Study On The Changes Of Medical Quality And The Influencing Factors In The Tertiary Public Hospitals Under The Global Budget System

[Purpose]The development and implementation of Global Budget System has impact on medical services.This work sorts out these effects and analysis whether they have brought significant changes to public hospital medical quality.By using several methods,such as content analysis,comprehensive literature research,statistical analysis and interview data analysis,changes on public hospital medical quality is discussed,alone with possible reasons.The global budget system optimization and medical quality improvement strategy are also proposed in this work.[Methods]For data collection,6 public general hospitals in the central urban area within the scope of the global budget policy for Wuhan from 2014 to 2017 as the research sample object.Those basic information of sample areas and documents of medical insurance payment policy system,basic operation data of sample hospitals and data of front pages of typical medical records were collected by field research.The research progress and trend of the changes of medical services under the global budget system,hospital medical quality evaluation and gross medical prepayment at home and abroad are explored with literature research.The scope of disease selection and quality evaluation index are determined by expert consultation and sample hospital baseline survey.Logistic regression and multiple linear regression are utilized for construction and calculation of risk adjustment model.The quality indicators of typical diseases in sample hospitals were analyzed and compared by descriptive statistical analysis,chi-square test and non-parametric statistical test,while the influencing factors system of medical quality in public hospitals with total advance payment was constructed by typical case analysis and content analysis.[Results]1.Global Budget System implementation in sample regionThe reform of medical insurance payment method is carried out in a conservative way.It has been through two main stages: Quota payment from 2001 to 2013 and Total payment from 2014 to now.Within the second stage,2015 is the transitional period of total advance payment.In 2016,the global budget system,which stands for ‘annual total budget,monthly advance payment,process supervision,index assessment and year-end liquidation',was thoroughly implemented.At present,the Global Budget System in sample area learns from classified payment,which follow the policy of over-expenditure allocation.The medical insurance assessment and supervision method considers both principle and flexibility.However,there are still some problems in quota verification,distribution,settlement,reimbursement scope and so on.The attitude and execution ability of the current system of global budget in sample hospitals are not entirely consistent.2.Analysis of sample hospitals' medical quality changes under Global Budget SystemAt the hospital level,the mortality rate and the number of medical disputes increased slightly in 2015,followed by decreasing;the infection rate fluctuated greatly in some hospitals;the average length of stay showed a continuous downward trend;the quality changes of different hospitals under Global Budget System were different.According to different typical diseases,after risk adjustment and excluding confounding factors,the in-hospital mortality of patients with acute myocardial infarction decreased by 2.86% in 2017 compared with that in 2014(P<0.001);the incidence of surgical complications of hip arthroplasty also decreased gradually,and the in-hospital mortality of patients with pneumonia decreased by 0.48% in 2017 compared with that in2014(P<0.001);The number of hospitalization days of patients with typical diseases showed a steady downward trend,which was 0.40% higher in 2017 than in 2014(P< 0.001).Horizontal comparison of the sample hospitals showed that there was polarization in the mortality rate and the incidence of surgical complications,and the difference of typical diseases quality level between different hospitals became larger,while the actual hospitalization days of patients gradually converged to the average level.3.Analysis of influencing factors of medical quality in public hospitals under Global Budget SystemA sample hospital with better comprehensive performance of medical quality under global budget and E sample hospital with lower overall quality level were selected for typical case analysis.58 records of interviews with key insiders were collated and analyzed by content analysis method,and the influencing factors system of medical quality in public hospitals under total advance payment was constructed.The main influencing factors are the insurer,the doctor,the patient and the other four aspects,eight secondary dimensions and 24 tertiary items.The top six influencing factors ranked by key frequency analysis are:the level of diagnosis and treatment technology(50,86.21%)of other internal factors of the doctor,the intensity of medical quality supervision(50,86.21%)of medical quality control dimension,and the safety of medical quality.The implementation of core system(49,84.48%),the implementation of clinical pathway or single disease quality management(48,82.76%),the attitude and decision-making of hospital leaders under global budget system(37,63.79%)in the strategic decision-making dimension of medical hospitals,and the medical insurance assessment and supervision criteria(34,58.62%)in the regulatory dimension of medical insurance for insurers.[Conclusions]1.Changes of Medical Quality in Tertiary Public Hospitals under Global budget systemThere are contradictions between the relatively lagging process of health insurance reform in sample areas and the complex and changeable medical and health market.There are contradictions between the rigid quota of global budget system and the demand of expansion and development of tertiary public hospitals.Under the background of the implementation of global budget,the medical quality of sample hospitals has changed significantly,and the quality of different diseases and hospitals has changed differently.From the beginning of the reform of medical insurance payment mode in 2015,sample hospitals may not have adapted to the new situation.The quality of medical servicedelivery has declined in a short period of time,then gradually improved,and the quality of medical care has improved as a whole.At the level of disease types,the overall increase of hospitalization mortality of pneumonia patients shows that there are certain quality defects in sample hospitals;the quality level of "polarization" between hospitals has changed and improved.The comprehensive development situation is related to the irrationality of the current global budget system in the sample areas.2.Influencing factors of medical quality in tertiary public hospitals under global budget systemUnder the background of global budget,the most direct impact on medical quality is the decision-making and management of doctors.Seeking "balanced decision-making" between cost control and hospital development may be the common trend of tertiary public hospitals in sample areas.With the comprehensive promotion of global budget system and the gradual deepening of the reform of medical insurance payment mode,clinical pathway has the advantage of "double control" of medical cost and medical quality.Increasingly prominent,it may be one of the breakthroughs for public hospitals to raise quality control fees in the future.Hospital's control fees for departments or doctors will affect medical quality by interfering with physicians' behavior.When choosing treatment options,physicians have a trade-off effect between "optimum" and "most economical".Medical insurance supervision plays a role in standardizing medical behavior to a great extent,reducing irrational medical behavior and promoting the quality of diagnosis and treatment;at the same time,many unreasonable or trap-like regulatory standards are easy for doctors to develop the habit of "saving while saving",and some medical quality risks arise accordingly;the global budget system of medical insurance in sample areas is in quota accounting,distribution and examination.Nuclear and other aspects are not perfect,and there are some deviations in guiding the role of designated hospitals.3.Medical Quality Improvement Strategy under Global Budget SystemThe insurer can improve the global budget policy system and avoid the quality risk under the global budget through scientific calculation and adjustment of the total limit,overall consultation and allocation of the total amount,standardizing the settlement and payment of medical expenses,exploring the mixed payment mode adapted to the regional medical environment,and earnestly fulfilling the supervision function of medical insurance.The doctor can strengthen the education,training and construction of the payment system.To adapt to the payment system and the management mechanism of hospital development,strictly control the medical quality,reasonably control the medical expenses,and guarantee the support of information platform,optimize the internal management of the hospital,and promote the improvement of the medical quality under the global budget.