Based on principal components analysis, we calculated the performance of 24 public hospitals in 12 cities, and compared the overall performance of four regions, focusing on the relationship between regional differences and price reform performance. Further, the effectiveness of the medical service price reform in the province was analyzed, as well as the advantages and disadvantages of the reform. Compared with the existing literature [24–26], the sample selected for this study was sufficiently large, the data more complete and reliable, and the analysis was not restricted to a certain hospital or region. Moreover, this study is the first to explore the specific performance differences related to medical service price adjustment policies in different regions.
This study showed that different service items in different regions exhibited significantly different adjustments in the medical service price. This may be related to differences in economic and basic health status in different regions. The level of regional economic development will affect local public hospitals, including the basic medical equipment available, medical environment, skill of employees, and the amount of attention each patient receives . The government needs to consider the status quo of public hospitals when formulating price policies. In addition, when a new price policy is implemented, changes in medical prices will affect the operation and development of public hospitals. A study of Norwegian hospitals found that medical prices fluctuated by 10% and the number of patients increased by 0.8–1.3% . Therefore, regional economic development, hospital tapes policy intentions, and medical prices are often in a process of balance and coordination, and tend to be rationalized.
The Pearl River Delta region is located in the south-central part of Guangdong Province and is one of the most developed regions in China . The number of public hospitals in the Pearl River Delta region accounts for more than 60% of the total public hospitals in Guangdong Province. The service quality of hospitals is much higher than in the other three regions. The higher economic level and quality of medical care in the Pearl River Delta region has led to generally higher basic fees for public hospitals than in the other three regions. However, its high medical expenses are predominately generated via examinations and consumables, while the cost of technical services such as diagnosis, treatment, and surgery is relatively low. Therefore, the local government generally increased the cost of diagnosis, treatment, nursing, surgery, and so forth, and lowered inspection costs in the Pearl River Delta region during the price reform.
Compared with the Pearl River Delta region, the lower economic levels of the other three regions led to lower hospital fees. These local governments are more concerned regarding how to improve the hospital profitability in order to maintain the normal development of public hospitals. Therefore, local governments have considered not only excessively burdening the people via fees, but also slightly increasing the price of surgery, treatment, and nursing. Among them, the focus has been on raising the price of Chinese medicine services that include government subsidies and preferential policies. At the same time, local governments in the Eastern and Western regions have only slightly lowered the prices of inspections to ensure the normal operation of the hospitals.
The results showed that the performance scores of general hospitals and traditional Chinese medicine hospitals in the Pearl River Delta region were higher than those of the other regions. The Pearl River Delta region is the center of politics, culture, and economy in Guangdong Province . Public hospitals in the Pearl River Delta region may be more susceptible to policy. The comprehensive analysis of general hospitals, and the regional performance rankings are consistent with regional economic strength rankings, which indicates that the local economic level is related to the effect of reforms on local general hospitals. Riedel made similar observations, and found that the development of German hospitals faced severe challenges. An important point is that hospital reform and development are constrained by local economic development . At present, public general hospitals in China rely primarily on medical income to maintain hospital operations. Therefore, the services provided by the comprehensive hospitals that are most affected by the policy are likely to be severely affected. In addition to Germany, public hospitals in Japan are also generally facing financial deficits. Konosuke confirmed this and suggested that the extent of public hospital development is related to local purchasing power . However, prior studies only described the operation of public hospitals in particular locations, and did not engage in in-depth analysis of the differences in policy effects among regions. The current study add such research content. Overall, for regions with different levels of economic development, the same policy may not be applicable, and the effects of policies will be different. Our subsequent studies will assess how to formulate and improve policies for public hospitals in regions with different levels of economic development.
Compared with general hospitals, the reform performance of traditional Chinese medicine hospitals is affected not only by local economics, but also by local government support policies. The more the local government attaches importance to the development of traditional Chinese medicine hospitals, the greater the support it provides.
The development of local traditional Chinese medicine hospitals is better than general hosipitals. However, under the influence of support policies, the medical prices and patient-incurred expenses of traditional Chinese medicine hospitals also increased rapidly. The financial burden on patients in Chinese medicine hospitals has increased. Therefore, the government need to find balance when supporting the development of traditional Chinese medicine hospitals.
Results showed that the policy effect of controlling fees is not straightforward, and the burden on patients continues to increase on a yearly basis. As can be seen from Table 3, the average growth rate of patients' fees is still high, far exceeding the growth rate of the national consumer price index (2.1%) in 2018. The cost of medical treatment for residents has not decreased, and the effect of controlling fees is not satisfactory. The average outpatient expenses in the Pearl River Delta region reached 20.12% of the total medical costs, and the average hospitalization expenses in the Western region reached 11.36% of the total medical costs. These are much higher than expected for the policy developers, adding a considerable burden to patients. Therefore, although the reforms reduced the cost of medicines and inspections, the overall cost of medical care has increased for some patients. Tianlin also found that the cost borne by patients did not significantly decrease after medical service price adjustment in a study of Qingdao City, Shandong Province . In addition, Cooper found that hospital medical service prices rose by 42% between 2007 and 2014, and patient-borne costs rose sharply in the US. He suggested that policy makers should consider a range of options to address hospital price increases, including antitrust enforcement, management of pricing, and the use of reference pricing . Overall, governments need to develop more effective measures to control the growth of medical expenses.
Principal components analysis showed that the effect of reforms were significantly better on comprehensive hospitals than traditional Chinese medicine hospitals. This may be because the proportion of income derived from inspections and drugs in general hospitals is much larger than that of traditional Chinese medicine hospitals, but the proportion of income derived from technical aspects such as surgery, treatment, and nursing is much lower. After the implementation of the policy, the average cost of patients in general hospitals increased less than that of traditional Chinese medicine hospitals. This also shows that the comprehensive hospitals were greatly affected by the policy, and such hospitals face greater difficulties and challenges than do Chinese medicine hospitals. Similar observations have been made by other researchers. Tang found that the cost of service-dependent hospitals and drug-dependent hospitals was significantly different in a study of public hospitals in Nanjing . He proposed that different pricing policies should be developed for different types of hospitals. At present, in China, an identical policy is implemented concurrently across the country or province. Therefore, policies can have different effects in different places and under different conditions. In this case, hospitals are facing increasing pressure, and the contradiction in the requirements of local governments and local medical institutions is prominent.
Tables 2 and 3 show that the cost of diagnosis, treatment, surgery, and nursing, which reflect the value of the technical labor of medical professionals, is rising, and inspection costs are reducing. This encourages hospitals to develop technical medical specialties, especially orthopedics and physiotherapy. After the reform, more hospitals are willing to carry out medical surgery that requires advanced technology because they now have sufficient income. The policy has somewhat reduced the occurrence of over-examination in hospitals, because the profit associated with inspections has been reduced. From this perspective, the change to hospitals’ income structures was benign, and the value of the labor of medical professionals has been recognized and valued. Li proposed that county-level public hospitals tend to have a reasonable income structure after adjusting for medical services . Wei suggested that the significance of this price adjustment is to make the price of medical services reflect the labor value of medical staff . Moreover, both researchers believed that the policy would have a positive impact on the internal management and performance of hospitals. This is consistent with the results of the current study.
There are also several limitations to this study. First, although principal components analysis was suitable for comparing the effects of reforms among hospitals or regions, the effects of reforms at the individual hospital level was not studied in depth. In future, it is necessary to further study the specific impact of the price adjustment policy within individual hospitals. Second, this study did not assess the different responses of local governments in implementing policies. Third, this we proposed that regional differences in economic development will influence the effects of policy changes, but the specific effects have not been thoroughly studied. These aspects represent important future research directions of our research team.