the medical service supply of public general hospitals under the global budget include two types:the first category is the hospital’s internal performance management factors and diagnosis and treatment behavior factors that are directly affected by the global budget.They included cost-control-oriented performance appraisal,total control quota decomposition,proportion of critically ill patients,per capita outpatient expenses and proportion of inpatients in December.The second category is the external environment and organizational structure factors that play a regulatory role in the path of global budget.They included The intensity of market competition,the proportion of the number of beds in tertiary hospitals,the number of single-disease-paid diseases,the construction of the medical consortium,the allocation of quotas,the number of beds,the proportion of income from financial subsidy,proportion of income from medical insurance compensation,the difference in medical insurance settlement and the regional medical center.3.The influence mechanism of the medical service supply of public general hospitals under the global budget system includes the relationship between the external environment subsystem,the organizational structure subsystem,the organizational behaviour process subsystem,and the result subsystem of organizational behaviour.The simulation results show that the number and cost of medical services under the global budget system are still showing rapid growth,and the quality and productivity of medical services are improved to a small extent in the later stage of the simulation observation.Trials using a single intervention target cannot simultaneously improve multiple dimensional outcomes,and multiple intervention targets need to be combined for comprehensive policy intervention.4.Optimizing the supply of medical services under the global budget needs to consider the establishment of an incentive and compatibility mechanism involving the participation of doctors,patients and insurance from following aspects,such as the top-level design of policies,the internal management of hospitals,the symmetry of doctor-patient information,and the medical behavior of insured patients.[Innovations and limitations]1.Study innovationsFirstly,expanded the content of research related to thet global budget system.The study systematically analysed the main factors affecting the performance of the medical service supply system under the global budget system.It is an extension of the research on the evaluation of the previous total prepayment effect.Secondly,quantitative analysis of the dynamic response mechanism of the medical service system under the effect of global budget.The study introduced a system dynamics model,and demonstrated the relationship and path between influencing factors and the medical services from the perspective of system theory and quantitative methods.Finally,constructed an incentive and compatible mechanism for the multiple stakeholders.The research innovatively puts forward an incentive compatible mechanism for the participation of multiple stakeholders within the framework of the global budget by bringing the supplier,the demander,and the insurance side into the same cognitive framework.It breaks the limitations of a single subject of isolated analysis.2.Study limitationsFirstly,the research sample hospitals come from 46 public general hospitals in Taiyuan City,Shanxi Province,which makes the generalization of the research results have certain limitations.Secondly,the selected measurement indicators for the quality of medical services are relatively rough,and the unplanned return rate and other indicators can be considered for analysis in the future.Thirdly,Regarding the influencing factors of hospital management system and diagnosis and treatment behavior,the research includes fewer variables in the model.In the future,more indicators can be considered for in-depth analysis. |
PDF Full Text Request