我国公立医院效率及其影响因素研究
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摘要
研究背景
目前我国96%的医院是公立医院,集中了最优质的医疗卫生资源,公立医院改革也通常被认为是医改中“最难啃的骨头”和“重中之重”。因此,公立医院的改革与中国亿万老百姓的生活密切相关,一举一动都受到万众的瞩目。
随着我国经济体制改革的进一步深入,医院逐步由社会公益性事业单位成长为自主经营、自负盈亏和具有独立法人地位的经济实体。在当今社会化大生产利润平均化、市场相对稳定和产品价格上调空间相对狭小的大环境下,如何既兼顾医院的社会公益性又提高医院的整体效率；在公立医院的管理中,既提高医院的社会效益,又提高医院的经济效益,成为医院亟需解决的问题。作为公立医院,提高医院效率是承担社会责任与发展医院自身经济的必然途径。医院效率要综合考虑社会效益和经济效益。在对医院效率进行管理的过程中,应以患者利益为中心,在提高医疗服务质量和医疗效果的前提下,降低医疗费用,产生良好的社会效益,提高医院的社会美誉度与社会影响力,由此吸引患者前来就医,增加医疗业务量和服务量,并努力降低医院的经营成本,提高收支结余,以这样的方式提高医院的经济效益。社会效益对经济效益有良好的正作用,同时良好的经济效益可以发展更多的优质卫生资源,更好地满足人民群众日益增加的医疗需求,也对社会效益产生正作用。
要提高医院的效率,就要解决如何对医院效率进行科学、准确地评价问题。医院效率主要包括“技术效率”、“规模效率”和“配置效率”三个方面。
只有对医院的技术有效性、规模有效性和资源配置有效性进行准确判断,并对效率低下的程度、环节和原因进行定量分析,才能为医院管理者改进医院效率提供客观依据和参考。
由于医疗卫生服务的提供具有较强的技术性、专业性和信息不对称性,因而具有复杂性的特点,因此对医院效率的评价很难用单一的指标来衡量。目前,常用的医院效率评价方法主要有四种,即比率分析法、回归分析法、数据包络分析法和随机前沿分析法。由于医疗卫生服务产业具有多投入和多产出的特点,传统的比率分析法如成本收益法、成本效果法和成本效用分析在评价医院效率方面显得并不是很适用。而非参数分析法中的数据包络分析法(DEA)在评价具有较复杂投入产出关系的组织经营效率方面应用非常广泛,如学校、医院、银行及公共部门等。DEA不仅可以确定各医院的技术效率值和规模效率值,而且能对低效率医院在投入和产出方面存在的问题进行定量分析,这将为医院管理者改进医院效率提供决策依据。
另外,本文还从成本的角度对医院的效率进行了分析,采用山东大学卫生管理与政策研究中心(卫生部卫生经济研究所成本测算中心)2008年研究的成本测算方法,结合所选取医院提供的2008年数据计算其总成本、科室成本、部分医疗服务项目成本、不同级别不同地域医院的诊次和床日成本及其构成,有利于医院控制总成本、科室成本、医疗服务项目成本,提高效率,为医院经济管理提供依据和参考。为了了解医疗服务项目成本与收费标准之间的差异情况,选取120种具有代表性的医疗服务项目,计算其成本并与价格进行比较,为政府合理补偿公立医院提供科学的依据。
通过对医院效率的测算,能够得到哪些医院的效率是高的,哪些医院效率是低的。而影响医院效率的因素有很多,比如医院级别、医院所在区域、医院职工人数、医疗人员与行政后勤人员的比例、医疗设备值、房屋建筑物、固定资产总值、门诊人次、门诊人均费用、床日成本、出院病人平均医药费用、医疗收入、药品收入等等,到底哪些因素能够影响医院的效率,它们对医院效率会产生积极影响还是负面影响,需要我们做进一步的研究,从而找出能够显著影响医院效率的因素,对这些因素进行有针对性的改进,以提高医院效率。
研究目的
本研究的总目标是：分析我国公立医院效率及其影响因素,为改善医院绩效提供依据。
(1)构建公立医院效率评价理论和方法学模型；
(2)测量我国公立医院效率；
(3)分析医院效率影响因素；
(4)比较医疗服务项目成本与价格差异；
(5)提出医院改善资源配置效率的建议。
研究方法
本文的资料来源于参加全国医疗机构成本监测工作的57家医院的2008年数据。本次成本监测工作是受卫生部规划财务司的委托,在全国按东、中、西部经济区域划分标准,选择12个省、直辖市和自治区作为全国医疗机构成本监测点,其中东部地区4个省,中部4个省,西部4个省。在每个省份,分别选择2家省级医院,3家市级医院和3家县级医院,共计96所医院进行成本监测,其中省级医院24所,市、县级医院各36所,具有相当的代表性与可比意义。从2009年5月份开始第一轮的成本监测工作,截止到2010年2月份,全国共有57家医院提供了完整的成本测算数据,总体参加率为59%,其中东、中、西部参加率分别为66%、56%和56%；省、市、县级医院参加率分别为58%、58%和61%。
本文用描述性方法描述样本医院的基本信息,主要包括医院的人员情况,不同地域不同级别医院的在职职工人数、行政后勤部门以及医疗部门人数的比重；从医院的固定资产总值、医疗设备值以及房屋建筑物三个方面分别描述不同级别不同地域医院的规模情况；从门诊服务量、住院服务量和人均服务量三个方面描述医院的服务量情况；从医院收入、医院支出和患者支出等角度分析不同级别不同地域医院的经营情况。在分析数据的过程中,对同一地区同一级别医院的数据进行归纳、整理和比较,分别选取各分析指标在同级别同地区不同医院中的最大值和最小值,并计算这些医院的平均值,通过对样本医院的这种描述性分析可以清楚地了解各指标数据在同地区同级别医院中的波动情况,以及不同地区或者不同级别医院间的差距。
在调查数据的基础上,利用山东大学卫生管理与政策研究中心(卫生部卫生经济研究所成本测算中心)研制的“医院医疗服务成本测算办法”,即采用阶梯分摊法自顶向下将医院医疗总成本分摊到各医疗服务项目,整个分摊过程分为三个步骤：第一,将医院医疗服务总成本分摊到各个医疗服务科室(包括间接成本科室和直接成本科室)；第二,将间接成本科室的成本分摊到直接成本科室；第三,将直接成本科室的成本分摊到各个医疗服务项目,按此三个步骤计算不同地区、不同级别医院的总成本、医疗成本、药品成本、医疗成本占总成本的比例、医疗成本中各项成本的组成比例、总支出与总收入的比率、医疗支出与医疗收入的比率、科室成本、部分代表性服务项目成本、诊次费用与诊次成本、医疗服务项目成本与收费标准的比例等。
用DEA方法研究样本医院的效率时,我们选用的DEA模型具有以下特点：
(1)DEA距离函数类型为径向模型(Radial)中的CCR模型；
(2)DEA效率测量的方向(Orientation):投入导向；
(3)DEA的效率计算是基于可变规模报酬(VRS),然后再分析其规模效率。
经过相关分析、变异系数分析、聚类分析三种指标筛选方法的筛选,结合评价指标应完整地反映医院的规模、效率、效益、质量等方面的导向性需求,最终确定应用于DEA分析的4个输入指标与4个输出指标分别为：投入指标四项(职工总人数、实际开放病床数、固定资产总额、医疗总支出)；产出指标四项(门诊人次数、急诊人次数、出院人次数、业务总收入)。
在分析影响医院效率的因素时,我们采用TOBIT回归方法分析医院效率的影响因素。因变量为医院的DEA效率得分,自变量包括影响医院效率的外部因素(财政补助比例、医院级别和医院所在区域)和内部因素(职工总人数、医护人员与行政后勤人员的比例、实际开放病床数、病床使用率、门诊住院比例、固定资产总额、仪器设备总值、仪器设备值占固定资产总值的比例、医疗总支出、门诊人次数、急诊人次数、出院人次数、医疗总收入、手术病人数、出院者平均住院天数、住院总床日数、病床使用率、每门诊人次收费水平、每床日平均收费水平、每床日平均药品费、出院病人平均医药费用、管理费用、药品收入占业务收入的百分比、急诊人次等)。
研究结果
一、成本测算结果
1.在参加成本监测的57家医院中,省级、市级和县级医院的平均总成本分别为6.6亿、3.6亿和1.3亿元。东部省、市、县级医院的总成本明显高于中部和西部同级医院,但中、西部医院总成本差别不大。
2.医疗成本构成中,劳务成本所占比例最大,在省、市、县级医院分别为40%、45%和48%。其次为材料成本,省、市、县级医院比例分别为32%、27%和25%,材料成本比例以省级医院最高。
3.57家监测医院中,省、市、县三级医院的平均诊次成本分别为169元、158元和117元。东部地区医院的诊次成本都要高于中部和西部地区相应级别医院的诊次成本。但中、西部医院的诊次成本差别不大。目前,各级医院在提供一个诊次的医疗服务时,药品成本占50%以上的比例,而在医疗成本中,大部分的成本来自于化验和检查服务。也就是说目前所有级别的医院提供的诊次服务中,主要是以提供药品,检查和化验服务为主。
4.57家监测医院中,省、市、县三级医院的平均床日成本分别为978元、677元和481元。东部地区各级别医院的平均床日成本要明显高于中西部地区同级别医院的平均床日成本。各级医院在提供一个床日的医疗服务时,药品成本仅占40%以上的比例,其余成本则来自医疗成本,但需要注意的是,在医疗成本中,来自间接医疗辅助科室的成本占有一定比例,这一成本构成分析结果为医院控制成本提供了科学依据。
5.无论医院级别和医院的地域分布,总体来讲,57家医院收支略有盈余,大部分的医院的医院成本高于医疗收入。同级别医院中,东部地区的医疗成本均高于医疗收入。只有中部的县级医院和西部的省级县级医院医疗成本低于医疗收入。
二、DEA效率分析的结果
在总共57家医院中,DEA有效的单元有21家,占全部医院的37%,其中省级医院6家,市级医院3家,县级医院12家。省级医院共17家,有效率为35.3%；市级医院共18家,有效率为16.7%；县级医院共22家,有效率为54.5%。而东部地区21家医院中总体有效的有7家,有效率为33.3%；中部地区18家医院中总体有效的有5家,有效率为27.8%；西部地区18家医院中总体有效的有9家,有效率为50%。可见按地域来看,西部地区医院的有效率最高；而按照级别来看,县级医院的有效率最高。
东部地区21家医院中总体有效的有7家,其中,省级医院4家,市级医院2家,县级医院1家。而东部21家医院中省级医院8家,市级医院6家,县级医院7家,东部地区省级医院有效率为50%,市级医院有效率为33.3%,县级医院有效率为14.3%。
中部地区18家医院中总体有效的有5家,其中省级医院1家,市级医院1家,县级医院3家。中部18家医院中省级医院4家,市级医院8家,县级医院6家,可见,在中部地区,县级医院的有效率最高,达到了60%,市级医院的有效率为12.5%,省级医院的有效率为25%。
西部地区18家医院中总体有效的有9家,其中省级医院1家,市级医院0家,县级医院8家。18家医院中省级医院5家,市级医院4家,县级医院9家。可见,在西部地区,省级医院的有效率为20%,市级医院的有效率为0%,县级医院的总体有效率占到了88.9%。
非DEA有效得分的单元有36家,占全部医院的63%。总的来讲,在此次调查中,按地域来看,西部地区医院的有效率最高,特别是四川和云南两省的被调查医院效率都很高,比1997年的相对效率值有了明显地提高,东南沿海地区医院的总体效率偏高于中部地区的医院；而按照级别来看,县级医院的有效率最高。
三、用Tobit回归分析医院效率影响因素的结果
用Tobit回归分析方法对影响效率的因素进行分析,结果显示：
1.显著影响医院效率的因素包括：医院级别、门诊人均费用、床日成本、出院者人均医药费用、病床使用率、固定资产总额；而医护人员与行政后勤人员的比例对医院效率没有显著性影响。其中,医院级别、门诊人均费用、出院者人均医药费用、固定资产总额与医院效率负相关,这几个因素的增加会显著降低医院效率；病床使用率、床日成本对医院效率有积极影响,这两个因素的增长会显著增加医院效率。
2.分地区来看,同地区医院效率既有相同的影响因素,也有各地区独有的影响因素。床日成本、出院者人均医药费用对东中西部地区医院效率的影响是一致的,然而门诊人均费用的影响对东中西部地区医院效率都不显著了；病床使用率仅对东部地区医院效率产生显著影响,对中西部地区医院效率没有显著影响；固定资产总额仅对西部地区医院效率产生显著影响；医护人员与行政后勤人员的比例仅对西部医院效率有显著影响,结果在10%显著性水平上有意义。
3.分级别来看,床口成本、固定资产总额对各个级别医院效率均产生显著影响,且床日成本与医院效率均正相关,固定资产总额与医院效率均为负相关；门诊人均费用只对省级和市级医院效率产生显著影响；出院者人均医药费用只对省级和县级医院效率产生显著影响,且都与医院效率负相关：病床使用率对市级和县级医院有显著影响,但影响的效果又截然不同,病床使用率与市级医院的效率负相关,而与县级医院的效率正相关；医护人员与行政后勤人员的比例仅对县级医院效率有显著影响。
四、医疗服务项目成本与价格比较的结果
1.120种医疗服务项目中,(去除极值后的结果)项目成本大于收费标准的项目数量比例在省、市和县级医院分别为92%、97%和99%。在扣除财政拨款和固定资产折旧后,在省、市和县级医院项目成本大于收费标准的项目数量比例仍然有84%、86%和82%。这一结果表明在120种监测的医疗服务项目中,绝大部分服务项日的收费标准要低于成本。医疗服务收费标准与项目平均成本有较大差距,因而医疗服务收费不能弥补医疗服务消耗的成本。
2.在省级医院,项目成本大于收费标准的倍数在1倍(普通视力检查)-6倍(急诊诊查费)之间。市级医院项目成本与收费标准间的倍数变化较大,比值在1倍(生长激素释放激素兴奋试验)-21倍(急诊诊查费)之间,而这一比值在县级医院则在1倍(B超常规检查)-15倍(红外线治疗)之间；并且反映医务人员技术和劳务价值的医疗服务项目,如急诊诊查、护理、床位、换药、挂号等,项目成本均大于目前的收费标准。但是,不论医院级别,成本小于收费标准的医院服务项目多是利用大型设备开展的检查类服务项目和利用高新技术开展的治疗类服务项目,如彩色多普勒超声常规检查、伽玛刀治疗、准分子激光屈光性角膜矫正术等。
结论与建议
1.通过对本次成本监测的57家医院的DEA效率分析,我们发现需要着重加强东部沿海地区县级医院的资源管理和建设,中部地区和西部地区需要着重加强市级医院的管理和资源投入；逐步推进县级医院综合改革。
2.医院级别、门诊人均费用、出院者人均医药费用、固定资产总额与医院效率负相关,这几个因素的增加会显著降低医院效率；病床使用率、床日成本对医院效率有积极影响,这两个因素增加也会显著增加医院效率。所以,为了提高医院的效率,应当着重降低门诊人均费用、出院者人均医药费用,减少固定资产投资的力度,提高病床使用率、床日成本。
3.在120种监测的医疗服务项目中,90%以上的医疗服务项目的收费标准要低于成本。反映医务人员技术和劳务价值的医疗服务项目,项目成本均大于目前的收费标准。但是无论医院级别,成本小于收费标准的医院服务项目多是利用大型设备开展的检查类服务项目和利用高新技术开展的治疗类服务项目。
4.在57家监测医院的诊次成本中,省级医院的平均诊次成本要明显高于市、县级医院,诊次成本中药品成本均占有较大的比例,而医疗成本中,化验和检查服务则占有较大的比例,这说明,目前在各级医院提供的诊次服务中,主要以提供药品、检查和化验为主。
5.在对各级医院的床日成本进行分析发现,省级医院的床日成本要高于市、县级医院,按地域划分的话,东部地区医院的平均床日成本要远远高于中西部地区同级别医院的平均床日成本。在床日成本构成中,直接医疗成本所占的比例最高,药品成本所占比例相对要少一些。值得注意的是,在医疗成本中,来自间接医疗辅助科室的成本占有一定的比例。
6.此次成本监测医院总体参与率仅60%,造成低参与率的主要原因是部分医院还不熟悉此次成本监测要求的网上数据采集系统。并且在成本分析过程中发现部分成本数据有异常值,可能的原因在于医院相关成本信息填报数据不准确,这是在下一步成本监测工作中需要完善的方面。
Background
At present,96%of hospitals in our country are public hospitals, which concentrate the most high quality medical and health resources, the reform of public hospitals is also considered as "the hardest bones to chew " and "top priority" in the reform. Therefore, the reform of public hospitals is closely related to the life of the people, every move attracts peoples'attention.
As further reform of China's economic system, the hospitals have gradually grown into the economic entities which operate independently and are responsible for their own profits and losses and have an independent legal status from the social public welfare enterprises. In the present environment of profit of socialized production being average, market being relatively stability and the rising space of product price being narrow, how to give attention to the social and public welfare undertakings of the hospital and improve the efficiency of the hospital; In the management of the public hospital, how to not only improve the social benefits of the hospital, but improve the economic benefits of the hospital, become the urgent matter of the hospital. As the public hospital, improving the efficiency of the hospital is an inevitable way to take social responsibility and develop its own economy. Efficiency of hospitals should comprehensively consider the social benefits and economic benefits. In the process of management of the hospital efficiency, we should regard patients'benefits as the center, in the premise of improving medical effect, reduce the medical cost, produce good social benefits and improve the social reputation and influence of the hospital, which attract patients to go to the hospital, increase the volume of medical business, and strive to reduce operating costs, improve the surplus balance of payments to improve the economic benefit of hospital in such a way. Social benefits obviously have a positive effect to economic benefits, at the same time good economic benefits can develop more health resources with high quality, meet people's increasing needs of medical treatment better, and also have a positive effect to social benefits.
To improve the efficiency of the hospital, we should solve the problem of how to scientifically and accurately evaluate efficiency of the hospital. Hospital efficiency mainly include "technology efficiency","scale efficiency" and "allocation efficiency".
Only the accurate judgment for the technology efficiency, scale efficiency and allocation efficiency of the hospital and the quantitative analysis to the degree, links and reasons of low efficiency, can we provide objective basis to improve the efficiency of hospital for hospital administrators.
Because the provision of medical and healthy service is strongly professional, technical and has strong information asymmetry, thus it is complex, so the evaluation on hospital efficiency is difficult to use a single index to measure. At present, the method commonly used to evaluate hospital efficiency mainly includes four kinds, namely ratio analysis, regression analysis, the data envelopment analysis and stochastic frontier analysis. Due to the healthy industry has the character that it has many inputs and outputs, the traditional ratio analysis method such as cost-benefit method, cost effective method and cost effectiveness analysis in the evaluation of hospital efficiency is not applicable. The data envelopment analysis (DEA) of the parameter analysis methods is widely used to evaluate the operation efficiency of organizations with complicated input-output relation, such as schools, hospitals, banks and public departments and so on.DEA can not only determine the technical efficiency value and scale efficiency value of hospitals, but are able to quantitatively analyze the existing problem in the input and output aspects of the hospitals with low efficiency, so it will provide decision basis for the hospital administrators to improve the efficiency of the hospital.
In addition, this paper also analyzes the hospital efficiency from a cost perspective, uses the cost estimation methods researched by the Calculating Center of the Health Economic Institute of the Health Ministry in2008, and calculates its department cost, part of the medical service item cost and the times of diagnosis and bed days cost and its composition of the hospitals of different levels and different region combined with the data in2008provided by the selected hospitals. Analyze and compare the differences between the cost of medical service and the price and provide scientific basis for the government to compensate public hospitals reasonably, which contributes to controlling the total cost, the department cost and the medical service item cost of hospitals, improving efficiency and providing the basis for the economic management of hospitals.
Based on the calculation of the efficiency of the hospital, we can get which hospital efficiency is high, which hospital efficiency is low. And there are many factors influence hospitals, such as hospital level, hospital area, the number of hospital staff, medical personnel and administrative personnel's scale, medical equipment value, housing building, fixed assets value, outpatient clinic visits, per capita expenses, bed day cost, discharged patients average medical expenses, medical income, drug income, etc., exactly what factors can influence the efficiency of the hospital, they will have a positive impact or negative effects?We need to do further research, so as to find out factors that have significant influence on hospital efficiency, improve these factors targeted, in order to improve the efficiency of the hospital.
Objectives
The overall goal of this research is to analyze the efficiency of the hospitals and to analyze the influenced factors of the efficiency of the hospitals, to put forward policy suggestions for hospitals to improve its efficiency.
(1) establishing evaluation theory and methodology model of the efficiency of the public hospital;
(2) analyzing the efficiency of the public hospital in our country;
(3) analyzing the affecting factors of the efficiency of hospitals
(4) analyzing and comparing the differences between the cost of medical service and the price;
(5) putting forward suggestions to improve the allocated efficiency of the hospital resource for hospitals.
Methods
The material of this paper comes from the data of57hospitals attending cost monitoring work of the national medical institution in2008. This cost monitoring work is entrusted by the Department of Planning and Finance of the Health Ministry, according to the division standard of the eastern, middle and western economic zone in the nation, and selects12provinces, municipalities and autonomous regions as the cost monitoring point of the national medical institutions, of which4provinces come from the eastern region,4provinces come from the middle,4provinces come from the western region. In each province, we respectively choose two provincial hospitals, three municipal hospitals and three county level hospitals, giving a total of96hospitals to monitor cost. There are24provincial hospitals,36municipal hospitals and36county level hospitals, which has considerable representativeness and comparable significance. We began the first round of cost monitoring work from May2009, and there were57hospitals across the country provide a complete set of cost calculating data by February2010, the overall participating rate is59%, the participating rate of the east, the middle and the west are respectively66%,56%and56%. The participation rate of provincial, municipal and county level hospitals are respectively58%,58%and61%.
This paper describes the basic information of the sample hospitals by using descriptive method, including the number of employees, total revenue and total expenditure, medical income and medical expenditure,medicine income and medicine expenditure, total value of fixed assets, total value of equipments; the average number of discharged patients, the average hospitalization days,and the average hospitalization expenses of hospitals of different regions and different levels and so on. On the analysis of the data in the process, to the same area and the same level hospital data induction, sorting and comparison, the analysis indicators were selected in the same level with different regions in the hospital, the maximum and the minimum value is calculated, and the average of the hospital, through the sample hospital this descriptive analysis can clearly understand each index data in the same region in the hospital with level fluctuations, and the gap between different level or different regions hospitals.
On the basis of surveyed data, we use the "hospital medical service cost calculating method" developed by the Health management and Policy Research Center of Shandong University(the Cost Calculating Center of the Health Economic Institute of the Health Ministry), that is apportioning the total cost of hospitals to the medical service items by using the apportionment method from top to down, the apportioning process is divided into three steps:first, apportioning the total cost of hospital medical service to all medical service departments (including indirect cost departments and direct cost departments); second, apportioning the cost of indirect cost departments to cost of direct cost departments; third, apportioning the cost of direct cost departments to all medical service items. According to the three steps to calculate the total cost, medical cost, drug cost, the proportion of medical cost in the total cost, the cost composition ratio of medical cost, the ratio of total expenditure and total income,the ratio of medical expenditure and medical income, department cost, some representative service item cost, diagnosis times expenses and cost and medical service item cost and the proportion of charging standard and so on.
When we empirically study the efficiency of sample hospitals, DEA model we used has the following characteristics:
(1) DEA distance function type is CCR model in the radial model (Radial);
(2) DEA efficiency measuring direction (Orientation):investment guide;
(3) Efficiency calculation of DEA is based on the variable returns to scale (VRS), and then analyze the scale efficiency.
By screening of three kinds of index screening methods which is correlation analysis, coefficient of variation analysis and cluster analysis combining with the demand that evaluation indicators should integrally reflect the quality oriented demand of the hospital scale, efficiency, effectiveness and other aspects, we ultimately determine4input indexes and4output indexes applied to the analysis of DEA,which respectively are four input indexes(the total number of employees, the actual number of beds opened, the total value of fixed assets and total medical expenditure); four output indexes (the number of outpatients, the number of emergency visits, the number of people leaving hospital and total business revenue).
In the analysis of the influencing factors of the hospital efficiency, we use the TOBIT regression analysis.The dependent variable is scores of hospitals'DEA efficiency, and independent variables include financial subsidy ratio, the total number of employees, staff and administrative staff ratio, actual number of beds opened, beds occupancy, outpatient hospitalization ratio, total value of fixed assets, total value of instruments and equipments, the proportion of the value of instruments and equipments in the total value of fixed assets, medical expenditure, the number of outpatients, the number of emergency, the number of leaving hospital, total medical revenue, the number of patients in hospital operation, the average length of stay hospital, total bed days in hospital, utilization rate of hospital beds, charge level of each outpatient visit, average charge level per day of each bed, average drug charges per day of each bed, average medical charges of patients leaving hospital, administrative expenses, the proportion of drug income in the business income, emergency visits and so on.
Main Results
I, the results of cost monitoring
1. In the57hospitals attending cost monitoring, the average total cost of provincial, municipal and county level hospitals is respectively660000000,360000000and130000000yuan. The total cost of provincial, municipal, county level hospitals in the east is significantly higher than that in the middle and the West at the same level, but there is little difference between the total cost of hospitals in the east and the west.
2. Labor cost accounts for the largest proportion in the medical cost, which respectively is40%、45%and48%in the provincial, municipal and county level hospitals.Material cost following labor cost is respectively32%,27%and25%, of which the highest proportion is the provincial hospital.
3. In the57hospitals attending cost monitoring, the average hospital visits cost of provincial, municipal, county level hospitals is respectively169yuan,158yuan and117yuan.The hospital visits cost of provincial, municipal and county level hospitals in the east is higher than that in the middle and the west corresponding to the level.But there is little difference between the hospital visits cost in the east and the west. At present, in hospitals at all levels to provide a clinical time medical service, drug cost accounts for more than50%of the proportion, and in the medical cost, most of the cost from the test and inspection service. That is currently all levels of hospital provides the diagnosis time service, is mainly to provide drugs, inspection and test mainly services.
4. In the57hospitals attending cost monitoring, the average hospital bed days cost is respectively978yuan,677yuan and481yuan. The average hospital bed days cost of the provincial, municipal and county level hospitals in the east is significantly higher than that in the middle and the west corresponding to the level. In hospitals at all levels to provide a bed, medical service, drug costs accounted for only40%of the proportion, the rest of the cost from the medical cost, but need to pay attention to, in the medical cost, from indirect medical assistant department cost occupies certain proportion, the cost composition analysis results for hospital provides scientific basis for cost control.
5. Regardless of the grade of hospitals and hospital geographic distribution, overall speaking,57hospital a balance of payments surplus,most of the hospital hospital costs than medical income.Along with the level in the hospital,the eastern region of medical costs are higher than the medical income.Only the central at or above the county level of the hospital and the west at or above the county level at the provincial level hospital medical cost less than medical income.
II, the results of DEA efficiency analysis
In the57hospitals, there are21DEA effective units accounting for37%, in which there are6provincial hospitals,3municipal hospitals,12county-level hospitals.There are17provincial hospitals whose efficiency is35.3%,18municipal hospitals whose efficiency is16.7%and22county-level hospitals whose efficiency is54.5%. Visible according to regional perspective, the western region hospital efficiency is highest; And according to hospital level, the county hospital efficiency is highest.
There are7general effective hospitals in21hospitals of the east, of which there are4the provincial hospitals,2municipal hospitals and1county-level hospital.And there are8provincial hospitals,6municipal hospitals,7county level hospitals in21hospitals of the east, so the efficiency of the provincial hospital in the east is50%, the municipal hospital is33.3%, the county level hospital is14.3%.
There are5general effective hospitals in18hospitals of the middle, of which there are1the provincial hospital,1municipal hospital and3county-level hospitals. And there are4provincial hospitals,8municipal hospitals,6county level hospitals in18hospitals of the middle. Visibly, the county level hospital has the highest efficiency in the middle which is60%, the municipal hospital is12.5%and the provincial hospital is25%.
There are9general effective hospitals in18hospitals of the west, of which there are1the provincial hospital,0municipal hospital and8county-level hospitals. And there are5provincial hospitals,4municipal hospitals,9county level hospitals in18hospitals of the middle. Visibly, the efficiency of the provincial hospital in the west is20%, the municipal hospital is0and the county level hospital reaches88.9%.
There are36units that DEA scoring is not effective accounting for63%of all hospitals.Generally speaking, the western hospitals'overall efficiency is highest in this survey,especially the efficiency of the investigated hospitals in Sichuan and Yunnan province is very high,which is significantly higher than the relative efficiency in1997,and the overall efficiency of hospitals in south-east coastal areas is higher than that in the central region.
Ⅲ, the results of affecting factors of the hospital efficiency by using Tobit regression analysis
The results by using Tobit regression analysis to analyze the affected factors of efficiency shows that the factors significantly affected the hospital efficiency include:
1. Outpatient fees per person, hospital bed days cost, medical expenses per person leaving hospital, utilization rate of hospital beds, the total value of fixed assets; But the medical staff and administrative staff ratio has no significant influence on hospital efficiency. Among them, outpatient fees per person, medical expenses per person leaving hospital and the total value of fixed assets are in negative correlation with hospital efficiency, and these several factors can significantly reduce the hospital efficiency; utilization rate of hospital beds and hospital bed days cost have an positive effect on hospital efficiency, and these two factors can significantly increase hospital efficiency.
2. From the view of region, hospital bed days cost and medical expenses per person leaving hospital have a consistent effect on hospital efficiency of the east, the middle and the west. However the effect of outpatient fees per person becomes less significant; The utilization rate of hospital beds only has a significant impact on hospital efficiency of the eastern region while there is no significant effect on hospital efficiency of the middle and the west; The total value of fixed assets significantly decreases the hospital efficiency of the west while there is no significant effect on hospital efficiency of the middle and the west; The medical staff and administrative staff ratio only has a significant effect on hospital efficiency of the western region, which has significance at a10%level. The hospital efficiency of different regions not only has the same affected factors, but there are various regional factors.
3. The hospitals of different level have their own characteristics and their affected factors of hospital efficiency also are the different.The hospital bed days cost has a significantly positive impact on the hospital efficiency of each level, and medical staff and administrative staff ratio has no significant effect on hospital efficiency of each level; The outpatient fees per person and total value of fixed assets significantly decrease the efficiency of provincial and municipal hospitals, but there is no significant effect on the efficiency of the county hospitals efficiency; The medical expenses per person leaving hospital significantly decreases the efficiency of provincial and county level hospitals,but there is no significant effect on the efficiency of municipal hospitals efficiency;The utilization rate of hospital beds has a significantly negative effect on the efficiency of municipal and county level hospitals, but there is no significant effect on the efficiency of provincial hospitals.
Ⅳ. the results of the medical service project cost and price comparison
1.120kinds of medical service projects,(results of eliminating extreme)the proportion of project cost greater than the charging standard project quantity proportion in the province, city and county hospital were92%,97%and99%. After deducting the financial appropriation and depreciation of fixed assets, in the province, city and county hospital project cost is greater than the charging standard project quantity proportion still have84%,86%and82%. The results show that in120kinds of monitoring of the medical service programs, most of the service fee standard is below the cost. The medical service fees and project average cost has a great distance, so medical service charge can not make up for the cost of medical service consumption.
2. In the provincial hospital, project cost more than the level of fees charged multiple between1times (common eye) to6times (emergency inspecting fee). In municipal hospital, project cost and charge standard of multiple change is bigger, ratio between1times (growth hormone releasing hormone excited test) to21times (emergency inspecting fee), and this ratio in the county level hospital is between in1times (B supernormal inspection) to15times (infrared therapy); And projects that reflect the medical staff technology and labor value of medical service, such as effective emergency treatment, care, beds, dressing, registered, etc., project cost is greater than the current charging standard. But, no matter the hospital level, hospital service that cost is less than charging standard are the use of large-scale equipment to carry out inspection class services and use high and new technology in treatment of service projects, such as color doppler ultrasonic routine inspection, gamma knife treatment, excimer laser refractive sex corneal orthotics, etc.
Conclusions and Policy Implications
1. By the DEA efficiency analysis on57hospitals attending the cost monitoring, we found that we should emphatically strengthen resource management and construction of county level hospitals in the eastern coastal areas and emphatically strengthen the management and resources inputting of the municipal hospitals in the middle and the west. Gradually promote the comprehensive reform of the county level hospitals. Develop county-level hospitals'comprehensive reform program.
2. Hospital level,the outpatient fees per person, the medical expenses per person leaving hospital and the total value of fixed assets are in negative correlation with hospital efficiency which significantly reduce the hospital efficiency; The utilization rate of hospital beds and hospital bed days cost have positive effect on hospital efficiency which will significantly increase the efficiency of hospitals.Therefore, we should focus on reducing the outpatient fees per person, the medical expenses per person leaving hospital and the total value of fixed assets and improving the utilization rate of hospital beds and hospital bed days cost in order to improve hospital efficiency.
3. In the monitoring of120medical service items, more than90%of the medical service items' charges are lower than the cost. The cost of the medical service items reflecting technology and labor value of medical staff is greater than the current charges.Most medical service items whose cost is less than charges use large equipments to carry out the inspection service projects and use high and new technology to carry out the treatment service items regardless of the level of hospitals.
4. In the hospital visits cost of57hospitals attending monitoring, the average hospital visits cost of the provincial hospitals is significantly higher than that of the municipal hospitals and the county level hospitals. The drug cost accounts for a large proportion in the hospital visits cost, while testing and inspection services occupy a large proportion in the medical cost regardless of the level and the location of the hospitals. These show that the diagnosis service provided by hospitals of each level mainly provide medicines, examination and laboratory tests at present. But the service cost also is reflected better in this service and occupies the largest proportion in the direct medical cost.
5. By the analysis on the hospital bed days cost of hospitals of each level, we found that the hospital bed days cost of the provincial hospitals is higher than that of municipal hospitals and the county level hospitals; From the view of region, the average hospital bed days cost of hospitals in the east is far higher than that in the middle and the west at the same level. In the composition of hospital bed days cost, direct medical cost accounts for the highest proportion and the proportion of the drug cost is relatively less. Notably, indirect medical auxiliary department cost occupies a certain proportion in the medical cost.
6. But the overall participation rate of hospital attending cost monitoring is only60%, which is mainly because part of the hospitals attending cost monitoring was not familiar with the requirements of the online data acquisition system. And we found that part of the cost data has outliers in cost analysis process, which is possibly because the collection data of the related cost information of hospitals is not accurate, but now we can only verify the logic of the collection of the cost data and can't verify whether the collection of the cost data is reasonable and accurate, which need to perfect in the next cost monitoring work.
目前我国96%的医院是公立医院,集中了最优质的医疗卫生资源,公立医院改革也通常被认为是医改中“最难啃的骨头”和“重中之重”。因此,公立医院的改革与中国亿万老百姓的生活密切相关,一举一动都受到万众的瞩目。
随着我国经济体制改革的进一步深入,医院逐步由社会公益性事业单位成长为自主经营、自负盈亏和具有独立法人地位的经济实体。在当今社会化大生产利润平均化、市场相对稳定和产品价格上调空间相对狭小的大环境下,如何既兼顾医院的社会公益性又提高医院的整体效率；在公立医院的管理中,既提高医院的社会效益,又提高医院的经济效益,成为医院亟需解决的问题。作为公立医院,提高医院效率是承担社会责任与发展医院自身经济的必然途径。医院效率要综合考虑社会效益和经济效益。在对医院效率进行管理的过程中,应以患者利益为中心,在提高医疗服务质量和医疗效果的前提下,降低医疗费用,产生良好的社会效益,提高医院的社会美誉度与社会影响力,由此吸引患者前来就医,增加医疗业务量和服务量,并努力降低医院的经营成本,提高收支结余,以这样的方式提高医院的经济效益。社会效益对经济效益有良好的正作用,同时良好的经济效益可以发展更多的优质卫生资源,更好地满足人民群众日益增加的医疗需求,也对社会效益产生正作用。
要提高医院的效率,就要解决如何对医院效率进行科学、准确地评价问题。医院效率主要包括“技术效率”、“规模效率”和“配置效率”三个方面。
只有对医院的技术有效性、规模有效性和资源配置有效性进行准确判断,并对效率低下的程度、环节和原因进行定量分析,才能为医院管理者改进医院效率提供客观依据和参考。
由于医疗卫生服务的提供具有较强的技术性、专业性和信息不对称性,因而具有复杂性的特点,因此对医院效率的评价很难用单一的指标来衡量。目前,常用的医院效率评价方法主要有四种,即比率分析法、回归分析法、数据包络分析法和随机前沿分析法。由于医疗卫生服务产业具有多投入和多产出的特点,传统的比率分析法如成本收益法、成本效果法和成本效用分析在评价医院效率方面显得并不是很适用。而非参数分析法中的数据包络分析法(DEA)在评价具有较复杂投入产出关系的组织经营效率方面应用非常广泛,如学校、医院、银行及公共部门等。DEA不仅可以确定各医院的技术效率值和规模效率值,而且能对低效率医院在投入和产出方面存在的问题进行定量分析,这将为医院管理者改进医院效率提供决策依据。
另外,本文还从成本的角度对医院的效率进行了分析,采用山东大学卫生管理与政策研究中心(卫生部卫生经济研究所成本测算中心)2008年研究的成本测算方法,结合所选取医院提供的2008年数据计算其总成本、科室成本、部分医疗服务项目成本、不同级别不同地域医院的诊次和床日成本及其构成,有利于医院控制总成本、科室成本、医疗服务项目成本,提高效率,为医院经济管理提供依据和参考。为了了解医疗服务项目成本与收费标准之间的差异情况,选取120种具有代表性的医疗服务项目,计算其成本并与价格进行比较,为政府合理补偿公立医院提供科学的依据。
通过对医院效率的测算,能够得到哪些医院的效率是高的,哪些医院效率是低的。而影响医院效率的因素有很多,比如医院级别、医院所在区域、医院职工人数、医疗人员与行政后勤人员的比例、医疗设备值、房屋建筑物、固定资产总值、门诊人次、门诊人均费用、床日成本、出院病人平均医药费用、医疗收入、药品收入等等,到底哪些因素能够影响医院的效率,它们对医院效率会产生积极影响还是负面影响,需要我们做进一步的研究,从而找出能够显著影响医院效率的因素,对这些因素进行有针对性的改进,以提高医院效率。
研究目的
本研究的总目标是：分析我国公立医院效率及其影响因素,为改善医院绩效提供依据。
(1)构建公立医院效率评价理论和方法学模型；
(2)测量我国公立医院效率；
(3)分析医院效率影响因素；
(4)比较医疗服务项目成本与价格差异；
(5)提出医院改善资源配置效率的建议。
研究方法
本文的资料来源于参加全国医疗机构成本监测工作的57家医院的2008年数据。本次成本监测工作是受卫生部规划财务司的委托,在全国按东、中、西部经济区域划分标准,选择12个省、直辖市和自治区作为全国医疗机构成本监测点,其中东部地区4个省,中部4个省,西部4个省。在每个省份,分别选择2家省级医院,3家市级医院和3家县级医院,共计96所医院进行成本监测,其中省级医院24所,市、县级医院各36所,具有相当的代表性与可比意义。从2009年5月份开始第一轮的成本监测工作,截止到2010年2月份,全国共有57家医院提供了完整的成本测算数据,总体参加率为59%,其中东、中、西部参加率分别为66%、56%和56%；省、市、县级医院参加率分别为58%、58%和61%。
本文用描述性方法描述样本医院的基本信息,主要包括医院的人员情况,不同地域不同级别医院的在职职工人数、行政后勤部门以及医疗部门人数的比重；从医院的固定资产总值、医疗设备值以及房屋建筑物三个方面分别描述不同级别不同地域医院的规模情况；从门诊服务量、住院服务量和人均服务量三个方面描述医院的服务量情况；从医院收入、医院支出和患者支出等角度分析不同级别不同地域医院的经营情况。在分析数据的过程中,对同一地区同一级别医院的数据进行归纳、整理和比较,分别选取各分析指标在同级别同地区不同医院中的最大值和最小值,并计算这些医院的平均值,通过对样本医院的这种描述性分析可以清楚地了解各指标数据在同地区同级别医院中的波动情况,以及不同地区或者不同级别医院间的差距。
在调查数据的基础上,利用山东大学卫生管理与政策研究中心(卫生部卫生经济研究所成本测算中心)研制的“医院医疗服务成本测算办法”,即采用阶梯分摊法自顶向下将医院医疗总成本分摊到各医疗服务项目,整个分摊过程分为三个步骤：第一,将医院医疗服务总成本分摊到各个医疗服务科室(包括间接成本科室和直接成本科室)；第二,将间接成本科室的成本分摊到直接成本科室；第三,将直接成本科室的成本分摊到各个医疗服务项目,按此三个步骤计算不同地区、不同级别医院的总成本、医疗成本、药品成本、医疗成本占总成本的比例、医疗成本中各项成本的组成比例、总支出与总收入的比率、医疗支出与医疗收入的比率、科室成本、部分代表性服务项目成本、诊次费用与诊次成本、医疗服务项目成本与收费标准的比例等。
用DEA方法研究样本医院的效率时,我们选用的DEA模型具有以下特点：
(1)DEA距离函数类型为径向模型(Radial)中的CCR模型；
(2)DEA效率测量的方向(Orientation):投入导向；
(3)DEA的效率计算是基于可变规模报酬(VRS),然后再分析其规模效率。
经过相关分析、变异系数分析、聚类分析三种指标筛选方法的筛选,结合评价指标应完整地反映医院的规模、效率、效益、质量等方面的导向性需求,最终确定应用于DEA分析的4个输入指标与4个输出指标分别为：投入指标四项(职工总人数、实际开放病床数、固定资产总额、医疗总支出)；产出指标四项(门诊人次数、急诊人次数、出院人次数、业务总收入)。
在分析影响医院效率的因素时,我们采用TOBIT回归方法分析医院效率的影响因素。因变量为医院的DEA效率得分,自变量包括影响医院效率的外部因素(财政补助比例、医院级别和医院所在区域)和内部因素(职工总人数、医护人员与行政后勤人员的比例、实际开放病床数、病床使用率、门诊住院比例、固定资产总额、仪器设备总值、仪器设备值占固定资产总值的比例、医疗总支出、门诊人次数、急诊人次数、出院人次数、医疗总收入、手术病人数、出院者平均住院天数、住院总床日数、病床使用率、每门诊人次收费水平、每床日平均收费水平、每床日平均药品费、出院病人平均医药费用、管理费用、药品收入占业务收入的百分比、急诊人次等)。
研究结果
一、成本测算结果
1.在参加成本监测的57家医院中,省级、市级和县级医院的平均总成本分别为6.6亿、3.6亿和1.3亿元。东部省、市、县级医院的总成本明显高于中部和西部同级医院,但中、西部医院总成本差别不大。
2.医疗成本构成中,劳务成本所占比例最大,在省、市、县级医院分别为40%、45%和48%。其次为材料成本,省、市、县级医院比例分别为32%、27%和25%,材料成本比例以省级医院最高。
3.57家监测医院中,省、市、县三级医院的平均诊次成本分别为169元、158元和117元。东部地区医院的诊次成本都要高于中部和西部地区相应级别医院的诊次成本。但中、西部医院的诊次成本差别不大。目前,各级医院在提供一个诊次的医疗服务时,药品成本占50%以上的比例,而在医疗成本中,大部分的成本来自于化验和检查服务。也就是说目前所有级别的医院提供的诊次服务中,主要是以提供药品,检查和化验服务为主。
4.57家监测医院中,省、市、县三级医院的平均床日成本分别为978元、677元和481元。东部地区各级别医院的平均床日成本要明显高于中西部地区同级别医院的平均床日成本。各级医院在提供一个床日的医疗服务时,药品成本仅占40%以上的比例,其余成本则来自医疗成本,但需要注意的是,在医疗成本中,来自间接医疗辅助科室的成本占有一定比例,这一成本构成分析结果为医院控制成本提供了科学依据。
5.无论医院级别和医院的地域分布,总体来讲,57家医院收支略有盈余,大部分的医院的医院成本高于医疗收入。同级别医院中,东部地区的医疗成本均高于医疗收入。只有中部的县级医院和西部的省级县级医院医疗成本低于医疗收入。
二、DEA效率分析的结果
在总共57家医院中,DEA有效的单元有21家,占全部医院的37%,其中省级医院6家,市级医院3家,县级医院12家。省级医院共17家,有效率为35.3%；市级医院共18家,有效率为16.7%；县级医院共22家,有效率为54.5%。而东部地区21家医院中总体有效的有7家,有效率为33.3%；中部地区18家医院中总体有效的有5家,有效率为27.8%；西部地区18家医院中总体有效的有9家,有效率为50%。可见按地域来看,西部地区医院的有效率最高；而按照级别来看,县级医院的有效率最高。
东部地区21家医院中总体有效的有7家,其中,省级医院4家,市级医院2家,县级医院1家。而东部21家医院中省级医院8家,市级医院6家,县级医院7家,东部地区省级医院有效率为50%,市级医院有效率为33.3%,县级医院有效率为14.3%。
中部地区18家医院中总体有效的有5家,其中省级医院1家,市级医院1家,县级医院3家。中部18家医院中省级医院4家,市级医院8家,县级医院6家,可见,在中部地区,县级医院的有效率最高,达到了60%,市级医院的有效率为12.5%,省级医院的有效率为25%。
西部地区18家医院中总体有效的有9家,其中省级医院1家,市级医院0家,县级医院8家。18家医院中省级医院5家,市级医院4家,县级医院9家。可见,在西部地区,省级医院的有效率为20%,市级医院的有效率为0%,县级医院的总体有效率占到了88.9%。
非DEA有效得分的单元有36家,占全部医院的63%。总的来讲,在此次调查中,按地域来看,西部地区医院的有效率最高,特别是四川和云南两省的被调查医院效率都很高,比1997年的相对效率值有了明显地提高,东南沿海地区医院的总体效率偏高于中部地区的医院；而按照级别来看,县级医院的有效率最高。
三、用Tobit回归分析医院效率影响因素的结果
用Tobit回归分析方法对影响效率的因素进行分析,结果显示：
1.显著影响医院效率的因素包括：医院级别、门诊人均费用、床日成本、出院者人均医药费用、病床使用率、固定资产总额；而医护人员与行政后勤人员的比例对医院效率没有显著性影响。其中,医院级别、门诊人均费用、出院者人均医药费用、固定资产总额与医院效率负相关,这几个因素的增加会显著降低医院效率；病床使用率、床日成本对医院效率有积极影响,这两个因素的增长会显著增加医院效率。
2.分地区来看,同地区医院效率既有相同的影响因素,也有各地区独有的影响因素。床日成本、出院者人均医药费用对东中西部地区医院效率的影响是一致的,然而门诊人均费用的影响对东中西部地区医院效率都不显著了；病床使用率仅对东部地区医院效率产生显著影响,对中西部地区医院效率没有显著影响；固定资产总额仅对西部地区医院效率产生显著影响；医护人员与行政后勤人员的比例仅对西部医院效率有显著影响,结果在10%显著性水平上有意义。
3.分级别来看,床口成本、固定资产总额对各个级别医院效率均产生显著影响,且床日成本与医院效率均正相关,固定资产总额与医院效率均为负相关；门诊人均费用只对省级和市级医院效率产生显著影响；出院者人均医药费用只对省级和县级医院效率产生显著影响,且都与医院效率负相关：病床使用率对市级和县级医院有显著影响,但影响的效果又截然不同,病床使用率与市级医院的效率负相关,而与县级医院的效率正相关；医护人员与行政后勤人员的比例仅对县级医院效率有显著影响。
四、医疗服务项目成本与价格比较的结果
1.120种医疗服务项目中,(去除极值后的结果)项目成本大于收费标准的项目数量比例在省、市和县级医院分别为92%、97%和99%。在扣除财政拨款和固定资产折旧后,在省、市和县级医院项目成本大于收费标准的项目数量比例仍然有84%、86%和82%。这一结果表明在120种监测的医疗服务项目中,绝大部分服务项日的收费标准要低于成本。医疗服务收费标准与项目平均成本有较大差距,因而医疗服务收费不能弥补医疗服务消耗的成本。
2.在省级医院,项目成本大于收费标准的倍数在1倍(普通视力检查)-6倍(急诊诊查费)之间。市级医院项目成本与收费标准间的倍数变化较大,比值在1倍(生长激素释放激素兴奋试验)-21倍(急诊诊查费)之间,而这一比值在县级医院则在1倍(B超常规检查)-15倍(红外线治疗)之间；并且反映医务人员技术和劳务价值的医疗服务项目,如急诊诊查、护理、床位、换药、挂号等,项目成本均大于目前的收费标准。但是,不论医院级别,成本小于收费标准的医院服务项目多是利用大型设备开展的检查类服务项目和利用高新技术开展的治疗类服务项目,如彩色多普勒超声常规检查、伽玛刀治疗、准分子激光屈光性角膜矫正术等。
结论与建议
1.通过对本次成本监测的57家医院的DEA效率分析,我们发现需要着重加强东部沿海地区县级医院的资源管理和建设,中部地区和西部地区需要着重加强市级医院的管理和资源投入；逐步推进县级医院综合改革。
2.医院级别、门诊人均费用、出院者人均医药费用、固定资产总额与医院效率负相关,这几个因素的增加会显著降低医院效率；病床使用率、床日成本对医院效率有积极影响,这两个因素增加也会显著增加医院效率。所以,为了提高医院的效率,应当着重降低门诊人均费用、出院者人均医药费用,减少固定资产投资的力度,提高病床使用率、床日成本。
3.在120种监测的医疗服务项目中,90%以上的医疗服务项目的收费标准要低于成本。反映医务人员技术和劳务价值的医疗服务项目,项目成本均大于目前的收费标准。但是无论医院级别,成本小于收费标准的医院服务项目多是利用大型设备开展的检查类服务项目和利用高新技术开展的治疗类服务项目。
4.在57家监测医院的诊次成本中,省级医院的平均诊次成本要明显高于市、县级医院,诊次成本中药品成本均占有较大的比例,而医疗成本中,化验和检查服务则占有较大的比例,这说明,目前在各级医院提供的诊次服务中,主要以提供药品、检查和化验为主。
5.在对各级医院的床日成本进行分析发现,省级医院的床日成本要高于市、县级医院,按地域划分的话,东部地区医院的平均床日成本要远远高于中西部地区同级别医院的平均床日成本。在床日成本构成中,直接医疗成本所占的比例最高,药品成本所占比例相对要少一些。值得注意的是,在医疗成本中,来自间接医疗辅助科室的成本占有一定的比例。
6.此次成本监测医院总体参与率仅60%,造成低参与率的主要原因是部分医院还不熟悉此次成本监测要求的网上数据采集系统。并且在成本分析过程中发现部分成本数据有异常值,可能的原因在于医院相关成本信息填报数据不准确,这是在下一步成本监测工作中需要完善的方面。
Background
At present,96%of hospitals in our country are public hospitals, which concentrate the most high quality medical and health resources, the reform of public hospitals is also considered as "the hardest bones to chew " and "top priority" in the reform. Therefore, the reform of public hospitals is closely related to the life of the people, every move attracts peoples'attention.
As further reform of China's economic system, the hospitals have gradually grown into the economic entities which operate independently and are responsible for their own profits and losses and have an independent legal status from the social public welfare enterprises. In the present environment of profit of socialized production being average, market being relatively stability and the rising space of product price being narrow, how to give attention to the social and public welfare undertakings of the hospital and improve the efficiency of the hospital; In the management of the public hospital, how to not only improve the social benefits of the hospital, but improve the economic benefits of the hospital, become the urgent matter of the hospital. As the public hospital, improving the efficiency of the hospital is an inevitable way to take social responsibility and develop its own economy. Efficiency of hospitals should comprehensively consider the social benefits and economic benefits. In the process of management of the hospital efficiency, we should regard patients'benefits as the center, in the premise of improving medical effect, reduce the medical cost, produce good social benefits and improve the social reputation and influence of the hospital, which attract patients to go to the hospital, increase the volume of medical business, and strive to reduce operating costs, improve the surplus balance of payments to improve the economic benefit of hospital in such a way. Social benefits obviously have a positive effect to economic benefits, at the same time good economic benefits can develop more health resources with high quality, meet people's increasing needs of medical treatment better, and also have a positive effect to social benefits.
To improve the efficiency of the hospital, we should solve the problem of how to scientifically and accurately evaluate efficiency of the hospital. Hospital efficiency mainly include "technology efficiency","scale efficiency" and "allocation efficiency".
Only the accurate judgment for the technology efficiency, scale efficiency and allocation efficiency of the hospital and the quantitative analysis to the degree, links and reasons of low efficiency, can we provide objective basis to improve the efficiency of hospital for hospital administrators.
Because the provision of medical and healthy service is strongly professional, technical and has strong information asymmetry, thus it is complex, so the evaluation on hospital efficiency is difficult to use a single index to measure. At present, the method commonly used to evaluate hospital efficiency mainly includes four kinds, namely ratio analysis, regression analysis, the data envelopment analysis and stochastic frontier analysis. Due to the healthy industry has the character that it has many inputs and outputs, the traditional ratio analysis method such as cost-benefit method, cost effective method and cost effectiveness analysis in the evaluation of hospital efficiency is not applicable. The data envelopment analysis (DEA) of the parameter analysis methods is widely used to evaluate the operation efficiency of organizations with complicated input-output relation, such as schools, hospitals, banks and public departments and so on.DEA can not only determine the technical efficiency value and scale efficiency value of hospitals, but are able to quantitatively analyze the existing problem in the input and output aspects of the hospitals with low efficiency, so it will provide decision basis for the hospital administrators to improve the efficiency of the hospital.
In addition, this paper also analyzes the hospital efficiency from a cost perspective, uses the cost estimation methods researched by the Calculating Center of the Health Economic Institute of the Health Ministry in2008, and calculates its department cost, part of the medical service item cost and the times of diagnosis and bed days cost and its composition of the hospitals of different levels and different region combined with the data in2008provided by the selected hospitals. Analyze and compare the differences between the cost of medical service and the price and provide scientific basis for the government to compensate public hospitals reasonably, which contributes to controlling the total cost, the department cost and the medical service item cost of hospitals, improving efficiency and providing the basis for the economic management of hospitals.
Based on the calculation of the efficiency of the hospital, we can get which hospital efficiency is high, which hospital efficiency is low. And there are many factors influence hospitals, such as hospital level, hospital area, the number of hospital staff, medical personnel and administrative personnel's scale, medical equipment value, housing building, fixed assets value, outpatient clinic visits, per capita expenses, bed day cost, discharged patients average medical expenses, medical income, drug income, etc., exactly what factors can influence the efficiency of the hospital, they will have a positive impact or negative effects?We need to do further research, so as to find out factors that have significant influence on hospital efficiency, improve these factors targeted, in order to improve the efficiency of the hospital.
Objectives
The overall goal of this research is to analyze the efficiency of the hospitals and to analyze the influenced factors of the efficiency of the hospitals, to put forward policy suggestions for hospitals to improve its efficiency.
(1) establishing evaluation theory and methodology model of the efficiency of the public hospital;
(2) analyzing the efficiency of the public hospital in our country;
(3) analyzing the affecting factors of the efficiency of hospitals
(4) analyzing and comparing the differences between the cost of medical service and the price;
(5) putting forward suggestions to improve the allocated efficiency of the hospital resource for hospitals.
Methods
The material of this paper comes from the data of57hospitals attending cost monitoring work of the national medical institution in2008. This cost monitoring work is entrusted by the Department of Planning and Finance of the Health Ministry, according to the division standard of the eastern, middle and western economic zone in the nation, and selects12provinces, municipalities and autonomous regions as the cost monitoring point of the national medical institutions, of which4provinces come from the eastern region,4provinces come from the middle,4provinces come from the western region. In each province, we respectively choose two provincial hospitals, three municipal hospitals and three county level hospitals, giving a total of96hospitals to monitor cost. There are24provincial hospitals,36municipal hospitals and36county level hospitals, which has considerable representativeness and comparable significance. We began the first round of cost monitoring work from May2009, and there were57hospitals across the country provide a complete set of cost calculating data by February2010, the overall participating rate is59%, the participating rate of the east, the middle and the west are respectively66%,56%and56%. The participation rate of provincial, municipal and county level hospitals are respectively58%,58%and61%.
This paper describes the basic information of the sample hospitals by using descriptive method, including the number of employees, total revenue and total expenditure, medical income and medical expenditure,medicine income and medicine expenditure, total value of fixed assets, total value of equipments; the average number of discharged patients, the average hospitalization days,and the average hospitalization expenses of hospitals of different regions and different levels and so on. On the analysis of the data in the process, to the same area and the same level hospital data induction, sorting and comparison, the analysis indicators were selected in the same level with different regions in the hospital, the maximum and the minimum value is calculated, and the average of the hospital, through the sample hospital this descriptive analysis can clearly understand each index data in the same region in the hospital with level fluctuations, and the gap between different level or different regions hospitals.
On the basis of surveyed data, we use the "hospital medical service cost calculating method" developed by the Health management and Policy Research Center of Shandong University(the Cost Calculating Center of the Health Economic Institute of the Health Ministry), that is apportioning the total cost of hospitals to the medical service items by using the apportionment method from top to down, the apportioning process is divided into three steps:first, apportioning the total cost of hospital medical service to all medical service departments (including indirect cost departments and direct cost departments); second, apportioning the cost of indirect cost departments to cost of direct cost departments; third, apportioning the cost of direct cost departments to all medical service items. According to the three steps to calculate the total cost, medical cost, drug cost, the proportion of medical cost in the total cost, the cost composition ratio of medical cost, the ratio of total expenditure and total income,the ratio of medical expenditure and medical income, department cost, some representative service item cost, diagnosis times expenses and cost and medical service item cost and the proportion of charging standard and so on.
When we empirically study the efficiency of sample hospitals, DEA model we used has the following characteristics:
(1) DEA distance function type is CCR model in the radial model (Radial);
(2) DEA efficiency measuring direction (Orientation):investment guide;
(3) Efficiency calculation of DEA is based on the variable returns to scale (VRS), and then analyze the scale efficiency.
By screening of three kinds of index screening methods which is correlation analysis, coefficient of variation analysis and cluster analysis combining with the demand that evaluation indicators should integrally reflect the quality oriented demand of the hospital scale, efficiency, effectiveness and other aspects, we ultimately determine4input indexes and4output indexes applied to the analysis of DEA,which respectively are four input indexes(the total number of employees, the actual number of beds opened, the total value of fixed assets and total medical expenditure); four output indexes (the number of outpatients, the number of emergency visits, the number of people leaving hospital and total business revenue).
In the analysis of the influencing factors of the hospital efficiency, we use the TOBIT regression analysis.The dependent variable is scores of hospitals'DEA efficiency, and independent variables include financial subsidy ratio, the total number of employees, staff and administrative staff ratio, actual number of beds opened, beds occupancy, outpatient hospitalization ratio, total value of fixed assets, total value of instruments and equipments, the proportion of the value of instruments and equipments in the total value of fixed assets, medical expenditure, the number of outpatients, the number of emergency, the number of leaving hospital, total medical revenue, the number of patients in hospital operation, the average length of stay hospital, total bed days in hospital, utilization rate of hospital beds, charge level of each outpatient visit, average charge level per day of each bed, average drug charges per day of each bed, average medical charges of patients leaving hospital, administrative expenses, the proportion of drug income in the business income, emergency visits and so on.
Main Results
I, the results of cost monitoring
1. In the57hospitals attending cost monitoring, the average total cost of provincial, municipal and county level hospitals is respectively660000000,360000000and130000000yuan. The total cost of provincial, municipal, county level hospitals in the east is significantly higher than that in the middle and the West at the same level, but there is little difference between the total cost of hospitals in the east and the west.
2. Labor cost accounts for the largest proportion in the medical cost, which respectively is40%、45%and48%in the provincial, municipal and county level hospitals.Material cost following labor cost is respectively32%,27%and25%, of which the highest proportion is the provincial hospital.
3. In the57hospitals attending cost monitoring, the average hospital visits cost of provincial, municipal, county level hospitals is respectively169yuan,158yuan and117yuan.The hospital visits cost of provincial, municipal and county level hospitals in the east is higher than that in the middle and the west corresponding to the level.But there is little difference between the hospital visits cost in the east and the west. At present, in hospitals at all levels to provide a clinical time medical service, drug cost accounts for more than50%of the proportion, and in the medical cost, most of the cost from the test and inspection service. That is currently all levels of hospital provides the diagnosis time service, is mainly to provide drugs, inspection and test mainly services.
4. In the57hospitals attending cost monitoring, the average hospital bed days cost is respectively978yuan,677yuan and481yuan. The average hospital bed days cost of the provincial, municipal and county level hospitals in the east is significantly higher than that in the middle and the west corresponding to the level. In hospitals at all levels to provide a bed, medical service, drug costs accounted for only40%of the proportion, the rest of the cost from the medical cost, but need to pay attention to, in the medical cost, from indirect medical assistant department cost occupies certain proportion, the cost composition analysis results for hospital provides scientific basis for cost control.
5. Regardless of the grade of hospitals and hospital geographic distribution, overall speaking,57hospital a balance of payments surplus,most of the hospital hospital costs than medical income.Along with the level in the hospital,the eastern region of medical costs are higher than the medical income.Only the central at or above the county level of the hospital and the west at or above the county level at the provincial level hospital medical cost less than medical income.
II, the results of DEA efficiency analysis
In the57hospitals, there are21DEA effective units accounting for37%, in which there are6provincial hospitals,3municipal hospitals,12county-level hospitals.There are17provincial hospitals whose efficiency is35.3%,18municipal hospitals whose efficiency is16.7%and22county-level hospitals whose efficiency is54.5%. Visible according to regional perspective, the western region hospital efficiency is highest; And according to hospital level, the county hospital efficiency is highest.
There are7general effective hospitals in21hospitals of the east, of which there are4the provincial hospitals,2municipal hospitals and1county-level hospital.And there are8provincial hospitals,6municipal hospitals,7county level hospitals in21hospitals of the east, so the efficiency of the provincial hospital in the east is50%, the municipal hospital is33.3%, the county level hospital is14.3%.
There are5general effective hospitals in18hospitals of the middle, of which there are1the provincial hospital,1municipal hospital and3county-level hospitals. And there are4provincial hospitals,8municipal hospitals,6county level hospitals in18hospitals of the middle. Visibly, the county level hospital has the highest efficiency in the middle which is60%, the municipal hospital is12.5%and the provincial hospital is25%.
There are9general effective hospitals in18hospitals of the west, of which there are1the provincial hospital,0municipal hospital and8county-level hospitals. And there are5provincial hospitals,4municipal hospitals,9county level hospitals in18hospitals of the middle. Visibly, the efficiency of the provincial hospital in the west is20%, the municipal hospital is0and the county level hospital reaches88.9%.
There are36units that DEA scoring is not effective accounting for63%of all hospitals.Generally speaking, the western hospitals'overall efficiency is highest in this survey,especially the efficiency of the investigated hospitals in Sichuan and Yunnan province is very high,which is significantly higher than the relative efficiency in1997,and the overall efficiency of hospitals in south-east coastal areas is higher than that in the central region.
Ⅲ, the results of affecting factors of the hospital efficiency by using Tobit regression analysis
The results by using Tobit regression analysis to analyze the affected factors of efficiency shows that the factors significantly affected the hospital efficiency include:
1. Outpatient fees per person, hospital bed days cost, medical expenses per person leaving hospital, utilization rate of hospital beds, the total value of fixed assets; But the medical staff and administrative staff ratio has no significant influence on hospital efficiency. Among them, outpatient fees per person, medical expenses per person leaving hospital and the total value of fixed assets are in negative correlation with hospital efficiency, and these several factors can significantly reduce the hospital efficiency; utilization rate of hospital beds and hospital bed days cost have an positive effect on hospital efficiency, and these two factors can significantly increase hospital efficiency.
2. From the view of region, hospital bed days cost and medical expenses per person leaving hospital have a consistent effect on hospital efficiency of the east, the middle and the west. However the effect of outpatient fees per person becomes less significant; The utilization rate of hospital beds only has a significant impact on hospital efficiency of the eastern region while there is no significant effect on hospital efficiency of the middle and the west; The total value of fixed assets significantly decreases the hospital efficiency of the west while there is no significant effect on hospital efficiency of the middle and the west; The medical staff and administrative staff ratio only has a significant effect on hospital efficiency of the western region, which has significance at a10%level. The hospital efficiency of different regions not only has the same affected factors, but there are various regional factors.
3. The hospitals of different level have their own characteristics and their affected factors of hospital efficiency also are the different.The hospital bed days cost has a significantly positive impact on the hospital efficiency of each level, and medical staff and administrative staff ratio has no significant effect on hospital efficiency of each level; The outpatient fees per person and total value of fixed assets significantly decrease the efficiency of provincial and municipal hospitals, but there is no significant effect on the efficiency of the county hospitals efficiency; The medical expenses per person leaving hospital significantly decreases the efficiency of provincial and county level hospitals,but there is no significant effect on the efficiency of municipal hospitals efficiency;The utilization rate of hospital beds has a significantly negative effect on the efficiency of municipal and county level hospitals, but there is no significant effect on the efficiency of provincial hospitals.
Ⅳ. the results of the medical service project cost and price comparison
1.120kinds of medical service projects,(results of eliminating extreme)the proportion of project cost greater than the charging standard project quantity proportion in the province, city and county hospital were92%,97%and99%. After deducting the financial appropriation and depreciation of fixed assets, in the province, city and county hospital project cost is greater than the charging standard project quantity proportion still have84%,86%and82%. The results show that in120kinds of monitoring of the medical service programs, most of the service fee standard is below the cost. The medical service fees and project average cost has a great distance, so medical service charge can not make up for the cost of medical service consumption.
2. In the provincial hospital, project cost more than the level of fees charged multiple between1times (common eye) to6times (emergency inspecting fee). In municipal hospital, project cost and charge standard of multiple change is bigger, ratio between1times (growth hormone releasing hormone excited test) to21times (emergency inspecting fee), and this ratio in the county level hospital is between in1times (B supernormal inspection) to15times (infrared therapy); And projects that reflect the medical staff technology and labor value of medical service, such as effective emergency treatment, care, beds, dressing, registered, etc., project cost is greater than the current charging standard. But, no matter the hospital level, hospital service that cost is less than charging standard are the use of large-scale equipment to carry out inspection class services and use high and new technology in treatment of service projects, such as color doppler ultrasonic routine inspection, gamma knife treatment, excimer laser refractive sex corneal orthotics, etc.
Conclusions and Policy Implications
1. By the DEA efficiency analysis on57hospitals attending the cost monitoring, we found that we should emphatically strengthen resource management and construction of county level hospitals in the eastern coastal areas and emphatically strengthen the management and resources inputting of the municipal hospitals in the middle and the west. Gradually promote the comprehensive reform of the county level hospitals. Develop county-level hospitals'comprehensive reform program.
2. Hospital level,the outpatient fees per person, the medical expenses per person leaving hospital and the total value of fixed assets are in negative correlation with hospital efficiency which significantly reduce the hospital efficiency; The utilization rate of hospital beds and hospital bed days cost have positive effect on hospital efficiency which will significantly increase the efficiency of hospitals.Therefore, we should focus on reducing the outpatient fees per person, the medical expenses per person leaving hospital and the total value of fixed assets and improving the utilization rate of hospital beds and hospital bed days cost in order to improve hospital efficiency.
3. In the monitoring of120medical service items, more than90%of the medical service items' charges are lower than the cost. The cost of the medical service items reflecting technology and labor value of medical staff is greater than the current charges.Most medical service items whose cost is less than charges use large equipments to carry out the inspection service projects and use high and new technology to carry out the treatment service items regardless of the level of hospitals.
4. In the hospital visits cost of57hospitals attending monitoring, the average hospital visits cost of the provincial hospitals is significantly higher than that of the municipal hospitals and the county level hospitals. The drug cost accounts for a large proportion in the hospital visits cost, while testing and inspection services occupy a large proportion in the medical cost regardless of the level and the location of the hospitals. These show that the diagnosis service provided by hospitals of each level mainly provide medicines, examination and laboratory tests at present. But the service cost also is reflected better in this service and occupies the largest proportion in the direct medical cost.
5. By the analysis on the hospital bed days cost of hospitals of each level, we found that the hospital bed days cost of the provincial hospitals is higher than that of municipal hospitals and the county level hospitals; From the view of region, the average hospital bed days cost of hospitals in the east is far higher than that in the middle and the west at the same level. In the composition of hospital bed days cost, direct medical cost accounts for the highest proportion and the proportion of the drug cost is relatively less. Notably, indirect medical auxiliary department cost occupies a certain proportion in the medical cost.
6. But the overall participation rate of hospital attending cost monitoring is only60%, which is mainly because part of the hospitals attending cost monitoring was not familiar with the requirements of the online data acquisition system. And we found that part of the cost data has outliers in cost analysis process, which is possibly because the collection data of the related cost information of hospitals is not accurate, but now we can only verify the logic of the collection of the cost data and can't verify whether the collection of the cost data is reasonable and accurate, which need to perfect in the next cost monitoring work.
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