Study On The Resistance Model Of Rural Inpatients’ Reasonable Selection Of Medical Institutions Based On Systematic Analysis

[Purpose]From the perspective of “resistance”,this study is to analyze the effect and action path of the current typical policies to promote rural inpatients to select medical institutions rationally,and to analyze the mechanism of micro-behavior of rural inpatient institutions based on prospect theory,further to realize the relevance of behavior of rural inpatients,medical staff,medical institutions,medical insurance and the government.Through the system dynamics analysis,the resistance model of rural inpatients’ reasonable selection of medical institutions is constructed.On this basis,the resistance sides are explicated,so as to find the key policy intervention targets to promote the rational medical institution selections of rural inpatients.[Methods](1)Literature research and policy analysis: Through literature research and policy collection,the resistance factors of reasonable medical institution selection of rural inpatients are preliminarily determined,and the policy orientation of the country and region on promoting rational selection of rural inpatients is clearly defined,which lays a theoretical and methodological foundation for this study.(2)Theoretical analysis: Using the prospect theory,the decision-making mechanism and preferences of rural inpatients’ medical institution selection were analyzed.The system dynamics feedback dynamic complex modeling analysis method was used to construct the system model of resistance of the rural inpatients’ rational medical institution selection.(3)On-the-spot investigation: Investigations were conducted in Huining County of Gansu Province,Funan County of Anhui Province and Dangyang City of Hubei Province.Relevant policies,interview data,organization tables,inpatients’ medical insurance settlement database,doctor’s questionnaire,county-level inpatients questionnaire and resident’s questionnaire were collected.(4)Statistical analysis: Generalized additive model and multiple regression were utilized to analyze the medical insurance database,the medical institution selection and benefits of rural inpatients under different policies.Through multiple linear regression and multiple logistic regression,the influencing factors of preference of county-level inpatients’ medical institution selection and the influencing factors of weakening county-level preference of county-level inpatients and residents’ were analyzed.Hierarchical regression analysis was used to clarify the different impacts of different influencing factors on the weakening of patient/resident preference at county level under different characteristics.T-test and chisquare test were used to compare the referral preferences of doctors with different characteristics.[Results](1)The main modes in Huining,Funan and Danyang to promote the rational distributions of rural inpatients were "disease restriction & differentiated payment / compensation","medical community & regional prepayment based on capitation" and "Internet & grading treatment",respectively.These modes have achieved some effects: the overall institutional level of NRCMS inpatients declined,and the ratio of self payment has decreased year by year.In 2017,the overall institutional level in Danyang increased.The decreasing trends of institutions level of the inpatients suffering from township-level diseases in Huining and Funan counties were more obvious than that suffering from non-township diseases.The proportion of inpatients within townships in Huining County is positively correlated with the distance between the township hospitals and the county hospital,as well as the income of doctors;the proportion of inpatients within townships in Funan County is negatively correlated with the per capita net income of rural residents,and positively correlated with the number of doctors practicing(assistants)per thousand population.(2)Based on prospect theory,rural residents and county-level inpatients were predominant in health reference points,and the county-level medical institutions were considered to have significantly higher service capacity than township-level medical institutions.When choosing an institution,the severity of the disease should be considered first,followed by the quality of service,costs and convenience.(3)The weakening of rural residents’ preference for county-level institutions was related to doctors’ technical level(β=0.34),medical equipment(β=0.34)and indirect expenditure(β=-1.93).The influencing factors of weakening preference were different in different counties: Huining was the medical environment(β=0.75),Funan was the drug category(β=0.48),and Dangyang were the technical level of doctors(β=0.78),medical equipment(β=0.51),indirect expenditure(β=-6.31)and time for hospitalization(β=-1.77).The influencing factors of county-level preference weakening of different types of residents were different according to the classification of whether there had township-level medical institutions experience,income level,independent decision-making,and risk preference types when faced with acquisition and loss.(4)For inpatients in county-level hospitals,the type of drugs(β=-0.05)was an important factor restricting their hospitalization in township-level medical institutions.For patients who had not been treated in township hospitals,the severity of the disease(β=-0.03),medical equipment(β=-0.06)and types of drugs(β=-0.07)were important factors limiting their admission to township-level medical institutions.The weakening preference of county-level inpatients was positively correlated with the severity of the disease(β=0.09)and the types of drugs(β=0.30).The influencing factors of county-level preference weakening were different among patients with different self-awareness of disease and experience in township-level medical institutions.(5)At present,doctors at the county and township levels were not motivated to lead patients to select institutions rationally and county-level doctors were not to motivated to help primary medical institutions.These were because the economic incentives of the doctors did not match the value of doctors’ services,and the relationship between county and township medical institutions was split,which further hinders the rational distribution of rural inpatients.(6)Resistance to the rural inpatients’ appropriate medical institution selection includes patients’ needs,policy responsiveness,rationality of resource allocation,medical insurance payment system,service motivation of county-level medical staff,integration of county and township medical institutions,service capability of primary medical institutions,service motivation of primary medical staff and rationality of service mode.Policy responsiveness is the most controllable and interventional among the resistances.[Conclusions]Rural inpatients are the micro-subject of decision-making of selecting medical institutions.Their preferences determine the decision-making results.Their preferences are influenced by resistance factors from doctors,county-level and primary medical institutions,medical insurance and the government.There are interrelationships among the resistance factors.In order to promote the rationality of rural inpatients’ medical institution selection,this study proposes to enhance policy responsiveness to create the prerequisites for the rational medical institution selection of rural inpatients;to improve the reform systematicness to optimize the service and support system for the rational distribution of rural inpatients;to enhance the service attractiveness to constrict the micro-environment for the rational distribution of rural inpatients.[Innovation and Deficiency]Innovations:(1)Analysis perspective: From the perspective of "resistance" as the main body of analysis,this paper evaluates and analyses the micro,meso and macro resistance faced by the rationality of rural inpatients’ medical institution selection.(2)The innocations of theories: The decision-making behavior of rural inpatient institutions’ selections of medical instituions were analyzed based on the prospect theory in behavioral economics;service contact theory,value theory,new public service theory,etc.,were introduced to broaden the theoretical analysis methods in the field of health services;(3)Methodological innovations: The system dynamics flow rate basic tree-entry normative modeling method was utilized to deeply analyze the resistance of the rationality of rural inpatients’ medical institution selection and the correlation between the resistance;the generalized additive models were introduced to analyze the overall distribution and rationality of rural inpatients,combining with multiple regression analysis to supplement the evidence.Deficiencies:(1)The years of medical insurance database extracted from three research areas were not uniform,and it is impossible to compare the effects of different reform modes.(2)Although the individual economic level was taken into account in the questionnaire analysis of residents and inpatients,the actual level of development of the region was difficult to be included in the analysis,and the uneven distribution of sample size in the survey area might affect the preference results of residents and patients.(3)Because of the limited sample size of medical staff,it is not able to carry out more in-depth analysis of influencing factors.(4)Resistance model of rural inpatients’ ratian selections of medical instituions was qualitative model.Quantitative analysis of resistance will continue in the next research.