| Research backgroundThe reform of public hospitals is essentially to find out a "Chinese style solution"for the "medical reform".It should not only solve the problem that "it is difficult and expensive for people to see a doctor",which is strongly focused on by the public and society.More importantly,it is the top-level design and in-depth promotion of the health reform in medical treatment,medicine and medical insurance,and a deep reform involving reconstruction of medical and health service system,change of health intervention model and the innovation of governmental public service models under the condition of socialist market economy.The county hospitals with large quantity,scattered areas and large population of services are the key to solving the problem of core subsidence and graded diagnosis and treatment in medical reform.We should promote the comprehensive reform of the county public hospitals in an all-round way,and improve the medical service capacity of county hospitals and the visiting rate of the masses within the county,and finally realize the reform objective that "People don’t need to go out of the county for serious illness",which is closely related to the success or failure of the new medical reform.Shandong is China’s second most populous province with the permanent resident population of 97.33 million,and it has jurisdiction over 17 cities and 140 counties(cities,districts).It has obvious differences between the regions,so Shandong is an epitome of China to a certain extent.For a comprehensive understanding of the progress and overall effectiveness of the comprehensive reform in county public hospitals in Shandong,this study is entrusted by Health and Family Planning Commission of Shandong Province to evaluate the progress and effect of the comprehensive reform of the county public hospitals in Shandong as the third party.The object of evaluation and study is 184 county public hospitals in the first and second batch of pilot counties,including 72 hospitals in the first batch of pilots and 112 hospitals in the second batch of pilots,97 general hospitals,65 hospitals of traditional Chinese medicine and 22 special hospitals.The evaluation adopts qualitative and quantitative methods,and data reporting and field investigation methods to complement each other.It investigated 34 counties on the spot,and recovered 173 questionnaires of pilot hospitals in the investigation conducted by correspondence and investigated 1,114 medical staff and 931 residents through self-made questionnaires.Research purpose and significanceThe comprehensive reform of county public hospitals is a major livelihood project.From the perspective of evaluation of project management,we take the research on the reform effects of county public hospitals as a scientific research project,systematically collect information in project activities,characteristics and the output to assess the role of the project at the end of the project and confirm the value of the project,and then conduct comprehensive judgment of the project implementation effect,improve the medical service and scientific management of county hospitals.The comprehensive reform of county public hospitals is a major livelihood policy involving a wide range and a strong system.From the point of view of public policy analysis,the reform involves the adjustment and distribution of interests,which is the process of policy change,as well as the process of system coupling and institutional governance in public hospitals.Research on the comprehensive reform progress and effect evaluation of county public hospitals,and analyzing the feasibility and popularization of the policy can put forward relevant suggestions and supporting measures for further deepening the reform,and provide reference for the policy of medical reform and government decision-making.The specific purposes of the study include:1)To evaluate the progress and overall effect of the comprehensive reform in county public hospitals in Shandong,and conduct a comprehensive,authentic and objective survey and analysis as the third party.2)To enrich the data and research results of the comprehensive reform of county public hospitals.3)To summarize the successful practice and experience of comprehensive reform of county public hospitals in Shandong and set up advanced and typical models by means of score ranking,thereby providing paradigm reference for the reform of public hospitals.4)To conduct the quantitative analysis of scoring indexes,and make comprehensive ranking of the county public hospital to participate in the pilot reform,and summarize the reform effect of county public hospitals,as well as analyze the satisfaction of medical staff and the masses with the reform of county public hospitals.5)To analyze the key factors affecting the reform effect of county public hospitals based on scoring indexes and non-scoring indexes,and point out the difficulties and problems at the current stage of the reform,as well as to analyze and discuss problems and difficulties in the comprehensive reform of county public hospitals and put forward relevant policy suggestions.Research methodsThis study adopts qualitative and quantitative methods,and data monitoring and field investigation methods to complement each other for evaluation,and tries to scientifically and objectively reflect the actual situation of the reform of county public hospitals in Shandong.The evaluation indexes can be divided into two categories.One is the scoring index,which is carried out according to the scoring method in the evaluation index system of the comprehensive reform in county public hospitals so as to reflect the reform promotion and effectiveness of county public hospitals.The other is the non-scoring index,to analyze the main factors that affect the effectiveness of the comprehensive reform in county public hospitals.According to different research purposes,this paper adopts literature review,case analysis,depth interview,thematic group discussion,index scoring and other research methods.This study conducts unified coding on the collected questionnaires according to the region and the hospital and designates special personnel for unified entry through Epidata.Before entry,unified training is conducted on the data entry staff to define the name of each variable and related matters needing attention.Furthermore,special personnel are designated to compare the entry results and initial data through a selective examination to ensure the accuracy of entry.After the data entry is completed,the database is logically analyzed,and the abnormal values and logical problems are corrected in a timely manner.In this study,Excel 2007 and SPSS v21.0 are used for statistical analysis,and statistical analysis methods are mainly descriptive analysis.Excel is mainly used for plotting operations,and SPSS is used to count relevant reviews and composition ratios.Key findings1.Theoretical researchThe starting point and logical foundation of the study is to comb the analysis framework for the theory of the effect evaluation of public hospital reform,answer questions in the policy change and improvement of public hospital reform and provide theoretical support for the reform of public hospitals.Using the important concepts of various theories for reference,the paper interprets the reform process of public hospitals in an integrated way.This research focuses on the possibility of integrating six aspects,and constructs the theoretical analysis framework for the effect evaluation of the comprehensive reform in county public hospitals.The six aspects for integration are as follows:1)Fundamental compliance of public hospital reform2)Economic considerations on the public hospital reform3)Policy "window phase" of the public hospital reform4)Systematic coupling of public hospital reform5)Institutional governance of public hospital reform6)Evaluation of the effect of public hospital reformThe overall design of this study is to take the study on progress and effect evaluation of the comprehensive reform in county public hospitals as the outline,and point out the key link in the theoretical research of the policy process through forced question,so as to analyze and study the creation,formulation and implementation of the policy,and then to discuss the policy of the public hospital reform in a macroscopic view and make quantitative analysis and evaluation in practice on the process and effect of the reform of public hospitals.Quantitative analysis provides the necessary foreshadowing and verification for qualitative analysis,and qualitative analysis makes specific definition and sublimation of quantitative analysis.2.Progress evaluation of comprehensive reform of county public hospitals in Shandong1)It should abolish the mechanism of supporting the doctor with medicine.According to the requirements of the reform,the pilot hospitals cancel the drug markup policy,and adjust the price of medical services,mainly involving medical fee,operation fee,nursing fees,bed charges,TCM service charges,large equipment inspection fee and costs of high-value medical consumables.In 2015,the total income of the pilot hospitals was reduced by 3.041 billion Yuan due to the abolition of the drug markup,and the total amount of financial subsidies for the abolition of the drug markup was 597 million Yuan,accounting for 19.6%of the reduced income of drugs.By adjusting the price of medical services,the hospital increased its income by 1.368 billion Yuan,accounting for 45%of the reduced income of drugs.2)It is the reform of medical insurance payment system.In the 172 hospitals which filled in the data,141 hospitals(82%)reformed the mode of medical insurance payment,102 hospitals(59.3%)established the negotiation and risk sharing mechanism between the hospitals and medical insurance agencies,and 80 hospitals(46.5%)established the cohesion mechanism between the dynamic adjustment of the price of medical services and medical insurance payment policy,and 151 hospitals(87.8%)brought the adjusted price of medical services into the coverage of medical insurance payment.3)It is the reform of personnel distribution system.83.1%of the hospitals adopted the system of competition for employment in the personnel recruitment and post management,and 98 hospitals(57.0%)adopted four systems,namely,competition for employment,contract management,setting up posts according to needs and employment according to posts.The vast majority of hospitals are inclined to the front-line clinical staff in income distribution,but not much.The income of hospital staff is mainly composed of regular wages and performance pay,and the average monthly regular wage is 3,165.1 Yuan(62.2%of monthly income),and the monthly average performance pay is 1,920.8 Yuan(37.8%of the monthly income).The formally authorized personnel accounts for 53.4%and the contract staff accounts for 46.5%,in which doctors account for 20.9%and nurses account for 59.6%.The main difference in income between the contract staff and permanent staff is that the contract staff has low regular wages,while the average monthly regular pay is 4,322.2 Yuan for permanent staff,and that is only 1,661.6 Yuan for contract staff.4)It is the reform of the guarantee mechanism for drug supply.91.8%of the pilot hospitals implement the centralized drug purchasing at provincial level,78.8%of the hospitals can guarantee high-value medical consumables which have been put on the network adopt online centralized purchasing,and there are 73 hospitals in which the income of basic drugs and common drugs account for more than 80%of the total drug revenue.90%of the hospitals can guarantee the priorities to low-priced drugs,but there will be often such conditions that low-priced drugs are on the rise,or the drugs are not put on the network or the drugs are in short supply for a long time.5)It is the implementation of governmental responsibility.The survey found that financial subsidies in many hospitals are appropriated by the government in package,while there are no specific items and hospitals are not clear about the specific fees of the items.Overall,the infrastructure subsidies have increased significantly after 2014,the funds in large equipment,discipline construction,and retired personnel have declined year by year after the substantial increase in 2013,and policy-related losses and funds in basic public health have increased year by year.By the end of 2015,total liabilities of pilot hospitals were 26.197 billion Yuan,and total liability ratio reached 45.4%.36.6%of the medical institution debt has been included in the county-level government debt platform for management.3.Overall effect evaluation of comprehensive reform of county public hospitals in Shandong1)Changes in medical expensesThe average medical expenses for outpatient services showed a slight growth trend,which were 178.6 Yuan in 2012 and 191.8 Yuan in 2015.There was little change in average outpatient drug expenses,which were 79.3 Yuan in 2012 and 81 Yuan in 2015.The medical expenses per inpatient showed an increasing trend,which were 4,509.8 Yuan in 2012 and 5,442.4 Yuan in 2015.The drug expenses per inpatient showed a downward trend,which were 2,172.0 Yuan in 2012 and 1,863.9 Yuan in 2015.2)Changes in balance of payment structure in hospitalsThe proportion of drug income to medical income continued to decline,from 47.4%in 2012 to 36.6%in 2015.The proportion of inspection income to medical income was on the rise,from 20.2%in 2012 to 23.9%in 2015.The proportion of health material revenue in medical income increased year by year,from 6.4%in 2012 to 8.7%in 2015.There was an increasing trend in the proportion of the total of registration,examination,bed,treatment and nursing to the medical income,from 24.9%in 2012 to 27.5%in 2015.The proportion of personnel expenditure to business expenditure increased year by year,from 30.1%in 2012 to 35.4%in 2015.The proportion of management expenses to the business expenditure continued to decline,from 15.3%in 2012 to 12.7%in 2015.3)Operational efficiency of hospitalsThe average length of stay in the county general hospitals and the traditional Chinese medicine hospitals decreased year by year,from 8.29 days in 2012 to 8.04 days in 2015.The overall utilization rate of beds decreased,from 91.6%in 2012 to 82.9%in 2015.The medical income of 100-Yuan fixed assets in hospitals(excluding drug income)showed an upward trend,from 78.0 in 2012 to 90.4 in 2015.4)Medical insurance fund paymentThe actual proportion of reimbursement for employee hospitalization in medical insurance increased from 73.3%in 2012 to 74.7%in 2015.The actual proportion of reimbursement for urban residents’hospitalization in medical insurance increased from 52.7%in 2012 to 55.9%in 2014.The actual proportion of reimbursement for rural residents’ hospitalization in medical insurance increased from 50.6%in 2012 to 51.3%in 2014.In 2015,the urban residents’ medical insurance and the new rural cooperative medical scheme were merged into urban and rural residents’ medical insurance,and the actual reimbursement rate of hospitalization of urban and rural residents in medical insurance was 51.9%in 2015.There are an increasing number of hospitals with arrears of medical insurance funds year by year.In 2015,there were 83 county-level hospitals with arrears of medical insurance funds,the amount of arrears was more than 1 billion Yuan,and the total amount of arrears accounted for 10%of the total medical insurance income in 83 hospitals.5)Satisfaction of medical staff and satisfaction of the masses with medical treatmentThrough the questionnaire survey,we found that 34.8%of the medical staff was satisfied with the overall reform of county public hospitals.Doctors and nurses are more satisfied with technical training and hospital management.Medical staff has increased their satisfaction with the income,pay equity,personal work pressure and personal working time compared to that before the reform,but the overall satisfaction is low.Through the questionnaire survey,we found that the masses have high satisfaction with the hospital as a whole and the convenience of medical treatment,and the satisfaction rate was above 90%.The satisfaction rate of medical reimbursement and medical expenses was lower,and the satisfaction rate of medical expenses was 64.2%.69.5%of the masses believe that compared with three years ago,it has relieved the phenomenon that "it is difficult and expensive for people to see a doctor".Policy suggestions1.Implementation of governmental responsibilityIn the crucial stage of deepening the reform of public hospitals,we suggested that the governments at the provincial,municipal and county levels should establish the contact system for medical reform,the main member units of the provincial and municipal leading groups in medical reform should divide up the work and assign a part to each group and supervise the relevant functional departments of county governments to guarantee the organization of the reform for county public hospitals and implement the responsibilities,and really form a promotion mechanism in the linkage from top to bottom and cooperation with multiple departments,so as to promote the reform and the development of county public hospitals.Governments at all levels should make it clear that the finance departments should concentrate the resources and efforts to increase investment in medical reform,implement the six governmental responsibilities,and exchange the input for the mechanism to strengthen the public welfare of public health care.The county government should be urged to take the lead in resolving the historical debts.Governments of higher levels should be appropriately tilted to the less developed areas,but also explore the promotion of PPP mode reform,and actively defuse the historical debts of the hospitals.2.Joint reform of medical treatment,medication and medical assuranceWe should gradually put together the functions of medical insurance in functional departments,including the departments of human resources and social security,health and family planning commissions,price bureaus and civil administration departments,solve the fragmentation of the management,play a combination of advantages,and improve operational efficiency.Meanwhile,we should establish the professional third-party agencies of de-administration of medical insurance funds for scientific management and actuarial of medical insurance funds,while strengthening the supervision of the hospital,to ensure that all the medical insurance funds are spent on patients,the agencies don’t default on the medical insurance charges of hospitals and make the direction and use of medical insurance funds known to the public.It should promote the cooperative mode of medical insurance departments and commercial insurance to ensure the health of residents in Weihai,strengthen the supply and early warning of drug shortage,establish a linkage mechanism for consultation between departments,and improve the reporting system for shortage of drugs.We should establish the traceability mechanism for the ex factory price of drugs,implement the "two votes system" in the province,and recommend the introduction of the entrustment of pharmaceutical companies to hospital pharmacies so as to remove the pharmacies from hospitals.3.Personnel distribution systemCounty public hospitals should accelerate the preparation of the filing system,conduct filing management of off-staff workers,separate the positions from identities,and allow the in-staff and filing management personnel to enjoy the same pay at the same post,to form a flexible employment mechanism.In terms of the salary payment of doctors and nurses,we propose to give full consideration to the occupational characteristics of medical personnel,formulate policy in the province,and raise the upper limit of performance pay,so that the income of medical staff will be more than 50%higher than that of similar personnel in other institutions.Under the premise that the hospital has the balance,we should relax restrictions on the hospital’s right to distribute its own balance,and invigorate the internal distribution,and further incline the performance to the backbone of the business.4.Hospital management systemThe government should earnestly carry out the functions of medical management,and establish the management committee of county public hospitals,and implement the management autonomy of county public hospitals,as well as fully develop the corporate governance structure for county public hospitals,and formulate the specific implementation opinions for the corporate governance structure of county public hospitals in accordance with "Implementation plan of corporate governance structure of public hospitals in Shandong Province".5.Adjustment of the prices of medical serviceIn accordance with the steps of "Clearing space,adjusting structure and maintaining links",we should further straighten out the price of medical services and implement it step by step.When the price of medical service is adjust,we cannot only adjust the price in the abolition of drug markup,further increase the prices of service items,including nursing fees and bed charges,and adjust the prices of service items in traditional Chinese medicine in place as soon as possible,so as to promote the development of traditional Chinese medicine hospitals.For hospitals with high proportion of financial compensation for drug markup,if the price of medical service is not adjusted,the sustainability of financial input should be ensured.6.Control of overtreatmentWe should formulate a list of control objectives for the growth of medical expenses for medical institutions,establish a monitoring system for medical expenses in county public hospitals,and strictly control the unreasonable growth of medical expenses.Hospitals with high proportion of drugs should further control the drug proportion through the index decomposition,prescription reviews,and performance link,ranking report and other measures,reaching the target of 30%.Hospitals should implement the "negative list" of various diseases without infusion in quality control to further reduce the infusion rate in hospital outpatient department,implement the"positive list" of the indications in cesarean section to further reduce the rate of cesarean section in midwifery institutions,standardize the medical service,and make regular comparative analysis and ranking report on the structure and changes in increase of the average fees per time(drug charges,inspection fees and material fees)for hospitalization in similar designated medical institutions at the same level.7.Promotion of the implementation of the hierarchical medical systemWe should formulate policies to allow higher public hospitals to reduce or stop providing medical services that do not meet their functional orientation.It is suggested that besides the children’s hospitals,the hospitals at the second level or above in the province should stop the venous transfusion of out-patients,distribute the basic medical services,and implement the obvious differentiation of service prices and medical insurance reimbursement,and greatly reduce the proportion of medical insurance reimbursement outside the county.Taking county hospital as the leader,we should implement the vertical integration of medical service resources in the county and rural areas,strengthen the referral service and technical assistance,encourage doctors in hospitals at the second level or above to practice at multiple sites,develop personalized signing services for the general practitioner team,and establish a "double gatekeeper" system for resident health and medical insurance funds.Moreover,we should unify the essential drug list of health and family planning departments and the drug list of basic medical insurance of human resources and social security departments,improve the drug list of primary-level medical and health care institutions,and strengthen the link between hospitals at the second level or above and primary health institutions,and bring the drug list for medical insurance of hypertension,diabetes mellitus and other chronic diseases in primary-level medical and health care institutions into the coverage of the chronic diseases in outpatient reimbursement,and guide the patients in chronic diseases and in recovery to primary-level medical and health care institutions for medical treatment.Innovation and insufficiency1.Innovations1)So far,this study is the largest evaluation study on the reform of county public hospitals in Shandong,and uses the quantitative evaluation and qualitative analysis,and the data involves a large number of samples covering a wide range so that the quality of data is credible.2)The evaluation index system in this study comes from the national evaluation index system of the comprehensive reform in county public hospitals,and the research tool is credible.3)This study contains rich contents,combs specific documents,reports and practices of reform in county public hospitals in Shandong,and analyzes the progress of reform in county public hospitals in Shandong,and evaluates the reform effect from the relevant indexes,including the hospital operation,related data to the medical insurance of hospitals,and the satisfaction of the masses and medical personnel.2.InsufficienciesThe evaluation of this study was carried out in 2016,and the related data was from 2012 to 2015.As the reform practice on the second batch of county public hospitals started late,some indexes change with hysteresis in effect evaluation,and some of the indexes affected by the reform of county public hospitals may be underestimated and need to be further analyzed in future studies. |
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