上海市医院规模和布局建设现状分析与评价研究
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摘要
一、研究背景
(一)医改背景下医院规模和布局建设进展和效果应及时总结和评价
在我国,众所周知,“看病贵、看病难”已被定位为重大民生问题,国家为此进行了新一轮的医药卫生体制改革,提高基本医疗卫生服务可及性是其近期目标之一,推进公立医院改革试点是新医改近期(2009-2011年)五项重点改革内容,其意义在于“提高公立医疗机构服务水平,努力解决群众‘看好病’问题”,“适度规模”、“合理布局”被确立为公立医院试点改革的指导思想和要求。新医改背景下,医院规模和布局建设至少有两点需要深入研究,一是各地医院规模和布局建设的进展情况,二是“适度规模”、“合理布局”的评价问题。
(二)上海市医院规模和布局建设具有特殊性,其建设效果亟需评价
上海市医院建设面临较特殊的外部环境。上海市早在1997年就明确了由城市医疗中心和社区卫生服务中心构成新的城市医疗卫生服务体系改革目标,其后不断整合其医疗资源、不断调整辖区医院布局,域内医院规模和布局建设动作不断,其中影响和反响最大的是郊区三级综合医院建设项目(“5+3+1”)。为贯彻国家新一轮医改精神,上海市提出“完善医疗服务体系,优化医疗资源布局和结构,推进医疗资源整合,形成‘1560’就医圈”,以改善基本医疗服务可及性的改革与发展目标。上海市医院规模和布局建设分析和评价的任务更为紧迫。
(三)国内医院规模和布局测评视角、方法待发展,以服务卫生实践
规模经济性测评是医院规模研究的适宜方法。近些年来,国内医院规模经济研究趋于活跃,研究方法也趋于多样化,但还存在个别视角如动态研究案例少见、成本函数法研究案例和模型使用不够丰富、DEA法规模经济性多为技术效率测评副产出、核心问题结论不一致、样本医院地域有限等问题。另外、医院规模性受内外环境影响,其他国家的研究、以前的研究不能替代本地化、现阶段的研究。
传统的资源人口比值法和卫生公平性测评方法在区域内医院布局方面存在缺陷,空间可达性是区域内医院布局评价的适宜方法。国外卫生服务空间可达性的研究已较为成熟,方法多样、案例丰富,理论和实践应用广泛。近些年来,国内也积累少量研究案例,但总体上还处于起步阶段,受资料等限制,研究方法有限、规模偏小,学术意义大于应用意义,不能满足医院等布局决策实践需要。
二、研究目的
探索适宜的医院规模和布局评价方法,对上海市医院规模和布局建设情况进行系统分析和专题评价,为上海市医院规模和布局优化提供决策依据。具体而言,是在对医院规模、布局理论和方法进行梳理的基础上,总结和描述上海市医院规模、布局建设的背景与环境、过程与现状,探索和发展医院个体规模和区域内布局的适宜评价方法,对上海市二三级医院规模经济性进行测量,分析其影响因素,对上海市医院布局建设的核心内容即三级医院的空间可达性、公平性进行测评,综合理论和实证研究结果提出政策建议。
三、内容与方法
(一)总体特征
本研究的总体特征在于理论分析与实践分析相结合、历史回顾和现状描述相结合、定性研究与定量研究相结合、统计描述与统计推断相结合,多角度、多方法综合评价上海市医院规模和布局。
(二)研究内容、具体方法
1、医院规模、布局研究的理论分析与方法述评。此部分资料来源于国内外文献数据库文献,研究主要采用文献复习法,通过广泛的国内外文献阅读、梳理,对医院规模、布局研究的理论与方法进行归纳、总结和评价。
2、上海市医院规模、布局建设的背景与环境分析。此部分资料来源于规划文件及各种年鉴,研究综合运用文献复习法、统计描述法,对上海市城市发展规划和自然地理条件、经济社会人口交通与卫生情况进行分析。
3、上海市医院规模、布局建设的过程与现状分析。此部分资料来源于各种年鉴及官网资料,研究综合运用历史回顾和统计描述等手段,对上海市医院规模、布局建设的历史过程、现阶段发展现状进行总结、描述和分析。
4、上海市二三级医院的规模经济性测评及影响因素分析。此部分研究运用上海市卫生经济学会提供的50家二、三级公立医院经济运行数据,在对样本医院投入产出规模进行统计描述、分组比较的基础上,先对样本医院经济运行效益进行多指标逐项描述,采用因子分析法对其进行综合评价和单因素、多因素影响因素分析,再使用可变成本函数对其进行规模经济性、边际成本指标测算和单因素、多因素影响因素分析,最后使用DEA法CRS、VRS、NIRS、Malmquist指数等模型对其静态、动态规模经济和技术效率、成本效率进行测评和单因素、多因素影响因素分析,以全面把握医院规模经济性及其影响因素。
5、上海市三级(市级)医院的空间可达性测评及公平性分析。此部分资料来源于上海卫生局卫生监督所等官网资料、政府文件及新闻报道,并借助互联网地图服务商(搜狗地图)提供的API即应用程序编程接口和JavaScript程序代码进行地址解析、距离测算,基于欧式直线距离,使用最近距离、累积机会、引力可达性指数三种模型对上海市三级(市级)医院空间可达性进行测评,分析其地区差异、时间趋势及受益情况,并运用测算结果,使用变异系数、基尼系数、洛伦茨曲线、泰尔指数等技术工具对三级(市级)医院布局公平性进行了测评。
6、上海市医院规模、布局建设进一步优化的建议分析。此部分综合医院规模、布局建设理论分析结果、背景和环境分析结果、过程和现状分析结果、医院规模经济性和空间可达性及公平性测评结果,有针对性提出上海市医院规模、布局进一步优化调整的政策建议。
四、主要的研究结果、结论
(一)上海市城市发展大环境要求医院规模总量和空间布局做出调整
1、上海城市发展定位和经济社会发展形势要求增加医院资源配置总量
上海城市规划定位于“现代化国际大都市”、“国际经济、金融、贸易、航运中心”,在长三角地区中处于“核心”、“龙头”地位。其人口基数大,2010年常住人口2302.66万,外来人口比重大(38.67%,2010)、密集高(3632人/平方公里,2010)。经济运行平稳,发展较快,GDP增长率2005年以来一直大于8.2%。域内外交通便捷、有利出行。但其卫生发展滞后于人口和经济发展,2005-2010年累积增长率医生、床位数在16%左右,常住人口为21.82%、GDP为85.63%、财政收支在100%左右,人均可支配收入城市为71%、农村为65%、卫生系统业务量增长幅度达287-434%,卫生系统效率提升空间极小。
2、上海城市发展定位和经济社会发展形势要求改善郊区(县)医院配置
上海市城市化水平高,2009年城镇人口比重为88.6%,城乡一体化多中心都市区发展趋势明显,郊区(县)人口聚集,经济发展势头强劲。2010年郊区(县)常住人口数为1132.2万,比重69.7%,比2005年增长了42.7%和6.5%。2005年以来,郊区(县)GDP逐年增长率一直大于10%,高于市区。随着郊区化进程的推进,郊区人口规模还会增加,经济发展趋势也将更好。
(二)上海市医院规模和布局不断调整优化,依然存在问题
1、上海市医院规模、布局建设的过程与主要特点
1997年以来,上海医院规模和布局建设融入到上海市医药卫生改革进程之中,在建设新型城市医疗卫生服务体系的大背景下,先后受企业医院属地化改革、医疗机构联合重组改革特别是医院集团化运动、医疗机构分类管理、医院新一轮评审、医疗机构间对口支援、区域医疗联合体试点等项工作的影响和推动。其主要特点在于：政府主导和市场导向共存,政府主导为主；与城市总体发展和布局建设相配合、匹配；医院微观规模建设和整体布局调整相结合；医院规模、布局建设以公立三级医院为主；不同地域、级别的医院间的联系趋于紧密。
2、上海大医院规模扩张趋势明显,布局有所改善
上海市医院医生、床位绝对数、相对比重呈上升趋势,2000-2010年床位累计增长48.46%、医生累计增长19.41%,2010年医院医生、床位比重依次为80.72%和61.81%。800张以上张床位医院占百张以上床位医院比重由2003年7.14%增至2010年15.06%,500张以上床位医院比重36.75%,仅略低于北京39.13%水平。三级(市级)医院数和执业点数均在增加,并通过医院集团等方式影响其他医疗机构,用其名称冠名的医院分院、门诊部数量增加,市场控制力增强。“5+3+1”建设项目、部分三级医院搬迁、设分院等改善医院特别是三级医院的空间布局。
3、上海市医院规模、布局建设依然存在的问题
突出的问题在于是郊区(县)医院特别是三级医院资源不足问题依然存在。城市建设重心向郊区转移带来人口格局的改变,2010年郊区(县)人口1132.2万,比重69.7%,比2005年增长42.7%和6.5%。2010年中心城区医院每万人口床位数在52.53-209.69之间,高于广大郊区(县)18.62-49.41水平,中心城区该指标普遍增长,郊区(县)则普遍在下降。三级(市级)医院执业点主要分布在中心城区。其他问题还包括：上海市医院规模、布局建设与上海城市的规划定位要求还有差距；以公立三级医院为主,市场垄断程度加深；加剧产权和管理关系复杂性,管理难度大；需注意老品牌稀释、新品牌建设问题；面临医保预付制约束；未触动医院补偿机制,群众获益有限；有助长现有就医秩序的问题等。
(三)医院具有规模经济性,但规模过大会产生规模报酬递减
1、样本医院投入产出规模分析与比较
市级样本医院的规模明显大于区级医院。2008-2010年间医院固定资产、服务提供、收入支出规模扩张较为明显,特别是市级医院,医院人员和床位投入增加不明显。市区两级医院“以药养医”补偿机制无改变,药品收入比重在45-47%。
2、经济运行效益指标描述分析与比较
从住院服务效率与工作负荷、货币投入和收支比值、业务收支比和要素补偿比率、资产水平与盈余发展能力、服务单元费用等几个方面对样本医院经济运行效益进行指标描述,显示市级医院在住院服务效率、经济补偿和资产收益等方面具有优势,区级医院在单元费用、净资产增长方面更具有优势。
3、应用因子分析法综合评价经济运行效益及影响因素
医院经济运行效益与规模高度相关,因子总得分与核定床位数的相关系数为0.784,市级(三级)医院高于区级(二级)医院。综合单因素与多因素分析结果,因子得分与Roemer指数、是否是附属医院、是否是西医院、(区级医院)冠名是否有市级医院、医院是否在市区、(市级医院)是否具有郊区分院等无关。
4、基于成本函数法医院规模经济性测评和影响因素分析
2010年样本医院门急诊边际成本、住院边际成本、短期规模报酬、长期规模经济均值依次为310.28元、14146.29元、0.99、0.84,前两者在增加、后两者在下降。2010年50家医院短期规模报酬、长期规模经济大于1的医院比重依次为44%、24%。研究支持规模过大医院会产生规模不经济的结论,规模不经济在住院边际成本、长期规模经济和2010年更为明显。区级医院是否在市区、是否有市级医院冠名对门急诊边际成本的影响有统计意义。
5、基于数据包络法医院规模经济性测评和影响因素分析
样本医院2010年DEA法规模效率、CRS技术效率、成本效率平均值依次为0.970、0.837、0.741,规模报酬递减医院数33个。2008-2010年规模报酬改变指数为1.0113,全要素生产率Malmquist指数为1.0301。医院规模效率值抛物线特征明显。医院规模与CRS技术效率、成本效率两指数有关但不呈简单线性关系。规模过大引起规模报酬递减。Roemer指数对CRS技术效率有影响。时间因素对成本效率、规模报酬区间分布有影响。
因子分析法综合评价、成本函数法、DEA法研究结果均证实规模经济的存在,但成本函数法和DEA法研究结果不支持医院规模经济无限存在的假设,证实医院规模过大也产生规模报酬递减,变化的规模成本函数法短期均衡和DEA法在500张左右核定床位数,成本函数法长期均衡和边际成本在1-000张左右。
(四)上海三级(市级)医院可达性、公平性在改善,但地区差异依然大
1、基于最近距离法可达性测评结果与结论
2012年预期与2007年相比,全市有一半的街道、乡镇到三级(市级)医院最近距离降低,涉及1157万人口数,以崇明县、奉贤区、嘉定区、浦东新区最近距离下降最为明显,其他郊区次之,最后是市区,市区有5个区没有受影响。2012年底预期各街道、乡镇到三级(市级)医院最近距离在169.43-35169.87米之间,均值为6666.47米,最近距离均值郊区(县)是市区6.36倍,浦东地区、扩展区、郊区、崇明三岛地区是市区倍数依次为5.43、3.02、1.17、2.32。
2、基于累积机会法可达性测评结果与结论
2012年预期与2007年相比,全市5000米、10000米、20000米、50000米、100000米阈值水平下到三级(市级)医院累积机会均值增长依次为0.45、1.63、4.62、12.29、14.98。各地区累积机会增加是有差异的,市区在20000米以下各阈值显著高于郊区(县),地区间累积机会的离散程度不是在下降,而是在增加,尤以20000米阈值最为明显。2012年底预期全市在5000米、10000米、20000米、50000米、100000米阈值水平下累积机会均值依次为4.91、13.35、26.22、50.47、57.92。累积机会市区一直高于郊区(县),郊区(县)基本呈扩展区最高、浦东地区次之,郊区再次之、崇明三岛地区最差的态势。
3、基于引力模型法可达性测评结果与结论
2012年预期与2007年相比,全市各街道、乡镇到三级(市级)医院引力可达性指数几乎100%增长。当β=1时,2007、2011、2012年全市引力可达性指数均值依次为1.24、1.39、1.70,累积增长率为37.10%,当β=1.2时,2007、2011、2012年依次为1.26、1.41、1.72,累积增长率为36.51%。当β=1时,2007、2011、2012年市区与郊区(县)引力可达性指数均值倍数关系依次为3.68、3.53、2.79,当β=1.2时依次为4.76、4.52、3.32。郊区(县)各地区街道、乡镇到三级(市级)医院的引力可达性指数内部差异在拉大,2007-2012年浦东地区、扩展区、郊区、崇明三岛地区该指标标准差累积增长量当β=1时依次为0.09、0.02、0.06、0.25,当β=1.2时依次为0.11、0.02、0.05、0.50。
4、基于可达性指标的公平性测评结果与结论
以最近距离、10000米阈值累积机会、20000米阈值累积机会、β=1和β=1.2引力可达性指数为分析指标,使用变异系数、基尼系数、泰尔指数和洛伦茨曲线分析工具,对上海市三级(市级)医院空间布局公平性进行测评分析,显示上海市三级(市级)医院空间布局公平性趋于改善,不公平主要来源于地区间差异。以β=1引力可达性指数为例,2007、2011、2012年变异系数依次为0.832、0.793、0.654,基尼系数依次为0.510、0.496、0.413,泰尔指数依次为0.149、0.145、0.101,区域间泰尔指数对总泰尔指数的贡献率依次是75.17%、77.24%、72.28%,洛伦茨曲线2012年最接近对角线,其次是2011年、2007年。
动态分析显示,郊区(县)各街道、乡镇到三级(市级)医院最近距离、累积机会、引力可达性指数普遍改善,彰显“5+3+1”建设项目及个别医院设分院等行为对郊区(县)优质医院资源缺乏状态改进成效显著,基于最近距离、累积机会、引力可达性指数的相对公平指标趋于更优,提示医院布局更趋公平。
五、研究的政策启示
1、与上海经济社会人口发展形势相适应,提高医院资源总量配置水平；
2、继续改善郊区(县)医院资源配置水平与质量,改善医院布局公平；
3、适当控制医院规模,使医院规模扩张与医院能力、技术发展相适应；
4、推进医药卫生体制改革,使医院规模和布局调整成效取得更大效益。
六、研究创新与价值
1、本研究对医院规模和布局建设评价方法进行了探索和应用：
研究者综合性应用了一套基于卫生统计常规数据多视角测评医院规模经济性的方法。具体包括采取经济运行效益逐项描述和综合评价,基于成本函数法测算门急诊、住院服务边际成本、短期规模报酬、规模经济指标,基于数据包络分析测算规模效率指数、动态变动指数及其他效率指数。
研究者综合性应用了一套基于街道、乡镇尺度、基于地理信息系统(GIS)获取地理资料、基于空间可达性视角的医院布局适宜性测评方法。该方法借鉴地理学理论和方法,借助互联网地图服务商API功能获取居民点到医院的距离资料,用最近距离、累积机会、引力可达性指数评价医院布局。
并通过对上海数据的分析,使评价更全面,结果更有说服力。评价方法对其他地区医院规模和布局建设的评价也有借鉴意义。
2、本研究对上海市二、三级医院规模和布局建设的背景与环境、过程和现状进行了系统分析,对医院规模经济性和布局公平性进行了专题评价,结合理论分析结果提出了几点建设性建议。
3、本研究分析了区级医院是否有市级医院冠名、市级医院是否设立郊区分院等因素与医院规模经济性指标的联系,丰富了医院规模经济性研究。
七、研究不足与展望
1、受样本量和数据限制,医院规模经济性测评和影响因素分析部分,某些分析没法深入展开,如病例组合差异对医院规模经济的影响等；
2、医院规模经济综合评价指标和权重的确定基于统计学方法,是否科学合理,还有待于在更多的实践中加以应用,接受实践检验；
3、上海市医院规模和布局建设以三级医院为主,因时间限制,本研究主要测评了三级(市级)医院空间可达性,二级医院的测评有待下一步继续进行。
1Background
1.1Construction progress and effectiveness of hospital size and layout should be summarized and evaluated under the background of health care reform
In our country, the difficulty and high cost of seeing a doctor had been positioned as a major livelihood issues. In order to dissolve this issues, central government had launched a new round reform on the medical and health system, improving the accessibility of fundamental health care is one of the reform immediate goals, promote public hospital reform pilot program is one of five key elements of reform in recently (2009-2011). The significance of the public hospital reform pilot program is "'to improve the standard of service of public medical institutions, make great efforts to dissolve the problem of curing the diseases,"moderate scale", and" rational layout" were basic guiding ideology and demand of public hospital reform pilot program Under the background of the new medical reform, at least two points need in-depth study around hospital size and layout, the first was how about hospital size and layout building progress in all regions, the second was how to evaluate "moderate scale","rational distribution".
1.2Shanghai hospital size and layout building is unique, the urgent need for evaluation of the construction effects
Shanghai hospital building had more special external environment. In Shanghai as early as in1997, government had explicated the objectives to establish urban medical service system composing with community health centers and urban medical centers. From then on, Shanghai government integrated the medical resources and adjusted the layout of hospital uninterrupted within the region, the action of construct scale and layout of the area hospitals continuous. The impact and repercussions of the largestwas was "5+3+1" suburbs three hospital building projects.To implement the country's spirit of the new round of medical reform, Shanghai proposed to improve the health care system to optimize the layout and structure of health care resources, and promote the integration of health care resources, the formation of the "1560" medical circles "to improve basic medical services accessibility as it reform and development goals. Shanghai hospital size and layout building analysis and evaluation were more urgent.
1.3Domestic study on hospital size and layout evaluation perspective and method need to be developed to serve the health practice
The measurement of scale economies is appropriate method of study scale. In recent year, the study of scale economies effective of hospital was getting active in our country, variety of methods had been used, but there were some problems, such as the cases of some point of view was scare, the study and model used by cost function was not abundant, the scale economies study using DEA often were assistant product of technology efficacy measurement, some important problem conclusions were not inconformity, the region of hospital were finitude, etc. The scale economies of hospital were influenced by the inside and outside environment of hospital, the study of other country and region can't substitute the study of our country, preciously study can't not substitute study at present.
Traditional method of study of hospital layout included provider-population ratio and equity measurement of health resources, those methods had limitations. The measurement of spatial accessibility was a good method for studying this problem. In western country the study of health care spatial accessibility had very matured, there were a lot of models and study cases, had a very widely practical application. In recent year, our country had some study cases with applying the methods of health care spatial accessibility, but the number of cases was small and the types of study model was limited, the study scale often little, the academic significance exceeded the practical significance, this situation can't satisfy the demand of hospital layout decision in the practices environment.
2Objectives
This study would explored and developed methods of evaluation on the hospitals individual size and layout within the region, empirical analyzed and evaluated the development of hospital size and layout in Shanghai, put forward some advice on the development of hospital size and layout in Shanghai. In order to get this goal, the study would summarize hospital size and layout's theories and methods of firstly, the study would also summarize and describe hospital size and layout development's environment, background, procedure and status in quo In Shanghai secondly, and most important parts of this study were the study would be to measure the hospital scale economies and analyze theirs influencing factors effect, would be to measure hospital spatial accessibilities and evaluate theirs influences on equity. Finality, the study would put forward some advice on the development of hospital size and layout in Shanghai.
3Content and Methods
3.1Overall Characteristic of the Study
Overall characteristic of this study lied the united use of theories analysis and practices study, the combination of history reviews and status in quo descriptions, the united use of qualitative and quantitative analysis, the incorporation of statistical description and statistical inference, studying those problems with multi-dimension and various kinds of methods comprehensively.
3.1Content and Definite Methods
3.1.1Reviews on the hospital size and layout's theories and methods. In this part, the maternities were domestic and overseas literature on the hospital size and layout's theories and methods, author would read and review them.
3.1.2Analysis on the environment, background of the development of hospital size and layout. In this part, the data including city planning of Shanghai, all kinds of yearbooks and scholarly literature were analyzed, the situation of Shanghai city development on city planning, physical geography, economic social population and health status in quo were summarized.
3.1.3Analysis on the procedure and status in quo of the development of hospital size and layout. In this part, the data from all kinds of yearbooks, scholarly literature and website of hospital and government health department on the procedure and status in quo of the development of hospital size and layout were analyzed and summarized.
3.1.4Measurement on the scale economies of secondary and tertiary hospitals in Shanghai and the analysis on theirs influencing factors effect. In this part, the data of50secondary and tertiary hospitals on the economic operation from Shanghai health economic society were analyzed. The study content and methods including:Statistical description and grouping comparative on hospitals input and output scale; Indicator statistical description and grouping comparative on hospitals economic operation efficiency; Comprehensive evaluation on hospitals economic operation efficiency by factor analysis method and the analysis on theirs influencing factors effect; Measurement the scale economies of hospitals by cost function coefficient evaluating and calculating marginal cost indicators and scale economies indicators based on cost function coefficient and the analysis on theirs influencing factors effect; Measurement the scale economies of hospitals by calculating scale economies, technology efficiency and cost efficiency indicators through DEA models of CRS、VRS、NIRS、 Malmquist productivity index, etc. And analyzing on theirs influencing factors effect. All the analysis no the influences factors effect including single factor analysis and multivariate analysis.
3.1.5Measurement on the hospital spatial accessibilities and the assessment of theirs influences on equity. This part of data comes from the Shanghai Health Bureau of Health supervision official website, government documents and news reports. The study measured and assessed hospitals spatial accessibilities by making use of the API that is, application of procedures programming interface provided by the Internet map service providers (Sogou Map) and JavaScript program code carried Address Resolution, distance calculation, applying three models of spatial accessibilities that were, the closest distance, the cumulative opportunities, gravity index based on European straight-line distance. After that, Authors calculated coefficient of variation, the Gini Coefficient, Lorenz Curve and Their s index using the calculation results of spatial accessibilities.
3.1.6Recommendations to further optimize Shanghai hospital size and layout. In this part, author synthesize theoretical analysis of hospital size and layout, background and environmental analysis of shanghai hospital size and layout, process and status quo analysis of shanghai hospital size and layout, hospital economies of scale and spatial accessibility and fairness of hospital layout, put forward some recommendations to further optimize Shanghai hospital size and layout.
4Major findings, conclusions
4.1Urban development orientation and economic and social development situation calls for hospital total resources and layout to make adjustments
4.1.1Shanghai urban development orientation, and economic and social development situation calls for increased total hospital resource allocation
Shanghai's Urban Planning orientation was to build "a modern international metropolis "," international economic, financial, trade and shipping center ". Shanghai city was the "core" and "leading" in the Yangtze River Delta region. Its population base was large,23,026,600resident population in2010. The immigrant population proportion was high, with38.67%in2010. Population dense was high,3632people/square kilometers in2010. Its convenient transportation favored travelling. Health development is lagging behind population and economic development.2005-2010cumulative growth rate of doctors, number of beds were about16%, with resident population21.82%and for GDP85.63%, fiscal revenue and expenditure of around100%, urban per capita disposable income of71%,65%in rural areas, the health systems work volume287-434%, significantly higher than the investment of resourcesgrowth, the space of the medical and health facilities efficiency enhance would be small.
4.1.2Urban development orientation and economic and social development situation requires to improve the allocation of the suburbs (County) Hospitals
The proportion of urban population in Shanghai in2009was88.6%this meaned high level of urbanization. Shanghai has formulated the development planning of urban and rural integration, multi-center metropolitan area. Its suburban population concentred, its momentum of economic development was strong. Suburbs (counties) resident population in2010was11,322,000; its proportion was69.7%,42.7%and6.5%growth over2005. Since2005, its every year GDP growth rate had been greater than10%, Higher than urban. With the advance of the process of suburbanization, suburban population size would be increase, the trend of economic development also be better.
4.2Shanghai hospital size and layout adjust constantly, made great achievements, but the problem persists
4.2.1Shanghai hospital size and layout building process and features
Since1997, Shanghai hospital size and layout building had blend into Shanghai medical and health reform process in the background of the construction of new urban medical service system, this building process were influenced and promoted by a lot of reform action such as the localization reform of enterprise hospital, medical institutions consolidation and reorganization in particular the hospital group movement, classified management of medical institutions, medical institutions counterpart support, the Regional Medical Commonwealth pilot and other work. Its main features are:government-led and market-oriented co-exist, government-led is major; compatible with the overall urban development and layout building; combination of hospital micro-scale construction and the overall adjustment of layout; hospital size and layout the building main body is the public tertiary hospitals; tends to close links between the different regions, different levels of hospitals.
4.2.2Shanghai hospital expansion was evident, the layout has improved
Shanghai hospital's doctors and beds were increased year by year in absolute numbers and in relative proportion. In the2000-2010decade, cumulative growth rate of beds was48.46%, doctors was19.41%. In2010, the proportions of hospital doctors, beds were80.72%and61.81%respectively. Hospitals proportions more than800beds of hospitals more than one hundred beds accounted for from7.14%in2003to15.06%in2010. Hospitals proportion more than500beds accounted for36.75%, only slightly lower than the39.13%level in Beijing. Numbers of Tertiary (municipal) hospitals and theirs practice point were increasing both. Tertiary (municipal) hospital's influence over other medical establishment increased by way of hospital group and other ways, the numbers of Hospital Branch and out-patient department having tertiary (municipal) hospital name in their title increased."5+3+1" construction projects, and the earlier some individual tertiary hospitals relocation, setting Branch, etc. improved the hospital, especially tertiary hospital's layout.
4.2.3Shanghai hospital size and layout construction process problems
Prominent problem was hospitals resources especially three hospitals resource in suburbs (counties) was inadequate.The emphasis of city construction transfering from the city center to the suburbs brought the population distribution pattern changed,2010suburbs population was11.322million,69.7%percent,42.7%and6.5%growth over2005. the number of beds per million population in the central city hospital in2010were52.53-209.69, higher than18.62-49.41in suburbs (counties), Index in the central city were increase, Index in suburbs (counties) were are on the decline. Tertiary (municipal) hospital practice points are mainly distributed in the central city. Other issues include:the Shanghai hospital size and the layout were still lagging behind Shanghai Urban Planning and positioning requirements; tertiary hospitals had a deeper level of monopolization of the market; Shanghai hospital size and layout construction exacerbated the complexity of the property right's relationship and management's relationship, difficult to manage; should pay attention to dilution of the old brand, new brand-building; constraints from the Medicare prospective payment; untouched hospital compensation mechanism reform, the masses benefit was limited; issue of contributing to the existing medical orderly.
4.3The hospital has economies of scale, too big might occur decreasing returns to scale
4.3.1Input-output scale analysis and comparison of sample hospitals
The size of the municipal sample hospitals was significantly greater than the scale of district hospitals.2008-2010. the hospital fixed assets, service provided, income and expenditure expansion were more obvious, especially the municipal hospital, hospital staff and beds investment increase is not obvious. Proportion of the drug incomes were45-47%,"drugs to support medical'"s compensation mechanism remains unchanged in2008-2010.
4.3.2The economic operation efficiency indicators characterization analysis and comparison
Description from the efficiency and workload of hospital services, the money invested and the income and expenditure ratio, the ratio of operating income, and elements of compensation ratio, the level of assets and surplus development capacity, the service unit costs, the economic and operational benefits of the sample hospitals indicators showed that City level hospital had an advantage in-patient services efficiency, financial compensation and return on assets, district hospitals has more cheap on unit costs, higher on the net asset growth.
4.3.3Factor analysis of the economic operational benefits and influencing factors analysis
Hospital economic operation efficiency and scale were height correlated, factor total score and the approved number of beds correlation coefficient is0.784. Municipal tertiary hospital's score were higher than the district-level, namely secondary hospitals'. Comprehensive analysis outcomes from single factor and multi-factor, factor total score was unrelated with factors such as Roemer index, whether Affiliated Hospital, West hospital or not,(district hospitals) naming a municipal hospital or not, the hospital is in the urban areas or not,(municipal hospitals) whether having suburbs branch and so on.
4.3.4Cost function method hospital evaluation of the economies of scale and analysis of influencing factors
The marginal cost of the sample of hospital in2010of outpatient and emergency, marginal costs of in-patient short-term returns to scale, long-term economies of scale in turn was310.28yuan,14146.29yuan,0.99,0.84, with the former two were increasing and the latter two were in the fall. In2010the proportion of hospital's short-term returns to scale, long-term economies of scale greater than1are44%and24%respectively in50hospitals. The study supports the conclusions that if the hospital size is too lager may lead to diseconomies of scale, diseconomies of scale happened more in hospital marginal costs, long-term economies of scale, in2010. District-level hospital position and title had statistical significance on marginal cost of outpatient and emergency.
4.3.5Hospital economies of scale evaluation by data envelopment analysis and impact factor analysis
Sample hospitals in2010the DEA scale efficiency, the CRS cost efficiency, cost efficiency average in turn were0.970,0.837.0.741, number of hospitals decreasing returns to scale was33.2008-2010, returns to scale change index was1.0113, and the total factor productivity Malmquist index was1.0301. Hospital scale efficiency value was the parabolic shape. Hospital size had related with CRS technical efficiency, cost efficiency, but not a simple linear relationship. Scale is too large to cause decreasing returns to scale. The Roemer Index affected the CRS technical efficiency. The time was the influence factor on the cost-efficiency, returns to scale range.
Comprehensive analysis on findings from factor analysis evaluation, cost function and DEA confirmed the existence of economies of scale, but the findings from cost function and DEA does not support the assumption of infinite existence of hospital scale, confirmed that the scale is too large to produce decreasing returns to scale. Its turning point of the short-term balance of the cost function method and DEA method were500approved beds, the long-run equilibrium and the marginal cost of the cost function method were1000approved beds.
4.4Shanghai hospital accessibility, fairness had improved, but still had large regional differences
4.4.1The results and conclusions based on nearest distance method
To compared with2007, the city's half of the street, township nearest distance to tertiary (municipal) hospitals would be reduced by2012expected, involving11.57million population,. Chongming County, Fengxian District, Jiading District, Pudong New Area, nearest distance dropped most obvious, followed by the other suburbs, finally were urban five districts. Expected by the end of2012, nearest distance of the streets, villages and towns to the tertiary (municipal) hospital ranged169.43-35169.87m, an average of6666.47m, the nearest distance mean of suburbs (county) is6.36times the urban, the nearest distance mean of Pudong district, Expansion area, Suburban and Chongming county area in turn were5.43,3.02,1.17,2.32to urban ones.
4.4.2The results and conclusions based on cumulative opportunity method
To compared with2007, in2012expected city's the cumulative opportunity mean growth in the threshold level of5000m,10000m,20000m,50000m and100,000meters to tertiary (municipal) hospitals followed by0.45,1.63.4.62,12.2914.98. Regional cumulative opportunity growth were different, urban area's cumulative opportunity growth in the20,000m threshold significantly higher than the suburbs (counties), cumulative opportunities in the regional degree of dispersion was not declining, but increasing, especially in the20,000m threshold. Expected by the end of2012the city's cumulative opportunity mean in the threshold level of5000m,10,000m,20,000m.50,000m and100,000m in turn were4.91,13.35,26.22,50.47,57.92. Cumulative opportunity to urban areas had been higher than the suburbs (counties), expansion area was highest in suburbs (counties), following was Pudong area, Suburban and Chongming county was poorer.
4.4.3The results and conclusions based on gravity model method
To compared with2007, in2012expected city's the accessibility index to tertiary (municipal) hospitals were almost100%increased. When P=1,2007,2011,2012's gravity index mean in turn were1.24,1.39,1.70, cumulative growth rate was37.10%; when β=1.2,2007,2011,2012's gravity index mean in turn were1.26,1.41,1.72, the accumulated growth rate was36.51%. When β=1, in2007,2011and2012, multiple relationship of urban and rural areas (counties)" s gravity index mean in turn were3.68,3.53,2.79, when β=1.2followed by4.76,4.52,3.32. The differences of the street and town's gravity index to the tertiary (municipal) hospital in the suburbs (counties) regions were pulled large,2007,2011,2012's standard deviation of the amount of cumulative growth in Pudong area, Expansion area, the suburbs, Chongming county in turn were0.09,0.02,0.06,0.25when β=1,0.11,0.02,0.05,0.50when β=1.2.
4.4.4The results and conclusions of equity evaluation based on accessibility
Indicators including closest distance,10000m threshold's cumulative opportunity,20000m threshold's cumulative opportunity, gravity index when β=1and β=1.2were used to calculated the coefficient of variation, the Gini coefficient, Theil's index and the Lorenz curve for the equity evaluation, Shanghai tertiary (municipal) hospital space layout fairness tended to improve, unfair derived from the differences between regions. Gove gravity index when β=1for example,2007、2011、2012's variation coefficients were0.832,0.793,0.654respectively, Gini coefficients were0.510,0.496,0.413, the Theil's index were0.149,0.145,0.101, Contribution rates of region differences to the total Theil index were75.17%,77.24%,72.28%, the2012Lorenz curve closest to the diagonal, followed in2011,2007.
5Policy Significances
5.1Compatible with the economic and socio-demographic developments, to improve the level of total hospital resources allocation;
5.2Continue to improve the suburbs (county) level and quality of hospital resource allocation, to ameliorate hospital layout equity;
5.3To control of hospital size properly, hospital expansion are compatible with hospital capacity and technology development;
5.4To promote the medical and health system reform, making benefit of hospital size and layout adjustment to get greater efficiency.
6Research Innovation
6.1Evaluation methods on hospital size and layout are explored and applied:
6.1.1The researchers applied a set of methods of evaluation on hospital economies of scale based on health statistics conventional data with multi-view. The methods including:Itemized description and comprehensive evaluation of the economic operation effect; Estimates of outpatient and emergency hospital services to marginal cost, short-term returns to scale, the scale of economic indicators based on the cost function method; Estimated scale efficiency index, the dynamic change index and other kind of efficiency indexs based on data envelopment analysis.
6.1.2The researchers applied a set of methods with a scale of streets, towns, based on the geographic information system (GIS) access to distances information, of evaluation on the layout of the hospital based on spatial accessibility perspective. This method borrowing ideas from geography theory and methods, with the help of the Internet map service provider API function, based geographic information system (GIS) to obtain the distance information from settlements to hospitals, applying of a variety of models to measure spatial accessibility to the tertiary (municipal) hospitals in Shanghai, to evaluate layout fair based on these measurement.
6.2This study systems analyzed the background and environmentof, process and status of Shanghai secondary, tertiary hospital's size and layout, thematic evaluation on hospital's size and layout were made, put forward some constructive suggestions based on research results.
6.3This study analyzed whether there is contact between factors such as whether the district hospitals had municipal hospitals title, whether municipal hospitals seted suburbs branch and other factors and hospital indicators of the economies of scale, enriching the studys of hospital economies of scale.
7Limitations
7.1By sample size and data limitations, hospital economies of scale evaluation and impact factor analysis section, some analysis can not expand in depth, such as case mix differences in hospital economies of scale;
7.2The indicators and weights determined based on the statistical method in comprehensive evaluation of hospital economies of scale, wether it was scientific and rational, yet to be applied in more practice, to accept the test of practice;
7.3Shanghai hospital size and layout's building are tertiary hospital-based, due to time constraints, study only evaluated the tertiary (municipal) hospital accessibility, two hospital evaluation to be next to continue.
(一)医改背景下医院规模和布局建设进展和效果应及时总结和评价
在我国,众所周知,“看病贵、看病难”已被定位为重大民生问题,国家为此进行了新一轮的医药卫生体制改革,提高基本医疗卫生服务可及性是其近期目标之一,推进公立医院改革试点是新医改近期(2009-2011年)五项重点改革内容,其意义在于“提高公立医疗机构服务水平,努力解决群众‘看好病’问题”,“适度规模”、“合理布局”被确立为公立医院试点改革的指导思想和要求。新医改背景下,医院规模和布局建设至少有两点需要深入研究,一是各地医院规模和布局建设的进展情况,二是“适度规模”、“合理布局”的评价问题。
(二)上海市医院规模和布局建设具有特殊性,其建设效果亟需评价
上海市医院建设面临较特殊的外部环境。上海市早在1997年就明确了由城市医疗中心和社区卫生服务中心构成新的城市医疗卫生服务体系改革目标,其后不断整合其医疗资源、不断调整辖区医院布局,域内医院规模和布局建设动作不断,其中影响和反响最大的是郊区三级综合医院建设项目(“5+3+1”)。为贯彻国家新一轮医改精神,上海市提出“完善医疗服务体系,优化医疗资源布局和结构,推进医疗资源整合,形成‘1560’就医圈”,以改善基本医疗服务可及性的改革与发展目标。上海市医院规模和布局建设分析和评价的任务更为紧迫。
(三)国内医院规模和布局测评视角、方法待发展,以服务卫生实践
规模经济性测评是医院规模研究的适宜方法。近些年来,国内医院规模经济研究趋于活跃,研究方法也趋于多样化,但还存在个别视角如动态研究案例少见、成本函数法研究案例和模型使用不够丰富、DEA法规模经济性多为技术效率测评副产出、核心问题结论不一致、样本医院地域有限等问题。另外、医院规模性受内外环境影响,其他国家的研究、以前的研究不能替代本地化、现阶段的研究。
传统的资源人口比值法和卫生公平性测评方法在区域内医院布局方面存在缺陷,空间可达性是区域内医院布局评价的适宜方法。国外卫生服务空间可达性的研究已较为成熟,方法多样、案例丰富,理论和实践应用广泛。近些年来,国内也积累少量研究案例,但总体上还处于起步阶段,受资料等限制,研究方法有限、规模偏小,学术意义大于应用意义,不能满足医院等布局决策实践需要。
二、研究目的
探索适宜的医院规模和布局评价方法,对上海市医院规模和布局建设情况进行系统分析和专题评价,为上海市医院规模和布局优化提供决策依据。具体而言,是在对医院规模、布局理论和方法进行梳理的基础上,总结和描述上海市医院规模、布局建设的背景与环境、过程与现状,探索和发展医院个体规模和区域内布局的适宜评价方法,对上海市二三级医院规模经济性进行测量,分析其影响因素,对上海市医院布局建设的核心内容即三级医院的空间可达性、公平性进行测评,综合理论和实证研究结果提出政策建议。
三、内容与方法
(一)总体特征
本研究的总体特征在于理论分析与实践分析相结合、历史回顾和现状描述相结合、定性研究与定量研究相结合、统计描述与统计推断相结合,多角度、多方法综合评价上海市医院规模和布局。
(二)研究内容、具体方法
1、医院规模、布局研究的理论分析与方法述评。此部分资料来源于国内外文献数据库文献,研究主要采用文献复习法,通过广泛的国内外文献阅读、梳理,对医院规模、布局研究的理论与方法进行归纳、总结和评价。
2、上海市医院规模、布局建设的背景与环境分析。此部分资料来源于规划文件及各种年鉴,研究综合运用文献复习法、统计描述法,对上海市城市发展规划和自然地理条件、经济社会人口交通与卫生情况进行分析。
3、上海市医院规模、布局建设的过程与现状分析。此部分资料来源于各种年鉴及官网资料,研究综合运用历史回顾和统计描述等手段,对上海市医院规模、布局建设的历史过程、现阶段发展现状进行总结、描述和分析。
4、上海市二三级医院的规模经济性测评及影响因素分析。此部分研究运用上海市卫生经济学会提供的50家二、三级公立医院经济运行数据,在对样本医院投入产出规模进行统计描述、分组比较的基础上,先对样本医院经济运行效益进行多指标逐项描述,采用因子分析法对其进行综合评价和单因素、多因素影响因素分析,再使用可变成本函数对其进行规模经济性、边际成本指标测算和单因素、多因素影响因素分析,最后使用DEA法CRS、VRS、NIRS、Malmquist指数等模型对其静态、动态规模经济和技术效率、成本效率进行测评和单因素、多因素影响因素分析,以全面把握医院规模经济性及其影响因素。
5、上海市三级(市级)医院的空间可达性测评及公平性分析。此部分资料来源于上海卫生局卫生监督所等官网资料、政府文件及新闻报道,并借助互联网地图服务商(搜狗地图)提供的API即应用程序编程接口和JavaScript程序代码进行地址解析、距离测算,基于欧式直线距离,使用最近距离、累积机会、引力可达性指数三种模型对上海市三级(市级)医院空间可达性进行测评,分析其地区差异、时间趋势及受益情况,并运用测算结果,使用变异系数、基尼系数、洛伦茨曲线、泰尔指数等技术工具对三级(市级)医院布局公平性进行了测评。
6、上海市医院规模、布局建设进一步优化的建议分析。此部分综合医院规模、布局建设理论分析结果、背景和环境分析结果、过程和现状分析结果、医院规模经济性和空间可达性及公平性测评结果,有针对性提出上海市医院规模、布局进一步优化调整的政策建议。
四、主要的研究结果、结论
(一)上海市城市发展大环境要求医院规模总量和空间布局做出调整
1、上海城市发展定位和经济社会发展形势要求增加医院资源配置总量
上海城市规划定位于“现代化国际大都市”、“国际经济、金融、贸易、航运中心”,在长三角地区中处于“核心”、“龙头”地位。其人口基数大,2010年常住人口2302.66万,外来人口比重大(38.67%,2010)、密集高(3632人/平方公里,2010)。经济运行平稳,发展较快,GDP增长率2005年以来一直大于8.2%。域内外交通便捷、有利出行。但其卫生发展滞后于人口和经济发展,2005-2010年累积增长率医生、床位数在16%左右,常住人口为21.82%、GDP为85.63%、财政收支在100%左右,人均可支配收入城市为71%、农村为65%、卫生系统业务量增长幅度达287-434%,卫生系统效率提升空间极小。
2、上海城市发展定位和经济社会发展形势要求改善郊区(县)医院配置
上海市城市化水平高,2009年城镇人口比重为88.6%,城乡一体化多中心都市区发展趋势明显,郊区(县)人口聚集,经济发展势头强劲。2010年郊区(县)常住人口数为1132.2万,比重69.7%,比2005年增长了42.7%和6.5%。2005年以来,郊区(县)GDP逐年增长率一直大于10%,高于市区。随着郊区化进程的推进,郊区人口规模还会增加,经济发展趋势也将更好。
(二)上海市医院规模和布局不断调整优化,依然存在问题
1、上海市医院规模、布局建设的过程与主要特点
1997年以来,上海医院规模和布局建设融入到上海市医药卫生改革进程之中,在建设新型城市医疗卫生服务体系的大背景下,先后受企业医院属地化改革、医疗机构联合重组改革特别是医院集团化运动、医疗机构分类管理、医院新一轮评审、医疗机构间对口支援、区域医疗联合体试点等项工作的影响和推动。其主要特点在于：政府主导和市场导向共存,政府主导为主；与城市总体发展和布局建设相配合、匹配；医院微观规模建设和整体布局调整相结合；医院规模、布局建设以公立三级医院为主；不同地域、级别的医院间的联系趋于紧密。
2、上海大医院规模扩张趋势明显,布局有所改善
上海市医院医生、床位绝对数、相对比重呈上升趋势,2000-2010年床位累计增长48.46%、医生累计增长19.41%,2010年医院医生、床位比重依次为80.72%和61.81%。800张以上张床位医院占百张以上床位医院比重由2003年7.14%增至2010年15.06%,500张以上床位医院比重36.75%,仅略低于北京39.13%水平。三级(市级)医院数和执业点数均在增加,并通过医院集团等方式影响其他医疗机构,用其名称冠名的医院分院、门诊部数量增加,市场控制力增强。“5+3+1”建设项目、部分三级医院搬迁、设分院等改善医院特别是三级医院的空间布局。
3、上海市医院规模、布局建设依然存在的问题
突出的问题在于是郊区(县)医院特别是三级医院资源不足问题依然存在。城市建设重心向郊区转移带来人口格局的改变,2010年郊区(县)人口1132.2万,比重69.7%,比2005年增长42.7%和6.5%。2010年中心城区医院每万人口床位数在52.53-209.69之间,高于广大郊区(县)18.62-49.41水平,中心城区该指标普遍增长,郊区(县)则普遍在下降。三级(市级)医院执业点主要分布在中心城区。其他问题还包括：上海市医院规模、布局建设与上海城市的规划定位要求还有差距；以公立三级医院为主,市场垄断程度加深；加剧产权和管理关系复杂性,管理难度大；需注意老品牌稀释、新品牌建设问题；面临医保预付制约束；未触动医院补偿机制,群众获益有限；有助长现有就医秩序的问题等。
(三)医院具有规模经济性,但规模过大会产生规模报酬递减
1、样本医院投入产出规模分析与比较
市级样本医院的规模明显大于区级医院。2008-2010年间医院固定资产、服务提供、收入支出规模扩张较为明显,特别是市级医院,医院人员和床位投入增加不明显。市区两级医院“以药养医”补偿机制无改变,药品收入比重在45-47%。
2、经济运行效益指标描述分析与比较
从住院服务效率与工作负荷、货币投入和收支比值、业务收支比和要素补偿比率、资产水平与盈余发展能力、服务单元费用等几个方面对样本医院经济运行效益进行指标描述,显示市级医院在住院服务效率、经济补偿和资产收益等方面具有优势,区级医院在单元费用、净资产增长方面更具有优势。
3、应用因子分析法综合评价经济运行效益及影响因素
医院经济运行效益与规模高度相关,因子总得分与核定床位数的相关系数为0.784,市级(三级)医院高于区级(二级)医院。综合单因素与多因素分析结果,因子得分与Roemer指数、是否是附属医院、是否是西医院、(区级医院)冠名是否有市级医院、医院是否在市区、(市级医院)是否具有郊区分院等无关。
4、基于成本函数法医院规模经济性测评和影响因素分析
2010年样本医院门急诊边际成本、住院边际成本、短期规模报酬、长期规模经济均值依次为310.28元、14146.29元、0.99、0.84,前两者在增加、后两者在下降。2010年50家医院短期规模报酬、长期规模经济大于1的医院比重依次为44%、24%。研究支持规模过大医院会产生规模不经济的结论,规模不经济在住院边际成本、长期规模经济和2010年更为明显。区级医院是否在市区、是否有市级医院冠名对门急诊边际成本的影响有统计意义。
5、基于数据包络法医院规模经济性测评和影响因素分析
样本医院2010年DEA法规模效率、CRS技术效率、成本效率平均值依次为0.970、0.837、0.741,规模报酬递减医院数33个。2008-2010年规模报酬改变指数为1.0113,全要素生产率Malmquist指数为1.0301。医院规模效率值抛物线特征明显。医院规模与CRS技术效率、成本效率两指数有关但不呈简单线性关系。规模过大引起规模报酬递减。Roemer指数对CRS技术效率有影响。时间因素对成本效率、规模报酬区间分布有影响。
因子分析法综合评价、成本函数法、DEA法研究结果均证实规模经济的存在,但成本函数法和DEA法研究结果不支持医院规模经济无限存在的假设,证实医院规模过大也产生规模报酬递减,变化的规模成本函数法短期均衡和DEA法在500张左右核定床位数,成本函数法长期均衡和边际成本在1-000张左右。
(四)上海三级(市级)医院可达性、公平性在改善,但地区差异依然大
1、基于最近距离法可达性测评结果与结论
2012年预期与2007年相比,全市有一半的街道、乡镇到三级(市级)医院最近距离降低,涉及1157万人口数,以崇明县、奉贤区、嘉定区、浦东新区最近距离下降最为明显,其他郊区次之,最后是市区,市区有5个区没有受影响。2012年底预期各街道、乡镇到三级(市级)医院最近距离在169.43-35169.87米之间,均值为6666.47米,最近距离均值郊区(县)是市区6.36倍,浦东地区、扩展区、郊区、崇明三岛地区是市区倍数依次为5.43、3.02、1.17、2.32。
2、基于累积机会法可达性测评结果与结论
2012年预期与2007年相比,全市5000米、10000米、20000米、50000米、100000米阈值水平下到三级(市级)医院累积机会均值增长依次为0.45、1.63、4.62、12.29、14.98。各地区累积机会增加是有差异的,市区在20000米以下各阈值显著高于郊区(县),地区间累积机会的离散程度不是在下降,而是在增加,尤以20000米阈值最为明显。2012年底预期全市在5000米、10000米、20000米、50000米、100000米阈值水平下累积机会均值依次为4.91、13.35、26.22、50.47、57.92。累积机会市区一直高于郊区(县),郊区(县)基本呈扩展区最高、浦东地区次之,郊区再次之、崇明三岛地区最差的态势。
3、基于引力模型法可达性测评结果与结论
2012年预期与2007年相比,全市各街道、乡镇到三级(市级)医院引力可达性指数几乎100%增长。当β=1时,2007、2011、2012年全市引力可达性指数均值依次为1.24、1.39、1.70,累积增长率为37.10%,当β=1.2时,2007、2011、2012年依次为1.26、1.41、1.72,累积增长率为36.51%。当β=1时,2007、2011、2012年市区与郊区(县)引力可达性指数均值倍数关系依次为3.68、3.53、2.79,当β=1.2时依次为4.76、4.52、3.32。郊区(县)各地区街道、乡镇到三级(市级)医院的引力可达性指数内部差异在拉大,2007-2012年浦东地区、扩展区、郊区、崇明三岛地区该指标标准差累积增长量当β=1时依次为0.09、0.02、0.06、0.25,当β=1.2时依次为0.11、0.02、0.05、0.50。
4、基于可达性指标的公平性测评结果与结论
以最近距离、10000米阈值累积机会、20000米阈值累积机会、β=1和β=1.2引力可达性指数为分析指标,使用变异系数、基尼系数、泰尔指数和洛伦茨曲线分析工具,对上海市三级(市级)医院空间布局公平性进行测评分析,显示上海市三级(市级)医院空间布局公平性趋于改善,不公平主要来源于地区间差异。以β=1引力可达性指数为例,2007、2011、2012年变异系数依次为0.832、0.793、0.654,基尼系数依次为0.510、0.496、0.413,泰尔指数依次为0.149、0.145、0.101,区域间泰尔指数对总泰尔指数的贡献率依次是75.17%、77.24%、72.28%,洛伦茨曲线2012年最接近对角线,其次是2011年、2007年。
动态分析显示,郊区(县)各街道、乡镇到三级(市级)医院最近距离、累积机会、引力可达性指数普遍改善,彰显“5+3+1”建设项目及个别医院设分院等行为对郊区(县)优质医院资源缺乏状态改进成效显著,基于最近距离、累积机会、引力可达性指数的相对公平指标趋于更优,提示医院布局更趋公平。
五、研究的政策启示
1、与上海经济社会人口发展形势相适应,提高医院资源总量配置水平；
2、继续改善郊区(县)医院资源配置水平与质量,改善医院布局公平；
3、适当控制医院规模,使医院规模扩张与医院能力、技术发展相适应；
4、推进医药卫生体制改革,使医院规模和布局调整成效取得更大效益。
六、研究创新与价值
1、本研究对医院规模和布局建设评价方法进行了探索和应用：
研究者综合性应用了一套基于卫生统计常规数据多视角测评医院规模经济性的方法。具体包括采取经济运行效益逐项描述和综合评价,基于成本函数法测算门急诊、住院服务边际成本、短期规模报酬、规模经济指标,基于数据包络分析测算规模效率指数、动态变动指数及其他效率指数。
研究者综合性应用了一套基于街道、乡镇尺度、基于地理信息系统(GIS)获取地理资料、基于空间可达性视角的医院布局适宜性测评方法。该方法借鉴地理学理论和方法,借助互联网地图服务商API功能获取居民点到医院的距离资料,用最近距离、累积机会、引力可达性指数评价医院布局。
并通过对上海数据的分析,使评价更全面,结果更有说服力。评价方法对其他地区医院规模和布局建设的评价也有借鉴意义。
2、本研究对上海市二、三级医院规模和布局建设的背景与环境、过程和现状进行了系统分析,对医院规模经济性和布局公平性进行了专题评价,结合理论分析结果提出了几点建设性建议。
3、本研究分析了区级医院是否有市级医院冠名、市级医院是否设立郊区分院等因素与医院规模经济性指标的联系,丰富了医院规模经济性研究。
七、研究不足与展望
1、受样本量和数据限制,医院规模经济性测评和影响因素分析部分,某些分析没法深入展开,如病例组合差异对医院规模经济的影响等；
2、医院规模经济综合评价指标和权重的确定基于统计学方法,是否科学合理,还有待于在更多的实践中加以应用,接受实践检验；
3、上海市医院规模和布局建设以三级医院为主,因时间限制,本研究主要测评了三级(市级)医院空间可达性,二级医院的测评有待下一步继续进行。
1Background
1.1Construction progress and effectiveness of hospital size and layout should be summarized and evaluated under the background of health care reform
In our country, the difficulty and high cost of seeing a doctor had been positioned as a major livelihood issues. In order to dissolve this issues, central government had launched a new round reform on the medical and health system, improving the accessibility of fundamental health care is one of the reform immediate goals, promote public hospital reform pilot program is one of five key elements of reform in recently (2009-2011). The significance of the public hospital reform pilot program is "'to improve the standard of service of public medical institutions, make great efforts to dissolve the problem of curing the diseases,"moderate scale", and" rational layout" were basic guiding ideology and demand of public hospital reform pilot program Under the background of the new medical reform, at least two points need in-depth study around hospital size and layout, the first was how about hospital size and layout building progress in all regions, the second was how to evaluate "moderate scale","rational distribution".
1.2Shanghai hospital size and layout building is unique, the urgent need for evaluation of the construction effects
Shanghai hospital building had more special external environment. In Shanghai as early as in1997, government had explicated the objectives to establish urban medical service system composing with community health centers and urban medical centers. From then on, Shanghai government integrated the medical resources and adjusted the layout of hospital uninterrupted within the region, the action of construct scale and layout of the area hospitals continuous. The impact and repercussions of the largestwas was "5+3+1" suburbs three hospital building projects.To implement the country's spirit of the new round of medical reform, Shanghai proposed to improve the health care system to optimize the layout and structure of health care resources, and promote the integration of health care resources, the formation of the "1560" medical circles "to improve basic medical services accessibility as it reform and development goals. Shanghai hospital size and layout building analysis and evaluation were more urgent.
1.3Domestic study on hospital size and layout evaluation perspective and method need to be developed to serve the health practice
The measurement of scale economies is appropriate method of study scale. In recent year, the study of scale economies effective of hospital was getting active in our country, variety of methods had been used, but there were some problems, such as the cases of some point of view was scare, the study and model used by cost function was not abundant, the scale economies study using DEA often were assistant product of technology efficacy measurement, some important problem conclusions were not inconformity, the region of hospital were finitude, etc. The scale economies of hospital were influenced by the inside and outside environment of hospital, the study of other country and region can't substitute the study of our country, preciously study can't not substitute study at present.
Traditional method of study of hospital layout included provider-population ratio and equity measurement of health resources, those methods had limitations. The measurement of spatial accessibility was a good method for studying this problem. In western country the study of health care spatial accessibility had very matured, there were a lot of models and study cases, had a very widely practical application. In recent year, our country had some study cases with applying the methods of health care spatial accessibility, but the number of cases was small and the types of study model was limited, the study scale often little, the academic significance exceeded the practical significance, this situation can't satisfy the demand of hospital layout decision in the practices environment.
2Objectives
This study would explored and developed methods of evaluation on the hospitals individual size and layout within the region, empirical analyzed and evaluated the development of hospital size and layout in Shanghai, put forward some advice on the development of hospital size and layout in Shanghai. In order to get this goal, the study would summarize hospital size and layout's theories and methods of firstly, the study would also summarize and describe hospital size and layout development's environment, background, procedure and status in quo In Shanghai secondly, and most important parts of this study were the study would be to measure the hospital scale economies and analyze theirs influencing factors effect, would be to measure hospital spatial accessibilities and evaluate theirs influences on equity. Finality, the study would put forward some advice on the development of hospital size and layout in Shanghai.
3Content and Methods
3.1Overall Characteristic of the Study
Overall characteristic of this study lied the united use of theories analysis and practices study, the combination of history reviews and status in quo descriptions, the united use of qualitative and quantitative analysis, the incorporation of statistical description and statistical inference, studying those problems with multi-dimension and various kinds of methods comprehensively.
3.1Content and Definite Methods
3.1.1Reviews on the hospital size and layout's theories and methods. In this part, the maternities were domestic and overseas literature on the hospital size and layout's theories and methods, author would read and review them.
3.1.2Analysis on the environment, background of the development of hospital size and layout. In this part, the data including city planning of Shanghai, all kinds of yearbooks and scholarly literature were analyzed, the situation of Shanghai city development on city planning, physical geography, economic social population and health status in quo were summarized.
3.1.3Analysis on the procedure and status in quo of the development of hospital size and layout. In this part, the data from all kinds of yearbooks, scholarly literature and website of hospital and government health department on the procedure and status in quo of the development of hospital size and layout were analyzed and summarized.
3.1.4Measurement on the scale economies of secondary and tertiary hospitals in Shanghai and the analysis on theirs influencing factors effect. In this part, the data of50secondary and tertiary hospitals on the economic operation from Shanghai health economic society were analyzed. The study content and methods including:Statistical description and grouping comparative on hospitals input and output scale; Indicator statistical description and grouping comparative on hospitals economic operation efficiency; Comprehensive evaluation on hospitals economic operation efficiency by factor analysis method and the analysis on theirs influencing factors effect; Measurement the scale economies of hospitals by cost function coefficient evaluating and calculating marginal cost indicators and scale economies indicators based on cost function coefficient and the analysis on theirs influencing factors effect; Measurement the scale economies of hospitals by calculating scale economies, technology efficiency and cost efficiency indicators through DEA models of CRS、VRS、NIRS、 Malmquist productivity index, etc. And analyzing on theirs influencing factors effect. All the analysis no the influences factors effect including single factor analysis and multivariate analysis.
3.1.5Measurement on the hospital spatial accessibilities and the assessment of theirs influences on equity. This part of data comes from the Shanghai Health Bureau of Health supervision official website, government documents and news reports. The study measured and assessed hospitals spatial accessibilities by making use of the API that is, application of procedures programming interface provided by the Internet map service providers (Sogou Map) and JavaScript program code carried Address Resolution, distance calculation, applying three models of spatial accessibilities that were, the closest distance, the cumulative opportunities, gravity index based on European straight-line distance. After that, Authors calculated coefficient of variation, the Gini Coefficient, Lorenz Curve and Their s index using the calculation results of spatial accessibilities.
3.1.6Recommendations to further optimize Shanghai hospital size and layout. In this part, author synthesize theoretical analysis of hospital size and layout, background and environmental analysis of shanghai hospital size and layout, process and status quo analysis of shanghai hospital size and layout, hospital economies of scale and spatial accessibility and fairness of hospital layout, put forward some recommendations to further optimize Shanghai hospital size and layout.
4Major findings, conclusions
4.1Urban development orientation and economic and social development situation calls for hospital total resources and layout to make adjustments
4.1.1Shanghai urban development orientation, and economic and social development situation calls for increased total hospital resource allocation
Shanghai's Urban Planning orientation was to build "a modern international metropolis "," international economic, financial, trade and shipping center ". Shanghai city was the "core" and "leading" in the Yangtze River Delta region. Its population base was large,23,026,600resident population in2010. The immigrant population proportion was high, with38.67%in2010. Population dense was high,3632people/square kilometers in2010. Its convenient transportation favored travelling. Health development is lagging behind population and economic development.2005-2010cumulative growth rate of doctors, number of beds were about16%, with resident population21.82%and for GDP85.63%, fiscal revenue and expenditure of around100%, urban per capita disposable income of71%,65%in rural areas, the health systems work volume287-434%, significantly higher than the investment of resourcesgrowth, the space of the medical and health facilities efficiency enhance would be small.
4.1.2Urban development orientation and economic and social development situation requires to improve the allocation of the suburbs (County) Hospitals
The proportion of urban population in Shanghai in2009was88.6%this meaned high level of urbanization. Shanghai has formulated the development planning of urban and rural integration, multi-center metropolitan area. Its suburban population concentred, its momentum of economic development was strong. Suburbs (counties) resident population in2010was11,322,000; its proportion was69.7%,42.7%and6.5%growth over2005. Since2005, its every year GDP growth rate had been greater than10%, Higher than urban. With the advance of the process of suburbanization, suburban population size would be increase, the trend of economic development also be better.
4.2Shanghai hospital size and layout adjust constantly, made great achievements, but the problem persists
4.2.1Shanghai hospital size and layout building process and features
Since1997, Shanghai hospital size and layout building had blend into Shanghai medical and health reform process in the background of the construction of new urban medical service system, this building process were influenced and promoted by a lot of reform action such as the localization reform of enterprise hospital, medical institutions consolidation and reorganization in particular the hospital group movement, classified management of medical institutions, medical institutions counterpart support, the Regional Medical Commonwealth pilot and other work. Its main features are:government-led and market-oriented co-exist, government-led is major; compatible with the overall urban development and layout building; combination of hospital micro-scale construction and the overall adjustment of layout; hospital size and layout the building main body is the public tertiary hospitals; tends to close links between the different regions, different levels of hospitals.
4.2.2Shanghai hospital expansion was evident, the layout has improved
Shanghai hospital's doctors and beds were increased year by year in absolute numbers and in relative proportion. In the2000-2010decade, cumulative growth rate of beds was48.46%, doctors was19.41%. In2010, the proportions of hospital doctors, beds were80.72%and61.81%respectively. Hospitals proportions more than800beds of hospitals more than one hundred beds accounted for from7.14%in2003to15.06%in2010. Hospitals proportion more than500beds accounted for36.75%, only slightly lower than the39.13%level in Beijing. Numbers of Tertiary (municipal) hospitals and theirs practice point were increasing both. Tertiary (municipal) hospital's influence over other medical establishment increased by way of hospital group and other ways, the numbers of Hospital Branch and out-patient department having tertiary (municipal) hospital name in their title increased."5+3+1" construction projects, and the earlier some individual tertiary hospitals relocation, setting Branch, etc. improved the hospital, especially tertiary hospital's layout.
4.2.3Shanghai hospital size and layout construction process problems
Prominent problem was hospitals resources especially three hospitals resource in suburbs (counties) was inadequate.The emphasis of city construction transfering from the city center to the suburbs brought the population distribution pattern changed,2010suburbs population was11.322million,69.7%percent,42.7%and6.5%growth over2005. the number of beds per million population in the central city hospital in2010were52.53-209.69, higher than18.62-49.41in suburbs (counties), Index in the central city were increase, Index in suburbs (counties) were are on the decline. Tertiary (municipal) hospital practice points are mainly distributed in the central city. Other issues include:the Shanghai hospital size and the layout were still lagging behind Shanghai Urban Planning and positioning requirements; tertiary hospitals had a deeper level of monopolization of the market; Shanghai hospital size and layout construction exacerbated the complexity of the property right's relationship and management's relationship, difficult to manage; should pay attention to dilution of the old brand, new brand-building; constraints from the Medicare prospective payment; untouched hospital compensation mechanism reform, the masses benefit was limited; issue of contributing to the existing medical orderly.
4.3The hospital has economies of scale, too big might occur decreasing returns to scale
4.3.1Input-output scale analysis and comparison of sample hospitals
The size of the municipal sample hospitals was significantly greater than the scale of district hospitals.2008-2010. the hospital fixed assets, service provided, income and expenditure expansion were more obvious, especially the municipal hospital, hospital staff and beds investment increase is not obvious. Proportion of the drug incomes were45-47%,"drugs to support medical'"s compensation mechanism remains unchanged in2008-2010.
4.3.2The economic operation efficiency indicators characterization analysis and comparison
Description from the efficiency and workload of hospital services, the money invested and the income and expenditure ratio, the ratio of operating income, and elements of compensation ratio, the level of assets and surplus development capacity, the service unit costs, the economic and operational benefits of the sample hospitals indicators showed that City level hospital had an advantage in-patient services efficiency, financial compensation and return on assets, district hospitals has more cheap on unit costs, higher on the net asset growth.
4.3.3Factor analysis of the economic operational benefits and influencing factors analysis
Hospital economic operation efficiency and scale were height correlated, factor total score and the approved number of beds correlation coefficient is0.784. Municipal tertiary hospital's score were higher than the district-level, namely secondary hospitals'. Comprehensive analysis outcomes from single factor and multi-factor, factor total score was unrelated with factors such as Roemer index, whether Affiliated Hospital, West hospital or not,(district hospitals) naming a municipal hospital or not, the hospital is in the urban areas or not,(municipal hospitals) whether having suburbs branch and so on.
4.3.4Cost function method hospital evaluation of the economies of scale and analysis of influencing factors
The marginal cost of the sample of hospital in2010of outpatient and emergency, marginal costs of in-patient short-term returns to scale, long-term economies of scale in turn was310.28yuan,14146.29yuan,0.99,0.84, with the former two were increasing and the latter two were in the fall. In2010the proportion of hospital's short-term returns to scale, long-term economies of scale greater than1are44%and24%respectively in50hospitals. The study supports the conclusions that if the hospital size is too lager may lead to diseconomies of scale, diseconomies of scale happened more in hospital marginal costs, long-term economies of scale, in2010. District-level hospital position and title had statistical significance on marginal cost of outpatient and emergency.
4.3.5Hospital economies of scale evaluation by data envelopment analysis and impact factor analysis
Sample hospitals in2010the DEA scale efficiency, the CRS cost efficiency, cost efficiency average in turn were0.970,0.837.0.741, number of hospitals decreasing returns to scale was33.2008-2010, returns to scale change index was1.0113, and the total factor productivity Malmquist index was1.0301. Hospital scale efficiency value was the parabolic shape. Hospital size had related with CRS technical efficiency, cost efficiency, but not a simple linear relationship. Scale is too large to cause decreasing returns to scale. The Roemer Index affected the CRS technical efficiency. The time was the influence factor on the cost-efficiency, returns to scale range.
Comprehensive analysis on findings from factor analysis evaluation, cost function and DEA confirmed the existence of economies of scale, but the findings from cost function and DEA does not support the assumption of infinite existence of hospital scale, confirmed that the scale is too large to produce decreasing returns to scale. Its turning point of the short-term balance of the cost function method and DEA method were500approved beds, the long-run equilibrium and the marginal cost of the cost function method were1000approved beds.
4.4Shanghai hospital accessibility, fairness had improved, but still had large regional differences
4.4.1The results and conclusions based on nearest distance method
To compared with2007, the city's half of the street, township nearest distance to tertiary (municipal) hospitals would be reduced by2012expected, involving11.57million population,. Chongming County, Fengxian District, Jiading District, Pudong New Area, nearest distance dropped most obvious, followed by the other suburbs, finally were urban five districts. Expected by the end of2012, nearest distance of the streets, villages and towns to the tertiary (municipal) hospital ranged169.43-35169.87m, an average of6666.47m, the nearest distance mean of suburbs (county) is6.36times the urban, the nearest distance mean of Pudong district, Expansion area, Suburban and Chongming county area in turn were5.43,3.02,1.17,2.32to urban ones.
4.4.2The results and conclusions based on cumulative opportunity method
To compared with2007, in2012expected city's the cumulative opportunity mean growth in the threshold level of5000m,10000m,20000m,50000m and100,000meters to tertiary (municipal) hospitals followed by0.45,1.63.4.62,12.2914.98. Regional cumulative opportunity growth were different, urban area's cumulative opportunity growth in the20,000m threshold significantly higher than the suburbs (counties), cumulative opportunities in the regional degree of dispersion was not declining, but increasing, especially in the20,000m threshold. Expected by the end of2012the city's cumulative opportunity mean in the threshold level of5000m,10,000m,20,000m.50,000m and100,000m in turn were4.91,13.35,26.22,50.47,57.92. Cumulative opportunity to urban areas had been higher than the suburbs (counties), expansion area was highest in suburbs (counties), following was Pudong area, Suburban and Chongming county was poorer.
4.4.3The results and conclusions based on gravity model method
To compared with2007, in2012expected city's the accessibility index to tertiary (municipal) hospitals were almost100%increased. When P=1,2007,2011,2012's gravity index mean in turn were1.24,1.39,1.70, cumulative growth rate was37.10%; when β=1.2,2007,2011,2012's gravity index mean in turn were1.26,1.41,1.72, the accumulated growth rate was36.51%. When β=1, in2007,2011and2012, multiple relationship of urban and rural areas (counties)" s gravity index mean in turn were3.68,3.53,2.79, when β=1.2followed by4.76,4.52,3.32. The differences of the street and town's gravity index to the tertiary (municipal) hospital in the suburbs (counties) regions were pulled large,2007,2011,2012's standard deviation of the amount of cumulative growth in Pudong area, Expansion area, the suburbs, Chongming county in turn were0.09,0.02,0.06,0.25when β=1,0.11,0.02,0.05,0.50when β=1.2.
4.4.4The results and conclusions of equity evaluation based on accessibility
Indicators including closest distance,10000m threshold's cumulative opportunity,20000m threshold's cumulative opportunity, gravity index when β=1and β=1.2were used to calculated the coefficient of variation, the Gini coefficient, Theil's index and the Lorenz curve for the equity evaluation, Shanghai tertiary (municipal) hospital space layout fairness tended to improve, unfair derived from the differences between regions. Gove gravity index when β=1for example,2007、2011、2012's variation coefficients were0.832,0.793,0.654respectively, Gini coefficients were0.510,0.496,0.413, the Theil's index were0.149,0.145,0.101, Contribution rates of region differences to the total Theil index were75.17%,77.24%,72.28%, the2012Lorenz curve closest to the diagonal, followed in2011,2007.
5Policy Significances
5.1Compatible with the economic and socio-demographic developments, to improve the level of total hospital resources allocation;
5.2Continue to improve the suburbs (county) level and quality of hospital resource allocation, to ameliorate hospital layout equity;
5.3To control of hospital size properly, hospital expansion are compatible with hospital capacity and technology development;
5.4To promote the medical and health system reform, making benefit of hospital size and layout adjustment to get greater efficiency.
6Research Innovation
6.1Evaluation methods on hospital size and layout are explored and applied:
6.1.1The researchers applied a set of methods of evaluation on hospital economies of scale based on health statistics conventional data with multi-view. The methods including:Itemized description and comprehensive evaluation of the economic operation effect; Estimates of outpatient and emergency hospital services to marginal cost, short-term returns to scale, the scale of economic indicators based on the cost function method; Estimated scale efficiency index, the dynamic change index and other kind of efficiency indexs based on data envelopment analysis.
6.1.2The researchers applied a set of methods with a scale of streets, towns, based on the geographic information system (GIS) access to distances information, of evaluation on the layout of the hospital based on spatial accessibility perspective. This method borrowing ideas from geography theory and methods, with the help of the Internet map service provider API function, based geographic information system (GIS) to obtain the distance information from settlements to hospitals, applying of a variety of models to measure spatial accessibility to the tertiary (municipal) hospitals in Shanghai, to evaluate layout fair based on these measurement.
6.2This study systems analyzed the background and environmentof, process and status of Shanghai secondary, tertiary hospital's size and layout, thematic evaluation on hospital's size and layout were made, put forward some constructive suggestions based on research results.
6.3This study analyzed whether there is contact between factors such as whether the district hospitals had municipal hospitals title, whether municipal hospitals seted suburbs branch and other factors and hospital indicators of the economies of scale, enriching the studys of hospital economies of scale.
7Limitations
7.1By sample size and data limitations, hospital economies of scale evaluation and impact factor analysis section, some analysis can not expand in depth, such as case mix differences in hospital economies of scale;
7.2The indicators and weights determined based on the statistical method in comprehensive evaluation of hospital economies of scale, wether it was scientific and rational, yet to be applied in more practice, to accept the test of practice;
7.3Shanghai hospital size and layout's building are tertiary hospital-based, due to time constraints, study only evaluated the tertiary (municipal) hospital accessibility, two hospital evaluation to be next to continue.
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