Study On Modeling Of Institutional Unreasonable Increase Of Medical Expense In China

1. Research Background and SignificanceSince the reformation and opening, Chinese healthcare system has developed with a high-speed, which, at the meanwhile, brings the medical expense's increasing. According the pushing factors of medical expense's increasing, we divided the medical expense into two parts: the naturally increasing part and the institutionally increasing part. The former part means that the medical expense increases along with the development of economy, population's aging, changing of disease structure and development of medical technology. The other part means the medical expense increases because of the national and local policies. Part of the medical expense brought benefit to people's life, however, part of it was wasted. These institutional policies involved drug plus policy, hospital management, price regulation, medical insurance and the like. The relationships among these policies involved antagonist, cooperation, cause and effect and other complicated relationships. What's more, after several decades, these relationships have run-in and hade the stable restructure, which brought the institutional unreasonable increase of medical expense. If these policies could be adjusted, the problem described above would be relieved and, at the same time, people's benefit would not be harmed.The unreasonable increase of medical Expense is a great problem, on which many policy researchers have been studying on different aspects. Most of them concluded that: because of the insufficiency of government financial input, the hospitals have to make money by themselves in the policy environment. However, the National Development and Reform Commission limits the price of medical labor service on a low level. The hospitals have to selling drugs and providing technological examinations by medical inducement service, which brings the unreasonable increase medical Expense. Under the incomplete medical insurance system, people's medical financial burden becomes heavier and heavier. Professor Hu Shanlian of Fudan University proposed that it should take measures on medical expense paying mode, driving mechanism of hospital charging, market competition and so on to control medical expense.The former research was the sound foundation for this study. We realized that healthcare system is a complicated social system. On solving this kind of complicated system problems, system dynamics is the most suitable.2. Material, method and resultsThis study had the "system dynamics" as its guiding research method. This study restricted its research thought to the system dynamics:defining problems, defining systems, defining the quanlitative relationships among systems, establishing system dynamics model and testing the model, among which, the step of defining problems had been done in the parts of summary and introduction. The left steps are as following:(1) Confirmed the subsystems related to the problem of institutional unreasonable increase of medical expense1) Data resource and research methods●the macro model of healthcare system The macro model of healthcare system (Chart 1) is the theory model explaining the operating rules of healthcare system. This model has a clear boundary and it analyzes the subsystems clearly. As one of the "system results", the medical expense was used in this study to seek the other subsystems involved in the problem of institutional unreasonable increase of medical expense.●Documents retrievalIn《Chinese hospital management magazine》,《Chinese healthcare economy》,《Chinese hospital management》,《healthcare economy research》,《Chinese primary healthcare》,《Chinese rural healthcare management》,《Chinese healthcare resource》and the like, in the area of healthcare, we retrieved a great many of documents by the topics of drug plus policy, medical insurance, rural cooperation medical insurance, system dynamics, healthcare reform, public hospital reform and business medical insurance and curve fitting and so on. By reading those documents, we concluded the factors resulting the increase of medical expense and among which which were the reasonable factors and which were the unreasonable ones and with those unreasonable ones how to deal by policies. After seeking out those factors, we went on to find out the subsystems where those factors stayed.In addition, we red several monographs:《System dynamics model study on the management system of city rubbish-taking the case of Beijing》(written by Cailin),《Introduction of system dynamics model of environmental system-environment simulation》(written by Andrew Ford, translated by Tang haiping and Shi peijun) and so on. By reading those books, we learned the basic knowledge of system dynamics, especially the practical modeling process. We also learned the software of Vensim.●Experts group discussionWe had organized five experts consulting conferences and several weekly group discussion meetings. By learning from professors from health bureau, healthcare development and research center, NCMS office and dept. of information, we concluded a lot, which helped us a lot in establishing the system dynamics model.2) Research resultsFirst, we found out the subsystems by the macro model of healthcare system. Then, we testified the results by the document analyzing and experts group discussion. Finally, we concluded the set of subsystems including hospital subsystem, government financial subsystem, pricing subsystem, medical insurance subsystem and patients subsystem.(2) Established the system dynamics model of institutional unreasonable increase of medical expense1) Established the system structure chart of institutional unreasonable increase of medical expense●Data resource and research methodsThe main method of this part is the system structure chart of the system dynamics. System structure chart is using a circle or a box to explain the system's main blocks (or subsystems) and describe the material flow between them. Simply put, this method is to explain the relationships among the model subsystems by simple lines.●Research resultsAndrew Ford had given the readers a suggestion in his monograph: the model establishment is a repeating and debugging process. The best method is to establish a simple model first and then, if the simple model could not present the realism, the variable changing the model should be brought into the model. This process will lead to a completed and complicated model. The best thing is trying to establish a perfect model at the first. According to this suggestion, we established a simple model of the ideal status of the increase of medical expense at first, and then, we brought the political variables into the model gradually. Finally, we established the completed model of institutional unreasonable increase of medical expense (Chart 2).We start the explanation from the subsystem of hospital. Hospital revenues are the margin between the total cost of the hospital and the total income. The total cost of the hospital is composed of three components:public hospital expenditure, hospital labor expenses, hospital expenses of fixed assets. Hospital total income is the dominant medical services funds, which is paid by: medical insurance, finance, patient at their own expense. Ideally, the government finance undertake the whole health care costs, at this case, medical insurance nature has the same character with government finance, we can call it universal medical insurance system. Patients do not need to bear the cost at their own expense. But in fact, universal medical insurance system does not exist, in the imperfect medical insurance system, there must be some people's medical needs depressed for medical expenses. This part of the suppressed demand for medical services made cuts the potential funding of medical services. The compressed fund of medical services directly reduces the hospital's the total income and hospital becomes losses. At the same time, price departments of the health care services adhere to a policy of low prices, lowering the potential funding of medical services again, the hospital becomes even more losses. Hospitals need to use the surplus to protect the hospital's development of the hospital, so the hospitals use their own characteristics of monopoly industries, under the space of the policies, going onto a road of "induction service" to obtain additional compensation. As the existence of the yield, the hospital is actually improving the hospital's incomes through increasing its cost. Expansion of the dominant health care funds, in the condition of the stable government finance and the medical insurance fund, make the final impact point on the patients without medical insurance. In the increasingly heavy cost burden, the self-paying patient gradually urges the Government to change the funding policies, such as:requirements on expanding health insurance coverage, increasing the proportion of health insurance compensation, establishing universal health insurance system. Government, on the condition of compensation payments pressure becoming heavier, has two ways: one is to urge the price dept. to adjust the medical service price; the other is to use of existing control policies to make a business income, or to ask the government to relax the controlling policy in the hospital.2) Established the flow chart of institutional unreasonable increase of medical expense●Data resource and research methodsThe main methods of this part are the cause and effect diagram, the tree structure diagram and flow chart, bull's-eye map.■The cause and effect diagramWe can simply understand the cause and effect diagram as the "fullness" process ot the system structure chart: specifying the relationship in system structure chart by using specific indicators to link up the variables.The process of medical expenses research contains a lot of feedbacks, similar to the fluid flow The cause and effect diagram can only describe the basic aspects of feedback, a loop or a feedback process. In this study, we need to reflect the growth of medical expense in the process of a series of mechanisms, not a simple one step process. Therefore, we established the flow diagram on the base of the cause and effect diagram.■The tree structure diagram and flow chartBy defining the current position variables, flow rate variables, auxiliary variables and added variables, according to the causal relationship and feedback relations among variables, we firstly established the reasons for each variable tree structure diagram, and then the reasons for the variable tree structure diagram, and then connected those diagrams by lines and finally established the flow chart.■Bull's-eye mapBull's-eye map, also being called the boundary map, is an extremely simple way to display the model's variables. It can indicate the need for the input variables and the relative balance between endogenous variables. The way of expressing Bull's-eye map is:using two nested rings to divide the plane into three parts, the endogenous variables are in the small ring, the exogenous variables are between the big and the small ring, other excluded variables are outside the big ring. Bull's-eye map has a general rule:at the center of the bull's-eye map, there at least three or four key variables, if in the center of the bull's-eye chart there omits an important variable, there will not be a complete system model.●Research resultsThis section established the flow chart on the base of the system structure chart in the last part. Note:The dotted line frames in the chart explain the processes of adding the parts of medical insurance policy, price policy, hospital inducement service into the ideal model.(the chart is omitted)(3) Quantitatively testifying the model of institutional unreasonable increase of medical expense1) Data resource and research methods■The materials resourceThe main quantitative resource of this study is as follows:《China Statistical Yearbook》《China Medical Statistical Yearbook》,《Healthcare final accounts information》(1991-2007). We collected the indexes of social environment, price index, government finance, hospital operational index and so on.■The data analyzing methodsIn general, the software of Vensim is the professional one for system dynamics model. Considering the limited time, we chose the Excel 2003 software to complete the process of quantitatively testifying. The Excel 2003 has the data linking function and its methods of descriptive statistical analysis can support the process of quantitative simulation.In addition, in the process of demonstrating of the rationality of the model, we used the "area of fitting" method. The approach was advanced by Professor Dong Yuheng from Norman Bethune Medical University, endemic studies institution. In line with the traditional habit of goodness of fit test, that is:R2 value is closer to 1, indicating better goodness of fit, we used the following formula to represent the curves of goodness of fit面积拟合度=1-(拟合曲线与实际曲线间面积/实际曲线与均数直线间面积)■The idea of quantitatively simulationThe idea of quantitatively simulation is: Firstly, we simulate in the ideal condition, hospital developing, medical expenses increasing at the same pace with the social economy, that is:the variables related to the hospital total income and expenditure have the same increasing pace with the growth of GDP. Second, we establish the growth of various indicators under the socio-economic and the total population, that is a reasonable value. Then, we simulate price policy, the relative lack of government financial assistance, expansion of hospital procedures such as labor costs. Under the limits of these policies, the hospital's total revenue and total costs exist gaps. At this time there are the temp "simulated value" for various indicators. The next step is to simulate the hospital's "inducing service" process. Adding the medical expenses, costs produced by the hospital aming to fill gaps to the former "simulated value", we can have the final value of medical expenses, hospital expenses and other indicators. 2) Research resultsThe chart of the medical expense simulated and the real medical expense is as following. Adjust gradually the quantitatively simulating parameter values to make the value of the area fitting as far as possible being close to 1. Upon demonstrating, when all relevant parameters in Table 1, the simulation of the actual medical expenses and simulated medical expenses are close and the value of area fitting is 0.9403. This study also proved that the reasonable model of institutional unreasonable increase of medical expense. (the charts are omitted)...