Grounded theory research on the factors that lead to doctor moral hazard / Pesquisa sobre fatores que levam ao risco moral médico com base na teoria fundamentada

Abstract Moral hazard clearly exists among doctors, and it has a dramatic impact on doctor-patient relationships, medical costs and medical risks. This study explored the factors that lead to doctor moral hazard, as well as the interrelationships and internal regularity of these factors. This study takes doctor moral hazard as the research content and the inducing factors as the core theme, conducting grounded theory research on the causes of doctor moral hazard. Scientific understanding of doctor behavior would facilitate the prevention and control of doctor moral hazard behavior. This study used the principles and methodology of Glaser and Strauss's grounded theory. Theoretical and snowball samplings were used to identify 24 subjects. Semi-structured in-depth interviews were conducted with each subject. Themes were identified through substantial (open) coding and theoretical coding. The factors that lead to doctor moral hazard were categorized into five dimensions, i.e. motivation, opportunity, self-rationalization, exposure and punishment. These five factors influence each other, forming the inducing mechanism of doctor moral hazard. This will provide useful theoretical support and method guidance for the follow-up prevention and control of moral hazard for doctors.

Resumo O risco moral existe claramente entre os médicos e tem um impacto dramático nas relações médico-paciente, custos e riscos médicos. Este estudo explorou os fatores que levam ao risco moral por parte do médico, bem como as inter-relações e a regularidade interna desses fatores. Este estudo considera o risco moral do médico como o conteúdo da pesquisa e os fatores indutores como o tema central, conduzindo pesquisas de teoria fundamentada sobre as causas do risco moral do médico. A compreensão científica do comportamento do médico facilitaria a prevenção e o controle do comportamento de risco moral do médico. Este estudo usou os princípios e a metodologia da teoria fundamentada de Glaser e Strauss. Amostragens teóricas e em snowball foram utilizadas para identificar 24 sujeitos. Entrevistas semiestruturadas em profundidade foram realizadas com cada sujeito. Os temas foram identificados por meio de codificação substancial (aberta) e codificação teórica. Os fatores que levam ao risco moral do médico foram categorizados em cinco dimensões: motivação, oportunidade, autorracionalização, exposição e punição. Esses cinco fatores influenciam-se mutuamente, formando o mecanismo indutor do risco moral médico. Isso fornecerá suporte teórico útil e orientação metodológica para o acompanhamento da prevenção e controle de risco moral para os médicos.

De la intención al comportamiento: modelo analítico del comportamiento de riesgo moral del médico basado en la teoría del comportamiento planificado / From intention to behavior: analytical model of doctor's moral hazard behavior-based on planned behavior theory / Da intenção ao comportamento: modelo analítico do comportamento moral de risco de médicos baseado na teoria do comportamento planejado

Resumen Basado en el concepto de comportamiento de riesgo moral del médico y el modelo teórico de comportamiento planificado, este artículo construye un modelo teórico del comportamiento de riesgo moral del médico y analiza en detalle los principales factores que influyen en el comportamiento de riesgo moral del médico, incluidas las actitudes conductuales, subjetivas normas y control conductual percibido. En combinación con los resultados de la encuesta por cuestionario, este artículo utiliza un modelo de ecuación estructural y un análisis factorial para verificar las hipótesis. Los resultados muestran que en el modelo teórico de la conducta de riesgo moral del médico, las intenciones de riesgo moral de los médicos se ven afectadas por tres variables independientes: actitudes conductuales, normas subjetivas y control conductual percibido. Como variable intermedia, las intenciones de riesgo moral tienen un efecto mediador en el comportamiento de riesgo moral de los médicos. Todos los coeficientes de trayectoria cumplen los requisitos y se verifican todos los supuestos del modelo. El modelo teórico del comportamiento de riesgo moral del médico establecido en este estudio puede explicar eficazmente la ley de ocurrencia del comportamiento de riesgo moral del médico y predecir este comportamiento de acuerdo con la situación real de varios factores influyentes. Esto proporciona una guía teórica eficaz para el siguiente paso para llevar a cabo mejor la investigación relevante sobre el riesgo moral del médico basada en la perspectiva de la gestión, especialmente el establecimiento de estrategias de prevención y control para el comportamiento de riesgo moral del médico.

Abstract Based on the concept of doctor's moral hazard behavior and the theoretical model of planned behavior, this paper constructs a theoretical model of doctor's moral hazard behaviorm and analyzes the main influencing factors of doctor's moral hazard behavior in detail, including behavioral attitudes, subjective norms and perceived behavioral control. Combined with the results of questionnaire survey, this paper uses structural equation model and factor analysis to verify the hypotheses. The results show that in the theoretical model of doctor's moral hazard behavior, doctors' moral risk intentions are affected by three independent variables: behavioral attitudes, subjective norms and perceived behavioral control. As an intermediary variable, moral risk intentions have a mediating effect on doctors' moral hazard behavior. All path coefficients meet the requirements, and all assumptions of the model are verified. The theoretical model of doctor's moral hazard behavior established in this study can effectively explain the occurrence law of doctor's moral hazard behavior and can predict doctor's moral hazard behavior according to the actual situation of various influencing factors. This provides an effective theoretical guidance for the next step to better carry out the relevant research on doctor's moral hazard based on the management perspective, especially the establishment of prevention and control strategies for doctor's moral hazard behavior.

Resumo Baseado no conceito de comportamento moral de risco de médicos e o modelo teórico do comportamento planejado, este artigo constrói um modelo teórico de comportamento de risco moral de médicos e analisa os fatores principais que influenciam o comportamento moral de risco de médicos em detalhes, incluindo atitudes comportamentais, normas subjetivas e controle comportamental percebido. Combinado com os resultados de levantamentos com questionários, esse artigo usa o modelo de equação estrutural e análise fatorial para verificar as hipóteses. Os resultados mostram que no modelo teórico do comportamento de risco moral de médicos, as intenções de risco moral de médicos são afetadas por três variáveis independentes: atitudes comportamentais, normas subjetivas e controle comportamental percebido. Como uma variável intermediária, intenções de risco moral tem um efeito mediador no comportamento de risco moral de médicos. Todos os coeficientes de caminho cumprem os requisitos e todas as suposições do modelo são comprovadas. O modelo teórico do comportamento de risco moral de médicos estabelecidos nesse estudo podem efetivamente explicar a lei de ocorrência do comportamento de risco moral de médicos e pode predizer o comportamento de risco moral de médicos de acordo com a situação real de vários fatores de influência. Isto fornece um guia teórico efetivo para os próximos passos para melhor conduzir pesquisas relevantes sobre risco moral de médicos baseadas na perspectiva de gestão, especialmente o estabelecimento de estratégias de prevenção e controle para o comportamento de risco moral de médicos.

Understanding changes in doctor moral hazard behaviour in response to government healthcare reform / Entendiendo los cambios en el riesgo moral del comportamiento médico en respuesta a la reforma de atención de salud del gobierno / Compreendendo mudanças no comportamento de risco moral médico em resposta a reforma governamental de cuidados à saúde

Doctor moral hazard has a significant effect on the doctor-patient relationship, increases the cost of healthcare, and introduces medical risks. It is a global concern. Doctor moral hazard behaviour is evolving in response to China's healthcare reform program which was inaugurated in 2009.A scientific understanding of doctor behaviour would facilitate the prevention and control of doctor moral hazard behaviour. This study used the principles and methodology of Glaser and Strauss's grounded theory. Theoretical and snowball samplings were used to identify 60 subjects. Semi-structured in-depth interviews were conducted with each subject. Themes were identified through substantial (open) coding and theoretical coding. Six types of doctor moral hazard behaviour were extracted from the data. A behavioural model was described and diagrammed to provide a conceptual framework of current doctor moral hazard behaviour. The conceptual model of doctor moral hazard behaviour can be used in several ways to correct or prevent undesirable actions. Rules governing hospital procedures can be strengthened and enforced by supervision and punishment; the asymmetry of information between doctor and patient can be reduced; patient participation in treatment decisions can be increased; the effectiveness of medical ethics education can be improved.

Para un médico, el riesgo moral tiene un efecto significativo en la relación médico-paciente, incrementa el costo de la atención de salud e introduce riesgos en la salud. Se trata de una preocupación global. El riesgo moral del comportamiento médico ha evolucionado en respuesta al programa de reforma de atención de salud del gobierno de China, inaugurado en 2009. Un entendimiento científico del comportamiento de los médicos facilitaría la prevención y el control del riesgo moral. El presente estudio usa los principios y metodología de la teoría fundamentada de Glaser y Strauss. Se usaron muestras teóricas y multiplicativas para identificar 60 sujetos y realizar entrevistas semiestructuradas en profundidad. Los temas se identificaron mediante codificación sustancial abierta y teórica. De los datos se extrajeron seis tipos de riesgo moral del comportamiento médico. Se describió y diagramó un modelo de comportamiento para proporcionar una estructura conceptual del riesgo moral del comportamiento médico actual. El modelo conceptual de riesgo moral del comportamiento médico puede usarse de varias maneras para corregir o prevenir acciones no deseadas. Las normas procedimentales de los hospitales pueden fortalecerse y exigirse mediante supervisión y castigo; se puede reducir la asimetría de la información que se da entre el médico y el paciente, incrementar la participación del paciente en decisiones de tratamiento y mejorar la efectividad en la educación en ética médica.

Risco moral médico tem um efeito significativo na relação médico-paciente, aumenta o custo dos cuidados à saúde e introduz riscos médicos. É uma preocupação global. Comportamento de risco moral médico vem se desenvolvendo em resposta ao programa de reforma de cuidados à saúde da China, que se iniciou em 2009. Uma compreensão científica do comportamento médico facilitaria a prevenção e controle do comportamento de risco moral médico. Este estudo utilizou os princípios da metodologia da Teoria Fundamentada de Glaser e Strauss. Amostragem teóricas e por bola de neve foram utilizadas para identificar 60 participantes. Entrevistas detalhadas semi-estruturadas foram realizadas com cada participante. Temas foram identificados através de codificação (aberta) substancial e codificação teórica. Seis tipos de comportamento de risco moral médico foram obtidos dos dados. Um modelo comportamental foi descrito e diagramado de forma a fornecer um enquadre conceitual do comportamento de risco moral médico. O modelo conceitual de comportamento de risco moral médico pode ser utilizado de diversas formas para corrigir ou prevenir ações indesejáveis. Regras que governam procedimentos em hospitais podem ser fortalecidas e reforçadas por supervisão e punição; a assimetria de informações entre médicos e pacientes pode ser reduzida; a participação dos pacientes nas decisões sobre tratamento pode ser aumentada; e a efetividade da educação ética médica pode ser melhorada.

Can prepayment reform of medical insurance control the rise of medical expenses in China? Empirical analysis based on PSM model and CHARLS data / 中国卫生政策研究

At present, China's medical service costs keep rising, and residents' out-of-pocket medical expen-ses are also increasing heavily. The prepayment reform of medical insurance is considered as an important starting point to solve the problem. It is of great significance to evaluate the effect of prepaid medical insurance reform on con-trolling medical expenses and reducing economic burden when sick. In order to achieve the objective of this study, a use of CHARLS data 2011 &2015 and DIDPSM theory, and a combination of the Interaction Item Model and PSM model, and make use of a natural experiment developed from experimental reform stage for the comprehensive promo-tion stage of new rural cooperative medical system (NCMS) in 2012, were very crucial. This paper finds that:(1) Prepayment system can control the rise in outpatient and inpatient expenses. Compared with those who did not partici-pate in NCMS in the initial stage of reform, after the universal reform, outpatient and inpatient expenses dropped by 6. 3％ and 41％, the average decrease was 1041yuan and 2895yuan, respectively. (2) After the universal reform, the insured patients' medical burden of outpatient and inpatient reduced by 17％ and 33％. Prepayment system has, to some extent, resisted the rise in medical expense, and alleviated the burden of medical treatment. (3) On the basis of PSM, the estimated value and significance of coefficients have not changed, the effect of PPS reform is good. The poli-cy implication is that accelerating the prepayment system reform is the key way to control the growing medical expenses.

Research on Multi-stage Constraint Gaming with the Moral Hazard from the Supply Side in Public Hospitals of China / 中国卫生经济

Objective:To discuss the constraint mechanism of moral hazard from the supply side in the medical market of China.Methods:It analyzed the effectiveness of government regulation and of the influencing factors of the doctors and patients expected profits through the establishment 4 stage dynamic game model involved the doctors,patients and the government as the subject.Results:In the case of other conditions unchanged,the effective probability of government regulation would increase with the increase of profits made by excessive medical treatment,but would decrease with the increase of doctor's punishment cost and the increase of doctor's reputation value.Given the reasonable probability about medical treatment,the doctor's expected profits would increase with the increase of the value of a reasonable medical gain and doctor's reputation increase.The prospective profits of patients would increase as the doctor's profits increased,but decrease with the over-increased medical treatment.Conclusion:The effective restraint mechanism of moral hazard from the supply side of public hospitals in China included relax the price control,improve the market value of medical services,form effective doctor reputation incentive mechanism,reduce government supervision costs and improve government regulation on the basis of promoting incentive compatibility.

Study on the reimbursement rules of catastrophic disease health insurance in China / 中国卫生政策研究

Moral hazard in the catastrophic disease health insurance has challenged the sustainability of med-ical budget funds. This paper studies the health care reimbursement rule to counteract moral hazard. Theoretical a-nalysis shows that in the target to maximize social welfare, the optimal rule is to provide consumers who choose low-cost treatment with subsidies and charge a co-payment to those who choose high-cost one. Adopting simulation ap-proach shows that this difference with respect to single reimbursement rules, healthcare expenses and medical insur-ance premiums will be significantly reduced compared to a unified co-payment ratio. This paper also selects the sensitivity test simulation parameters and the results show that different values will not change the herein disclosed mechanism results.

An analytic framework on over-investment of large medical equipment in public hospitals un-der multiple moral hazards / 中国卫生政策研究

This paper analyzed the moral hazard of public hospitals 'investment stakeholders in the investment process and how to affect the hospital medical equipment over-investment from the perspective of institutional arrange-ments.The result showed that each agent has a severe moral .The impulse of over-investment from patients to doc-tors, managers, government regulators is strong .This paper also put forward the suggestions on the prevention and governance of over-investment from institutional innovation .

Discussion on Moral Hazard and Its Influences under China’s Health Care Reform / 中国卫生经济

It is a well-recognized difficult empirical task to disentangle the moral hazard effect from adverse selection impact by using the health insurance data in the empirical research of health economics. In the research, the unique social experiment in China’s health care reform, which enables cleanly identify moral hazard is applied. Using individual-level hospital patient data, it estimates the impact of the reimbursement rate increase on Chinese patients’ demand for health care service. Difference-in-Difference Propensity Score Matching approach and find strong evidence for moral hazard are approached. For instance: if the reimbursement rate increases by 5% while other factors remain the same, the corresponding health care service expenditure will increase by around 7%. The finding also has important implication for policy making. Chinese government pledges to lower the average individual out-of-pocket cost from the current 37.5% of total health care service cost to 30 % in 5 years. According to the former estimation, if the goal of the policy is successfully achieved, moral hazard problem itself will cost Chinese health care system around 200 billion yuan.

The Influence of Private Health Insurance on Admission among Some Patients with Cervical or Lumbar Sprain / 農村醫學 地域保健

BACKGROUND: In Korea, private health insurance has neglected to induce externality on national health insurance by moral hazard. Therefore, we conducted this study in order to explore the influence of private health insurance on unnecessary medical utilization among patients with cervical or lumbar sprain. METHOD: The study examined a population of 449 patients (admission, 384; out-patient; 85) diagnosed with simple cervical or lumbar sprain without neurological symptoms at 20 small hospitals or clinics in Gwangju and Jeollanam provinces from Jul. 1 to Aug. 31 2008. The data were collected using structured, self-administrated questionnaire which collected information such as whether or not the patient was admitted (as a dependent variable), whether or not they had private health insurance (as a independent variable), and covariates such as socio-demographic characteristics, the factors related to the sprain, and characteristics of the insurance provider. RESULTS: From hierarchical multiple logistic regression analysis, it was found that the admission rate of patient with private health insurance was higher than that those without it (Odds ratio=3.31, 95% Confidence interval; 1.14-9.58), meaning that private health insurance was an independent factor influencing the admission of patients with these conditions. Other determinants of admission were patient age and physician referral. CONCLUSIONS: This study is the first empirical study to explore the influence of private health insurance on inducing moral hazard in admission services, specifically among patients with cervical or lumbar sprain. Regulation of benefits provided by private health insurance may be necessary, as the effect of this moral hazard may mean existence of externality.

Effects of Private Health Insurance on Health Care Utilization and Expenditures in Korean Cancer Patients: Focused on 5 Major Cancers in One Cancer Center / 예방의학회지

OBJECTIVES: To identify the effects of supplemental private health insurance on health care utilization and expenditure under the mandatory National Health Insurance(NHI) system in Korea. METHODS: The data were collected by the National Cancer Center in Korea. Cancer patients who were newly diagnosed with stomach (ICD code, C16), lung(C33-C34), liver (C22), colorectal cancer(C18-C20) or breast(C50) cancer were included as study subjects. Data were gathered using a structured questionnaire from face-to-face interviews, the hospital Order Communication System (OCS) and medical records. Clinical, socio-demographic and private health insurance related factors were also gathered. The differences of health care utilization and expenditure were compared between those who have private health insurance and those who do not using t-test and multivariable regression analysis. RESULTS: Individuals with private health insurance spent larger inpatient costs than those without, but no differences were found in utilization in other service such as hospital admissions, hospital days and physician visits. CONCLUSIONS: We found that private health insurance exerts a significant effect on the health care expenditure in inpatient service. These study results can provide a rational basis to plan a national health policy regarding private health insurance. Further studies are needed to investigate the impacts of private health insurance on cancer patients' outcomes and survival rates.

College nepotism based on information asymmetry / 中华医学教育探索杂志

The formation mechanism of converse selection and moral hazard of college nepotism is discussed in terms of the information asymmetry theory,and several suggestions are also presented to avoid nepotism. A college-teacher employment system should be well established to manage and supervise the information about teachers,and there should be regulations for teachers' practices.

An Empirical Analysis of Price Elasticity of the Demand for Medical Care Services in Korean National Health Insurance Program / 예방의학회지

This paper tested by using Micro TSP, an empirical econometric analysis to approve officially a hypothesis of price elasticity of the demand for medical care services in Korean national medical insurance and the economic effect of health care delivery system with time-series datas of Medical Insurance statistical yearbook(1981-1993). The results suggest that the korean medical insurance system shows moral hazard due to the change of coinsurance and the economic effect according to intervention of the health care delivery system, but it is different by insurers regardless of the same structure of the medical insurance scheme.

The Summary on the Moral Hazards in Medical Insurance / 中国医学伦理学

There are serious moral hazards in medical insurance because of information asymmetry.Moral hazards can make different degree influence on the medicare supply,demand and supervision of usage.From the 1960s,scholars have much research and discussion on the different main body that be of moral hazard,on the influence of moral hazard to welfare,on the measure of moral hazard and on the methods that how to control moral hazard.This paper summarizes the related viewpoints and conclusions that come from the above four aspects.

The Study on the Evading of Moral Hazards of the Urban Workers' Basic Medical Insurance / 中国医学伦理学

The moral risk exists on various kinds of insurance markets,but more complicated on the medical insurance market.It makes hospitalization cost expand excessively,the urban resident's medical insurance level decrease relatively,and the decline of the whole social morals.Tracing to its cause,besides of the chasing benefit behavior of each participant,it's relational to personal morality and the relevant institution.The text holds that the normative and rational regulation is the fundamental guarantee to prevent morals risk.It's the core of evading morals risk that the establishment of social morals system.Relevant concrete measures are essential also.

Moral Hazard in Medical Insurance and Its Precaution / 中国医学伦理学

Since there is dissymmetry of information in medical insurance market,it is inclined to result in moral hazard.In our country,moral hazard in medical insurance has always been very conspicuous.To maximize their profit,doctors and patients either excessively supply or excessively demand the medical service.This has led to unreasonable and remarkable increase in medical expenditure and great waste in medical resources.At the same time,Moral hazard has deteriorated the relationship between doctors and patients and degraded the social integrity.This thesis adapts the document research method to discuss the appearance,causes and influences of moral hazard in medical insurance in order to put forward some measures for its precaution.

Ethical Issues on the Information Asymmetry in Medicine Sector and the Counter-Measures / 中国医学伦理学

As a common issue,information asymmetry has been a hot topic in the micro-economy field.It is also prominent in clinic as well as the medical insurance.The low efficiency and unfairness caused by information asymmetry will lead to a series of ethical problems.To solve the problems,the construction of moral system and rule are needed.