The Effect Of The Global Budget Prospective Payment System: A Theoretical And Empirical Study

[Background]With the rapid development of Chinese economy, the health care system in China has made great progress. And the coverage and benefits of social health insurance improved greatly. However, the rapid increase of health expenditures has caught great attention. From 2009-2011, the growth rates of total health expenditures in China are 20.7%,13.9%,21.5%, which are greater than the GDP growth (9.2%,10.4%,9.2% respectively). Controlling health cost has become one of the most key issues. Scientific and appropriate payment system is pivotal to the containment of health cost. A lot of studies have shown that global budget prospective payment system is effective way to control health expenditure. Chinese government documents have also demonstrated that payment system reform, especially global budget prospective payment system is one of the key components of the health care system reform. Hence, it is necessary and urgent to study the effect of global budget prospective payment system.Most of current foreign studies focus on the payment system itself, and emphasize on the ultimate effect of global budget, i.e. cost, quality, efficiency, accessibility of the health care service provided after the implementation of global budget prospective payment system. Chinese studies on global budget focus on the positive and negative effects, and most of them are case studies. Hence, abstract research on the effect of global budget is of importance.[Objective]Based on theoretical research, mathematical modelling and empirical study results, to explore the effect of global budget prospective payment system and make recommendations as reference for related administrators and decision makers.Theoretical research is based on the qualitative study and modelling results. Hospital utility function is established with the restriction of budget. To maximize the hospital utility function, establish Lagrangian function and solve it. Explain the results and translate the effect of global budget prospective payment system.Empirical research is based on field investigation. Structural questionnaires should be made respectively for the administrators, doctors and patients. The surveyed doctors filled in the questionnaire themselves. Questionnaire for administrators was filled by the investigator through a qualitative talk. Questionnaire for patients was filled through a face to face investigation between the investigator and patient surveyed. To explore the potential impact and its possible reasons of global budget on hospitals, doctors and patients and make related recommendations for decision makers.[Methods]Theoretical researchAnalyze the mechanism and impact of global budget prospective payment system through literature review. Design mathematical model to analyze the effect of global budget theoretically on the basis of qualitative research. The basic methods of modelling are the design of utility function and extreme theory.After the mathematical model design, solve the extremum of the base and extension model of hospital utility.Empirical researchInvestigate 10 tertiary hospitals in Shanghai which have implemented global budget prospective payment system pilot. Amongst them,23 hospital administrators, 400 doctors,399 hospitalized patients (at least 7 days) and 400 out-patients were surveyed in 2011.Structural questionnaires should be made respectively for the administrators, doctors and patients. The surveyed doctors filled in the questionnaire themselves. Questionnaire for administrators was filled by the investigator through a qualitative talk. Questionnaire for patients was filled through a face to face investigation between the investigator and patient surveyed. The investigation content of hospital administrators includes hospital strategy, opinions on global budget, hospital economic data etc. The investigation content of doctors includes hospital and doctor behaviors, opinions on global budget etc. The investigation of patients focuses on the patient perception.To investigate hospital management measures of global budget in 10 tertiary hospitals in 7 provinces, applying key informant interviews and questionnaire investigations, which focus on the budget distribution within the hospital, actual implementation status and supervision measures especially for the radiofrequency ablation of atrial fibrillation.Use Epidata to input the field investigation data. After that export the database into Excel and make fundamental analysis. Finally make descriptive analysis through Stata 10.0 and make multivariant analysis through SAS. [Results]Considering hospitals can only provide health care services to the insured patients covered by global budget, which is called base model. Hospitals can provide health care services both to the insured patients and uninsured patients, which is called extension model. As hospitals can only provide health care services to the insured patients, the effect of global budget is that it will worsen the quality of service provided. As hospitals can provide health care services both to the insured patients and the uninsured patients, the effect of global budget is that it will enhance the uncertainty of the quality of service provided.[Conclusions and Recommendations]The results of both theoretical research and empirical research show that global budget will possibly affect the quality of health care services provided by hospitals. Hospitals may tend to refuse insured patients, provide insufficient services and distribute more resources to uninsured patients, which could affect the quality of services provided and accessibility of insured patients. It is recommended that elaborate supportive policies should be employed to support global budget, clinical pathway could be part of supervisory system of global budget and global budget of medical complex should further studied and practiced.