Efficiency Evaluation Of Medical Services In Shandong County Public Hospitals

BackgroundThe Chinese Government has been committed to improving the level of China’s medical and health services, improving the performance of health system, so as to maintaining the health of residents. However, the current status of development of China’s medical and health undertakings is still not optimistic. Issues include health service demand, supply and irrational use of health care resources, etc. remains to be solved, which are also the concerns of health policy-makers and health service managers. As a carrier providing medical services, the reform and development of medical institutions is a hot topic in the field of health care currently, especially the primary health care institutions that play a cornerstone role in the health care system. And county public hospitals as the leader of primary health care system, its current situation and development prospects is attracting widespread attention of many health policy-makers, academics and hospital managers.The "New Health System Reform" (NHSR) which launched at 2009, pointed out that the reform and development of health system should focus on both the equity and efficiency which means to give priority to the accessibility of basic health services to promoting equity, while also focusing on allocating health resources rationally, improving efficiency, reducing cost, and establishing urban and rural residents basic health system etc. And public hospital reform is an important point of NHSR. In 2011, the government issued a multiple document for further promoting the reform of public hospitals, and county public hospitals reform is the key point. In 2012, the Chinese government began to implement county public hospital reform work, and in 2014 the comprehensive county public hospitals reform officially put in full swing across the whole county. The government tries to establish a scientific reimbursement mechanism, improve drug supply security system, reform Medicare payment system, and deepen comments system reform to accelerate the pace of county public hospital reform and consolidate the reform achievements.Despite the gradual improvement of the national health policy, there are still many problems among public hospitals, such as the irrational allocation of health resources, lack of medical resources, and inappropriate scale of hospitals etc. which seriously affect the health service productivity, and thus impact residents’demand for health service which is not conducive to the development of China’s medical and health undertakings. As an important principle of public hospitals, the efficiency of the hospitals is not only the basis for hospitals survival, but also an important condition for people’s health needs met. So how to comprehensively and scenically evaluate the efficiency of hospitals has become the focus of the current academics, health policy makers, and hospital administrators concerned. Current research on hospital efficiency evaluation is mainly focused on the evaluation of hospital static technical efficiency, and data used for the research are mostly belongs to sectional data, while the use of panel data is inadequate.The methods used for efficiency evaluation analysis are diverse. Data envelopment analysis (DEA) and stochastic production frontier (SFA) are used commonly, but mostly are descriptive analysis, only a few researchers use econometric models for further influence factors of technical efficiency of the hospitals.Through reviewing the existing literature and research we found that there are still many problems needed more solved in current research on hospital efficiency evaluation. Firstly, comprehensive analysis for evaluating the efficiency of the hospitals which combine the dynamic efficiency and static efficiency is limited, most of the studies only focus on evaluating the technical efficiency of the hospital, while dynamic processes of hospitals efficiency were analyzed inadequately; secondly, the current researchers mostly focus on the evaluating the current situation of the hospital, and less researchers try to find geographic economic environment factors that could affect hospital efficiency.However there are no further researches on the changes of regional differences after got a clear idea of regional differences, which mean that in a certain period, what is the change trend of the development of technical or production efficiency between different areas? And the difference is gradually expanded or decreased? The answers for the above questions could provide scientific basis for the allocation of resources as well as the coordinated development of regional health services; thirdly, researches on the influencing factors analysis of hospitals efficiency still need improved. Although the methodology for the research has been relatively more mature, but the construction of the indicator system needs theoretical basis. Which factors need to be considered? Why should we consider these factors? What effect of those factors will have on hospitals efficiency? They are all urgently to be answered; fourthly but not lastly, what is the influence of the NHSR for hospitals efficiency need to be explored. We need to figure out whether the purpose of NHSR has been achieved which need in-depth analysis and more discussion. It is not only for the evaluation of NHSR, but also providing policy wizard for the further development of healthy public hospitals.To compensate for the inadequate of existing research, this study will evaluate the county public hospitals medical service efficiency comprehensively in Shandong Province and will do a systematic analysis on evaluating the current situation of hospitals efficiency and its changes trend, as well as the explore work for the influencing factors of hospitals efficiency. Thus it could provide effective references for optimal allocation of resources and improvement of health policy.ObjectivesThe overall goal of this study is to analyze the county public hospitals efficiency and its influencing factors under the background of New Health System Reform and put forward policy suggestions for the improvement of county hospitals efficiency and the development of public hospitals reform.More specific study objectives include:analyzing the changes of input and output factors of county public hospitals; evaluating county public hospitals efficiency based on the classification of economic level and hospitals scale systematically, figuring out the factors that affect hospitals efficiency and proving suggestions for improving hospitals efficiency.MethodsThis study chose 321 county public hospitals including 132 comprehensive hospitals and 99 traditional Chinese medicine hospitals as our objects. The data used in this study mainly came from the Health Department of Health Information and Statistics Center of Shandong Province and some descriptive data came from Shandong Provincial Health Statistics Yearbook and National Statistical Yearbook.This study used SPSS20.0, MaxDEA, DEAP2.1, STATA11.0 for data descriptive analysis, correlation analysis, calculation of efficiency, Tobit regression analysis, convergence tests, and so on.In this study, data envelopment analysis (DEA) and its correlation models were used to measure county hospitals efficiency in Shandong Province. Wherein DEA-CCR model was used for the measurement of county public hospitals’ integrated technical efficiency, DEA-BCC model was used to explore the hospital’s pure technical efficiency and scale efficiency, amd DEA-Malmquist index was mainly used for measurement and analysis of county-level public hospitals Dynamic Efficiency during the period from 2006 to 2012; Descriptive statistical analysis methods were used to analyze the changes of hospitals’economic, input and output indicators; Chi-square test and nonparametric test were mainly used to analyze the statistically significant difference of efficiency among different income regions, different hospital size as well as different period; Tobit regression was used to investigate the main factors that affect county public hospital efficiency in Shandong Province, and fixed-effects regression analysis was mainly used for the county public hospital TFP convergence analysis.Results1. Static efficiency measurement results(1) The total technical efficiency (TE) and pure technical efficiency (PTE) of county comprehensive hospitals in Shandong Province rose from 0.7809,0.7902 to 0.8499,0.8704 respectively during the period 2006～2012, while the scale efficiency (SE) decreased from 0.9891 to 0.9774 (P<0.01). The PTE and TE in the Traditional Chinese Medicine (TCM) hospitals increased from 0.7729,0.8127 to 0.8643,0.9102 respectively during 2006 to 2012, while SE decreased from 0.9518 to 0.9493 (P<0.01);(2) There were differences in the efficiency of hospitals in different income areas. The technical efficiency of hospitals in developed regions was higher than that in other regions, but the SE was lower than other regions. The effect of income level on the efficiency of TCM hospitals was higher than that of comprehensive hospital;(3) There were significant differences in the efficiency of different size hospitals, especially in SE. The SE in the small size hospital was significantly higher than that in other hospitals, but the improvement of the efficiency of the large scale hospitals was higher than that of the smaller hospitals;(4) The PTE and TE of county public hospitals in Shandong province increased from 0.7867,0.7970 to 0.8327 and 0.8515 respectively after the New Health System Reform, while SE was significantly decreased from 0.9881 to 0.9789 (P<0.01). The TE and PTE of TCM hospitals were increased from 0.7743,0.8151 to 0.8285,0.8805, but the change of SE was not significant;(5) The analysis on the appropriate size of the hospital showed that, when the bed size of comprehensive hospitals controlled between 250 and 500, their SE would keep at a high level, while for the TCM hospitals, it should be between 200 and 350.2. Efficiency factors analysis(1) The factors affecting the TE efficiency of comprehensive public hospitals at county level in Shandong province included both internal and external environmental factors. The new health care reform policies, population, outpatient expenses per capita, asset liability ratio, drug accounted had a significant negative effect, and the net income per capita of rural residents, wage income per capita of hospital workers, hospitalization per capita, hospitalization expenses per capita, asset turnover rate, etc. had significant positive effect. In addition to the hospitals’PTE and SE were affected by the factors associated with the above factors;(2) The analysis of the technical efficiency of TCM hospitals at county level in Shandong province showed that TCM hospitals was not sensitive to external environmental factors, but the income per capita of hospital workers and the proportion of medicine have a significant positive effect on the technical efficiency. The population capacity had negative effect of TCM hospitals’PTE, while the hospital actual open beds and medicine accounted played the positive role.The scale efficiency of TCM hospitals could be improved with the increase of the number of beds, the wage income per capita and the balance of the assets, but would increase with the decreased proportion of the drug.3. Dynamic efficiency evaluation(1) In the period of 2006～2012, the total factor productivity (TFP) of public hospitals at county level in Shandong province was growing at an average annual rate of 3.7%, while the TFP of traditional Chinese medicine hospitals was growing at an average annual rate of 3.5% during 2006-2012;(2) TFP in hospitals located at different economic regions was different. Comprehensive hospitals located at high income areas showed highest TFP, and the lowest TFP belong to hospitals in the middle income areas. While for the traditional Chinese medical hospitals, hospitals located at higher income level achieved higher TFP;(3) TFP performance of hospitals with different sizes was different. In comprehensive hospitals, the hospital scale was larger, the hospital TFP growth rate was faster; while for the Chinese traditional medicine hospital, the TFP performance of the middle scale hospital was the best, the small scale performance was the worst, with an average annual growth rate of 2.4%;(4) Hospitals showed significantly difference on TFP before and after the New Health System Reform. The growth rate of the general hospital was 5.1%.7%, which fell to 2.7% after medical reform. The growth rate of TFP in the traditional Chinese medicine hospitals increased from 2.7% to 4.3%.4. Total Factor Productivity convergence test results(1)The TFP index of county public hospitals in Shandong Province did not showed a convergence trend, which means the productivity gap among them would continue to expand;(2) The TFP of the comprehensive hospitals at county level in Shandong province showed a significant absolute β convergence (β=-0.157), and the convergence rate was 30.74%(μ=-0.3074). While the traditional Chinese medicine hospital was not to achieve absolute P convergence (β=0.143), which meaned the TFP gap between different TCM hospitals was gradually expanding without considering any conditions.(3)The TFP of comprehensive hospitals at county level in Shandong province showed the conditional β convergence (β=-0.726), and the convergence rate was 19.34%. The TFP of the traditional Chinese medicine (TCM) had the same conditional β convergence (β=-0.730), and the convergence rate was 19.34%.Conclusions and Policy ImplicationsThe main conclusions of this study are as follows:1. County public hospitals’input and output factors were improved in Shandong Province;2. County public hospitals in Shandong province during the period 2006～2012 showed more inefficiency, but technical efficiency levels showed a rising trend. And the scale of inefficiency was the main factor affecting the efficiency of the hospital;3. The efficiency of county public hospitals in Shandong Province was affected by both internal and external environmental factors of the hospital, but there were differences in factors between different types of hospitals;4. The "New Health System Reform" helped to improve county public hospitals technical efficiency in Shandong Province significantly, while its effect on the efficiency of scale of hospitals was limited;5. The total factor productivity growth of county public hospitals in Shandong Province was different between comprehensive hospitals and traditional Chinese medicine hospitals, but with the passage of time, total factor productivity growth gap showed a narrowing trend.Based on the above conclusions, the following policy recommendations were put forward:(1) controlling the scale of county public hospitals rationally in Shandong Province; (2) adjusting the medicine prices, reducing medical costs per patient, and strictly implementing the county public hospital reform; (3) improving hospital incentives methods to improve the quality and efficiency of human resources, so as to promote efficiency levels of hospitals; (4) strengthening the hospital financial management, and improving the safety factor and the efficiency of the hospital asset management; (5) paying attention to the county health resource allocation planning and improving its effectiveness, at the same time strengthening government financial investment; (6) strengthening support for traditional Chinese medicine hospitals.