分级诊疗体系下的转诊决策与政府协调机制研究

针对我国当前分级诊疗制度下病人下转面临的困境，研究政府协调医院转诊有效推行的支付机制及医疗服务体系的运营绩效问题.通过构建一个排队论框架下的四阶段序贯博弈模型，探讨政府，三甲医院，社区医院及病人各参与方之间的动态决策关系，进而给出包括转诊支付价格、三甲医院下转率、社区医院服务能力的均衡决策.研究结果表明，政府是否应该协调社区医院对三甲医院提供转诊支付价格，取决于医疗预算量与三甲医院对病人等待时间敏感度，当且仅当医疗预算高于一个阈值或者三甲医院延时敏感度低于一个阈值时，转诊支付方式可促使并协调各参与方共赢.数值实验发现，病人对三甲医院的服务感知水平较社区医院的差距越大或者治疗价格越低，政府应通过降低支付价格减少病人下转率，从而提高社会福利，但等待时间可能反而更长.

Referral decision and government coordination scheme in the hierarchical healthcare systems

In view of the patient referral's problem in the current Chinese hierarchical healthcare systems, we study the government coordination scheme to effectively implement hospital referral and the operational performance of the healthcare service systems. By developing a four-stage sequential game-theoretic model with a queuing framework, we capture the dynamic interaction relationships among the government, the 3A hospital, the community hospital, and patients, and then present the equilibrium decisions including payment price for referral, 3A hospital's downstream referral rate, and community hospital's service capacity. Our results indicate that whether government coordinates the community hospital to offer a referral payment price to 3A hospital depends on healthcare budgets and 3A hospital's sensitivity in its patients' waiting time. The referral payment scheme can promote and coordinate the win-win situation of all participants only when the budget is higher than a threshold or the delay sensitivity of the 3A hospital is lower than a threshold. Numerical experiments show that the patients' perceived gap of healthcare service levels between 3A hospital and community hospital is the higher or the treatment price is the lower, the government should decrease the referral rate of patients via reducing the payment price so as to improve social welfare, but the total waiting time may become longer.