【作者】 陈斌；

【导师】 罗五金；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2011， 博士

【摘要】 研究目的系统分析区域医疗协同内涵,评估区域医疗协同现状,探索医疗协同影响因素,揭示网络协同缺陷根源；创建区域医疗协同的管理框架模型；建立促进区域医疗协同持续改进的政策群。研究方法本研究以文献研究、规范分析为主,辅以实证研究,以定性研究为主,辅以定量分析研究,在对协同功能要素充分解析的基础上,运用综合性研究系统的重要范式：系统-结构-功能分析方法,从传递系统功能分工协作、组织分化整合的角度考查,围绕政策问题,探讨建立综合性的协同管理模型。数据主要有三种来源：一是武汉地区与武汉协和医院集团现场调查得来的数据与资料；二是从我国和武汉地区卫生年鉴抽提的数据,对数据主要采用描述性的分析方法；三是对收集的相关调查报告进行二次分析。研究结果(1)区域医疗服务协同网络的协同功能按要素可分为服务一体化、管理一体化和卫生信息化等内容,协同网络管理体制、卫生保健筹资制度、补偿与支付方式等因素不但深刻影响着区域医疗医疗协同网络的分化、分工与整合,同时也对协同功能的发挥产生重要影响；(2)区域医疗服务协同网络的组织模式和网络的协同功能相互作用相互影响,形成区域医疗服务协同网络结构与功能的关系；(3)网络的协同模式主要有托管、并购、对口支援(协议模式),其中托管、直接开办对提升医院与社区之间协同功能效果相对明显。研究结论虽然都存在改善卫生保健服务,提高服务的效率、效果的迫切需要,但和OECD等高收入国家和地区相比,我国医疗服务传递系统存在明显的区域化与组织化不足的缺陷,区域医疗协同建设的不足是我国新一轮医疗卫生体制改革必须面对和克服的难题。我国区域医疗协同功能方面主要存在以下不足：(1)我国医疗服务主要以单一机构提供为主,协同性较差,存在连续性障碍；(2)由于技术、管理等方面的差距,使医疗服务组织难于形成有效的管理协同；(3)我国卫生信息化程度较低,发展的阶段性特征明显,无法给予区域医疗服务协同和管理协同有力支持。协同功能发挥不畅主要受以下宏观卫生政策因素影响：(1)我国现行的医疗卫生管理体制限制了区域医疗协同网络化组织和功能分化整合的探索：高度集中的财权使地方政府普遍缺乏提高和改善保健提供的资金支持,高度分敞的事权既不利于有效管理,形成合力,又难于追责；(2)我国卫生保健筹资主要以个人自费为主,医疗保险筹资水平不高,保障力度较低和医保管理的高度分散,从而不能覆盖参保者的大部分医疗费用,其作为第三方购买者控制费用的机制也无从运作,也不能利用补偿杠杆推动医疗机构进行有效的分化分工,没能利用成本控制手段促进医疗机构整合,没能建立守门人制度和严格的社区首诊制引导民众合理消费；(3)我国目前交叉补贴的补偿制度和按项目付费制度为医疗机构提供了拼规模、拼设备、拼高新技术的激励机制,从而抑制了机构间的分工合作。微观影响因素主要有：(1)学科因素；(2)患者流：(3)机构水平和能力的差异；(4)网络治理制度与治理结构。建议我国区域医疗协同的长期目标是促进服务提供主体从单一机构转变为区域整体,医疗机构的经营方式从抢地盘转向服务地域,低效资源向资源优化配置、高效利用转变。这些目标的达成有赖于管理体制和运行机制改革的成功,并且还需保健制度改变支付方式与补偿内容,从而提供有效激励促进医疗机构加快分工、分化与整合的步伐。不过,短期内,仍可以从以下方面加强区域医疗网络的协同：(1)在优先保证公共卫生的前提下,以医院托管社区的模式整合医疗资源,以点组线,以线促而的方式分步骤促进医疗机构整合,形成从基层到高度专业化的专科紧密协作的集团化的区域网络,以法人化促进医疗集团管理的自主化,使医院的功能调整与基层机构的发展同步进行；(2)通过托管、培训等方式,加强医院对基层的扶持力度,促进医院与基层服务与管理的一体化,加快提升基层医疗机构的服务能力,增加居民对其信任感和认可度；(3)促进医疗服务中间体的分化,如康复医院、临终医院、长期护理中心等；(4)通过组织各种专科学会制定相关标准和提高培训力度,促进诊疗技术和服务流程规范化；(5)通过重大疾病策略、重点人群策略(如针对困难群体的惠民医院和针对老年人的长期护理)、重点项目策略(如基本技能训练、区域医疗信息协同网络建设)等增加卫生领域从项目计划、投资到绩效考核的协同性和提高服务提供的协同能力；(6)加快医疗机构改革步伐和政府职能的转变,落实医疗机构经营管理权,促进医疗服务的外部监管与内部控制职能的合理分配,加强医疗服务一体化的管理协同能力。创新(1)理论创新国内外对于医疗服务协同网络的研究主要局限于单一功能的研究,如服务连续性、信息协同、管理协同,或者限于单一机构或网络的单一层面。通过吸收产业集群的组织理论,制度经济学企业理论,本研究从协同网络组织模式和协同功能出发,系统研究了区域服务网络协同功能的构成和宏观、微观影响因素,增加了服务网络研究的系统性和综合性,并提出了相应的我国区域医疗服务网络协同功能管理模型,对实践具有理论指导意义。(2)方法创新从区域医疗服务协同网络结构-功能出发,不但加深了对卫生资源的认识,增加了研究的全面性和综合性,而且吸收了国外在医疗服务系统协同功能与组织集群方面的研究成果,既结合我国实际,也扩大了协同功能的内涵和意义,有利于阐明医疗服务网络协同功能和相互影响关系,也更有利于管理模型的建立。更多还原

【Abstract】 Objectives:The aim of the study is to create a model of management and establish the coordinated policy framework which promote continuously improvement of the coordination of the Chinese regional medical service network through systemic analysis of the network and its cooperation function, evaluation to the present situation of cooperation of medical service regional network, exploration of the influence factors in network and the synergies deficiency causes.Methods:This study uses the methods of standard research, qualitative research, documentary research and normative analysis, supported by empirical research and quantitative analysis. On the comprehensive study of coordination functions essentials, study applies the important comprehensive analysis paradigm of system:system-structure-function, to explore the establishment of a comprehensive and coordinated management of the model, from division of work, integration and coordination of medical delivery system, centre on the policy problem.There are three main sources of data:A’s from the survey in WuHan and WuHan XieHe Hospital Group; B’s from the health almanac of China and WuHan; C’s from the second analysis of the investigation reports collected.Results:(1)Medical service regional network synergies function can be divided into the elements of integrated services, management integration and health information. The collaborative function of network is affected by systematization degree, management system and health care financing system, compensation and the paid way, which also deeply influence the differentiation, the division of labor and integration of the network. (2)The organizational model and the col laborative function of network interact and affect each other, which format the relationship of the construction and the function of network; (3)The organizational model of collaboration are those:trusteeship、merger and acquisition、invest and run、one-to-one assistance、contract, and so on.Conclusions:Although there are urgent needs to improve the health care service, enhance service efficiency and effectiveness as well, compared with the OECD and so on other high income countries and regions, our regional medical services system obviously lack of regionalization and organization, which is the new round of medical and health system reform must confront and overcome.The deficiency of co-ordination function of our medical service regional network are primarily the fol lowing:①Our medical services are provided mainly in a single, collaborative lack, there is a continuity obstacles;②The gaps of technological and management etc. among the medical services institutions make the organizations are difficult to create an effective synergies management;③The development of our health information is less, which provides coordination and management of operations vigorous support.The reasons why the coordination function is poor smooth are those:①Our current health management system restricts the exploration of the medical institutions in the area of organization, division and integration:high concentration of public finance power make the local governments are usually deficit financing public health work, Highly decentralized functional authority is hard to conduct effective management and catch the resultant. So there is lack of motivation to improve our health care;②Our primary health care financing emphasizes so much on individual responsibility that the level of medical insurance funds is too low to ensure more health services covering the mass of people. And the management of founds is highly decentralized, which could not cover the most of medical expenses, the reduce-expenses mechanism as a third party is hard to operate, so it can’t prompt the medical institutions effective division of labor and integration, and no strict confine of community-first visit to guide the reasonable consumption of medical services;③The present cross-subsidizing and pay-for-fee system provide an incentive mechanism for medical institutions striving to a scale model, which using equipment and high technology to provide services and suppressing the inter-agency cooperation.Suggestions:The long-term goals of our regional medical service network are these:①Promote the services provided by a single agency changing to by medical institutions network;②The operate model of the medical institutions changes from competition as rival to co-operational service the whole domain;③Promote the transition of the inefficient resources to the configuration and efficient use. The chieve of these goals depends on the reform of the management system and operational mechanisms are successful. And the medical insurance system are needed to change the way of compensation to provide incentives to promote the division of labor effective, and differentiation and integration. However, in short term, there are still in the following ways to enhance the co-operation of our regional medical service network:①Through conglomeracy of the grass-roots and special hospitals to continuity medical services as a whole before public health services with a group of lines, and then step by step cluster lines into scope of the domain. Through integration and governance of hospital groups to promote management autonomy. Making the adjustment of hospital function and development of grass-roots institutions working in parallel;②By means of hosting, training to strengthen hospital supporting to grass-roots, promoting hospital and grass-roots management integration, enhancing the services capacity of primary health care sector, Increasing the trust and recognition of the residents on the grass-roots;③Promote medical services of intermediate differentiation, such as terminal hospitals, rehabilitation hospitals, long-term care centre etc.;④Through the Organization of the series professional institutes specialist and training to promote the standardization of diagnosis, treatment technologies and services processes;⑤By focusing on major diseases strategy and special population (such as the long-term care services for the old, the charity hospital for the poor, etc.)policy, key project policy (such as basic skills training, the construction of regional Collaborative medical information network, etc.) to increase the coordination ability of health areas such as project plans, investment, performance appraisal, etc.;⑥Accelerate the pace of medical institutions reform and Transition of Government function, implement the right management to medical institutions, promote the rational allocation of external regulation and internal control functions, strengthen integration of health services management interoperability.Innovations:(1)Theoretical innovationThe formal study of medical services co-ordination was limited primarily to the single-function research, such as continuity of services, the collaborative of informat ion and management, or confined to single institution or single level of network. This research studys the regional coordination function of the service network and macroscopic and microcosmic influencing factors, started from the collaborative network organization and co-ordination functions increased the research of systematic and comprehensive, and presents our corresponding coordination function management model of medical services regional network, which have the theory guide meaning of practice.(2)Innovation of methodsThis study starts from the collaborative network organization and co-ordination functions, recruits from the cluster and medical services network research results, which help to clarify the medical service network synergies and mutual influence, also be conducive to the establishment of management model.更多还原