【作者】 张涛；

【导师】 陶红兵；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2021， 博士

【摘要】 【目的】本研究以医保总额预付为政策背景,旨在分析政策实施前后公立综合医院医疗服务供给的变化情况,并进一步识别出总额预付制下影响医疗服务供给的关键因素,探究其中的影响机制,在此基础之上探讨多元利益主体参与的激励相容机制,形成优化医疗服务供给的管理策略,以期为医院管理制度和相关政策的制定提供参考。【方法】（1）文献研究法。通过检索国内外主要数据库,系统梳理不同医保支付方式下,医疗服务供给的评价指标及其影响因素,以进一步确定研究框架和研究方案。（2）专家咨询法。研究选取了16名从事医院管理和医保领域研究和实践工作的专家,就本研究所涉及的医疗服务数量、质量和生产力测量评价指标进行两轮专家咨询,以确定测量医疗供给的具体评价指标。（3）二手资料收集。研究以山西省太原市为样本地区,共收集了样本地区46家公立综合医院2013-2019年卫生资源配置、医疗服务供给以及运营方面的数据。（4）中断时间序列回归。研究采集了样本医院总额预付实施前后共计36个月观测指标的数据,并借助中断时间序列回归分析了改革前后医疗服务供给的变化。（5）知情人深度访谈和扎根理论。研究选择了样本地区医保和卫生行政管理人员、医院管理人员以及医务人员共计35人,围绕总额预付背景下医疗服务供给的关键影响因素进行深入访谈。并采用扎根理论分析范式对深入访谈的资料进行三级编码,以识别出主要的影响因素,并构建出相应的理论框架。（6）广义线性混合模型。研究分别在总额预付前后构建广义线性混合模型,对比分析在改革后对医疗服务供给影响更为显著的因素。（7）系统动力学模型。研究采用了系统动力学建模的方式分析了总额预付下公立综合医院医疗服务的影响机制,并进行了仿真模拟和干预试验。【结果】1.总额预付前后公立综合医院医疗服务供给的变化情况（1）在医疗服务数量方面,改革后医院出院人数的增长趋势提高了24.14人/月,并且预算额度较大的医院出院人数增长趋势更快（β₃=34.05,p=0.002）。改革后,预算额度较大的医院在手术人次数上提高了3.59人次/月（p=0.020）。（2）在医疗服务质量方面,总额预付制改革后预算额度较大的医院治愈好转率下降了0.05%/月（p=0.011）,但是改革前后医院死亡率的变化趋势并未发生显著性改变。（3）在医疗服务生产力方面,总额预付改革后医院出院患者的平均住院日下降了0.02天/月（p=0.019）,医院床位周转次数提高了0.04次/月（p<0.001）。2.总额预付下公立综合医院医疗服务供给的影响因素扎根理论分析结果显示总额预付下影响公立综合医院医疗服务供给的主要因素包括9类,分别为社会经济环境、市场环境、政策环境、人力资源、物力资源、财力资源、品牌与技术、内部绩效管理和诊疗行为。回归模型分析结果显示总额预付下对医疗服务供给影响更为显著的因素包括:（1）在医疗服务数量上,参与医联体建设时间（β=0.274,p=0.009）、床位数（β=0.006,p=0.008）、12月住院患者占比（β=0.012,p=0.003）、额度分配（β=-0.427,p=0.001）、财政补助收入占比（β=-0.024,p=0.014）、控费导向绩效考核（β=-0.008,p<0.001）和人均门诊费用（β=-0.001,p=0.004）在改革后对出院人数的影响程度提高。此外,上述因素在改革后同样对手术人次数产生了更为显著的影响。（2）在医疗服务质量上,单病种付费病种数（β=0.003,p=0.018）、床位数（β=-0.011,p=0.048）和总控额度分解（β=-0.217,p=0.014）在改革后对治愈好转率的影响增加。市场竞争强度（β=0.247,p=0.017）、区域医疗中心（β=0.093,p=0.001）、控费导向的绩效考核（β=0.011,p=0.016）在改革后对死亡率产生了更为显著的正向影响。（3）在医疗服务生产力上,预算额度分配（β=0.279,p=0.022）、医保补偿收入占比（β=0.048,p=0.040）、控费为导向的绩效考核（β=0.061,p<0.001）、总控额度分解（β=0.399,p<0.001）、三级医院床位数占比（β=-0.164,p=0.042）、财政补助收入占比（β=-0.047,p=0.044）、医保结算差额（β=-0.271,p=0.036）和人均门诊费用（β=-0.010,p=0.029）在总额预付实施后对床位周转次数的影响程度进一步增加。医保结算差额（β=0.554,p=0.003）、人均门诊费用（β=0.006,p=0.041）、总控额度分解（β=-0.564,p<0.001）和控费导向绩效考核（β=-0.016,p<0.001）在改革后则对平均住院日产生了更为显著的影响。3.总额预付下公立综合医院医疗服务供给的影响机制系统动力学建模结果显示总额预付下公立综合医院医疗服务供给的关键影响因素作用路径表现为:总额预付通过直接作用医院内部绩效管理制度,继而影响到诊疗服务行为,最终带来医疗服务供给的改变。同时,外部政策环境因素和医院内部资源配置因素会在其中起到调节作用。仿真模拟的结果显示:（1）在医疗服务数量上,出院人数可从2015年的12778人增加到2030年的30822人,住院患者手术人次数从2015年的4808人次增加到2030年的23309人次。（2）在医疗服务质量上,出院患者治愈好转率在2019年以后改善不明显,维持在94%以上。出院患者死亡率在2022年之后维持在0.22%以下。（3）在医疗服务生产力上,出院患者平均住院日可从2015年的11.91天可以下降到2030年的6.5天。病床周转次数在2020年以后维持在29-30次/年。（4）在医疗服务费用上,出院患者的人均费用预计到2030年可增长至11436元。人均门诊费用的增速要快于住院费用,预计到2030年人均门诊费用可达到361.41元。干预试验结果显示,减少医院床位增速、提高高级职称医护人员比重、增加临床路径病种管理数以及降低百元收入成本所产生的效果较好,但是调节单个干预靶点的参数并不能同时改善医疗服务质量、生产力和费用多个结局指标。4.总额预付下优化公立综合医院医疗服务供给的管理策略总额预付政策设计缺少健全的激励约束机制,对供方、需方和保方的激励存在偏差。在医保总控背景下制定医院医疗服务供给的管理策略需要满足“激励相容”的原则,具体为:（1）优化政策的顶层设计,实现政府与医院的激励相容;（2）强化医院内部管理,实现医院和医生的激励相容;（3）建立医患合作关系,实现医生和患者的激励相容;（4）规范管理参保患者就医行为,实现政府与患者的激励相容。【结论】1.总额预付制改革后医院医疗服务数量的增长趋势提高,其中预算额度较大医院的增长趋势更为明显。在医疗服务质量方面,总额预付制改革后,预算额度较大的医院出院患者治愈好转率上升趋势放缓,但是出院患者死亡率的变化趋势尚未发生显著性改变。在医疗服务生产力方面,总额预付制改革加速了出院患者平均住院日的下降趋势,同时也提高了病床周转次数的上升趋势。2.总额预付制下影响公立综合医院医疗服务供给的关键因素包括两类:第一类是受到总额预付直接作用的医院内部绩效管理因素和诊疗行为因素,包括控费导向绩效考核、总控额度分解、危重症患者占比、人均门诊费用和12月住院患者占比。第二类是在总额预付作用路径中起到调节作用的外部环境和组织结构因素,包括市场竞争强度、三级医院床位占比、单病种付费的病种数、医联体建设时间、额度分配、床位数、财政补助收入占比、医保补偿收入占比、医保结算差额和区域医疗中心。3.总额预付制下公立综合医院医疗服务供给的影响机制包含了外部环境子系统、组织结构子系统、组织行为过程子系统和组织行为结果子系统之间的作用的关系。总额预付制下公立综合医院医疗服务数量和费用仍呈现出较快的增长,医疗服务质量和产生力在政策实施后期的改善程度变小。总额预付下优化医疗服务供给需要联合使用多个干预靶点进行综合干预。4.总额预付制下优化医疗服务供给的管理策略需要从政策的顶层设计、医院的内部管理、医患信息的对称性以及参保患者的就医行为等方面考虑建立医方、患方和保方共同参与的激励相容机制。【创新与不足】1.研究创新首先,拓展了总额预付制相关研究的内容。研究重点分析了总额预付对哪些关键因素产生影响,从而使得这些因素进一步影响到医疗服务供给,是对既往总额预付效果评价研究的延伸。其次,量化分析了总额预付作用下医疗服务供给系统的动态反应机制。引入了系统动力学模型,以系统论的视角和定量的方法分析论证了影响因素与医疗服务供给之间的作用关系和作用路径。最后,构建了多元利益主体参与的激励相容机制。研究将供方、需方和保方纳入到同一认识框架内,创新性的提出了在医保总控背景下多元利益主体参与的激励相容机制,突破了孤立的分析单一主体的局限性。2.研究不足首先,研究样本医院来源于山西省太原市46家公立综合医院,研究结果的可推广性存在一定的局限性。其次,在医疗服务质量上所选取的测量指标较为粗略,未来可考虑纳入非计划重返率等指标进行分析。再次,有关医院管理制度和诊疗行为方面的影响因素,研究纳入到模型中的变量较少,未来可考虑量化更多的测量指标分析。更多还原

【Abstract】 [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.更多还原