关键词: 远程医疗, 演化博弈, 优质医疗资源下沉, 医联体

Abstract: With the continuous promotion of China’s hierarchical diagnosis and treatment system, China is faced with the realistic dilemma of unbalanced medical order, weak grass-roots medical service capacity, and the sinking of high-quality medical resources. Realizing the first diagnosis of patients in primary hospitals has become the basis and premise to solve the above problems, and promoting the construction of telemedicine in the medical association is an effective solution to effectively promoting the first diagnosis of patients in primary hospitals. However, in practice, there are two bottlenecks: the lack of both patient acceptance and incentives in grass-roots institutions. It is urgent to reveal the strategy interaction behavior and dynamic evolution mechanism between doctors and patients in the process of technology adoption, which not only helps to expand the theoretical analysis framework of digital medical adoption behavior, but also provides an empirical basis for the government to design incentive policies and optimize the resources sinking mechanism, which is of great significance in promoting the construction of hierarchical diagnosis and treatment pattern. From the perspective of evolutionary game, this study analyzes the stable conditions of telemedicine technology promotion through a dynamic game model, and provides theoretical support for optimizing resources allocation and policy design.
   Based on the hypothesis of bounded rationality, this study constructs an evolutionary game model between patient groups and primary medical institutions. The strategy space of patient groups is {use, not use}; the strategy space of primary medical institutions is {use, not use}. The model includes multidimensional parameters, including medical cost, sinking utility of medical resources, reimbursement ratio of medical insurance, reputation loss and cure rate of primary medical institutions, and describes the payment structure of strategic interaction between the two sides by establishing an income matrix. The evolution path of group strategy proportion is described by copying dynamic equation, and the evolution stability strategy of dynamic equation set is determined by using the local stability of Jacobian matrix system, and the parameter sensitivity is verified by a numerical simulation. In order to ensure that the parameter values are not only in line with the theoretical assumptions, but also close to the real scene, the parameter settings are comprehensively derived from the provincial health statistics bulletin and related literature, so as to ensure the reliability and comparability of the empirical basis. Through a numerical simulation, the influence of different parameter changes on the evolution path and stable state of the system is dynamically displayed.
   It is found that the system only converges to two stable points: {not used, not used} or {used, used}, and its convergence direction depends on the parameter structure and its critical level. Specifically, reputation loss has a significant threshold effect, which can effectively promote the technology adoption behavior of medical institutions; the sinking utility ratio of medical resources needs to be at a high level to encourage patients to choose remote services; the proportion of medical insurance reimbursement is the key economic lever that affects patients’ decision-making. It is worth noting that the cure rate at the grass-roots level presents the “ability paradox” effect: the low cure rate stimulates the technical needs of both doctors and patients, while the high cure rate inhibits the willingness to adopt. The case analysis and numerical simulation results based on Yanchuan county show that the system can be effectively guided to the evolutionary equilibrium of doctor-patient collaboration through the tilt of medical insurance policy, the dynamic adjustment of resource sinking efficiency, and the strengthening of institutional accountability and performance constraints. From the perspective of the evolutionary game, this study provides a theoretical reference for the mechanism design and policy optimization of telemedicine enabling primary care, and has enlightenment significance for the construction of a hierarchical diagnosis and treatment system based on primary care.

Key words: telemedicine, evolutionary game, sinking of high-quality medical resources, medical alliance