【作者】 郭石林；

【导师】 陶红兵； 方鹏骞；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2008， 硕士

【摘要】 研究目标本研究在文献研究的基础上,通过对医院与社区卫生服务机构双向转诊现状进行研究,分析各种双向转诊模式的影响因素以及激励与约束措施,进而建立适合我国实际的双向转诊激励与约束机制以及管理体系,从而实现病人的合理分流,为促进社区卫生服务机构和大中型医院之间双向转诊的实施,完善双向转诊制度提供决策依据。研究方法(1)文献回顾与情报分析:广泛查阅国内外双向转诊的有关专著、学术论文、专业杂志期刊以及网上检索相关文献资料,收集国内外双向转诊现状和影响因素、相关制度和运行机制的相关资料,并对收集来的各类文献资料中的主要观点进行归纳总结,作为研究方案的依据;同时收集居民就医行为与意愿的文献资料,为深入分析居民就医行为,合理引导患者就医提供依据;(2)现场调查:在武汉、深圳、南京、杭州、无锡、苏州等城市,对双向转诊开展较好的社区卫生服务机构和医院进行调查,对卫生管理部门、医保部门管理者进行访谈;收集北京市、上海市、天津市等28个社区卫生服务体系建设重点联系城市2006年双向转诊的有关数据,包括社区卫生服务机构向上级医疗机构转诊的人次数、从医院转回社区卫生服务机构的人次数、管理方式、监督机制、运行机制、医保支付方式、双向转诊流程、信息传递方式及其影响因素等;(3)专题小组讨论:邀请卫生管理学者、社区卫生专家、卫生行政部门官员、社区卫生服务机构人员、临床专业专家对双向转诊的影响因素和相应的对策建议进行讨论;(4)居民问卷调查:根据我国城市开展双向转诊情况,在武汉市开展双向转诊的医院和社区卫生服务机构中,随机抽取2-3家二甲以上医院及其有转诊关系的社区卫生服务机构作为调查对象,并按照系统抽样对就医患者440人进行调查;(5)联合分析法:采用联合分析法对患者就医偏好进行分析,并结合文献资料和个人访谈,对患者就医行为和意愿进行剖析;(6)利益相关者分析:将政府、医院、社区卫生服务机构以及患者(居民)定义为不同的利益相关者,进行利益相关集团分析,运用归纳演绎等方法,探索其行为特征的相互作用,研究双向转诊的动力和阻力;(7)PEST分析方法:运用PEST方法,从政治、经济、社会、技术4方面探索影响社区卫生服务机构、医院、居民三者在双向转诊中的深层次因素及其因素内部之间的复杂结构关系。研究结果(1)双向转诊现状对28城市的调查显示,截止2006年12月,以市辖区为单位,只有36.13%的区建立并实施医院与社区卫生服务机构的双向转诊制度,大部分市辖区尚未建立双向转诊制度。2006年平均每个社区卫生服务中心上转病人212人次,而上级医院转回到社区卫生服务中心的人次数仅为56人。目前一些城市选择部分病种开展双向转诊试点。医院和社区卫生服务机构双向转诊的激励与约束措施主要有:以经济手段吸引患者到社区就诊;对转诊的患者减免部分医疗费用;选择部分病种开展双向转诊试点;制定双向转诊的参考指征;政府部门加大对双向转诊的监督考核力度。(2)双向转诊存在的问题及其原因从政府、医院、社区卫生服务机构、居民4方面探讨双向转诊存在的问题:政府对机构功能界定不明,没有制定双向转诊的有关法律法规,双向转诊还处于无法可依的阶段,也导致政府对双向转诊缺乏监督和考核依据;医疗保险对双向转诊支持不足,而且支付方式落后,不利于激励和约束医院和社区卫生服务机构的转诊行为。医院担心因双向转诊而导致收入减少,不愿意将患者转回社区卫生服务机构。社区卫生服务机构自身技术实力有限,人员水平不够高,居民信任度低。居民就医时有选择大医院的偏好,就医观念不合理,门诊患者中,4.8%的患者在就诊前自我感觉病情严重,23.1%的患者就诊前自我感觉病情比较严重,由于存在信息不对称,在就医过程中存在非理性因素。(3)双向转诊的影响因素通过文献调查并结合专家咨询,影响医院与社区卫生服务机构双向转诊的因素可以归结为三个方面,一是政府相关的配套政策,包括制定双向转诊的上转和下转标准、推进医疗机构信息化建设、发展社区卫生服务措施等,二是医疗保险政策,三是居民就医意愿与行为。(4)双向转诊激励与约束机制的构建双向转诊激励与约束机制的前提条件:推进分级医疗,鼓励医院和社区卫生服务机构之间加强协作;制定双向转诊的转诊指征,建立基于临床路径的病种转诊标准;制定双向转诊过程中的医疗质量保障制度;制定转诊信息沟通制度。政府的激励和监管机制:对双向转诊开展较好的医院和社区卫生服务机构给予一定的经济奖励;出台双向转诊法律法规,确保双向转诊有法可依,建立双向转诊考核指标和标准,加强对双向转诊的考核;加强社区卫生服务能力建设,增强其对居民的吸引力。强化医疗保险对医院和社区卫生服务机构双向转诊的支持,建立基于医疗保险制度的激励和约束机制:改革医保支付方式,以临床路径为基础,根据疾病不同阶段分别测算急性期住院费用和康复期在社区卫生服务机构继续治疗的费用,医保经办机构分别向医院支付患者急性期住院费用和向社区卫生服务机构支付患者康复期在社区卫生服务机构继续治疗的费用;医保费用的支付与医院和社区双向转诊的考核结果挂钩。针对居民的激励与约束机制:社区卫生服务机构转变服务模式,提高服务质量,增强居民的信任感,吸引患者到社区首诊;加大对社区卫生服务的宣传力度,转变居民就医观念,引导居民理性就医。结论与建议(1)我国的医院与社区卫生服务机构双向转诊还处于起步和探索阶段,部分地方通过一系列的措施,取得一定的成效,但还存在较多问题:下转人数少、转诊标准不明确、激励与约束制度不健全等。(2)医院与社区卫生服务机构的双向转诊涉及面广,影响因素较多,是个系统工程,单一的激励与约束机制效果有限,应从政府、医疗保险等方面分别建立针对医院、社区卫生服务机构、患者的激励和约束机制。(3)双向转诊应坚持以患者为中心,政府在推动医院和社区卫生服务机构双向转诊发展过程中应发挥主导作用。更多还原

【Abstract】 ObjectiveThe study is based on the research of the literature, and the demonstration research of the dual referral between urban hospitals and community health service institutions. It analyses the effect factors and the incentive and restrain measures of the dual referral, and set up the incentive and restraint mechanism of urban dual referral and the manage system which is suitable for our country, that will deliver the patients properly. It will advance the hospital and community health service institutions, and will offer the basis for decision making to the dual referral system.Methods1. Review the literature and analyze the information: Reading widely the famous works, the learning discourse, the major magazine and the index literature information on the Internet in and abroad the country. Collecting the information in and abroad about the effect factors, the system and the running system of the dual referral. Concluding the main points of them. They are all the basis of the research. Meanwhile collecting the information of the denizen medical treatment and willings, which provides the basis to the denizen medical treatment and lead patients to have a treatment.2. Local research: Making research in the hospital and community health service institutions in Wuhan, Shenzhen, Nanjing, Hangzhou, Wuxi, Suzhou, ect, about dual referral; Having interviews with the managers in the health management and the medical insurance institution.3. The special group discussion: invite the health management scholars, the experts of community heath, the health officials of the executive branch, community health service staff and clinical professional experts to discuss on the dual referral of the factors and the corresponding countermeasures.4. Residents survey: According to the statu of dual referral in our country, in some hospital and community health service institution in Wuhan, we select optionally 2-3 hospital as the research and make a research among 440 patients in the system.5. Conjoint analysis: analysis of patient’s preference of medical agencies by conjiont analysis, combine the literature and interviews, and analyze the denizen treatments and willings.6. Analysis of stakeholders: take the analysis on the related benefit group by defining the government, hospitals, community health service institutions and patients (residents) into different stakeholders. Study the dynamic and resistance of the dual referral by the way of summarized interpretation to explore the interaction of the behavior character.7. Analysis of PEST: Analyze dual referral with politics, economic, society, technique. And explore the complex structure relationship between the deep-seated causes of the influence and the internal factors among community health service institutions, hospitals and residents.Results(1) Status of dual referralIn the survey show that 28 cities, to the city district as a unit, only 36.13 percent of the establishment and implementation of hospitals and community health services dual referral system, in 2006 the average community health service centres referred 212 patients to hospital. And the number of patients return from higher-level hospital to the community health service center is only 56, most of the city area has not yet been established dual referral system. The incentive and restrictive measures of the hospitals and community health services dual referral are: the economic means to attract patients to community treatment; relief to the referral of patients with some medical costs; choice of the disease in dual referral pilot ; Develop dual referral indications; government departments to increase dual referral of the intensity of supervision and examination.(2) Problems and causes of dual referralFrom the government, hospitals, community health service institutions, residents of dual referral to discuss the issue: the definition of the bodies of unknown function, the absence of dual referral of the relevant laws and regulations, dual referral is still unable to follow the stage, but also led to the dual referral lack of basis of supervision and examination. Dual referral was lack of support by medical insurance. And for the backward methods of payment, it was not advance to incentive and restraint the dual referral behavior of hospitals and community health service institutions.Dual referral hospital due to worries caused by reduced income patients do not want to be back to the community health service agencies.Community health service institutions its own technical strength is limited, staff level is not high enough, residents of low confidence.Residents for medical treatment at major hospitals have a choice of preference and to seek medical treatment concept of unreasonable, out-patients, 4.8 percent of patients in attendance before the self-serious condition, 23.1 percent of the former self-treatment in patients with more serious condition, because of asymmetric information, Medical treatment in the course of irrational factors.(3) Factors affecting of dual referralThrough the combination of literature survey and expert advice, the impact on hospitals and community health service agencies of the dual referral can be attributed to three factors. First, the government of supporting policies, including the development of dual referral on to the next turn and standards. And promoting the construction of medical information, the development of community health services, and other measures, the medical insurance policy, the three wishes of the residents for medical treatment and behavior.(4) Dual referral incentive and restraint mechanisms constructionAccording to existing problems and the main factors affecting of dual referral, the construction of the corresponding incentive and restrictive mechanism was provided. The basis of dual referral incentive and restrictive mechanism: promote the ratings medical treatment system to encourage hospitals and community health service institutions to strengthen collaboration; establishment of the medical referral process of quality assurance system: create the referral indications standards, based on the clinical pathway; establish an information sharing platform and communication system.Government incentives and regulatory mechanism: the better two-way referral to the hospitals and community health service agencies must give economic incentives; introduced dual referral laws and regulations to ensure that dual referral law, the establishment of dual referral assessment indicators And standards to strengthen dual referral of the assessment; strengthen capacity-building of community health services, enhance its attractiveness to the residents.Strengthening health insurance for hospital and community health service organizations in support of two-way referral, the establishment of the medical insurance system based on the incentive and restrictive mechanism: the reform of medical insurance payments, based on the clinical path, according to the disease were measured at different stages of the acute phase of hospital fees and Rehabilitation of health services in the community to continue treatment of the cost of health insurance agencies were paid to the hospital with acute phase of hospital fees and to pay for community health service organizations in the rehabilitation stage of community health service agencies to continue treatment costs; health insurance costs Cover and dual referral hospitals and communities linked to the examination results.For residents of the incentive and restrictive mechanism: changes in community health service agencies deliver services, improve service quality and enhance the residents a sense of trust and attract patients to the first community consultation; intensify the promotion of community health services, and changes in residents for medical treatment concepts, to guide residents Reason for medical treatment.Conclusions and recommendations(1) Dual referral of hospitals and community health service institutions was at the initial stage of exploration, in part through a series of measures, and achieved certain results. However, there were some problems of dual referral, including the number of referred from hospital to community health service institutions being too less, lack of the standard of dual referral, lack of incentive and restraint mechanisms.(2) Hospitals and community health service organizations involved in a wide range of dual referral, is a systems engineering project, a single incentive and restraint mechanism limited effect, respectively, should be established for hospitals, community health service institutions, with the incentive and restraint mechanisms from government and medical insurance.(3) The dual referral should be patients-oriental; the government should play a leading role in promoting dual referral process.更多还原