基于路径收敛设计的医院产出效率的识别与模拟研究
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摘要
中国医疗服务体系中的药品加成政策曾经推动了医院的发展,提高了医院的效率,然而也驱动了医院盈利行为,医院公益性受到质疑。自2000年以来,政策呼吁取消药品加成与完善补偿机制,2010年2月2日,《关于公立医院改革试点的指导意见》出台,确立了公立医院改革试点,其核心是增加财政补偿和增设药事服务费,取消药品加成政策,使公立医院走上“公益”回归之路。于是,如何识别医院的产出效率、医院的公益,以及效率与公益的统一的研究,具有重大现实的意义。
然而,已有关于医院效率和医院公益规制的研究无论是在内容,还是在方法上都存在缺陷。从研究内容上看,都从医院产出效率和医院公益规制两个单独的视角来研究,缺乏从效率与公益联合的视角来研究医院的运行机制。第二、从研究方法上看,以投入最小或产出最大化为目标函数的DEA模型和随机前沿的SFA模型主要用来评估医院的产出效率,并不能用来评价医院的公益性。公立医院产出最大化不仅追求医院本身的运行效率,而更重要的是追求的社会的公益效率。
本论文首次融合公益和效率视角,基于取消药品加成政策以减少病人负担和提高医院产出效率的改革背景,将公立医院产出效率的识别与模拟确定为研究主题,利用除经典的DEA模型外的半参数反事实方法、非参数路径收敛设计、非参数环境联动模型和模拟设计研究方法以浙江省省级医院为例从产出效率的视角对如何实现医院收入从药品收入补偿到财政收入补偿和医疗服务收入补偿的公益性转化问题展开探索,以期对当前亟待解决的医疗改革重大问题做出理论贡献。以下为本论文得到的主要结论。
第一、效率识别。首先,应用DEA方法2007年浙江省各省级医院产出效率进行识别,结合各医院迥异的盈利水平,DEA识别将14家省级医院分为高效率类医院(Group1)和低效率类医院(Group2)。Group 1包括医院：H1, H2, H4, H6, H7, H12, H13。Group2包括医院：H3, H5, H8, H9, H10, H11, H14。
其次,构建Logistic模型假设下的半参数反事实核密度分布,搜索影响药品结余的主要影响因素,剖析药品结余形成的主要机理。发现解释药品结余分布在2004-2008期间的变动主要要素是门急诊人次数和出院人天数,而不是药品处方数。这为取消药品加成政策时可以按照就诊量来增设药事物服务费提供了理论依据。
最后,构建非参数药品路径收敛模型和环境联动模型对医院产出效率的驱动要素和传导机制进行识别。发现：1.高效率的Group1类医院的产出主要驱动要素是固定资产维修购置费以及专用材料费构成的资本要素,而低效率的Group2医院的产出主要驱动要素是门急诊人次和住院人数构成的劳动力要素。2.药品路径对Group1类医院产出变化主要是通过门急诊人次和住院人数构成的劳动力来传导,而对Group2类医院产出变化主要是通过医院固定资产维护费和专用材料费的资本投入来传导。两类医院传导机制的不同蕴含着药品加成政策使较低效率医院(Group2类医院)的就诊量出现挤出效应,而较高效率医院(Group 1类医院)出现挤入效应,这与公众更倾向于到效率较高医院就诊现象相吻合。3.政府财政补偿等环境因素会使不同医院的传导机制发生转变。
第二、模拟研究。首先,根据DEA识别结果对低效率医院的下一期运营策略展开模拟。不同于已有的DEA模型,要么在投入不变下,增加产出,要么在产出不变下,减少投入,或者同时减少投入和增加产出使得医院从无效率到有效率。本研究设计了一种可实现的同时增加投入增加产出的将低效率医院向高效率医院转变的管理策略。通过确定理论增加值、搜索理论投入不变情形下的产出理想值和确定低效率医院的理想投入产出值三个步骤对Group2类医院展开模拟研究证实了该模拟方案可以在保证其他医院效率不恶化的前提下,提升Group2类医院效率。
其次,基于药品路径模型和环境联动模型的产出效率识别结果,构建路径-环境模型对如何弥补不同医院因取消药品加成而引起的产出缺口展开模拟研究。与已有研究中简单的填补总收入Y不变视角不同,本研究的模拟探索将目标放在假设取消药品加成策略实施时保持药品路径下要素K与L驱动产出作用上,并根据路径传导机制来确定需要从哪种要素(资本要素K还是劳动力要素L)的视角来实现补偿由于药品加成取消产生的Y缺少份额。模拟发现医院H2需要以增强资本要素的传导方式和医院H8需要以增强劳动力要素的传导方式来实现有效率产出,为此目的,可以利用增加政府财政补偿的方式来实现；医院H4需要以增强资本要素传导方式来展开同时增加财政补偿和增设药事服务费以弥补取消药品加成政策的产出缺口的模拟研究。模拟研究表明,对于各具体医院要有不同的财政补偿和增设药事服务费政策来实现弥补其产出缺口。
本文的主要创新是：(1)探索性地把效率与公益整合在非参数路径收敛研究框架。与已有的研究不同,不是分别孤立地去研究医院的产出效率和公益性规制政策,而是通过设计体现公益性的基准模型,体现效率的路径模型和将公益与效率相统一的收敛设计,来完成对医疗改革中涉及的取消药品加成、增设药品服务费、增加政府财政补偿等卫生资源配置效率问题的探索性研究。(2)探索性地识别药品加成对医院产出效率的驱动效应。不是停留在取消药品加成引发的医院收入缺口的已有的表面研究,而是进入到驱动医院收入产出效率的深层次研究。结合反事实方法,利用路径收敛设计识别药品路径对于医院产出效率的驱动模式和传导机制。(3)模拟实现取消药品加成下的财政补偿和药事服务费补偿机制。这是全新的探索性研究。引入模拟设计来探索如何将由药品收入补偿主导的医院补偿机制向政府财政补偿和医疗服务收入补偿主导的补偿机制转化。
The Drug Addition Policy in China's medical service system has stimulated the development and operation efficiency of public hospitals. However, it gradually incurs the profit-driven behavior of hospitals and challenges the equity features of public hospitals. Policies have been put forward to call for abolishing Drug Addition Policy and improving hospital compensatory mechanism since 2000. And "The Guidance on Reform Experiment of Public Hospital" was officially issued to push the health care reform on February 2th 2010, of which the core is to increase governmental fiscal subsidies and to set pharmaceutical additional service fee for abolishing Drug Addition Policy so as to make public hospitals return to equity. Therefore, the research on identification of output efficiency, equity and the integration of efficiency and equity is of great practical significance.
However, existed researches on hospital efficiency and on governmental price regulation have failures in both contents and approaches. First, from the perspective of research contents, isolated researches on hospital efficiency and on governmental price regulation are presented rather than the exploration of hospital operation mechanism with integration of efficiency and equity. Second, from the perspective of research approaches, DEA model and SFA model with the objective functions to maximize output with given inputs or to minimize inputs with given outputs are mainly applied to assess the hospital output efficiency rather than the public welfare efficiency. As commonweal institution, public hospitals should pursue not only itself economic efficiency but also the equal social efficiency.
Different from existed researches, the thesis integrates the perspectives of efficiency and equity for the first time and determines its theme as the identification and simulation of output efficiency of public hospital based on the reform backgrounds of abolishing Drug Addition Policy and improving hospital output efficiency. Semi-parametric counterfactual approach, nonparametric path converged design, nonparametric environmental interaction model and simulation design approach are established besides classic DEA approach with application to provincial hospitals in Zhejiang province to explore how to achieve the public conversion from drug revenues to governmental fiscal subsidies and pharmaceutical additional service fee revenues, which aims to make theoretical contributions to current major issues in health care reform. Moreover, the thesis obtains following conclusions.
Identification. First, DEA approach is applied to identify output efficiency of 14 provincial hospitals in Zhejiang province in 2007. Integrating the variable profit levels, the identification classifies the 14 provincial hospitals into efficient class hospital (Group 1) and inefficient class hospital (Group2). Group 1 class hospitals include H1, H2, H4, H6, H7, H12 and H13. Group2 class hospitals include H3, H5, H8, H9, H10, H11 and H14.
Second, semi-parametric counterfactual kernel density distribution under Logistic model is established with application to identify the formation mechanism of the hospital drug balances. The identification illustrates the major change of drug balance distribution during 2004-2008 can be explained by the number change of outpatients and discharged inpatients rather than the number change of drug prescriptions, which provides the basis of setting pharmaceutical additional service fee with the abolishment of Drug Addition Policy.
Finally, nonparametric drug converged path model and environment interaction model are established to identify the driven factor and transmission mechanism of hospital output efficiency.1. The main driven factor of Group 1 hospitals is capital, which is consists of acquisition and maintain fee of fixed assets and special material fees. The main driven factor of Group2 hospitals is labor, which is consists of the number of outpatient and emergency visits and the number of discharged inpatients.2. The drug path majorly exerts its role on hospital output efficiency through labor in Group 1 hospitals while through capital in Group 2 hospitals. The difference of transmission mechanism in two groups indicates Drug Addition Policy crowds out the treatment volume of Group2 hospitals and crowds in the one of Group 1 hospitals and implies the public is more inclined to go to efficient hospitals for treatment.3. The environmental factors such as governmental fiscal subsidies might shift the transmission mechanism in different hospitals.
Simulation. First, simulate the operation strategies of inefficient hospitals with DEA identification for the next period. Different from previous DEA models that pursue maximum outputs with given inputs, minimum inputs with given outputs or both decrease in inputs and increase in outputs for efficiency promotion, the thesis designs a feasible strategy with simultaneously increasing inputs and outputs for promoting inefficient hospitals to efficient ones. The simulation on Group2 hospitals through determining the theoretical added value, searching the ideal output with given inputs, and determining ideal inputs and ideal outputs for inefficient hospitals confirms the simulation program can enhance hospital efficiencies of Group2 hospitals under the premise of ensuring the efficiencies of other hospitals do not deteriorate, which can provide strong decision support for the inefficient DMU during next period.
Second, simulate on how to fill the output gap with abolishment of Drug Addition Policies with application of new established path environmental model from the perspective of production efficiency. Different from previous researches on keep total output Y unchanged, the thesis focuses on keeping the driven roles of factor K and L under drug path unchanged, and furthermore determines which factor (K or L) can be applied to compensate the output gap with abolishment of Drug Addition Policies based on transmission mechanism. Empirically, simulations on increasing governmental fiscal subsidies to compensate the output gap with abolishment of Drug Addition Policy are carried out for hospital H2 and H8 through enhancing the transmission mechanism of capital and labor respectively; and simulation on simultaneously setting pharmaceutical additional service fee and increasing governmental fiscal subsidies to compensate the output gap with abolishment of Drug Addition Policy is carried out for hospital H4 through enhancing the transmission mechanism of capital. The simulations indicate that different policies on increasing governmental fiscal subsidies and setting pharmaceutical additional service fee should be put forward for different hospitals in reform experiment of public hospitals.
The thesis contains three innovations. First, it creatively integrates the efficiency and equity under the framework of nonparametric path converged design. Different from existed isolated researches, the thesis realizes the exploration on involved resource allocation issues in medical care reform such as the abolishment of Drug Addition Policy, the increase in governmental fiscal subsidies and the set of pharmaceutical additional service fee through establishing a benchmark model that reflects equity, path model that reflects efficiency, and path converged design that integrates efficiency and equity. Second, the thesis identifies driven effect of Drug Addition Policy on hospital output efficiency. Different from the superficial study on the output gap due to the abolishment of Drug Addition Policy, the thesis explores the driven mode and transmission mechanism of Drug Addition Policy on hospital output efficiency with application of semi-parametric counterfactual approach and path converged design approach. Third, the thesis presents a brand-new exploratory simulation with design on realization of public conversion from drug revenues to governmental fiscal subsidies and pharmaceutical additional service fee revenues.
然而,已有关于医院效率和医院公益规制的研究无论是在内容,还是在方法上都存在缺陷。从研究内容上看,都从医院产出效率和医院公益规制两个单独的视角来研究,缺乏从效率与公益联合的视角来研究医院的运行机制。第二、从研究方法上看,以投入最小或产出最大化为目标函数的DEA模型和随机前沿的SFA模型主要用来评估医院的产出效率,并不能用来评价医院的公益性。公立医院产出最大化不仅追求医院本身的运行效率,而更重要的是追求的社会的公益效率。
本论文首次融合公益和效率视角,基于取消药品加成政策以减少病人负担和提高医院产出效率的改革背景,将公立医院产出效率的识别与模拟确定为研究主题,利用除经典的DEA模型外的半参数反事实方法、非参数路径收敛设计、非参数环境联动模型和模拟设计研究方法以浙江省省级医院为例从产出效率的视角对如何实现医院收入从药品收入补偿到财政收入补偿和医疗服务收入补偿的公益性转化问题展开探索,以期对当前亟待解决的医疗改革重大问题做出理论贡献。以下为本论文得到的主要结论。
第一、效率识别。首先,应用DEA方法2007年浙江省各省级医院产出效率进行识别,结合各医院迥异的盈利水平,DEA识别将14家省级医院分为高效率类医院(Group1)和低效率类医院(Group2)。Group 1包括医院：H1, H2, H4, H6, H7, H12, H13。Group2包括医院：H3, H5, H8, H9, H10, H11, H14。
其次,构建Logistic模型假设下的半参数反事实核密度分布,搜索影响药品结余的主要影响因素,剖析药品结余形成的主要机理。发现解释药品结余分布在2004-2008期间的变动主要要素是门急诊人次数和出院人天数,而不是药品处方数。这为取消药品加成政策时可以按照就诊量来增设药事物服务费提供了理论依据。
最后,构建非参数药品路径收敛模型和环境联动模型对医院产出效率的驱动要素和传导机制进行识别。发现：1.高效率的Group1类医院的产出主要驱动要素是固定资产维修购置费以及专用材料费构成的资本要素,而低效率的Group2医院的产出主要驱动要素是门急诊人次和住院人数构成的劳动力要素。2.药品路径对Group1类医院产出变化主要是通过门急诊人次和住院人数构成的劳动力来传导,而对Group2类医院产出变化主要是通过医院固定资产维护费和专用材料费的资本投入来传导。两类医院传导机制的不同蕴含着药品加成政策使较低效率医院(Group2类医院)的就诊量出现挤出效应,而较高效率医院(Group 1类医院)出现挤入效应,这与公众更倾向于到效率较高医院就诊现象相吻合。3.政府财政补偿等环境因素会使不同医院的传导机制发生转变。
第二、模拟研究。首先,根据DEA识别结果对低效率医院的下一期运营策略展开模拟。不同于已有的DEA模型,要么在投入不变下,增加产出,要么在产出不变下,减少投入,或者同时减少投入和增加产出使得医院从无效率到有效率。本研究设计了一种可实现的同时增加投入增加产出的将低效率医院向高效率医院转变的管理策略。通过确定理论增加值、搜索理论投入不变情形下的产出理想值和确定低效率医院的理想投入产出值三个步骤对Group2类医院展开模拟研究证实了该模拟方案可以在保证其他医院效率不恶化的前提下,提升Group2类医院效率。
其次,基于药品路径模型和环境联动模型的产出效率识别结果,构建路径-环境模型对如何弥补不同医院因取消药品加成而引起的产出缺口展开模拟研究。与已有研究中简单的填补总收入Y不变视角不同,本研究的模拟探索将目标放在假设取消药品加成策略实施时保持药品路径下要素K与L驱动产出作用上,并根据路径传导机制来确定需要从哪种要素(资本要素K还是劳动力要素L)的视角来实现补偿由于药品加成取消产生的Y缺少份额。模拟发现医院H2需要以增强资本要素的传导方式和医院H8需要以增强劳动力要素的传导方式来实现有效率产出,为此目的,可以利用增加政府财政补偿的方式来实现；医院H4需要以增强资本要素传导方式来展开同时增加财政补偿和增设药事服务费以弥补取消药品加成政策的产出缺口的模拟研究。模拟研究表明,对于各具体医院要有不同的财政补偿和增设药事服务费政策来实现弥补其产出缺口。
本文的主要创新是：(1)探索性地把效率与公益整合在非参数路径收敛研究框架。与已有的研究不同,不是分别孤立地去研究医院的产出效率和公益性规制政策,而是通过设计体现公益性的基准模型,体现效率的路径模型和将公益与效率相统一的收敛设计,来完成对医疗改革中涉及的取消药品加成、增设药品服务费、增加政府财政补偿等卫生资源配置效率问题的探索性研究。(2)探索性地识别药品加成对医院产出效率的驱动效应。不是停留在取消药品加成引发的医院收入缺口的已有的表面研究,而是进入到驱动医院收入产出效率的深层次研究。结合反事实方法,利用路径收敛设计识别药品路径对于医院产出效率的驱动模式和传导机制。(3)模拟实现取消药品加成下的财政补偿和药事服务费补偿机制。这是全新的探索性研究。引入模拟设计来探索如何将由药品收入补偿主导的医院补偿机制向政府财政补偿和医疗服务收入补偿主导的补偿机制转化。
The Drug Addition Policy in China's medical service system has stimulated the development and operation efficiency of public hospitals. However, it gradually incurs the profit-driven behavior of hospitals and challenges the equity features of public hospitals. Policies have been put forward to call for abolishing Drug Addition Policy and improving hospital compensatory mechanism since 2000. And "The Guidance on Reform Experiment of Public Hospital" was officially issued to push the health care reform on February 2th 2010, of which the core is to increase governmental fiscal subsidies and to set pharmaceutical additional service fee for abolishing Drug Addition Policy so as to make public hospitals return to equity. Therefore, the research on identification of output efficiency, equity and the integration of efficiency and equity is of great practical significance.
However, existed researches on hospital efficiency and on governmental price regulation have failures in both contents and approaches. First, from the perspective of research contents, isolated researches on hospital efficiency and on governmental price regulation are presented rather than the exploration of hospital operation mechanism with integration of efficiency and equity. Second, from the perspective of research approaches, DEA model and SFA model with the objective functions to maximize output with given inputs or to minimize inputs with given outputs are mainly applied to assess the hospital output efficiency rather than the public welfare efficiency. As commonweal institution, public hospitals should pursue not only itself economic efficiency but also the equal social efficiency.
Different from existed researches, the thesis integrates the perspectives of efficiency and equity for the first time and determines its theme as the identification and simulation of output efficiency of public hospital based on the reform backgrounds of abolishing Drug Addition Policy and improving hospital output efficiency. Semi-parametric counterfactual approach, nonparametric path converged design, nonparametric environmental interaction model and simulation design approach are established besides classic DEA approach with application to provincial hospitals in Zhejiang province to explore how to achieve the public conversion from drug revenues to governmental fiscal subsidies and pharmaceutical additional service fee revenues, which aims to make theoretical contributions to current major issues in health care reform. Moreover, the thesis obtains following conclusions.
Identification. First, DEA approach is applied to identify output efficiency of 14 provincial hospitals in Zhejiang province in 2007. Integrating the variable profit levels, the identification classifies the 14 provincial hospitals into efficient class hospital (Group 1) and inefficient class hospital (Group2). Group 1 class hospitals include H1, H2, H4, H6, H7, H12 and H13. Group2 class hospitals include H3, H5, H8, H9, H10, H11 and H14.
Second, semi-parametric counterfactual kernel density distribution under Logistic model is established with application to identify the formation mechanism of the hospital drug balances. The identification illustrates the major change of drug balance distribution during 2004-2008 can be explained by the number change of outpatients and discharged inpatients rather than the number change of drug prescriptions, which provides the basis of setting pharmaceutical additional service fee with the abolishment of Drug Addition Policy.
Finally, nonparametric drug converged path model and environment interaction model are established to identify the driven factor and transmission mechanism of hospital output efficiency.1. The main driven factor of Group 1 hospitals is capital, which is consists of acquisition and maintain fee of fixed assets and special material fees. The main driven factor of Group2 hospitals is labor, which is consists of the number of outpatient and emergency visits and the number of discharged inpatients.2. The drug path majorly exerts its role on hospital output efficiency through labor in Group 1 hospitals while through capital in Group 2 hospitals. The difference of transmission mechanism in two groups indicates Drug Addition Policy crowds out the treatment volume of Group2 hospitals and crowds in the one of Group 1 hospitals and implies the public is more inclined to go to efficient hospitals for treatment.3. The environmental factors such as governmental fiscal subsidies might shift the transmission mechanism in different hospitals.
Simulation. First, simulate the operation strategies of inefficient hospitals with DEA identification for the next period. Different from previous DEA models that pursue maximum outputs with given inputs, minimum inputs with given outputs or both decrease in inputs and increase in outputs for efficiency promotion, the thesis designs a feasible strategy with simultaneously increasing inputs and outputs for promoting inefficient hospitals to efficient ones. The simulation on Group2 hospitals through determining the theoretical added value, searching the ideal output with given inputs, and determining ideal inputs and ideal outputs for inefficient hospitals confirms the simulation program can enhance hospital efficiencies of Group2 hospitals under the premise of ensuring the efficiencies of other hospitals do not deteriorate, which can provide strong decision support for the inefficient DMU during next period.
Second, simulate on how to fill the output gap with abolishment of Drug Addition Policies with application of new established path environmental model from the perspective of production efficiency. Different from previous researches on keep total output Y unchanged, the thesis focuses on keeping the driven roles of factor K and L under drug path unchanged, and furthermore determines which factor (K or L) can be applied to compensate the output gap with abolishment of Drug Addition Policies based on transmission mechanism. Empirically, simulations on increasing governmental fiscal subsidies to compensate the output gap with abolishment of Drug Addition Policy are carried out for hospital H2 and H8 through enhancing the transmission mechanism of capital and labor respectively; and simulation on simultaneously setting pharmaceutical additional service fee and increasing governmental fiscal subsidies to compensate the output gap with abolishment of Drug Addition Policy is carried out for hospital H4 through enhancing the transmission mechanism of capital. The simulations indicate that different policies on increasing governmental fiscal subsidies and setting pharmaceutical additional service fee should be put forward for different hospitals in reform experiment of public hospitals.
The thesis contains three innovations. First, it creatively integrates the efficiency and equity under the framework of nonparametric path converged design. Different from existed isolated researches, the thesis realizes the exploration on involved resource allocation issues in medical care reform such as the abolishment of Drug Addition Policy, the increase in governmental fiscal subsidies and the set of pharmaceutical additional service fee through establishing a benchmark model that reflects equity, path model that reflects efficiency, and path converged design that integrates efficiency and equity. Second, the thesis identifies driven effect of Drug Addition Policy on hospital output efficiency. Different from the superficial study on the output gap due to the abolishment of Drug Addition Policy, the thesis explores the driven mode and transmission mechanism of Drug Addition Policy on hospital output efficiency with application of semi-parametric counterfactual approach and path converged design approach. Third, the thesis presents a brand-new exploratory simulation with design on realization of public conversion from drug revenues to governmental fiscal subsidies and pharmaceutical additional service fee revenues.
引文
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