| BackgroundThe family doctor contract service(FDCS)is to maintain the health of residents,with general practitioners as the main carrier,to provide comprehensive,continuous and convenient basic medical and health management services for residents.International experience and domestic practice have proven that promoting FDCS is an important way to guarantee and maintain people’s health under the new situation.After many years of exploration and practice,China has initially established the FDCS system with Chinese characteristics,and formed some FDCS models with local characteristics.But at the same time,there are some problems that restrict the progress of contracted services.At present,the actual contracted rate and utilization rate of FDCS in China need to be improved.In addition to improving the supporting measures and guarantee mechanism at the macro level,optimizing the design of contracted service plans is a key step to comprehensively promote the quality and efficiency of FDCS.The important prerequisite for this is to clarify the preferences of the residents(demand-side)and primary medical staff(supply-side)for the FDCS.Due to the information asymmetry of the contracted service parties,the imperfect principal-agent relationship and the influence of changes in the external environment,it is complicated and difficult to measure and evaluate the true preferences of the demand and supply side for the FDCS.Therefore,how to scientifically measure the preferences and willingness of the demand and supply side,and explore the FDCS that meets the preferences of both sides is an important issue that needs to be studied urgently.Through the extensive literature review,we found that the studies on evaluation of FDCS preferences in foreign countries started earlier,and related studies have been relatively systematical,but the reports on the preference differences between demand and supply were insufficient.Most of the domestic studies on the FDCS preferences focused on descriptive analysis and the influencing factors analysis.It is difficult to scientifically and quantitatively analyze the importance of each influencing factor.Few studies on FDCS preferences using discrete choice experiment(DCE)were limited by the single research perspective(demand-side)and small size of sample,and there is still a lack of comparative studies on preference of the demand and supply side.Up to now,the evidences on the true FDCS preferences of residents and medical staff were very scarce.Therefore,to make up for above research gap,our study aims to conduct a comprehensive and systematic quantitative study on preferences for FDCS using DCE method from the perspective of demand and supply side.ObjectivesThe overall goal of this study is:taking Tai’an city,Shandong Province as an example,from the perspective of demand(residents)and supply(primary medical staff)side,to analyze the status quo of the FDCS,to scientifically measure the demand and supply preferences for the FDCS using the DCE method,and to provide data support and decision-making references for the optimal design and strategic improvement of the FDCS.The specific objectives are as follows:(1)To analyze the status quo of the FDCS;(2)To measure the preferences of the demand and supply side for the FDCS;(3)To simulate the combination of different contract service plans,and predict the choice probability under different scenarios;(4)To propose countermeasures for the optimal design and strategic improvement of the FDCS.Data Source and SampleThe data of this study were derived from National Natural Science Foundation of China:Optimizing design and strategy of family doctor contract service from the perspective of behavioral economics:an empirical study on urban-rural supply and demand(71974118).The multi-stage stratified cluster random sampling was used to collect survey samples from six counties in Tai’an City.(1)Demand-side survey:taking the household as a unit,and the residents aged 15 and above were enrolled.(2)Supply-side survey:The subjects included the general practitioners,village doctors and family doctor team members.(3)FDCS preferences survey based on DCE:①DCE design:through literature review,qualitative interviews,and expert consultation,the six attributes were determined,and the consistency test question and visual elements were added into the questionnaire.②Participants:The demand-side preference survey subjects were pregnant women,patients with chronic diseases,and the elderly aged 60 years and above.The subjects of supply-side were all primary medical staff who participated in this survey.Research Contents and Methods(1)The literature method was used to summarize the FDCS preferences related studies at home and abroad,and to get a preliminary understanding of the current progress and existing problems of the studies on FDCS preferences.(2)Taking Tai’an City,Shandong Province as an example,the descriptive methods were used to analyze the awareness and satisfaction of both sides for the FDCS;Multiple linear regression and logistic regression models were used to explore possible factors that affect the awareness and satisfaction of both sides.(3)We used the DCE method to evaluate the FDCS preferences of the demand and supply side.The mixed logit models were used to reveal the preferences of both sides for FDCS;The mixed logit models and latent logit models were used to explore the preferences heterogeneity;And we also analyzed the marginal willingness to pay(WTP)and willingness of the supply(WTS)for the different attributes and levels.(4)The uptake rate equations were used to simulate the combination of different contracted service plans,and predict the choice probability under different scenarios,and to determine the optimal FDCS plan in this study.(5)Combining the results on the status quo and preferences of the FDCS,we put forward countermeasures and suggestions on the optimal design and strategic improvement of the FDCS.Main Results(1)Analysis on the status quo of FDCS① Demand-side:A total of 8500 residents were included,of which 5950 people had signed FDCS,and the overall contracted rate was 70.00%.The median score of residents’ overall awareness of FDCS was 3.00(1.00,4.00),and the attitude score was 4.50(4.00,5.00);compared with the non-contract group,the contracted group had higher scores of awareness and attitude of FDCS(P<0.001).The overall satisfaction score of the contracted group was 5.00(4.00,5.00),indicating that the contracted group was generally satisfied with the contracted service.② Supply-side:A total of 835 primary medical staff were included,of which 754(90.30%)have joined the family doctor contract team.The median score of the overall awareness of the medical staff for the FDCS was 4.50(4.00,5.00),and the overall attitude score was 4.20(3.60,4.60);compared with the medical staff who did not join the contract team,the awareness score of the contracted medical staff for the FDCS was higher(4.50 vs 4.25,P=0.002).The median score of overall job satisfaction of medical staff was 3.17(2.67,3.83).The overall job satisfaction score of medical staff who had joined the contract team was lower than that of the non-contract group(3.17 vs 3.50,P=0.001).(2)Analysis on the preferences for FDCS① 2226 residents were included in the analysis of preference of the demand-side,and those who failed the consistency test were excluded after the analysis.A total of 2159 residents were finally included in the mixed logit model analysis.The regression results showed that the six attributes(service cost,service content,service way,service type,accessibility of medicine and the level of medical treatment of doctor team)had significant impact on residents’ choice.Residents preferred to choose FDCS with lower cost,basic package,home-visit,integrated Chinese and Western medicine(ICWM),higher level of accessibility of medicine and higher level of doctor team.② 816 medical staff were included in the analysis of preference of the supply-side,and 729 were finally included in the mixed logit model analysis after excluding those who failed the consistency test.The regression results showed that the six attributes(service cost,service content,service way,service type,accessibility of medicine and the level of medical treatment of doctor team)had significant impact on the supply choice of medical staff.They preferred to provide contract services with higher cost,basic package,outpatient visit,higher accessibility of medicine and higher level of doctor team.③ By comparing the preference between the demand and supply side,we found that there were obvious preference differences between the demand and supply side in terms of service cost and service way.The residents preferred to choose the low-cost and home-visit services,while the medical staff preferred the high-cost and outpatient services;Meanwhile,there were also common preferences between the demand and supply side:residents and medical staff had a significant negative preference for individualized package,and both of them had a significant positive preference for the service types of ICWM,as well as the contracted services with higher availability of medicines and higher level of the doctor team;The level of the doctor team was the most important attribute affecting the preference of both sides.(3)Analysis on the preference heterogeneity for FDCS① Analysis on the preference heterogeneity of residents(demand-side):those residents aged 60 to 69 and over 70,living in rural areas and with low-income preferred to choose contracted services with lower cost;people with different characteristics tended to choose the contracted service with the higher accessibility of medicine and higher level of doctor team.In addition,based on the latent class logit model,residents were divided into three potential classes,which were respectively defined as economic type(class Ⅰ),comprehensive type(class Ⅱ)and high-quality type(class Ⅲ).The characteristics of gender,age and education level could affect the demand preference of different classes of residents for contracted services.② Analysis on the preference heterogeneity of medical staff(supply-side):medical staff in rural areas and with lower income were more likely to choose contract services with high cost.Medical staff with lower education(≤12 years)had a significant negative preference for providing individualized package services.Medical staff that working in village clinics(community health service stations),with lower technical titles and longer working years preferred to provide services with higher cost.Medical staff with different characteristics preferred to provide contracted services with higher level of doctor team.According to the analysis on the preference heterogeneity of medical staff using the latent class logit model,we found that,there were obvious preference differences between different classes of medical staff.Based on their different preferences for the FDCS,they were defined as common type(class Ⅰ),inducible type(class Ⅱ)and altruistic type(class Ⅲ).We also found that those medical staff who were women,living in urban areas and working in township health centers(community health service centers)were more likely to belong to the common type(class Ⅰ).(4)Analysis on the marginal willingness to pay(WTP)and willingness to supply(WTS)①The analysis results of demand-side marginal WTP showed that residents had the highest WTP for the attribute of medical treatment of doctor team.If the level of doctor team was improved from the level-I to level-III,the residents were willing to pay about 490.4 yuan for this;The WTP for the service of ICWM was also very high.If the service type was changed from traditional Chinese medicine(TCM)to ICWM,residents were willing to pay about 183.9 yuan.According to the subgroup analysis results,the WTP was higher among the residents aged 70 and above,with higher education,higher annual family income,and with chronic diseases.② The analysis result of the supply-side marginal WTS showed that if the service content was changed from the basic package to the individualized package,the medical staff would charge about 45.5 yuan.For other contracted service attributes and levels,if they were changed to the preferred level,medical staff were willing to sacrifice a certain service cost to provide preferred contracted services.Based on the subgroup analysis of medical staff with different characteristics,the low-income group had the lowest marginal WTS for individualized package services,and the medical staff with middle-income,higher technical titles were willing to sacrifice more service cost to provide their preferred contract services.(5)Prediction analysis on the choice probaility of different FDCS scenariosScenario prediction analysis results showed that,compared with the baseline level,if the contracted service was changed to "service cost-10 yuan+basic package+home-visit+ICWM+accessibility of medicines-middle+doctor team-level Ⅲ",the residents’ choice probability would increase by 0.848,and reach the highest.If the contracted service was changed to "service cost-100 yuan+basic package+outpatient visit+ICWM+accessibility of medicines-very high+doctor team-level Ⅳ",the probability of choice of medical staff was expected to increase by 0.572,and the probability would reach the highest(0.629).After comprehensive consideration and analysis,we found that under the contract combination of "service cost-50 yuan+basic package+outpatient visit+ICWM+accessibility of medicines-very high+doctor team-level Ⅱ",the choice probability of residents and medical staff was 0.642 and 0.580,respectively.At this time,the difference of choice probability between demand and supply side reached the minimum value(0.062),which could be determined as the optimal FDCS plan in this study.Conclusions and policy recommendationsConclusions:(1)The overall signing rate and satisfaction of residents for FDCS were high,and they had positive attitudes towards FDCS,but their awareness of the specific content of FDCS still needs to be improved.(2)Primary medical staff had high overall awareness and acceptance of the FDCS,but their job satisfaction was low,especially in the family doctor team members.(3)There were some common preferences of the demand and supply side for the FDCS.Firstly,residents and medical staff valued the level of medical treatment of doctor team most,and the WTP and WTS for this was the highest;secondly,they both preferred ICWM and basic package services.(4)There were preference differences between the demand and supply side for the FDCS.The primary medical staff preferred traditional outpatient visit,while residents had higher WTP for home-visit service.A reasonable financing and allocation mechanism is needed to reconcile the preferences difference between the demand and supply for service cost.(5)There was preference heterogeneity among both the demand and supply side for FDCS.Different characteristics and classes of residents had different preferences for FDCS.The supply-preferences of medical staff with different characteristics were different,and the altruistic social preference was found in the supply behavior of medical staff.(6)For the design and optimization of FDCS,we should not only take into account the potential preferences of the demand and supply side,but also consider the local practice environment to achieve the optimal FDCS mode.Policy recommendations:(1)Running through the concept of knowledge-attitude-practice in FDCS to improve the awareness level of both demand and supply side;(2)Improving the job satisfaction of the family doctor team and enriching the primary health personnel team;(3)Improving the level of medical treatment of doctor team to enhance the continuity and comprehensiveness of FDCS;(4)Giving full play to the advantages of integrated traditional Chinese and Western medicine to expand the connotation of FDCS;(5)Increasing the attractiveness of FDCS and promoting individualized paid contract services;(6)Exploring the multi-level service delivery and improving the standardization level of home-visit service;(7)Formulating appropriate service cost,and improving the financing and distribution mechanism for service cost of FDCS;(8)Narrowing the FDCS gap between urban and rural areas,and promoting fair supply of FDCS.Innovations and LimitationsInnovations:(1)Most of studies on FDCS preferences focused on the demand-side(residents/patients),this study explored the FDCS preferences from the perspectives of demand and supply side,which made up for the research gap;Through comparative analysis of FDCS preferences of residents and primary medical staff,we simulated the optimal contract services plans,and predicted the choice probability of both sides on the optimal plans,which provided more scientific evidences for further optimization design of FDCS plans to improve the enthusiasm and satisfaction of residents and primary medical staff for the FDCS.(2)This study,for the first time,evaluated the preferences of different classes of residents and medical staff for FDCS by constructing the latent class logit models,and verified that there was altruistic social preference in the service delivery behavior of primary medical staff.The results of this study provided references for health departments to formulate and implement multi-class and multi-level intervention and management strategies for the residents and primary medical staff.Limitations:(1)It is uncertain that the stated preferences based on the DCE survey are consistent with the actual behavior,which needs to be verified by future studies;(2)Limited by the DCE method itself,this study only included six most important attributes of the FDCS,which cannot reflect the possible influence of other attributes on the demand and supply preferences for the FDCS.(3)This study was conducted in a single city(Tai’an City,Shandong Province),which may limit the generalizability of the results in Shandong Province and other areas of China. |
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