Research On Shanghai Medical Resource Vertical Integration

1 BackgroundThe health resource is limited while the health needs are unlimited.There are always contradictions between the limited health resources and the increasing needs of the people in medical and health service.In order to alleviate the contradiction,the effective governmental planning and regulations are needed to involve in or directly intervene through regulations to reduce unit cost of each medical and health service, increase the efficiency of the utilization of current medical esource,obtain more output of the medical service and satisfy people's need on medial service in a greater extent.In order to realize the above goals,there are various means and strategies available,such as increasing governmental inputs in sanitation,perfecting medical insurance system,regulating the current medical service price system,strictly controlling medicine and inspection cost,widening charge price and medical insurance reimbursement proportion,and etc.But due to the contradictions in resource utilization that the big hospitals are crowded by large quantity of patients and the some other hospitals have few patients,and the situation of the small hospital, rural hospital and grassroots hospital,China health reform specially puts great effort on resource integration strategy to expand health service and alleviate the problem of "difficult medical care",hoping to increase overall utility efficiency to expand medical service provision through cooperation between various hospitals.Resource integration is an activity absorbing external resource,optimizing internal resource and reorganizing based on its existing resources,the aim of which is to make the limited resource exert more efficiency to apply in medical and health field, i.e.medical resource integration.Because integration targets have noticeable differences with regard to different social status and strength,it can be also called medical resource vertical integration which has two patterns;the first is mutual agreement or asset integration to promote premium medical resource output;the second is resource deployment,transfer or merging policy,such as the health administrative department calls on urban hospital to assign medical force to support medical work of the rural hospital or township hospitals.The study mainly focuses on medical resource vertical integration on institutional level,summarizes suitable mode and operational procedure for medical resource vertical integration and offers suggestion on Shanghai medical resource allocation and utilization through necessity analysis,implementation status quo,and obstacle analysis in implementation as well as case appraisal. 2 Contents2.1 Analyzing the necessies of medical resource vertical integration in Shanghai(1)Analyze geographical availability of medical care for Shanghai residents, doctor availability and sufficiency of communication with doctor,make clear manifestation of difficult medical care for Shanghai residents;(2) Analyze status quo of Shanghai medical institution,hospital beds,medical staff,medical equipment and medical expense and compare with the level of other municipality,average level of the country,and the level of some countries and regions;(3) Analyze basic situation of diagnosis service,outpatient and emergency treatment service,surgery service, analyze manpower effectiveness,hospital beds utility efficiency and average inpatient days,and compare with the level of municipality directly under the Central Government,average level of the country,and the level of some countries and regions.2.2 Making the actual development and obstacle clearly in Shanghai medical resource vertical integration(1)Analyze historical and practical experience of medical resource integration nationwide since the reform and opening-up;(2) Analyze medical resource integration mode,method and operational effect of typical countries and regions domestically and overseas;(3) Summarize mode of Shanghai medical resource vertical integration;(4) Analyze advantage,disadvantage and key points of medical resource vertical integration,and analyze problems and obstacles existing in medical resource vertical integration.2.3 Evaluating strengths and weaknesses of medical resource medical integration in ShanghaiCase study is applied based on the case with good operation recommended by experts.Research object is Ruijin Hospital and the former Central Hospital of Luwan District.The research is carried out mainly on medical level change and influence of the former Central Hospital of Luwan District after trusted to Ruijin Hospital, meanwhile,I further analyse precondition of the successful case and existing difficulties.2.4 Putting forward different mode and strategies for Shanghai medical resource vertical integrationPolicy,strategy,plan and operational procedure for medical resource vertical integration are put forward in accordance with obstacle in Shanghai medical resource vertical integration and precondition of successful cases.3 Methods(1) Data are collected from 2003 Shanghai health service survey report,the 3^rd national health service survey report and yearbook of health in the PRC through Shanghai municipal health bureau,Shanghai Shenkang hospital development center, resource allocation and utility efficiency and are compared with those of overseas and domestic cities.(2)Obtain information of domestic and overseas medical resource integration theory,practice and experience summary hrough literature;general investigate status quo of resource vertical integration of Shanghai GradeⅢhospital through questionnaire;make clear advantage,disadvantage,key points,existing problems and obstacle in various modes of the current Shanghai medicalresource vertical integration.(3)Obtain information for resource integration effect evaluation through inpatients medical reports in 1995,1997,1998,1999,2001,2003,2005 and 2007.The total inpatients were 53377,and samples of 5500 inpatients are obtained through systematic sampling with fixed amount((500or 1000),among which,4513 cases are effective samples for inpatients severity change appraisal,5124 cases are effective samples for inpatients distribution change appraisal.(4)Put forward strategy roadmap and necessary policy support for medical resource vertical integration through expert consultation and interview with professional team,253 people are consulted in total.Statistic software used is SPSS11.5,drawing software of SPSS11.5 and MAPINFO7.0.4 Results4.1 Potential effects of promoting medical resource vertical integration in optimization of Shanghai medical resource allocation and utilization4.1.1 Manpower and hospital bed allocation in Shanghai are at a high level,there are 3.33 certified doctors per thousand people,which are higher than Beijing(2.28), Tianjin(2.65),HK(1.65),Macau(2.82),Japan(2.12),Singapore(1.55),GB(2.30), USA(2.56) and Australia(2.72);there are 5.20 hospital beds per thousand people, which are lower than Beijing(6.41),Taiwan(6.03) and Japan(14.19) but higher than Tianjin(4.18),HK(4.92),Macau(2.33),Singapore(3.33),UK(4.0),USA(3.3) and Australia(3.93).4.1.2 Utililization efficiency of Shanghai medical resources is also high.Each Shanghai doctor diagnoses 9.1 people per day,much higher than Beijing(6.8), Tianjin(5.4) and Chongqing(5.8);each Shanghai doctor provides inpatient service for 2.0 days per year,also much higher than Beijing(1.3),Tianjin(1.4) and Chongqing (1.2);Utilization ratio of hospital beds in each Shanghai hospital amounts to 93.5%, also much higher than that of Beijing(77.3%),Tianjin(68.1%) and Chongqing(69.1 %)4.1.3 Overall utilization efficiency of Shanghai medical resource varies a lot in medical institution of various levels.Hospital bed utilization ratio in GradeⅢ hospital;average hospital days of GradeⅢhospital is only 13.55 days,but 16.28 days in GradeⅢhospital and 27.41 days in GradeⅠhospital.4.1.4 Implementation of medical resource vertical integration and sharing hospital beds among hospital at various levels can alleviate the problem of difficult hospitalization in high level hospital and low hospital bed utilization ratio in grassroots hospital,improve skills of the grassroots hospital,promote the patients to be hospitalized in grassroots hospital and optimize medical resource allocation and utilization efficiency.4.2 Four major modes for Shanghai medical resource vertical integration4.2.1 Trusteeship.Such as Central Hospital of Qingpu District is trusted to Zhongshan Hospital.Such mode does not involve ownership change,therefore is convenient to operate and helpful in realizing resource sharing and premium medical resource supporting the grassroots hospital.While,under the precondition of unclear ownership,main aim of the big hospital is to control medical market and relieve operational pressure,but they are not active in constructing the integrated hospital.4.2.2 Merge.It is mainly to revoke and merge some government run medical institution with bad operation,integrate its staff and hospital beds to government run medical institution with good operation,such as Ruijin Hospital merges the former Municipal Hospital and Zhongshan Hospital merges the former No.3 Textile Hospital.4.2.3 Conglomerate.It is to establish or co-establish hospital group based on special section and the academy of the key hospitals.The typical case is Shanghai Huashan Neurosurgery(Group) Hospital.Such mode has been the main stream of Shanghai medical resource vertical integration,on one hand,it alleviates the contradiction that some hospitals are too busy and some others are idle;on the other hand,it raises new challenge for implementation of regional health planning due to free resource integration.4.2.4 Coopeartion.Such as Tumor Hospital Attached to Fudan University cooperates with Shanghai Jiangong Hospital on mammary cancer.All the GradeⅢhospitals have established resource integration contract with grassroots hospital through certain mode,among which,cooperation and conglomerate are most common.4.3 Case appraisal on implementation effect of Shanghai medical resource vertical integrationInsiders think that conglomerate is the best one among various modes of Shanghai medical resource vertical integration,in addition,integration of the former Central Hospital of Luwan District to Ruijin Hospital has special meaning:on the one hand,Ruijin Hospital appoints president and technical backbone to the former Central Hospital of Luwan District,which means mandatory administration;on the other hand, Ruijin Hospital obtains half assets of the former Central Hospital of Luwan District, which means asset acquisition.In view of this,the study makes case appraisal integration effect of the former Central Hospital of Luwan District into Ruijin Hospital.4.3.1 After vertical integration,Ruijin Hospital helps the former Central Hospital of Luwan District enhance academic construction,experts and professors from Ruijin Hospital regularly carry on ward inspection,surgery,and characteristics diagnosis, guide works as clinic,scientific research and teaching,increase service ability and value of Luwan branch and increase the complexity of inpatients,which is proved by substantial increase of tumor patients in Luwan branch,from 1995 to 1999,tumor patients seek for medical treatment in Ruijin Hospital Luwan branch has been basically maintain at about 550 cases,later,quantity of tumor patients increased rapidly,about one times in 2001,reaching 1142 cases,and 3616 cases in 2007,taking 32.0%of its total inpatients.4.3.2 After vertical integration,Ruijin Hospital assigns neurological and endocrinological exports to be section head of Luwan branch,builds new neurological wards and diabetes intensive cure ward,and makes Luwan branch as the main channel to redirect patients,large quantity of tumor and hemopathic patients were transferred to Luwan branch for treatment.Due to the limited technique of Luwan branch,the transferred patients were generally in stable condition,which led to inpatients severity reduction in Luwan branch after integration.Average inpatients severity in the year of 1995 was 71.71 and then reduced to 64.96 in 1999,average inpatients severity increased to 82.21 in 2001,and then it is again in a downtrend,reduced to 64.19 in 2007.One-way ANOVA shows that average severity value are not the same in the eight years(F=11.598,P＜0.01),then the least significant difference(LSD) is made which shows that except for the year 1999,2003 and 2005,value in other years are all higher than that in 2007.Reduction of inpatients severity in Luwan branch one the one hand represents formation of rational division between hospital after resource vertical integration,on the other hand,it also represents that people expect too much on the good hospital guiding the inferior ones and remarkably improve skill of the inferior hospitals after resource vertical integration,during practice,the key hospital hopes the integrated hospital to play a complementary role.4.3.4 Prior to resource vertical integration,overall medical market of Ruijin Hospital Luwan branch is in shrink,there were 4974 inpatients in 1995,and reduced to 3751 in 1998.After the vertical integration,quantity of inpatients reduces and rises rapidly,increasing about one time in 2001,reaching to 6642,inpatients increased by 70.1%in 2007 than that in 2001,reaching to 11299.In the same period,there are 7439 and 11222 in the year of 2001 and 2007(increased by only 50.9%) in Central Hospital of Jingan District which is similar to scale and surrounding environment of Luwan branch,therefore,it can be deduced that vertical integration drives development of Luwan branch and expand its business scale. 4.3.5 Market share change after the integration.From 2001 to 2007,local patients treated by Luwan branch increased by 30.2%,patients not from Luwan district increased by 269.1%.Vertical integration of the former Central Hospital of Luwan District into Ruijin Hospital helps to upgrade radiative force of the former Central Hospital of Luwan District,at present;Luwan branch does not just play a role as regional medical service center in Shanghai medical market.4.4 Problems and obstacles in Shanghai medical resource vertical integration4.4.1 In the macro-level,there exists the problem of regional market monopoly. There are only or several big hospitals in the region,grassroots medical institution has little choice and is in unequal position,after integration,service charge of the grassroots hospital will be the same as that of the key hospitals,hence having suspicion of increasing treatment cost.4.4.2 In the government level,there exists the problem of motivation of the district government.Under the two layer financial management,district government is liable for constructing and developing medical institution.Once the vertical integration is implemented,grassroots medical institution is put under its administration of the key hospital,hence input from the district authority will be difficult to guarantee.4.4.3 In system level,there exist the problems as pricing and medical insurance settlement standard.If service price difference in each medical institution of the integration is not widen,or follow the medical insurance settlement standard which are similar in hospitals of different level,it will be difficult to realize double treatment transfer through price leverage.4.4.4 In health administrative department level,there exists the problem of function position.The integrated hospitals are usually GradeⅡor GradeⅠhospitals whose immediate supervisory department are district or county health administrative department.After integration,the integrated hospitals face double leadership,having to obey the management of the main hospital and the direction of the district or county health administrative department,from which the problems are easy to arise.4.4.5 In medical institution level,there exists the problem of cultural contradiction.Members of the integration have different growth procedure and business condition,therefore there will be difference in value,code of conduct, operational habit,work style,ceremony and management system,and the contradiction is unavoidable.4.5 International experience which can be learnt by Shanghai medical resource vertical integration4.5.1 Experience of Singapore shows that competitive mechanism is introduced at the time of implementing medical resource vertical integration to avoid monopoly; as such,two medical groups are set to promote competition between them.Meanwhile, effects similar to that of medical resource vertical integration through serials of policies are attained,such as "10—20%discount for the patients transferred from community hospital to the big hospital",and Taiwan also provides the similar experience.4.5.2 Experience of the UK shows that in order to actual implement medical resource integration,the established hospital group shall have sufficient autonomous fight in terms of HR reform at first,adding and reducing beds,etc,it shall pay attention to increase income of the staff on the basis that income of the hospital is increased to fully mobilize subjective initiative of the staff.The formed group includes medical institution of various layers and types to make the patients with different needs are served in corresponding institution of the group,and reduce the waiting period and the time indiscriminately seek for medical care in big hospital.The established hospital group may adopt various capital operation methods as direct holding and alliances.4.5.3 Experience of the USA shows that in order to drive medical resource vertical integration,medical insurance reimbursement system is reformed to promote the high level hospital to reduce cost,hence seek for support from the grassroots medical institution and form strategic alliance with it.For example,reimbursable inpatient days of special disease in large hospital is stipulated,in case the patients exceed the stipulated inpatient days,they shall be charge unless transferred to community service center.4.5.3 Experience of HK has more reference value.The first is to unify various systems,all the hospitals carry on uniform administrative management system,adopt the same financial management system,rules and modes,carry on uniform salary system,use the uniform information platform and data,uniformly procure medical equipment,medicine and other medical materials.The second is to implement hospital networking,special section within the networking region will not be reset in other hospital,nor reset large equipment.The third is to allocate budge for the hospital as per population,population of the aged and situation of population flow under the precondition of guarantee overall health insurance of the people.4.6 Roadmap and strategy proposal for Shanghai medical resource vertical integrationThe project team puts forward roadmap and strategy for Shanghai medical resource vertical integration based on analysis of Shanghai condition,domestic development overview,referring to international experience and consulting relevant experts.4.5.1 The first strategy is to lead the integration through policy and promote medical resource vertical integration based on existing medical institution management mechanism and operational mechanism with unchanged former medical institution property as the characteristic and from the perspective of institutional trusteeship and policy regulation.Specific conception is:(1) implement trusteeship or cooperation between GradeⅢand GradeⅡhospital.The district or county health bureau(entrusting party) forms trusteeship relation of "entrusted management——trustee management" between GradeⅡhospital(target hospital) under its administration and GradeⅢhospital(entrusted party),and transfer the operational management right of the target hospital to the entrusted party for reorganization and operation with certain conditions and terms.(2) Issue serials of health and medical insurance policy to adjust benefits distribution structure between hospitals of various level to promote premium medical resource flow to GradeⅠhospital and meanwhile promote the patients seek for more treatment and rehabilitation services in GradeⅠhospital,such as community health service of GradeⅢhospital,traditional Chinese medicine serve the community,famous doctor serve the community,diagnosis expense reduction and exemption policy in grassroots hospital,inpatient days regulation for high level hospital by the medical insurance, and etc.(3) Promote regional hospital group trial crossing asset relation in the place with proper condition.Carry on uniform administrative management,budget,and medical insurance settlement within the group.Under the precondition not changing asset property,further promote the current trusteeship cooperation to close cooperation and truly exert integration effect of the resource.The above targets are easy to be attained with little technical difficulty and are helpful for naturally form regional medical center and community sanitation service center as GradeⅡmedical service system.As for GradeⅡhospital unable to exist and develop by themselves, and whose ownership will not be abandoned by the district or county health bureau, trustee is the best resource integration method,but its disadvantage is its small reform intensity,therefore trustee is not fundamental solution.4.5.2 The second strategy is to separated integration between administration and operation,build vertical medical group with GradeⅡhospital as the core in each district and county based on the current financial allocation mechanism and social medical insurance,with separate administration and operation of government run medical institution,and promote medical resource vertical integration within the district and the county.Specific conceptions are(1)Promote separation of administration and operation of public run medical institution in the district or the county,set up medical institution administration center dedicatedly responsible for management work as HR,asset,finance,party affair and etc.Business income of the government run medical institution under its administration(including income from medical insurance) is uniformly turned in to medical institution management center, financial allocation to the government run medical institution is also directly turned into medical institution management center.The third party appraisal institution is entrusted to be responsible for appraisal performance of the public run medical institution.(2) Public run medical institution under its administration does not reset special section and large equipment.Resident physician are trained uniformly in GradeⅡhospital;doctors of community health service center are trained in rotation in GradeⅡhospital in a planned way to gradually upgrade medical skill of community health service center.The target does not involve much benefit adjustment,is easy and feasible and is helpful for effective utilization of the medical resource in the region. Its disadvantages are technical advantage of GradeⅢhospital is difficult to be exerted,hence not helpful for premium resource service transfer to inferior hospital. Such mode has little difficulty in policy and can be used as the first procedure of Shanghai medical resource conglomerate integration.4.5.3 The third strategy is conglomerate integration,divide networking region according to the needs on medical treatment by the region and population,integrate public run medical institution of Shanghai in various levels and kinds based on nationwide medical insurance,and establish several medical group with GradeⅢcomprehensive hospital as the core,with several GradeⅢspecialized hospital,GradeⅡhospital and community health service center as extension and based on community health service station and doctor team within the whole section.Specific conceptions are(1) Medical group possesses administration authority on asset,HR and financial management of the various medical institutions under its administration.The hospitals under its administration carry on uniform administrative management system, financial management system,rules and modes,and the medical staff carries on uniform salary system.(2)GradeⅡhospital,community health service center and healing hospital are equipped within the networking region.Special section and large equipment are not reset within the networking region to realize resource sharing and reduction of operation cost.Work places of the staff within the networking hospital are subject to transfer as work needs.(3)Medical institution within the networking region carries on budget fund system.Medical group obtains budget fund from government financial and social insurance department,allocate budget fund to the networking region each year as per planned budget,and then the networking region allocate budget fund to medical institution.Budget fund allocation is determined by population,aging population,floating population and special service(such as complex special section charge more).Budget fund ensures fundamental medical service for the people.Medical institution may provide non-fundamental medical service for which the patients are charge at their own expense.(4) Medical group carries on uniform and centralized procurement on medical material as medical equipment and medicine.Information platform is set up,all the medical institution and principle office use uniform information platform and data definition,etc.(5) Resident physician within the group are trained uniformly in GradeⅢhospital; doctors of GradeⅡhospital and community health service center are trained in rotation in GradeⅢhospital in a planned way to gradually upgrade medical skill of grassroots medical institution.Achieving the aim is helpful to exert accumulative effect of premium resource,effective utilization of medical resource,strengthen the appeal of grassroots institution on the patients,and then governmental management aim and purpose will be guaranteed.The disadvantage is that regional monopoly is formed and may create weakened service.The difficult point is to break through the former interest pattern,in which government determination is needed.4.5.4 The forth strategy is policy-induction.Based on the current medical institution's management system and operation mechanism,characterized by unchanging the property fight of original medical institution,from the point of institution trusteeship and policy adjustment,the medical resource vertical integration would be promoted.4.5.5 The fifth strategy is benefit conformity.The gradeⅢhospital was selected as principal part to be conbined with the gradⅡhospital or some community health service center through the way of project collaboration.The above medical resource vertical integration strategies need four policy support,the first is the uniform ownership subject;the second is medical insurance settlement method adjustment,transferring from charges total prepaid to payment as per service volume and population;the third is staffing system,carrying on annual salary system to promote smooth flow of medical staff within the member hospitals; the fourth is defining function of member institution,high level hospital mainly engaging in inpatients and emergency service,community service center mainly engaging in outpatient and preventive health service.5 Innovation and weak points5.1 Innovation5.1.1 Medical resource vertical integration is an important strategy to increase utilization efficiency of medical resource,expand medical health service and solve the problem of difficult medical care of the residents.There are mature overseas experience but fewer domestic successful experiences,and medical resource vertical integration is still in exploratory stage.The study analyzes status quo of configuration and utilization of Shanghai medical health resource and argues necessity of medical resource vertical integration.5.1.2 The study puts forward strategy roadmap and policy support needed for Shanghai medical resource vertical integration based on status quo of Shanghai medical resource,domestic practical case,successful overseas and domestic experience as well as analysis and judgment of expert.5.1.3 The study analyzes geographic distribution change of inpatients in the integrated hospital before and after medical resource vertical integration.At present, there is a lack of research on inpatients geographic distribution in our country.5.2 Weak points5.2.1 There were altogether 60 cases of Shanghai medical resource vertical integration between GradeⅢand GradeⅡhospital from 1999 to 2007.Due to the limited energy and ability of the project team,the study fails to make analysis for all the 60 cases,and only purposefully makes analysis on several cases and makes detailed appraisal on trusteeship relation between Ruijin Hospital and the former Central Hospital of Luwan District,therefore,the study is not wide and detailed enough.5.2.2 For effect appraisal of trusteeship relation between Ruijin Hospital and the former Central Hospital of Luwan District,considering outpatient medical records are kept by the patients and difficult to be collected,so the study focuses on collection, filing and analysis on inpatient data,which may result in insufficient representation of medical resource integration on medical service of the former Central Hospital of Luwan District.