Please wait a minute...
浙江大学学报(工学版)
浙江大学学报(工学版)  2020, Vol. 54 Issue (12): 2445-2456    DOI: 10.3785/j.issn.1008-973X.2020.12.020
计算机与控制工程     
“守门人”医疗系统中的转诊协调机制
张悦(),高照,李娜*()
上海交通大学 机械与动力工程学院，上海 200240
Referral coordination mechanism of gatekeeper healthcare system
Yue ZHANG(),Zhao GAO,Na LI*()
School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai 200240, China
 全文: PDF(1485 KB)   HTML
摘要：

为了探究“守门人”医疗系统的协调问题，建立系统内综合医院与社区医院间的转诊博弈模型，分别对非竞争型和竞争型的2种系统建模. 模型分别研究系统集中决策下的最优转诊阈值策略以及服务支付契约合作模式下的最优契约形式. 结论表明，降低系统内单位人员服务成本能够有效提升系统效用，引入竞争可以降低转诊率、促进社区医院首诊；非竞争与竞争型系统在不同规模下的服务支付契约对于实现系统协调均具有可行性，竞争系统下小规模设置的协调效率高于大规模设置的. 在医疗系统设计中若无法避免竞争的存在，设置多个小型竞争医院能带来更高的社会效率.
关键词： “守门人”系统;  医疗系统;  转诊博弈;  协调机制;  竞争    
Abstract:

A referral model with general hospitals (GH) and community health centers (CHC) was established to analyze the coordination problem of the gatekeeper healthcare system. The non-competitive and competitive models respectively studied the optimal referral strategies and the optimal contract forms from centralized decision-making and service payment contract cooperation, and provided the conditions for system coordination. Results show that reducing the unit service costs in the system can effectively improve the system, and competition can increase the referral threshold to promote community first diagnosis. The non-competitive and competitive systems for service payment contract coordination at different scales are feasible. The coordination efficiency of small-scale is better than that of large-scale in competitive system, then designing multiple small competitive hospitals can bring higher social efficiency.
Key words: gatekeeper system    healthcare system    referral decisions    coordination mechanism    competition
收稿日期: 2019-12-09 出版日期: 2020-12-31
CLC:  F 202  
基金资助: 国家自然科学基金资助项目（71871138，71432006）
通讯作者: 李娜     E-mail: zy_0036@sjtu.edu.cn;nali-03@sjtu.edu.cn
作者简介: 张悦（1994—），男，硕士生，从事医疗服务系统管理、协作机制研究. orcid.org/0000-0003-0365-7991. E-mail： zy_0036@sjtu.edu.cn
服务　　
把本文推荐给朋友
加入引用管理器
E-mail Alert
作者相关文章　　
张悦
高照
李娜

引用本文:

张悦,高照,李娜. “守门人”医疗系统中的转诊协调机制[J]. 浙江大学学报(工学版), 2020, 54(12): 2445-2456.

Yue ZHANG,Zhao GAO,Na LI. Referral coordination mechanism of gatekeeper healthcare system. Journal of ZheJiang University (Engineering Science), 2020, 54(12): 2445-2456.

链接本文:

http://www.zjujournals.com/eng/CN/10.3785/j.issn.1008-973X.2020.12.020    或    http://www.zjujournals.com/eng/CN/Y2020/V54/I12/2445

图 1  模型1：非竞争型转诊协调模型
图 2  模型2：竞争型转诊协调模型
医疗服务机构 SDF
情形1 情形2 情形3 情形4
CHC $\dfrac{1}{3}x + 1$ $3{x^2} + 1$ $3{e^x} - 2$ $3{e^x} - 2$
GH $\dfrac{1}{2}x + \dfrac{3}{2}$ $\dfrac{1}{2}x + \dfrac{3}{2}$ $\dfrac{1}{2}x + \dfrac{3}{2}$ $4{e^x} - \dfrac{5}{2}$
表 1  医疗服务机构不同就医环境情形的SDF设置
方案 ${c_{\rm{w}}}$ ${c_{\rm{m}}}$ $c_{\rm{s}}^{{\rm{chc}}}$ $c_{\rm{s}}^{{\rm{gh}}}$
A 0.3 0.5 1/3 2/3
B 0.3 0.5 1/6 2/3
C 0.3 0.1 1/3 2/3
D 0.1 0.1 1/3 2/3
E 0.3 0.5 1/3 3/5
表 2  实验方案参数设计
图 3  小规模非竞争模型不同情形下总效用函数
图 4  大规模非竞争模型不同情形下总效用函数
图 5  非竞争模型不同情形下完美协调解
就医环境情形 规模 $r_0^{ {\rm{NC*} } }$ ${\varPi ^{ {\rm{NC} } } }$ ${\omega _{\rm{p}}}^*$ $r_{{\rm{np}}}^{ {\rm{NC*} } }$ $\omega _{{\rm{np}}}^{ {\rm{NC*} } }$ ${\pi ^{{\rm{gh}}}}{\rm{ + }}{\pi ^{{\rm{chc}}}}$ ${\pi ^{{\rm{chc}}}}$ ${\pi ^{{\rm{gh}}}}$ $e$/%
1 S 0.459 27.515 2.886 0.627 2.795 27.345 11.690 15.655 99.38
L 0.469 295.538 2.949 0.644 2.846 293.723 125.748 167.975 99.39
2 S 0.358 27.353 2.827 0.653 2.370 26.459 9.385 17.074 96.73
L 0.374 293.980 2.898 0.663 2.449 285.528 104.640 180.888 97.12
3 S 0.197 26.905 2.752 0.583 1.998 25.168 6.100 19.068 93.54
L 0.228 289.617 2.835 0.598 2.090 273.302 74.047 199.255 94.37
4 S 0.534 9.213 2.109 0.730 1.631 8.585 4.847 3.738 93.18
L 0.554 125.156 2.191 0.740 1.740 119.406 62.493 56.913 95.41
表 3  非竞争型GK系统不同情形与不同规模环境下的协调分析
图 6  小规模竞争模型不同情形下总效用函数
图 7  大规模竞争模型不同情形下总效用函数
图 8  竞争模型不同情形下完美协调解
$\gamma $ β $r_0^{\rm{C*}}$ ${\varPi ^{\rm{C}}}$ $\omega _{{\rm{p}},i}^{{C*}}$ $r_{{\rm{np}}}^{\rm{C*}}$ $\omega _{{\rm{np}},i}^{{C*}}$ $2{\pi ^{{\rm{gh}}}}{\rm{ + }}{\pi ^{{\rm{chc}}}}$ $2{\pi ^{{\rm{gh}}}}$ ${\pi ^{{\rm{chc}}}}$ $e$/%
0.2 0.5 0.379 26.440 2.801 0.180 2.989 26.128 6.683 12.762 98.82
0.6 0.379 26.440 2.801 0.182 2.988 26.133 6.689 12.755 98.84
0.7 0.379 26.440 2.801 0.183 2.987 26.135 6.692 12.751 98.85
0.3 0.5 0.379 26.440 2.801 0.173 2.993 26.108 6.657 12.793 98.74
0.6 0.379 26.440 2.801 0.177 2.991 26.120 6.672 12.776 98.79
0.7 0.379 26.440 2.801 0.179 2.989 26.126 6.680 12.766 98.81
0.4 0.5 0.379 26.440 2.801 0.159 2.999 26.064 6.607 12.850 98.58
0.6 0.379 26.440 2.801 0.170 2.994 26.097 6.645 12.808 98.70
0.7 0.379 26.440 2.801 0.175 2.992 26.112 6.662 12.788 98.76
表 4  小规模竞争型GK系统不同竞争环境下的协调分析
$\gamma $ $\beta $ $r_0^{\rm{C*} }$ ${\varPi ^{\rm{C} } }$ $\omega _{{\rm{p}},i}^{{C*} }$ $r_{{\rm{np}}}^{\rm{C*} }$ $\omega _{{\rm{np}},i}^{{C*} }$ $2{\pi ^{{\rm{gh}}}}{\rm{ + }}{\pi ^{{\rm{chc}}}}$ ${\pi ^{{\rm{chc}}}}$ $2{\pi ^{{\rm{gh}}}}$ $e$/%
0.2 0.5 0.380 291.104 2.890 0.126 3.131 286.244 71.630 142.985 98.33
0.6 0.380 291.104 2.890 0.128 3.130 286.297 71.694 142.909 98.35
0.7 0.380 291.104 2.890 0.129 3.130 286.330 71.735 142.861 98.36
0.3 0.5 0.380 291.104 2.890 0.119 3.135 286.004 71.345 143.314 98.25
0.6 0.380 291.104 2.890 0.123 3.133 286.143 71.508 143.127 98.30
0.7 0.380 291.104 2.890 0.125 3.132 286.217 71.598 143.021 98.32
0.4 0.5 0.380 291.104 2.890 0.105 3.142 285.488 70.774 143.940 98.07
0.6 0.380 291.104 2.890 0.116 3.137 285.879 71.202 143.475 98.21
0.7 0.380 291.104 2.890 0.121 3.134 286.049 71.397 143.254 98.26
表 5  大规模竞争型GK系统不同竞争环境下的协调分析
1 张雪, 田文华 家庭医生制度的“守门人”作用及对我国的启示[J]. 中国社会医学杂志, 2013, 30 (2): 115- 117
ZHANG Xue, TIAN Wen-hua Effects of gatekeeper and inspirations of the family physician system in China[J]. Chinese Journal of Social Medicine, 2013, 30 (2): 115- 117
2 张淑娥, 孙涛 荷兰医改及对我国构建整合型健康服务体系的启示[J]. 中国卫生政策研究, 2019, 12 (8): 15- 22
ZHANG Shu-e, SUN Tao The netherland health reform experiences and its enlightenment for the construction of China’s integrated healthcare service system[J]. Chinese Journal of Health Policy, 2019, 12 (8): 15- 22
doi: 10.3969/j.issn.1674-2982.2019.08.003
3 SHUMSKY R A, PINKER E J Gatekeepers and referrals in services[J]. Management Science, 2003, 49 (7): 839- 856
doi: 10.1287/mnsc.49.7.839.16387
4 LI N, TENG D, KONG N Threshold control policy optimization for real-time reverse referral decision of Chinese comprehensive hospitals[J]. IEEE Transactions on Automation Science and Engineering, 2018, 16 (1): 45- 60
5 QIU Y, SONG J, LIU Z A simulation optimisation on the hierarchical health care delivery system patient flow based on multi-fidelity models[J]. International Journal of Production Research, 2016, 54 (21): 6478- 6493
doi: 10.1080/00207543.2016.1197437
6 LI N, KONG N, LI Q, et al Evaluation of reverse referral partnership in a tiered hospital system: a queuing-based approach[J]. International Journal of Production Research, 2017, 55 (19): 5647- 5663
doi: 10.1080/00207543.2017.1327731
7 HASIJA S, PINKER E J, SHUMSKY R A Staffing and routing in a two-tier call center[J]. International Journal of Operational Research, 2005, 1 (1/2): 8- 29
doi: 10.1504/IJOR.2005.007431
8 LEE H H, PINKER E J, SHUMSKY R A Outsourcing a two-level service process[J]. Management Science, 2012, 58 (8): 1569- 1584
doi: 10.1287/mnsc.1110.1503
9 LIU X, CAI X, ZHAO R, et al Mutual referral policy for coordinating health care systems of different scales[J]. International Journal of Production Research, 2015, 53 (24): 7411- 7433
doi: 10.1080/00207543.2015.1082039
10 GAO X, WEN J, SONG J Capacity allocation and revenue sharing in healthcare alliances[J]. Flexible Services and Manufacturing Journal, 2019, (2): 1- 23
11 ADIDA E, BRAVO F Contracts for healthcare referral services: coordination via outcome-based penalty contracts[J]. Management Science, 2018, 65 (3): 1322- 1341
12 BICHESCU B C, BRADLEY R V, SMITH A L, et al Benefits and implications of competing on process excellence: evidence from California hospitals[J]. International Journal of Production Economics, 2018, 202: 59- 68
doi: 10.1016/j.ijpe.2018.05.013
13 CACHON G P Supply chain coordination with contracts[J]. Handbooks in Operations Research and Management Science, 2003, 11: 227- 339
doi: 10.1016/S0927-0507(03)11006-7
14 CACHON G P, LARIVIERE M A Supply chain coordination with revenue-sharing contracts: strengths and limitations[J]. Management Science, 2005, 51 (1): 30- 44
doi: 10.1287/mnsc.1040.0215
15 YAO Z, LEUNG S C H, LAI K K Manufacturer′s revenue-sharing contract and retail competition[J]. European Journal of Operational Research, 2008, 186 (2): 637- 651
doi: 10.1016/j.ejor.2007.01.049
16 GUO L, WU X Capacity sharing between competitors[J]. Management Science, 2017, 64 (8): 3554- 3573
17 周健, 张玉华 传统零售商渠道选择策略微分博弈模型[J]. 浙江大学学报: 工学版, 2019, 53 (9): 1720- 1727
ZHOU Jian, ZHANG Yu-hua Differential game model for channel selection strategies of traditional retailer[J]. Journal of Zhejiang University: Engineering Science, 2019, 53 (9): 1720- 1727
18 秦星红, 李海南, 曹园园. 多服务商竞争环境下考虑利润公平分配的网购服务供应链激励契约[EB/OL]. [2020-02-21]. http://kns.cnki.net/kcms/detail/31.1738.T.20191223.1427.002.html.
19 邓晨卉, 潘杰 医院市场竞争与不同严重程度疾病医疗费用关系的比较研究?基于行手术治疗的腰椎间盘突出和老年性白内障住院病例的实证分析[J]. 现代预防医学, 2019, 46 (23): 4293- 4297
DENG Chen-hui, PAN Jie Comparative study on the relationship between hospital competition and medical expenses for diseases with different severity?an empirical analysis based on inpatients of lumbar disc herniation and senile cataract treated by surgery[J]. Modern Preventive Medicine, 2019, 46 (23): 4293- 4297
20 周奕男, 熊雪晨, 何世英, 等 基于竞争和需求测算的社会办基层医疗机构空间布局导引方法实证研究[J]. 中国医院管理, 2019, 39 (8): 18- 19
ZHOU Yi-nan, XIONG Xue-chen, HE Shi-ying, et al Empirical study on layout guidance method for private grassroots medical institutions based on competition and demand calculation[J]. Chinese Hospital Management, 2019, 39 (8): 18- 19
21 匡莉 我国医疗服务竞争机制的优化策略——建立纵向整合的医疗服务体系[J]. 中国卫生政策研究, 2012, 5 (9): 34- 39
KUANG Li Strategy for optimizing the mechanism of healthcare competition: establishing the vertical integrated healthcare delivery systems[J]. Chinese Journal of Health Policy, 2012, 5 (9): 34- 39
doi: 10.3969/j.issn.1674-2982.2012.09.006
22 蔡立辉 分层次、多元化、竞争式: 我国医疗卫生服务的公共管理改革[J]. 中国人民大学学报, 2010, 24 (1): 92- 100
CAI Li-hui Public administration reform of medical health servicein a competitive way with multi-models and in multi-levels[J]. Journal of Renmin University of China, 2010, 24 (1): 92- 100
23 JIANG H J, FRIEDMAN B, JIANG S Hospital cost and quality performance in relation to market forces: an examination of U.S. community hospitals in the“post-managed care era”[J]. International Journal of Health Care Finance and Economics, 2013, 13 (1): 53- 71
doi: 10.1007/s10754-013-9122-9
[1] 裴小兵,于秀燕,王尚磊. 混合帝国竞争算法求解旅行商问题[J]. 浙江大学学报(工学版), 2019, 53(10): 2003-2012.
[2] 俞晋频,邱坤赞,宋浩,高翔,周劲松. Cr/TiO2催化剂汞氧化的实验[J]. 浙江大学学报(工学版), 2015, 49(11): 2186-2192.
[3] 王跃,杨昆,杨华,陈国柱. 通用SPWM发生器的实现及脉冲竞争消除新方法[J]. 浙江大学学报(工学版), 2014, 48(6): 2-.
[4] 王跃,杨昆,杨华,陈国柱. 通用SPWM发生器的实现及脉冲竞争消除新方法[J]. 浙江大学学报(工学版), 2014, 48(11): 2087-2093.
[5] 富浩 蔡铭 董金祥 金星 龚宜. 于锁集合算法的增强型数据竞争检测方法[J]. J4, 2009, 43(2): 328-333.
[6] 余轶军 林怀忠 陈纯. 基于竞争凝聚的个性化网页推荐[J]. J4, 2007, 41(2): 239-244.
[7] 罗彤 陈裕泉. 视觉注意引导和区域竞争控制的医学图像分割[J]. J4, 2007, 41(11): 1797-1800.
[8] 江宇雷 李希 陈朝晖. 双组分协同吸附的非线性色谱波动特征[J]. J4, 2006, 40(5): 836-840.
[9] 余巧艳 刘鹏. 一种面向DSP深度压缩指令的数据竞争检测方法[J]. J4, 2005, 39(10): 1501-1506.