Reimbursement systems and regional inpatient allocation: a non-linear optimisation model

^** Email: marion.rauner{at}univie.ac.at^*** Email: georg.schneider{at}univie.ac.at^**** Email: kurt.heidenberger{at}univie.ac.at This study presents a non-linear optimisation model for investigatingthe optimal allocation of both budgets and inpatients with differenttreatments among hospitals within a geographic region such asVienna. The objective function maximises the overall qualityof treatment provided by regional hospitals. We compare theeffects of two different reimbursement systems—fixed versusvariable budgets—on optimal allocation strategies. Thecombination of modelling ideas from hospital location-allocationmodels and economic models to solve such a problem is new accordingto the literature. We found that fixed budgets outperformedvariable budgets as fewer Euros had to be invested for an incrementalunit of quality of care provided in most of the policy scenariosanalysed. Regional demand and supply patterns for differenttreatments affect the decision makers' choice of the most suitablereimbursement system. In our illustrative example, two hospitalsappeared inefficient regardless of the reimbursement system.Vienna policy makers are currently considering restructuringthese hospitals. They plan to merge one with nearby hospitalsand transform the other into a nursing home.     

Nash equilibria in the two-player kidney exchange game

Kidney exchange programs have been set in several countries within national, regional or hospital frameworks, to increase the possibility of kidney patients being transplanted. For the case of hospital programs, it has been claimed that hospitals would benefit if they collaborated with each other, sharing their internal pools and allowing transplants involving patients of different hospitals. This claim led to the study of multi-hospital exchange markets. We propose a novel direction in this setting by modeling the exchange market as an integer programming game. The analysis of the strategic behavior of the entities participating in the kidney exchange game allowed us to prove that the most rational game outcome maximizes the social welfare and that it can be computed in polynomial time.     

Patient flow-based allocation of inpatient resources: A case study

The paper considers the allocation of inpatient resources such as beds, operating theatres and nursing staff to specialties within a hospital setting. It describes an allocation procedure that takes patient flows as its starting point and enables an evaluation of combined impacts on the different resources involved. The paper is written in the format of a case study, dealing with a hospital that had serious problems with the utilization of beds and was faced with many admission-stops. However, the method can be used to a wide range of resource management problems in hospitals and can contribute to improving flexibility in the use of hospital resources.     

政府监管下的医院医疗信息分享演化博弈分析

在分析政府监管下医院间医疗信息分享特征的基础上,结合我国当前正在推行的医联体医院间信息分享运作模式,引入梅特卡夫定律并考虑患者评价的影响,分析了监管部门与医院各自的利益组成,建立了监管部门与医院两者之间的演化博弈模型,并采用复制动态方程研究了不同情形下医院间信息分享的演化博弈轨迹。研究表明,政府通过监管并建立激励惩罚机制等引导措施对医院最终达到的演化稳定态具有极大影响;降低医院主体信息分享的风险成本、规范提高医院分享信息的质量、引导患者增强对医院信息分享的关注、制定有吸引力和威慑力的奖惩政策,是促进医院医疗信息分享的关键。研究结果可为政府监管部门预测医院间的信息分享趋势和制定精准化政策以促进分享提供参考。     

Modelling the size and skill-mix of hospital nursing teams

Previously published work has described the development of a hospital capacity simulation tool, PROMPT. PROMPT has now been adopted by a number of hospitals in the UK and is used for both strategic and operational planning and management of key hospital resources. The work, as presented here, extends the PROMPT functionality to consider in more detail workforce issues. In particular, working with some of the current hospital users, the research has focussed on detailed planning for calculating the size and skill-mix of inpatient nursing teams. The chosen methodology utilizes both simulation and optimization. Outputs from the PROMPT three-phase discrete event simulation are fed into a stochastic programme which suggests the optimal number of nurses to employ (whole time equivalents) by skill-mix and the corresponding numbers by shift. A novel feature of the tool is the ability to predict and compare nursing needs based on different methods of capturing patient-to-nurse ratios as currently adopted across the UK National Health Service. Illustrative results from one hospital demonstrate that although the overall sizes of nursing teams on different wards are of an acceptable level and comparable to the outputs from the simulation phase of the work, often the number of nurses employed at different grades is not well matched to patient needs and the skill-mix should be reconsidered. Results from the optimization phase of the work suggest that it is cost beneficial to increase the number of permanently employed nurses to account for fluctuations in demand and corresponding high costs of temporary (agency) nurses. The scenario functionality of the tool permits for the study of changing size and skill-mix as a consequence of changes in patient volumes, patient case-mix, numbers of beds and length of stay.     

An evaluation of inventory and transportation policies of a regional blood distribution system

Blood is a valuable but perishable community resource. Regional blood centers coordinate the blood drawing and inventory policies of the hospital blood banks in a region for more efficient use of the resource. This study used a simulation model to analyze the costs and effects of several different operational policies for a regional blood center. Simulated experiments were carried out in four areas: (1) increasing the amount of blood available, (2) changing the number of delivery vehicles, (3) comparing two types of inventory consignment policies (shipping blood to hospitals with a recall privilege and frequent redistribution of blood amongst regional hospitals) to a direct-sale, no-redistribution policy, and (4) examining the effect of sending fresher blood supplies as inventories to hospitals with lower probabilities of transfusion. The results of the third experiment are presented in detail. It was found that periodic redistribution of the regional inventory yielded lower expiration rates and lower shortage rates. The results of the other three experiments are presented briefly.     

A comparison of shadow prices and reimbursement rates of hospital services

The purpose of this paper is to calculate shadow prices of hospital services and compare them to the reimbursement rates those hospitals receive. These shadow prices are calculated by estimating a multiple-output distance function and applying a dual Shephard's lemma, a technique suggested by Färe and Grosskopf [8]. In contrast to cost functions, distance functions require no price data and do not presume cost minimization. We apply this technique to a sample of California hospitals operating in 1986. We find that hospitals engaged in selective contracting for Medi-Cal patients exhibit closer agreement between relative shadow prices and relative reimbursement rates (Medi-Cal relative to private patients) than noncontracting hospitals.Contact author.     

A statistical Markov chain approximation of transient hospital inpatient inventory

Inventory levels are critical to the operations, management, and capacity decisions of inventory systems but can be difficult to model in heterogeneous, non-stationary throughput systems. The inpatient hospital is a complicated throughput system and, like most inventory systems, hospitals dynamically make managerial decisions based on short term subjective demand predictions. Specifically, short term hospital staffing, resource capacity, and finance decisions are made according to hospital inpatient inventory predictions. Inpatient inventory systems have non-stationary patient arrival and service processes. Previously developed models present poor inventory predictions due to model subjectivity, high model complexity, solely expected value predictions, and assumed stationary arrival and service processes. Also, no models present statistical testing for model significance and quality-of-fit. This paper presents a Markov chain probability model that uses maximum likelihood regression to predict the expectations and discrete distributions of transient inpatient inventories. The approach has a foundation in throughput theory, has low model complexity, and provides statistical significance and quality-of-fit tests unique to this Markov chain. The Markov chain is shown to have superior predictability over Seasonal ARIMA models.     

Allocating Blood to Hospitals

A method is proposed for the allocation of units of blood from a regional blood transfusion centre to the hospitals of its area, taking into consideration the characteristics of the individual hospitals, such as the transfusion activity, the demand of each hospital and the regional blood transfusion service policy concerning the allocation of units of blood expressed through a utility function. The problem is formulated as a stochastic programming problem but reduces to a linear programming problem and therefore is easily applicable. The method is suitable for application in systems with a National Health Service system, such as the British. Finally the results are given of an application to the despatches of units of blood in the Regional Blood Transfusion Service of Glasgow and West of Scotland.     

高校科研创新与管理的演化博弈分析

科学研究是高校的四大重要职能之一,也是一个大学综合实力的重要体现,高校对教师科研创新的激励政策和管理对全校科研氛围至关重要。以参与人有限理性为前提,本文首先分析了高校当前体制环境下影响科研工作者和管理部门决策的因素,基于演化博弈视角建立高校科研工作者与管理部门之间行为的博弈支付矩阵,构建了相关行为的复制动态方程,然后,基于演化博弈理论研究了科研人员和管理部门行为的演化路径以及影响演化的因素,研究得出了科研人员个体不同策略选择对群体行为产生的影响。为系统化、定量化的研究科研创新行为,本文基于Matlab GUI平台对科研创新与管理进行了演化仿真。系统分析了不同的初始条件和决策参数对演化结果的影响。本文的分析方法可为高校及科研管理部门提供决策支持,以适时采取适度的奖励政策,引导科研向高水平方向演化,提高高校的科研创新水平。     

Assessing the technical and allocative efficiency of hospital operations in Greece and its resource allocation implications

In this paper, we seek to develop a research framework concerning the assessment of the efficiency of public sector hospital operations. Public hospitals are increasingly under pressure to improve their operations both in terms of resources they use and also in terms of the quantity and quality of their outcomes. The assessment of efficiency entails both the notions of technical and allocative efficiency as they yield complementary information about the management effectiveness of individual hospitals. Technical efficiency has a diagnostic purpose as it yields comparative information about the effectiveness with which individual units convert their input resources into outputs. On the other hand allocative efficiency has a planning orientation since the objective of the assessment is to gauge efficiency improvements by means of resource reallocation. A linear programming based model is proposed for assessing allocative efficiency in the light of uncertainty about the prices of input factors. The empirical part of the paper is based on data from Greek public hospitals. Results and policy implications are discussed based on data from 98 general hospitals based on information from 1992. It was found that significant inefficiencies are present in the operations of Greek hospitals that account approximately for 100 MEcu in 1992 prices.     

A system dynamics-based simulation study for managing clinical governance and pathways in a hospital

This paper examines the development of clinical pathways (CP) in a hospital in Australia based on empirical clinical data of patient episodes. A system dynamics (SD)-based decision support system is developed and analysed for this purpose. The study highlights the scenarios that will help hospital administrators to redistribute caseloads among admitting clinicians with a focus on multiple diagnostic-related groups (DRGs) as the means to improve the patient turnaround and hospital throughput without compromising quality patient care. DRGs are the best known classification system used in a casemix funding model. Casemix is a DRG-based government funding model for hospitals with a mix of performance measures aiming to reward initiatives that increase efficiencies in hospitals. The classification system groups inpatient stays into clinically meaningful categories of similar levels of complexity that consume similar amounts of resources. Policy explorations reveal various combinations of the dominant policies that hospital management can adopt. With the use of visual interfaces, executives can manipulate the DSS to test various scenarios. Experimental evidence based on focus groups demonstrated that it can enhance group learning processes and improve decision making. The findings are supported by other recent studies of CP implementation on various DRGs. These showed substantial reduction in length of stay, costs and resource utilization.     

区域品牌过度使用与投入不足的风险防范及规避

区域品牌作为一种公共物品，同其他公共物品一样具有非竞争性和非排他性的性质，现有理论和研究表明，这种性质决定了区域品牌具有“公共地悲剧”风险，这种风险表现为过度使用.但通过构建博弈模型，对比模型的纳什均衡解和帕累托最优解，可以发现区域品牌化过程中的“公共地悲剧”风险不仅表现为过度使用，也表现为投入不足，即具有双重性.并通过对这种双重性的内在机理进行分析，提出有效防范和规避“公共地悲剧”风险的政策建议.     

Managing the overflow of intensive care patients

Many hospitals in the Netherlands are confronted with capacity problems at their intensive care units (ICUs) resulting in cancelling operations, overloading the staff with extra patients, or rejecting emergency patients. In practice, the last option is a common choice because for legal reasons, as well as for hospital logistics, rejecting emergency patients has minimal consequences for the hospital. As a result, emergency patients occasionally have to be transported to hospitals far away. In this work, we propose a cooperative solution for the ICU capacity problem. In our model, several hospitals in a region jointly reserve a small number of beds for regional emergency patients. We present a mathematical method for computing the number of regional beds for any given acceptance rate. The analytic approach is inspired by overflow models in telecommunication systems with multiple streams of telephone calls. Simulation studies show that our model is quite accurate. We conclude that cooperation between hospitals helps to achieve a high acceptance level with a smaller number of beds resulting in improved service for all patients.     

基于不完全信息的扩展审计博弈比较及应用

针对扩展审计博弈的不足及策略信息的不确定性,将审计博弃与统计抽样结合起来,研究不确定条件下,扩展审计博弈的扩展成本与利益转移、策略矩阵与审计风险、样本估计与内控评估,以实现审计师在不确定条件下的策略分析与选择.解决了动态博弈、风险计量系统性决策问题,提高了扩展审计博弈的可靠性与适用性.最后,给出了一个实例,用以演示扩展审计博弈过程,以证实该方法的有效性.     

两人进化博弈策略的决定机制与应用研究

通过建立一般情况下的两人进化博弈模型,给出了系统均衡点对应的矩阵行列式和迹表达式的经济含义,分析了16种典型情形下的进化稳定策略,详细讨论了均衡点稳定性分析结果所对应的博弈双方决策过程,从策略权衡的视角揭示了策略选择的内在机制。研究结果表明:不同策略前提下的相对净支付决定了系统的进化稳定策略,对方的策略选择以及自身可选策略的支付比较是影响博弈主体策略选择的两个基本要素,博弈主体会趋向于选择在对方策略既定下能够带来更大支付的策略。最后以环境治理中地方政府与企业以及地方政府之间的博弈关系为例,从对称博弈和非对称博弈两方面阐明了本文所构建模型在政策设计中的应用价值:针对不同案例,只要明确了两人博弈的支付矩阵,就可以通过计算相对净支付确定博弈双方的行为演化规律和稳定策略,从而简化计算过程,更加直接和更为便捷地为政策设计提供理论参考。     

基于不确定性回报的行为控制博弈分析

不确定型的行为控制较之确定型的行为控制更为复杂,但在现实中又有一定的广泛性,且目前的研究基础比较薄弱.把研究的视角放在不确定性回报下行为控制的博弈机理上,考察了博弈双方的行为观测偏差,定义了在信息不对称条件下管理者对被管理者的行为的观测矩阵、管理者的博弈策略矩阵、被管理者对管理者观测能力的估计矩阵及对管理者博弈策略的估计矩阵等,分析了管理者与被管理者之间的动态博弈过程和行为策略选择,给出了满足博弈均衡的不确定性回报的设计要求.这些都可以推广应用于各种具体管理制度的设计和改进当中,为行为控制研究提供了定量分析的新方法.在此基础上,选择房地产投资开发行为控制机制的实例进行了诊断研究.     

A multi-methodological approach to the development of a regional solid waste management system

The management of solid waste at regional level has received considerable attention over the last years. Increased consumption levels are causing an exacerbation of the problem, whereas the sensitivity of the public over environmental issues makes its solution harder. Although the main difficulties in resolving the different occurrences of the problem belong to the realm of policy making, so far the employment of operational research and systems methods seems to adopt a purely technocratic stance, concentrating on the content and understating the solution process. In the different formulations of the problem as static optimization relating to the economics of the location of the treatment facilities and the methods and routes of waste transportation, the dynamics of the issue and the intervention activities are neglected, whereas cognitive and social perspectives of the solution process are objectified and over-rationalized. This paper aims at demonstrating how the solid waste management (SWM) problem and its solution process can be addressed in a more holistic way by adopting a multi-methodological point of view. Towards this end, we present the combined application of soft systems methodology, system dynamics and multi-objective optimization in an action research project for the development of an SWM system for a specific region in Greece.     

A Hospital Cost Model for Policy Analysis

The paper describes the development of a model of hospital inpatient costs. The model has three components; overhead, hotel and treatment costs. The size of each component is estimated using regression on historical hospital cost and activity data. It is argued that, for certain types of policy analysis, the model provides a better picture of hospital costs than do conventional accounting methods. The application of the model to a number of policy issues is described.