The Impact Of The Private Hospitals Development On Healthcare Provision,Utilization And System Based On The Multi-source,Multi-level,and Spatiotemporal Data From Sichuan Province

Aiming to address long-standing problems of health care system,summarized by many as "Kan Bing Nan,Kan Bing Gui"(getting medical care is difficult and expensive),the Chinese central government launched a comprehensive and nationwide healthcare reform in 2009.One of main policies put forward was to relax the entrance of private investments in healthcare system,which is primarily designed to enhance the availability of healthcare to meet the people’s multilevel and diversified healthcare needs and fuel competition to promote hospitals,especially the public ones,to improve their quality and efficiency.Under this context,the private sectors expanded rapidly across the entirety of the Chinese healthcare delivery system,especially the private hospitals,and their numbers exceeded the public ones in 2015.However,there is a heated debate on the role of the private hospitals in the healthcare system between the pro-market and pro-government groups.Advocates believe that the efficiency of private hospitals is higher than public ones because of their better internal managements and lower operational cost,which in turn drive down medical expenses and improve quality of healthcare.Furthermore,increasing private hospitals could intensify the competition in healthcare system,which could promote public hospitals to improve their quality of care and hospital efficiency,even drive down the medical expenses to attract patients.However,the opponents think that healthcare market differentiates from the general goods market by some unique characteristics,including uncertainty of diseases and treatments,and high information asymmetry,resulting in“market failure”.Therefore,complete marketization may not work out in healthcare system and it might exacerbate “Induce Supply” and “Medical Arm Competition”,which could undermine the quality of care and efficiency and even increase medical expenses.Nowadays,there are growing concerns and heated debates on whether the development of private hospitals achieve our expected goals,or work out totally oppositely.Consequently,our research aims to assess the development of private hospitals and their impacts on healthcare market after ten-year healthcare reform.The concrete questions as follows:(1)As for healthcare provision,the service types of private hospitals prefer to provide? the locations of the private hospitals prefer to choose? Whether the development of private hospitals could improve the health accessibilities?(2)As for healthcare utilization,whether the private hospitals could provide healthcare services with higher quality of care but lower medical expenses due to their flexible operation and advanced management?(3)As for healthcare system,whether the private hospitals could fuel the healthcare competition to promote the public hospitals to improve their quality of care and efficiency as policies expected?In order to answer those questions mentioned above,our research collected the data from multiple sources,including the fourth quarter of 2016-2018 discharge reports of Sichuan provinces,2009-2018 administrative hospital reports of Sichuan province,2009-2018 Sichuan Health Statistics Yearbook and Sichuan Statistics Yearbook,2009-2018 Land-Scan Population data,2010 traffic network data.Coupled with our research goals,we conducted multiple statistical models to assess the impact of the development of private hospitals,including traditional and spatial descriptive statistical methods,Two-part models for continuous data with excess zeros,Enhanced Two-Step Floating Catchment Area and Chain Replacement methods,Fixed-effect models for panel data,multilevel log-linear models,multilevel logistic models for hierarchical data,data envelopment analysis and random-effect Tobit models for data with both left-and/or right-censoring and within-cluster dependence of the outcome variables.Part one,investigating the preference types of services and locations of private hospitals,and their impacts on healthcare accessibilities.Objectives: To investigate the preference types of services and locations of private hospitals,and their impacts on healthcare accessibilities.Methods: First,the fourth quarter of 2016-2018 discharge reports were collected and descriptive statistical methods were performed to analyze the healthcare services that private hospitals prefer to offer.Furthermore,we defined our healthcare market by counties,and compared the most common 30 diseases between private and public hospitals and calculated the concordance rate for each market.Second,this study collected data from 2009-2018 administrative hospital reports of Sichuan province and spatial descriptive analysis was conducted to investigate the preference locations of private hospitals.Then,the two-part models were performed to investigate the potential factors for influencing private hospital locations.Third,Enhanced Two-Step Floating Catchment Area and Chain Replacement Method were used to evaluate the dynamic change of spatial accessibility of private hospitals and their contribution to whole spatial accessibility after ten-year healthcare reform.Then,the fixed-effect models were used to analyze the impacts of spatial accessibilities of private hospitals.Results: We found that the private hospitals preferred to provide services of common diseases,especially bone and joint or eye system related diseases.Meanwhile,we found that private hospitals provided half services which were similar to public hospitals,but half services which were different to public ones.Meanwhile,the locations of private hospitals were significantly positively associated with population density,GDP per capital,and social insurance coverages.Interestingly,in the areas with private hospitals,there was a significantly negative association between private hospitals number and GDP per capital.Finally,we found that spatial accessibilities in Sichuan province increased rapidly,though the public hospitals still dominated in the spatial accessibilities.However,the growth of private hospitals might further exacerbate the inequity spatial accessibilities across Sichuan province.Conclusion: The private hospitals indeed supplemented the public hospitals in terms of services and improved the overall spatial accessibilities.But the preference locations of private hospitals were market-dominated,instead of supplementing the undersupplied areas of public hospitals,the private hospitals further exacerbate the inequity spatial accessibilities across Sichuan province,resulting in “Market Failure”.Thus,it is necessary to combine appropriate government interventions to optimize the distributions of healthcare resources,finally to both improve the efficiency and equality of resource allocations.Part two,investigating the difference of private hospitals and public hospitals in terms of hospital expenses and quality.Objectives: To compare the hospital expenses and quality among private not-forprofit hospitals,private for-profit hospitals,and public hospitals.Methods: We collected data from fourth quarter of 2016-2018 discharge reports,chose the secondary hospitals as our targeted hospitals,and identified the pneumonia(PNA),heart failure(HF)and acute myocardial infarction(AMI)as our representative diseases.The multilevel log-linear and logistic regressions were used to compare the hospital expenses and quality among private not-for-profit hospitals,private for-profit hospitals,and public hospitals,respectively.In the sensitive analyses,we first performed the coarsened exact matching(CEM)to match the patients between private and public hospitals by some characteristics,and then the multilevel log-linear and logistic regressions were used to compare the hospital expenses and quality between private and public hospitals in matched samples,respectively.Results: As for hospital expense,we found that medical expenses did not significantly differ across hospital ownership types for AMI.For PNA,our study indicated that medical expenses in private hospitals were higher than that in public hospitals.Specifically,average medical expenses for PNA were 9% and 9% higher in private not-for-profit and for-profit hospitals compared with public hospitals.As for HF,average medical expenses were 18% higher in private not-for-profit hospitals,and11% higher in for-profit hospitals compared with public hospitals.As for hospital quality,we found no difference in in-hospital mortality between public hospitals and private not-for-profit or for-profit hospitals,after controlling for an extensive set of patient and hospital characteristics for AMI and HF.By contrast,PNA patients in private not-for-profit hospitals were 1.66 times(95% CI: 1.09 to 2.53)more likely to die in hospital compared with public hospitals.Similarly,patients in private for-profit hospitals were 1.58 times(95% CI: 1.03 to 2.43)more likely to die than patients in public hospitals.Conclusion: The medical expenses were higher in private hospitals compared with private hospitals,but the hospital quality of private hospitals was not higher even lower than public hospitals.Part three,whether the private hospitals could fuel the healthcare competition to promote the public hospitals to improve their quality of care and efficiency?Objectives: To investigate the association between the private hospital development and hospital efficiency,hospital quality and medical expenses.Methods: We collected data from the 2009-2018 hospital reports,used the fixedradius method to define the market and private hospital market share to assess the development of private hospital.The data envelopment analyses were performed to evaluate the hospital efficiency.The random-effect Tobit models were used to assess the association between development of private hospitals and hospital efficiency;We collected the data from fourth quarter of 2016-2018 discharge reports,chose the chronic obstructive pulmonary disease,pneumonia,coronary heart disease,stroke,and intervertebral disc disease as the representative diseases.The multilevel log-linear models were used to assess the association between development of private hospitals and medical expenses.We collected the data from fourth quarter of 2016-2018 discharge reports,chose PNA,HF and AMI as the representative diseases.The multilevel logistic models were used to assess the association between development of private hospitals and hospital quality.Results: First,we found that for every one unit increase in private hospital market share,there was a correlation of 0.10,0.04 and 0.12 growth in the overall hospital efficiency,pure technical efficiency,and scale efficiency,respectively.Second,we found that for every 10% increase in private hospital market share,there was a correlation of,on average,a 6.15%,1.77%,4.28%,2.16%,and 1.60% decrease in total medical expense for obstructive pulmonary disease,pneumonia,coronary heart disease,stroke,and intervertebral disc disease,respectively.meanwhile,in public hospitals,chronic obstructive pulmonary disease,pneumonia,coronary heart disease,stroke and intervertebral disc disease showed that for every 10% increase in the private hospital market share,the medical expense in public hospitals will fall by 7.25%,2.08%,4.94%,2.23%,and 2.44%,respectively.Finally,we found that there were no significant associations between the private hospital market share and in-hospital mortality rates in hospitals for patients with pneumonia,heart failure and acute myocardial infarction(whether public hospitals or private hospitals).Conclusion: The development of private hospitals could improve the hospital efficiency and lower the medical expenses,but there is no significant association between development of private hospitals and hospital quality.In summary,the private hospitals expanded rapidly since 2009 when the Chinese government launched the healthcare reform.Their number surpassed the public hospitals in 2015,and private hospitals become an indispensable part of healthcare delivery system in China.Thus,this research tries to evaluate the impact of the private hospitals development on healthcare provision,utilization and system based on the multi-source,multi-level,and spatiotemporal data from Sichuan province.Even though the development of private hospital causes some problems,including further aggravating the inequity of healthcare resource distribution,and higher medical expenses and lower healthcare quality than public hospitals,the development of private hospitals has also made some achievements as the policies expected.First,private hospitals supplement public hospitals in terms of service provision,which comprehensively improves the absolute supply of healthcare services and partially meets the people’s diversified healthcare needs.Second,the rapid development of private hospitals fuels competition in the healthcare market,encouraging the public hospitals to improve efficiency and reduce medical expenses,especially out-of-pocket expenses.