| BackgroundThe price reform,as the cornerstone of the compensation mechanism reform,had always played a critical role in the health systems reform,which was the the key component of the new round medical reform since 2009.In order to change the irrational compensation mechanism in public hospitals,curb the rapid growth of medical expenses,promote the establishment of a new compensation mechanism,and improve the health care accessible and alleviate the economic burden of patients,one of the key contents of public hospital reform was to implement the zero-markup drug policy.The economic and social development of Shandong Province is a microcosm of the national economic and social development.The evaluation of the implementation effect of the zero-markup drug policy in county-level public hospitals in Shandong Province has a reference for the whole country.The implementation of the zero-markup drug policy in county-level public hospitals in Shandong Province experienced the first wave of pilots on January 1,2013,expanded pilots on October 1,2014,and achieved full coverage by the end of 2015.The literature review found that existing studies on the evaluation of the implementation effect of the zero-markup drug policy have the following limitations.First,in the research design,most studies were descriptive analysis of before and after comparison,and there were very limited number of policy evaluation studies based on quasi-experimental design.Second,in the research objects,most of studies focused on county-level general hospitals.However,since Chinese herbal medicine and Chinese herbal medicine pieces were not sold at zero-markup,the effect of the policy implementation may be different among county-level general hospitals,traditional Chinese medicine hospitals and specialized hospitals,resulting in a lack of comparative analysis of different types of hospitals.Third,in the evaluation cycle,most studies only focused on the short-term effect of the policy,but the effect of the reform may be different at different time points.Therefore,we need to pay attention not only to the instantaneous effect of the reform,but also to the dynamic effect of the reform.Fourth,in terms of evaluation indicators,most studies only focused on the effect on medical institutions themselves,and the long-term goals of the new medical reform were to change the behaviors of medical personnel and reduce the burden of patients.Therefore,we also need to pay attention to the effect of policies on the behaviors of medical personnel and the burden of patients.In order to make up for the shortcomings of existing researches,based on a quasiexperimental design and longitudinal data before and after the zero-markup drug policy,this study aimed to evaluate the implementation,the short-term effect and the long-term dynamic effect of the zero-markup drug policy in Shandong county-level public hospitals from three levels of medical institutions,medical personnel and patients,so as to provide reference for deepening the comprehensive reform of drug prices and promoting the high-quality development of public hospitals in the future.ObjectivesBased on a quasi-experimental design,this study amied to evaluate the impact of the implementation of the zero-markup drug policy on the county-level public hospitals,medical personnel and patients in Shandong Province,so as to provide a basis for the improvement of the comprehensive reform of drug prices.The specific objectives are as follows:(1)To sort out the implementation path of the zero-markup drug policy in countylevel public hospitals in Shandong Province.(2)To evaluate the differences in the impact of the zero-markup drug policy on the economic operation and service provision on different types of county-level public hospitals.(3)To reveal the impact of the zero-markup drug policy on the prescribing behaviors of the medical staff in county-level public hospitals.(4)To analyze the impact of the zero-markup drug policy on the hospitalization of patients in county-level public hospitals.(5)To provide suggestions for the improvement of the comprehensive reform of drug prices.MethodsThe data of this study mainly come from two aspects.First,we obtained the financial annual report data of Shandong health system,and the economic operation and service provision and other relevant data of all 220 county-level public hospitals,including general hospitals,traditional Chinese medicine hospitals,and specialized hospitals in Shandong Province from 2007 to 2017.Second,we used the sampling data of county-level public hospitals.According to the geographical location,economic level and the situation of the zero-markup drug policy carried out in different reform stages,six county-level public hospitals were selected from the eastern,central and western region of Shandong Province,and the outpatient prescription data before and after the reform of pneumonia,diabetes,and the first page data of inpatients’ medical records before and after the reform of four diseases,including pneumonia,diabetes,appendicitis,and lumbar disc herniation.Based on the theory of change,the theoretical framework of this study was constructed,and evaluation indicators were selected from three levels:medical institutions,medical personnel and patients.At the level of medical institutions,it mainly included two dimensions:service provision and economic operation.The service provision dimension selected the total number of people diagnosed and treated and the number of people discharged,and the economic operation dimension selected the total income,total expenditure,outpatient income,inpatient income,financial compensation income,drug income,medical service income and their proportion.At the level of medical personnel,the average number of drugs in outpatient prescriptions,the average drug cost of outpatient prescriptions,and the probability of prescriptions containing antibiotics,hormones and intravenous reagents were selected.At the patient level,the average total hospitalization cost,average hospitalization drug cost,average medical and examination cost,average length of stay,the probability of antibiotic use,and the probability of surgery were selected.When analyzing the medical institutions,the control variables were the number of beds and health technicians in the medical institutions.When analyzing the prescribing behaviors of medical staff,the control variables were patient’s gender,age,etc.When analyzing the patients’ medical care burden,the control variables were patients’ gender,age,marital status,occupation,etc.In terms of quantitative analysis methods,this study used a quasi-experimental research design with a DID model to evaluate the implementation effect of the zeromarkup drug policy.Descriptive statistical analysis method was used to analyze the changes of main outcome indicators of county-level public hospitals before and after the implementation of the policy.For continuous variables,mean and standard deviation were used to describe the basic situation.For categorial variables,the basic situation was described by the rate and composition ratio.In terms of the evaluation effect of the policy,the quasi-experimental research method was mainly used.The DID method was used to evaluate the effect of policy implementation,and analyze the impact of the zero markup drug policy in Shandong Province on the economic operation,service provision,outpatient prescriptions and inpatient burden of county-level public medical institutions.In addition,the event analysis method was used to estimate the change trend of different outcome variables in the intervention group and the control group to test the parallel trend and the dynamic change of the reform effect over time,assuming that the difference between the intervention group and the control group remained unchanged over time without reform.The Permutation test was used to test that the change of reform group trend was caused by reform exposure.For specific model estimation,according to the type of dependent variable,this study selected log linear regression,logit regression and Poisson regression.Results(1)The impact of the zero-markup drug policy on the county-level public hospitals in Shandong Province.In terms of service provision,after the implementation of the zero-markup drug policy,the total number of people diagnosed and treated and the number of people discharged in the county-level public hospitals in Shandong Province did not change significantly.In terms of overall economic operation,after the implementation of the zero-markup drug policy,the total income did not change significantly,but it had a downward trend in the long run.The total expenditure did not change significantly.In terms of revenue and expenditure structure,after the implementation of the zero-markup drug policy,the total drug revenue decreased by 17%,and there was a further downward trend in the long run.Medical income increased by 8%.The revenue from financial subsidies increased significantly,more than doubled.As for the proportion of revenue and expenditure,after the implementation of the zeromarkup drug policy,the proportion of total drug income decreased,the proportion of total medical income increased,and the proportion of financial subsidy income increased significantly,more than doubled.(2)Differences in the impact of the zero-markup drug policy on different types of county-level public hospitals in Shandong Province.After the implementation of the zero-markup drug policy,the total number of people diagnosed and treated in countylevel general hospitals and county-level specialized hospitals in Shandong Province did not change significantly,while that in county-level traditional Chinese medicine hospitals declined by about 12%.The total income of county-level general hospitals,traditional Chinese medicine hospitals and specialized hospitals did not change significantly.The total drug income of county-level general hospitals and county-level specialized hospitals decreased by about 20%,while that of county-level traditional Chinese medicine hospitals did not change significantly.The financial subsidy income of county-level general hospitals,county-level traditional Chinese medicine hospitals and county-level specialized hospitals increased significantly.(3)The impact of the zero-markup drug policy on outpatient prescription behaviors of doctors in county-level public hospitals in Shandong Province.After the implementation of the zero-markup drug policy,the average drug cost of outpatient prescriptions per time in county-level general hospitals in the year of the reform,the first year after the reform,and the second year after the reform decreased by 22.70 yuan,21.32 yuan,and 25.35 yuan respectively.The average drug number of outpatient prescriptions per time increased by 0.065 in the year of the reform,and decreased again the first year after the reform,the second year after the reform,and the third year after the reform.The probability of outpatient prescriptions containing antibiotics increased by 1%in the year of the reform,but decreased in the first year,the second year and the third year after the reform.The reform had no significant impact on the probability of outpatient prescriptions containing hormones and the probability of outpatient prescriptions containing infusion.(4)The impact of the zero-markup drug policy on the utilization of inpatient services in county-level public hospitals in Shandong Province.After the implementation of the zero-markup drug policy,the total cost of inpatients per hospitalization decreased,and the total cost of inpatients per hospitalization in the year of the reform and the first year after the reform decreased by 229.74 yuan and 227.04 yuan respectively compared with the year before the reform.The total drug cost of inpatient per hospitalization decreased.In the year of the reform and the first year after the reform,the total drug cost of inpatient per hospitalization decreased by 455.42 yuan and 475.53 yuan respectively compared with the year before the reform.The medical and examination expenses increased.The average medical and examination expenses of inpatients per hospitalization in the year of the reform and the first year after the reform increased by 175.10 yuan and 83.68 yuan respectively compared with the year before the reform.The reform had no significant impact on the average length of stay per hospitalization,the probability of antibiotic use,and the probability of surgery in the county-level public general hospitals in Shandong Province.Conclusions and Policy ImplicationsThe main conclusions of this study were as follows:(1)After the implementation of the zero-markup drug policy,the county-level public hospitals in Shandong Province had run smoothly and revenue structure had been optimized.(2)The implementation of the zero-markup drug policy had different impacts on different types of county-level public hospitals.(3)The implementation of the zero-markup drug policy had significant impacts on outpatient prescribing behaviors of doctors.(4)The zero-markup drug policy played a good role on optimizing the cost structure.Based on the above conclusions,the following policy recommendations were put forward:(1)To deepen the implementation of the zero-markup drug policy,and continuously improve the compensation mechanism of county-level public hospitals.(2)To strengthen hospital management,and continuously improve the operation efficiency and quality of county-level public hospitals.(3)To optimize the price policy of Chinese herbal medicine and Chinese herbal medicine pieces to promote the healthy development of traditional Chinese medicine.(4)To introduce supporting policies to further guide the rational use of drugs in the outpatient diagnosis and treat of countylevel public hospitals.(5)To take multiple measures to further reduce the economic burden of inpatients in county-level public hospitals.Strengths and LimitationsThe strengths of this study are as follows:(1)Based on the difference in the implementation time of the reform in different counties(districts),this study constructed a staggered Difference-in-Difference model,used the quasi-experimental research method to conduct Causal inference on the policy effect,improved the quality of policy evaluation research,and provided a high-level evidence-based basis for more scientific evaluation of the zero-markup drug policy and its implementation effect.(2)This study utilized institutional and individual level data to comprehensively evaluate the effectiveness of the zero-markup drug policy implementation from three dimensions:hospitals,doctors,and patients.It made up for the limitations of previous studies that used institutional level data or a single data source,and improved the systematic nature of researches in this field and the comprehensiveness of evidence.(3)This study utilized data from all county-level public hospitals in Shandong Province to analyze the impact of the reform on general hospitals,traditional Chinese medicine hospitals,and specialized hospitals,and further compared the differences in impact effects.It made up for the limitations of previous studies only targeting a certain type of hospitals and provided a scientific basis for precise policy implementation.The limitations of this study are as follows:(1)The implementation and role of the policy was a complex process.The zero-markup drug policy was an important measure in the reform of county-level public hospitals.During the implementation of the zeromarkup drug policy,other medical reform policies such as graded diagnosis and treatment and the zero-markup consumable policy had been introduced one after another.The superposition of these policies may have a certain impact on the results of this study.In order to reduce the impact of other policies,this study chose to study until the year before the zero-markup consumable policy in Shandong Province.By utilizing the staggered Difference-in-Difference model to control the fixed effects of institutions and time,as well as the development trend effects of regions,the influences of other factors were eliminated as much as possible.In addition,this study conducted a parallel trend test through the Event study method,and a placebo test using the Permutation test to verify the robustness of the zero-markup drug policy,and discussed the estimation results that may be biased.Therefore,the estimation of the outcome variables in this study can better reflect the effectiveness of implementing the zero-markup drug policy.(2)When analyzing the hospitalization burden of inpatients in county-level public hospitals in Shandong Province,due to data unavailability,the sum of expenses during hospitalization was analyzed,including medical insurance reimbursement and patient self-payment expenses.There was a certain deviation between the sum of expenses and the actual burden of inpatients.However,considering that the actual reimbursement level of medical insurance in Shandong Province did not change much during the study period,the change of total expenses could reflect the burden of patients at a certain level.Considering that there may be some differences between different diseases affected by the zero-markup drug policy,when analyzing the outpatient prescription behaviors of medical personnel and the utilization of inpatient services,we selected the two most common medical diseases in the county,namely pneumonia and diabetes,and two most common surgical diseases,namely Appendicitis and lumbar disc herniation,which were relatively representative. |
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