Coordination Mechanisms And Decision-making Methods In Hierarchical Healthcare Service Systems

The contradiction between the demand for and supply of healthcare service as well as the unreasonable allocation of medical resources have become increasingly prevailing in China.It is urgent to deepen the reform of the medical and health system,optimize the reasonable allocation of medical resources,and regulate the medical consumers to access to care orderly.Construction of hierarchical healthcare which takes implementing the downstream referral of patients and the sinking of high-quality medical resources as the important means,takes carrying out the development of medical association as an effective carrier,and takes improving the equalization and efficiency of medical services along with achieving the Healthy China strategy as the necessary paths,is a significant healthcare reform policy program,which is strongly popular by the state and local government at various levels.Currently,there are obvious conflicts of interest among all levels of medical institutions in the operations of hierarchical healthcare.Generally,there is a lack of incentive mechanisms that coordinate the patients to both transfer downstream and receive their treatment services from community hospitals,the medical resources sinking,and the sustainable development of the medical association.Consequently,the implementation of hierarchical healthcare is not obvious and has not reached the expected outcomes together with the problem of residents’ difficulty in accessing to care has not been fundamentally solved.However,the discussions on hierarchical healthcare service systems primarily focus on implementation status and significance.Both coordination mechanisms and operational decisions,which may significantly impact on the operational efficiency and coordination of the systems,have not paid sufficient attention.Thus,designing effective incentive mechanisms and studying operational decisions will play a critical role in the effective operational management of systems.In view of this,this thesis is based on two key research aspects from both the demand side and the supply side of healthcare service.To coordinate the development of the Chinese hierarchical healthcare service systems,this thesis designs the profit-sharing schemes among medical institutions at various levels,government subsidy scheme,and cooperation schemes between government and hospitals.Additionally,this thesis analyzes and studies in-depth the operational decisions in order to optimize service performance issues.Main contributions of this thesis are as follows.(1)Coordination of hierarchical healthcare service systems via profit-sharing scheme between all levels of hospitals.Considering the situation that the tertiary and community hospitals send and receive the healthcare demands and resources respectively,this thesis studies the schemes which the community hospital shares its profit with the tertiary hospital.By establishing a three-stage sequential game-theoretic queueing model under the healthcare referral and medical resource reallocation programs,the result shows that for only a medium profit-sharing rate,the downstream referral of patients can result in a win-win situation for all parties and there is a unique profit-sharing rate such that all the parties’ benefits are maximized.There exists a unique threshold for the revisit rate such that a revisit rate which does not exceed the threshold is greater,increasing the patient referral rate will more benefit both the improvement of operating profits and total patient utility as well as the reduction of total waiting time;otherwise,decreasing the referral rate will relieve the decrease in operating profits and patient utility along with the increase in waiting time.When the total high-quality resource is sufficiently low,all the Profit-Sharing for Capacity(PFC),Performance Profit-Sharing(PP),and Hybrid Profit-Sharing(HP)schemes are equally efficient in accelerating the high-quality resource sinking and improving both the care accessibility and social welfare.When the total high-quality resource is medium,the HP scheme is always more efficient than PP scheme,but only for a relatively low weight parameter of performance sharing in the hybrid scheme,the equilibrium outcomes of the HP scheme are closer to the benchmark case associated with the centralized system than those of the PFC scheme.However,when the total high-quality resource is high enough,sinking the resource is not beneficial for the overall system performance,and thus reduces social welfare.(2)Coordination of hierarchical healthcare service systems via government subsidy schemes.Under the circumstance that the Chinese government may implement subsidy policies for patients and hospitals with the goal of achieving hierarchical healthcare service,this thesis examines the effectiveness of subsidizing community hospitals and subsidizing transferring patient schemes for coordinating the referral service as well as evaluates the operational efficiency of Subsidy for Capacity(SFC)and Performance Subsidy(PS)schemes for coordinating the resource reallocation via establishing a four-stage sequential game-theoretic queueing model.The result shows that when the concerned degree of the operating profits is relatively low,medium-high,and high,or the cost of the community hospital’s capacity is relatively high,or the budget is low enough,subsidizing the community hospital is more beneficial for operating the patient referral,improving both the patient utility and social welfare,and reducing the waiting time.When the concerned degree of the operating profits is relatively low-medium,or the cost of the community hospital’s capacity is low enough,or the budget is relatively medium,subsidizing the downstream referral patient is more efficient for the improvement of patient referral effectiveness and the system performance.When both the concerned degree of the operating profits and the cost of the community hospital’s capacity are medium,and the budget is relatively high,subsidizing the community hospital is more efficient in the improvement of both the patient’s downstream referral rate and utility and the reduction of the waiting time,but it is less efficient in the improvement of social welfare.Particularly,when the subsidy budget is a shortage or the government’s concerned degree for the patient utility is relatively low and medium,the PFC scheme always outperforms the PP in terms of all performance measures.When both the subsidy budget and the concerned degree of the patient utility are medium,neither the PFC nor PP scheme could reach the optimums of the centralized systems.However,a Hybrid Subsidy(combining SFC and PS)scheme could alleviate their drawbacks and induce the operations of high-quality resource sinking and the improvement of healthcare delivery systems in a complementary manner.(3)Coordination of hierarchical healthcare service systems via cooperation schemes between government and hospitals.On the basis of the previous two chapters,this thesis further studies that the government and medical institutions cooperate to coordinate the operations of the hierarchical healthcare systems under a medical association model.This thesis explores the effects of competition among community hospitals on the decision of each party and sustainable operations of the medical association.This result shows that the number of community hospitals that act as the members of the medical association is more,the government will coordinate that the community hospitals share a lower rate of their expected profits,which is more beneficial for improving the efficiency of the overall systems.Specifically,for an adequate subsidy budget,when the number of community hospitals exceeds a certain amount,the government will coordinate that community hospitals do not share any rate of their expected profits.However,the relatively scarce budget is lower,the government will coordinate that the community hospitals share a more of their expected profits.When the number of community hospitals is more,the rate of profit-sharing is lower,which results in a lower subsidy price providing by the government.Fewer of the community hospitals’ number is more efficient in the operations of the healthcare referral program and the improvement of all parties’ performances.When the number of community hospitals is relatively low or high,it is more beneficial for saving the government subsidy funds in relation to the healthcare referral program.As a basis for comparison,this thesis first considers the case in which none the medical resources is sunk.It is found that more community hospitals’ number is more favorable to relieve the congestion of both the tertiary hospitals and the overall systems and improve the patient utility.Furthermore,the medium number of community hospitals is conducive to the improvement of social welfare.By contrast,fewer community hospitals’number is better for the operations of the medical association in terms of promoting the implementation of the resource sinking program.In the process of compensating for the tertiary hospital,when the concerned degree for the increment of the rate of patient visiting community hospitals is relatively low or high,the government could save the subsidy funds,and especially for a shortage subsidy budget,it is quite beneficial for the improvement of social welfare.Finally,this thesis proposes the coordination mechanisms and decision schemes for achieving the efficient operations of patient downstream referral and high-quality medical resource sinking,which enriches the related research of healthcare service and operation management problems.It offers the theoretic guidance for medical institution to provide the high quality and efficient services as well as government to establish a scientific and rational hierarchical healthcare delivery system.At the same time,this thesis has high an application reference value to optimize the medical resource reallocation,alleviate the congestion in the healthcare systems,and improve the overall efficiency of healthcare services.