Estimating the Distribution and Convergence of County-level Healthcare Resources Allocative Efficiency in China Based on DEA and Spatial Panel Model.

Although China's 2009 New Healthcare Reform aimed to correct the imbalance in the spatial allocation of healthcare resources with a focus on the county level, its impact on county-level allocative efficiency evolution and convergence remains unclear. This paper for the first time performs a spatial analysis to explore the distribution, evolution, and convergence of the allocative efficiency of healthcare resources with county-level data. This paper uses the sample data of 158 countries in Henan Province, China, to evaluate the evolution and convergence of the allocative efficiency of healthcare resources. Based on the estimated Data Envelopment Analysis (DEA) allocative efficiency, analysis of variance (ANOVA), and spatial descriptive analysis, we explore the county heterogeneity and efficiency evolution; a spatial panel model is then utilized to test the county-level convergence of the allocative efficiency of healthcare resources. Although the number of efficient counties has not increased, the number of inefficient individuals keeps decreasing, and the allocative efficiency of municipal districts is lower than that of nonmunicipal counties. There exists a positive spatial correlation of allocative efficiency in Henan Province, and significant and robust convergence results can be found at the county level after China's 2009 reform. This study reveals a diversified picture of China's county-level spatial evolution of allocative efficiency in healthcare resources, showing a more balanced spatial distribution of allocative efficiency since the triggering of China's 2009 reform. However, long-term investment incentives and a targeted allocation of healthcare resources are still needed to promote further efficiency convergence and increase the number of counties with efficiency.

The Effect of Descending Resources Reform on Reallocating Healthcare Resources: An Analysis Based on the Difference-in-Differences Method.

Since 2010, China has been exploring descending resources reform in order to correct the imbalanced allocation of healthcare resources and promote coordinated economic development among regions. This paper for the first time estimates the impact this reform has had on the reallocation of healthcare resources by using prefecture-level cities panel data from Zhejiang Province, China, which implemented the reform province-wide in 2013. The time-varying difference-in-differences (DID) method was used to estimate the reform's policy effects. The data used in this paper is from published statistical yearbooks and local governments, which include panel data from 11 prefecture-level and higher cities in Zhejiang Province as the treated group and 46 prefecture-level cities in Jiangsu, Henan, and Sichuan Province as the control group. The entropy weight method was used to construct the supply index and demand index to incorporate multiple inputs and outputs, and efficiency indicators were constructed using the ratio method. This research found that the reform has had a positive effect on outpatient visits in different prefecture-level cities with vast rural areas. However, this reform exerted no significant impact on inpatient services or supply-side or resource allocation efficiency. Several robust tests support the above conclusions, and one theoretical explanation is provided. The descending health resources reform can be a valuable reform path in promoting more balanced healthcare resource allocation; however, the resultant disparities in its effects should be considered when implementing it.

Estimating the spatial correlation and convergence of China's healthcare resources allocation: evidence from the Yangtze River Delta Region.

BACKGROUND: China's imbalanced allocation of healthcare resources mainly arises from urban-rural and intercity differences, the solution of which has been the goal of reforms during the past decades. Estimating the spatial correlation and convergence could help to understand the impact of China's fast-evolving medical market and the latest healthcare reforms. METHODS: The entropy weight method was used to construct a healthcare resource supply index (HRS) by using data of 41cities in a cluster in the Yangtze River Delta (YRD) from 2007 to 2019. The Dagum Gini coefficient, kernel density estimation, Moran's I, and LISA cluster map were used to characterize the spatiotemporal evolution and agglomeration of healthcare resources, and then a spatial panel model was used to perform ß convergence estimation by incorporating the spatial effect, city heterogeneity, and healthcare reforms. RESULTS: Healthcare resources supply in the YRD region increases significantly and converges rapidly. There is a significant spatial correlation and agglomeration between provinces and cities, and a significant spatial spillover effect is also found in ß convergence. No evidence is found that the latest healthcare reforms have an impact on the balanced allocation and convergence of healthcare resources. CONCLUSION: China's long-term investment in past decades has yielded a more balanced allocation and intercity convergence of healthcare resources. However, the latest healthcare reforms do not contribute to the balanced allocation of healthcare resources from the supply-side, and demand-side analysis is needed in the future studies.

Working intentions of medical students in response to healthcare workplace violence and descending resources reform in China.

BACKGROUND: In order to curb healthcare workplace violence (WPV) and better allocate healthcare resources, China launched the descending resources reform in 2013 and tightened the anti-violence legal environment simultaneously. Medical students are expected to reconsider their working intentions of entering the medical market (inter-market effect) and choosing high- or low-level hospitals (intra-market effect) in response to the evolving WPV. The goal of this study was to explore the link between the perceived WPV incidence and medical students' willingness to practice medicine in the context of China's descending resources reform. METHOD: Medical students were selected with cluster sampling from 8 medical colleges in Zhejiang Province, China, and 1497 valid questionnaires were collected by using a five-point unbalanced scale, to perform cross-sectional empirical research using the ordered logit model (OLM). RESULTS: The perceived WPV incidence negatively correlate with the willingness of medical students to practice medicine but positively correlate with their willingness to practice in low-level hospitals, indicating the existence of inter- and intra-market effects. The anti-violence legal environment has no direct link with working intention but contributes to the perceived decline in the incidence of violence. Descending resources reform has simultaneous opposite effects on medical students, with the coexistence of prudent motives driven by reform costs and optimistic expectations of sharing external benefits. CONCLUSIONS: Safety needs and risk aversion motive play an important role in medical students' career choice when facing severe WPV. Tightening of the anti-violence legal environment and the descending resources reform could drive medical students to low-level hospitals.

Does descending health resources reform impact patient low-level hospital selection behavior? Evidence from Zhejiang, China.

BACKGROUND: Since 2013, China launched descending resources reform, which is a new attempt to correct unbalanced allocation of health resources through human capital spillovers and brand implantation from high-level hospitals. The purpose of this paper is to explore the patients' hospital selection response to this reform with the focus of low-level hospitals to better understand the effect of this reform on correcting regional inequality of health resources allocation. METHODS: The European Consumer Satisfaction Index model (ECSI) was used to design a questionnaire, and cross-sectional data from 17 hospitals were collected through 1287 questionnaires from Zhejiang Province. Patient hospital selection (loyalty) is measured using ordinary variables by considering patient willingness to choose a low-level hospital when suffering an illness or severe illness. Analysis of variance (ANOVA) and the structure equation model are applied to examine the effect of reforms on patient behavior. RESULTS: The descending resources reform promotes improvements in the capabilities and medical environment of low-level hospitals, and descending doctors also have high accessibility. Perceived quality, patient expectations, and hospital image have significant positive effects on patient satisfaction, and the explanatory power of brand implantation from cooperative high-level hospitals and descending doctors is stronger than the image of the low-level hospital itself. And descending resources reform and patient satisfaction have significant positive impacts on patient's choice for low-level hospitals with the existence of mediating effect of satisfaction. CONCLUSIONS: This paper provides supporting empirical evidence of the descending resources reform's impact on patients' low-level hospital selection. This reform has been effective in improving the capabilities of low-level hospitals, and brand implantation of high-level hospitals shows strong explanatory power. China's reform offers a distinct and valuable approach to correcting the uneven allocation of health resources. Besides, the findings also suggest that policymakers could pay more attention to the importance of information channels in impacting patient awareness, responses, and hospital selection.

Does Descending Resources Reform Improve Patient Satisfaction and Reshape Choice of Care Providers? A Cross-Sectional Study in Zhejiang, China.

Patient satisfaction and choice of care providers have been the core concerns of China's descending resources reform launched in 2013. This health care reform attempts to improve low-level hospitals' capability and patient satisfaction through compulsory descending of doctors from high-level hospitals, thereby reshaping patients' behavior (loyalty). The goal of this paper is to explore the determinants of patient satisfaction, and its impact on patient loyalty with an emphasis on low-level hospitals in the reform context. By using a self-made 5-point scale that incorporates socio-demographic variables, reform, and revealed preference into the European Consumer Satisfaction Index model (ECSI), cross-sectional data from 17 hospitals, and 1287 questionnaires in Zhejiang province is collected to conduct empirical research. Satisfaction is measured as ordinary variables with the reform and with the low-level hospitals, respectively. Loyalty is measured by patients' willingness to choose low-level hospitals when suffering illness or severe illness. Analysis of variance and multiple comparisons are utilized to examine the different level of hospitals. An ordered logit model and ordinary least squares regression are applied to examine the determinants of satisfaction and loyalty. The results indicate that patient satisfaction can be explained by variables of perceived quality, patient expectations, and corporate image. Socio-demographic variable, providers, and the reform also have significant effects. Patients' satisfaction plays a pronounced role on improving their loyalty. The descending resources reform positively affects low-level hospitals' capability and patient satisfaction. The cost reduction and convenience significantly increase the reform satisfaction. Capability, medical environment, and accessibility of descending doctors are positively associated with the satisfaction with low-level hospitals. This paper evidences that the descending resources reform is an effective way to reallocate resources in supply side of health service market and reshape patients' choice of care providers with the accessibility and spillover of descending human capital.

An Economic Model of Optimal Penalty for Health Care Workplace Violence.

This article provides an economic model on the optimal penalty of health care workplace violence based on health care workplace classification and cost structure, aiming to deter potential offenders. By developing an EIP (externality, identifiability, and preventability) analytical method, we distinguish the characteristics of different workplaces and find that the health care workplace is the combination of externality, low identifiability, and low preventability. Besides the private cost to victims for ordinary workplace violence, the cost structure of health care workplace violence includes social costs like externality-related public safety cost, defensive medicine cost, and specific factors cost. When the optimal penalty corresponding to different levels of health care workplace violence increases, the threshold level of punishable violence decreases after incorporating the social costs into analysis. Our model shows that public safety costs are positively correlated with the importance of health care workplace in the service network, and a higher public safety cost should be matched with a greater optimal penalty.

Understanding congestion in China's medical market: an incentive structure perspective.

Congestion has become one of the most important factors leading to patient dissatisfaction and doctor-patient conflicts in the medical market of China. In this study, we explore the causes and effects of structural congestion in the Chinese medical market from an incentive structure perspective. Our analysis reveals that prior medical system reforms with price regulation in China have induced hospitals to establish incentives for capital-intensive investments, while ignoring human capital, and have driven medical staff and patients to higher-level hospitals, reinforcing an incentive structure in which congestion in higher-level hospitals and idle resources in lower-level hospitals coexist. The existing incentive structure has led to cost increases and degradation of human capital and specific factor effects. Recent reforms to reduce congestion in the Chinese medical market were not effective. Most of them had no impact on and did not involve the existing distorted incentive structure. Future reforms should consider rebalancing expectations for medical quality, free flow of human capital and price regulation reforms to rebuild a new incentive structure.