Study On The Influence Of Medical Insurance Payment Modes On Public Hospital Operational Performance

Public hospitals are the main body of China’s medical service system,which are responsible for providing basic medical service for the people.Under the background of the current new medical reform,with the increasing health needs of the people,and the implementation of major national strategies such as Healthy China,the operating environment of public hospitals has changed profoundly,leading to great challenges to the operation and management of public hospitals.As a key mechanism to guarantee the masses to obtain quality medical services,medical insurance payment deeply affects the diagnosis and treatment behavior of hospitals and doctors through compensation incentives and constraint orientation,and thus has a profound impact on the operational performance of public hospitals.How to improve the management level of public hospitals to dapt to the reform direction of medical insurance payment has become a realistic problem to be soved urgently.However,the theoretical and empirical research on the relationship between the reform of medical insurance payment methods and the operational performance of public hospitals is still in its infancy.Based on the above practical problems and theoretical gap,this dissertation focuses on the impact of medical insurance payment methods on the operational performance of public hospitals.Based on the theory of institutional change,following the main change path of the reform of medical insurance payment methods,that is,from Fee-For-Service(FFS)to Diagnosis-Intervention Packet(DIP)payment,and then DiagnosisRelated Group(DRG),and applying a combination of research methods,this dissertation explores the following questions "What is the operational performance of public hospitals?","What factors affect the operational performance of public hospitals?","How does medical insurance payment methods affect the operational performance of public hospitals?" and "Does the same medical insurance payment method affect different levels of public hospitals in the same way?" The main conclusions are as follows.(1)The connotative structure dimension of public hospital operational performance is constructed,and the influencing factors of operational performance are identified.First,through the grounded research on 6typical public hosptials,this dissertation finds that the main factors affecting the operatonal performance of public hospitals,including medical insrance payment,social responsibility and government governance.Subsequently,principal component analysis is used to identify the key factors affecting the operatonal performance of public hospitals.Furthermore,the dissertation elaborates the key role of health insurance payment methods on the operational performance of public hospitals.Finally,based on the theory of institutional change,the internal driving force,the process and the change direction of medical insurance payment methods are analyzed.(2)The impact mechanism of FFS on the operational performance of public hospitals is revealed.Based on the four-year operational panel data of Grade II and III public hospitals in H province,this dissertation uses fixed-effect regression multivariate regression model to establish a research framework to evaluate the effectiveness of FFS from the perspective of operational performance of public hospitals,and puts forward the research hypotheses of the impacts of FFS on the operational performance of public hospitals in four aspects: financial income,medical service capacity,efficiency and hospital sustainability.It is found that FFS has a significant negative relationship with the financial income,medical service capacity and sustainability of public hospitals,and a significant positive relationship with the efficiency of medical resources.At the same time,the moderating effect of classification of hospital on the relationship between FFS and hospital operational performance is tested.The results show that FFS is significantly positively related with the financial income and medical service capacity of grade III hospitals,but is negatively related with medical efficiency,while FFS is significantly negatively related with the financial income,medical service capacity of grade II hospitals,but is positively related with medical efficiency.The findings show that the problems of uneven distribution of medical resources and low medical efficiency are more serious under FFS payment scheme.These conclusions can provide an important basis for accelerating the reforms of medical insurance payment methods and public hospitals.(3)The impact mechanism of DIP on the operational performance of public hospitals is revealed.The collected medical insurance compensation data for urban and rural residents and urban employees in C city from 2015 to 2021 shall be sorted out into monthly series data on the operation of public grade I,grade II and grade III hospitals within such time period.Based on the Interrupted Time-Series regression analysis model,the changes and trends of financial performance,medical efficiency,medical service capacity,medical service quality and patient’s burden were analyzed.The results show that DIP is negatively related to the financial performance for public grade I hospitals,but has on effect on the financial performance of grade II and grade III hospitals.Besides,the phenomenon of “diagnosis upgrade” and “set high scores” exists in grade II and grade III hospitals,and there is a tendency that hospitals pass on medical costs to patients.In addition,research shows that DIP does not promote gradeddiagnosis and treatment,nor improve medical efficiency.However,it has a positive impact on promoting rational drug use by medical staff,thereby reducing the proportion of drugs and improving the quality of medical services.Overall,the implementation of DIP is not satisfactory.These conclusions are of great practical value for further optimizing DIP payment.(4)The impact mechanism of DRG on the operational performance of public hospitals is revealed.Based on the DRG payment being implemented in X City,the medical insurance settlement data of the inpatients are collected,and the differences-in-difference model is used to analyze the changes of operational performance of public hospitals before and after the implementation of DRG.It is found that the total amount of medical expenses and the detailed value of each expense of the inpatients in pilot hospitals have decreased significantly after the implementation of DRG payment,indicating that DRG payment has a significant negative impact on the financial performance of public hospitals.In addition,the proportion of drugs and the length of stay have also decreased significantly,indicating that DRG payment has a positive effect on improving the quality and efficiency of medical services.However,the implementation of DRG payment will enable medical institutions to increase the proportion of examination items to make up for the revenue reduction from drugs and medical supplies.The heterogeneity analysis of classification of hospitals shows that after the implementation of DRG payment,the control effect of various medical expenses of public hospitals in grade II hospitals is obvious,while the amount paid by the personal account of inpatients in grade III hospitals and the costs of examination and diagnosis services even increase,indicating that DRG payment does not have cost-controlling effects in grade III hospitals.In addition,after the implementation of DRG payment,the out-of-pocket ratio of patients in both grade II and grade III hospitals are increased significantly,indicating hospitals adopting DRG payment will transfer medical expenses to patients by increasing medical expenses beyound the scope of reimbursement by medical insurance,thus increase the burden of patients.The research results above can provide an empirical basis for strengthening cost control and standardizing clinical pathway of public hospitals under DRG payment,and provides a decisionmaking basis for further optimizing DRG payment scheme.Through the above research,this dissertation has made the following important contributions to the relevant theories:(1)Based on the background of deepening the reform of the medical and health system,this dissertation applies the grounded theory,principal component analysis and semi-open interview research methods to clarify the main factors affecting the operational performance of public hospitals,identifies the key role of the reform of medical insurance payment methods,and recognizes the main paths of the current reform of medical insurance payment methods,thus,providing a solide theoretical basis for the follow-up empirical research;(2)Based on the balanced scorecard theory,a theoretical model of the impact on the operational performance of public hospitals is constructed,providing a new interpretation perspective for evaluating the effectiveness of the implementation of medical insurance payment methods;(3)The mechanism of the impact of medical insurance payment methods on the operational performance of public hospitals is revealed,and the development direction of the refined transformation of the operation of public hospitals in China is also clarified,which makes up for the lack of macro-policy discussion in the study of the factors affecting the operational performance of public hospitals.The results of this dissertation provide a scientific theoretical basis for the reform of medical insurance payment methods.