“远程医疗”背景下的紧密型医联体建设探讨△

分析紧密型医联体和“远程医疗”在促进分级诊疗实施中的优势，发现“远程医疗”能够促进紧密型医联体建设，有益于分级诊疗实施。但由于缺乏政府的宏观调控和指导，基于“远程医疗”的紧密型医联体建设过程面临缺乏顶层设计、标准体系、基础设施不均衡等问题。本文从政府主导的角度，提出建立紧密型医联体“远程医疗”体系、“远程医疗”公共平台、利益分配体系的“远程医疗”背景下的紧密型医联体建设的对策建议。     

医联体建设背景下分级诊疗制度的优化研究:基于SD因果关系图

目的:探寻医联体建设背景下影响分级诊疗系统建设的重要因素,并提出针对性建议。方法:利用系统动力学中因果关系图分析方法,运用Vensim软件构建医联体建设背景下分级诊疗系统因果关系图。结果:通过对医联体建设背景下分级诊疗系统中的医疗卫生服务需求方(患者或居民)、供给方(医疗卫生服务机构)、组织方(医保部门、卫生管理部门)三个子系统的分析,从主要利益相关者的视角分析了影响医联体建设背景下分级诊疗系统中的关键性要素。结论:提出了引导患者形成对基层医疗合理期望值、改革医师薪酬制度、改革医保支付方式等优化建议。     

地方政府分级诊疗政策创新扩散研究——基于全国地级市数据的事件史分析

地方政府卫生政策改革创新对于深化我国医药卫生体制改革具有重要意义。本研究以我国分级诊疗政策为例,收集并构建了全国170个地级城市2014—2018年五年时间内的数据库,采用事件史方法分析了地方分级诊疗政策出台的影响因素。研究发现,地方政府卫生政策改革创新呈现自下而上政策推广和横向竞先模式;卫生部门、医保部门和大型公立医院在我国地方政府分级诊疗政策制定中存在着显著性影响,而基层医疗卫生机构作用不显著。基于此,本文提出以下政策建议:(1)加强中央政府推进分级诊疗改革协调力度;(2)构建以紧密型医联体为基础的多方主体利益激励共融机制;(3)突出以基层医疗卫生机构为导向的“开源”性改革。     

医联体模式下昆山市第四人民医院发展现状的调查研究

作为确立分级诊疗,全面提高社区服务能力,使公立医疗机构与社区卫生服务中心相互补充的一项重要举措,医联体在此过程中起着关键作用。昆山市第四人民医院以"531"行动计划为契机,依托医联体建设,积极推进分级诊疗制度的建设和完善。调查同时发现,居民对医疗联盟体的认识程度不够、双向转诊仍存在障碍、基层医疗机构服务能力欠缺、未能建立长效的利益机制,医疗体建设仍处于探索阶段,需具体分析其问题并制定有效的措施。     

中美医联体比较研究

为解决分级诊疗过程中存在的种种问题,医联体的构建应运而生。该文在分析美国医疗资源整合后的"医联体"发展现状的基础上,比较了美国医联体与我国医联体的差异所在。在此过程中发现我国现行医联体普遍存在的诸如发展水平低、双向转诊问题多、基层机构待加强等问题。针对这些问题并结合我国国情,文章提出了鼓励发展医疗集团、构建医院资源共享机制、充分发挥保险公司的作用、提高医护人员薪酬水平等对策建议。     

分级诊疗背景下医联体“协同”关键因素探析

调研厦门、上海、镇江等地医联体运行状况,分析各地分级诊疗、公立医院改革等相关政策,探析医联体"协同"的关键因素,提出促进医联体协同效益提升的相关建议,为分级诊疗顺利推进提供参考。研究指出,发挥医联体协同作用是推动分级诊疗的重要支撑,影响医联体"协同"的关键因素包括诊疗疾病种类与医疗机构类型"协同"、患者自由就医选择与全科医生推荐"协同"、药品供给协同、医务人员协同以及医保政策协同。促进医联体协同可从提升患者对医联体的认知与认同、借助家庭医生签约建立患者与医疗机构的桥梁、发挥医保政策的价格引导作用、强化不同类型医疗机构间的药品"协同"几个方面入手,以推进分级诊疗落实。     

医联体背景下基于系统动力学的分级诊疗实施效果仿真模拟研究

目的:研究江苏医联体背景下分级诊疗实施效果的核心影响因素.方法:通过构建医联体背景下的分级诊疗系统动力学模型,以基层首诊人次数为核心评价指标,通过对不同靶点进行干预,研究对基层首诊人次数产生的影响.结果:所选取的4个干预靶点对分级诊疗均有正向促进作用,对基层首诊人数提升效果由高至低分别为医疗资源下沉、基层医疗技术水平、医保差异化水平以及基层医疗服务价格.结论:为更好推动分级诊疗制度的发展,可重点从医联体建设方面入手:如促进优质医疗资源下沉、提升基层医疗机构服务技术水平、完善医联体内部的医疗、医药、医保工作联动机制和完善医联体成员间的利益共享机制等,逐步实现就医格局有序合理化.     

关于我国分级诊疗制度实施路径选择的探讨

对国内外实施分级诊疗的主要措施和实施效果的分析表明,政府在分级诊疗制度实施过程中要承担主体责任,主导对患者(疾病)和医疗机构进行分级,加强基层首诊刚性约束,通过行政和经济手段约束各级医疗机构的诊疗行为,通过医疗保险报销比例等经济手段引导患者的就医行为,通过医疗保险捆绑支付实现医联体内经济利益的捆绑和风险共担。从而,建立起强制性分级诊疗制度,实现就医秩序的有序进行。     

无锡市基于全民健康信息平台的医联体建设实践

目的探索提供信息化技术手段支撑,进一步深化医联体建设,实现新医改背景下的医联体分级诊疗体系。方法基于全民健康信息平台,充分利用互联互通成果与区域卫生健康数据设计医联体分级诊疗系统。结果构建了基于全民健康信息平台的"三位一体"的医联体分级诊疗系统,为基层医疗卫生机构与医院提供了高效协同的通道与支撑,县域内就诊率达到95%以上;基层就诊率从2018年的51.44%提高到52.74%。结论基于全民健康信息平台构建医联体分级诊疗系统,有利于区域内医疗数据资源及知识的共享,对于提升基层医疗能力,推进医联体分级诊疗政策的落地起到了很好的辅助作用。     

郑州市“医联体”模式实践与探索

近年来,医联体成为中国医疗界的热议话题,各地纷纷探索构建"医联体",希望促进医疗资源整合和纵向流动,提升基层医疗服务能力,构建分级诊疗服务模式。然而,医联体是否真的能够将上中下三级医疗资源进行合理的配置?是否真的能够改变无序就医的状况?结合郑州市某三甲医院医联体实践与探索,对医联体运行、管理中取得的成绩和存在问题进行总结和分析,分析表明虽然在优质医疗资源下沉效率、人员培训体系、双向转诊渠道、医联体各级医疗机构业务收入、手术例数、门急诊人次等方面取得了一些成效,但是"医联体"模式要想广泛推广,一是强化政府主导支持;二是树立"不求所有、但求所用"办医理念,突破分级办医和编制人事制度限制;三是绩效管理必须要有新改革;四是相关政策必须改变,这样才能使所有成员单位的利益趋于一致,更好地从区域范围内做好患者的整体健康服务工作。     

建立分级诊疗制度的动力与阻力分析——基于利益相关者理论

分级诊疗体系的构建和运行涉及到医疗卫生服务的需求方、供给方、管理方和筹资方等多个利益相关方。各利益相关方的利益诉求、政策影响力和执行意愿各异,在建立分级诊疗制度的过程中发挥着不同程度的推动或阻碍作用。本文从利益相关者的角度深入分析分级诊疗,认为卫生部门和医保部门是建立分级诊疗制度的主要推动力量,但二者在实施路径上存在差异;财政、发改(物价)等部门的协调配合是分级诊疗顺利推进的必要条件;基层医疗卫生机构的管理者和医务人员是分级诊疗的重要推动因素,但前提是要对相关体制机制进行深层次改革;医院的管理者和医务人员在分级诊疗中利益受损的可能性较大,是政策推行的主要阻碍因素,但二者的阻碍程度不同;居民/患者本应是分级诊疗的重要受益者,但若政策运行不畅、引导措施不当,也有可能成为阻碍因素;医药器械商选择性地参与部分环节,有望成为推动分级诊疗的支持力量。     

平台理论视角下的互联网与“分级诊疗”

本文运用产业经济学中的平台理论对当前我国推进分级诊疗的难点、互联网促进分级诊疗的可能性及其可行模式进行了分析,得出结论:分级诊疗的主要障碍为事业单位体制下医生对医院的依附关系、医院分级管理制度与医院平台正外部性三者的相互作用,使三甲医院"强者愈强"、基层"弱者愈弱";互联网医疗平台促进医生走出体制自由执业,有助于破除传统医院平台的正外部性,实现分级诊疗;互联网医疗平台采取双层结构,"大平台套小平台",是推动分级诊疗的可行模式。     

行动者中心制度主义视角下县域医疗卫生服务整合路径

国家卫生健康委《关于推进紧密型县域医疗卫生共同体建设的通知》(2019年5月)明确了构建县域紧密型医共体(以下简称“医共体”)建设的政策目标。从现有的医疗资源分配机制来看,在政策执行过程中,推动县域医共体行动者间的有效互动和协调行动才能顺利达成政策目标,并切实优化医疗资源配置,提升县域医疗服务能力。本文基于行动者中心制度主义理论框架,分析县域紧密型医共体建设相关行动者的关系,揭示县域医共体构建中不同行动者受利益诉求、动机选择等多重博弈关系的影响状况。探讨紧密型县域医共体的建构进程中,如何促成行动者之间达成利益相容和联动,最大限度满足县域人民群众获得优质高效的一体化医疗服务。     

Medical dominance and strategic action: the fields of nursing and psychotherapy in the German health care system

The paper seeks to identify and explain shifts in dominance relationships between the medical profession and allied health professions in Germany, taking the occupational fields of nursing and psychotherapy as examples. It suggests an actor-based perspective which focuses on the strategic interplay between collective actors in the fields in question, namely professional associations and unions, state actors, sickness funds, universities, polytechnics and associations of work organisations. It considers the context of governance of the German health care system and an awareness of a changed demand. The thesis is that the interplay between the actors has led to a small reduction of medical dominance. It is examined whether changes in governance structures of the health care system have led to a more favourable context for shifts in the dominance relationships. Moreover, the possible effects of the recent re-organisation of health provision are considered. Based on an empirical investigation using the method of document analysis, the paper shows that there has been a small reduction of medical dominance which is essentially the outcome of the interrelated strategic actions of various collective actors in the fields. A public perception of a new kind of health care demand has facilitated this development.     

Medical and health administration education in managed care: needs, content and readings

With both public and private reform initiatives moving toward managed care, curriculum designs are timely and useful to a diverse audience. This paper discusses the need for and design of education in managed care in medical schools and health services programs. The pressures for offering education regarding managed care are derived from interests of various actors of the health system e.g. regulators, purchasers, providers and consumers. The content of education in managed care is defined in seven areas: (1) managed care and health systems design-history and concepts; (2) environment and governmental policy; (3) models, products, services, outcomes and quality; (4) managed care economics and finance; (5) organization and strategic management; (6) legal issues; and (7) future designs/redesigns. Education in managed care is delivered by universities, professional associations and private training and development corporations. All can benefit from a dialogue on curricular content.     

对基本医疗保险支付改革与医疗联合体建设的利益相关性研究

政策的制定和实施与各方利益相关者利益紧密相关,政策改革必然导致各方利益再分配,从而影响改革进程。文章从利益相关者角度出发,探讨近年我国医药卫生体制改革过程中基本医疗保险支付方式改革与医疗联合体建设的利益相关性,分析出两者有5类共同利益相关,并且通过医疗保险支付方式改革中的按人头打包支付等复合支付方式、结合分级诊疗和家庭医生签约服务制度、健全医疗联合体内协商谈判机制这三项政策支持了医疗联合体建设。但仍有待改善之处,需要继续推进医保政策改革,以打包支付积极推动紧密型医疗联合体的构建,发挥并强化信息技术的支撑作用,从而更有利于推动医疗保险支付方式改革和医疗联合体建设。     

The mental health users’ movement in Argentina from the perspective of Latin American Collective Health

ABSTRACT

The mental health users’ movement is a worldwide phenomenon that seeks to resist disempowerment and marginalisation of people living with mental illness. The Latin American Collective Health movement sees the mental health users’ movement as an opportunity for power redistribution and for autonomous participation. The present paper aims to analyze the users’ movement in Argentina from a Collective Health perspective, by tracing the history of users’ movement in the Country. A heterogeneous research team used a qualitative approach to study mental health users’ associations in Argentina. The local impact of the Convention on the Rights of Persons with Disabilities and the regulations of Argentina’s National Mental Health Law are taken as fundamental milestones. A strong tradition of social activism in Argentina ensured that the mental health care reforms included users’ involvement. However, the resulting growth of users’ associations after 2006, mainly to promote their participation through institutional channels, has not been followed by a more radical power distribution. Associations dedicated to the self-advocacy include a combination of actors with different motives. Despite the need for users to form alliances with other actors to gain ground, professional power struggles and the historical disempowerment of ‘patients’ stand as obstacles for users’ autonomous participation.     

总额预付和增加基层医疗资源对分级诊疗的影响——基于CHARLS数据的实证分析

我国在建立分级诊疗制度过程中,分别通过对医疗资源需求端制定差异化报销比例,对供给端进行资源结构性调整,以引导患者向基层流动就诊,实现医疗资源更高效利用,缓解看病难、看病贵的社会问题。本文采用2013年"中国健康与养老追踪调查"(CHARLS)数据,运用Logit回归模型,分析预付制及增加基层医疗资源是否促进了患者到基层接受门诊治疗。实证研究发现:总额预付以及增加基层医疗卫生机构医师资源对分级诊疗的促进作用显著;但单纯增加人均基层医疗卫生机构数量对患者到基层就诊没有明显吸引力。后续政策可考虑进一步完善总额预付制度、促进基层医疗资源质量的提高,并引导患者转变就医观念,以实现分级诊疗效果,调节医疗资源供给与需求不均衡的矛盾。     

Social and political actors in the formulation of health reform in Spain

An analysis of the participation of social and political actors in the process of formulating health policy allows one to understand the specific characteristics of the organization and operation of a health system. This study analyzes the drafting process for the General Health Act (LGS) in Spain with the purpose of establishing the relationship between social, political, and economic actors in both the formulation of the Act itself and the organization of the Spanish Health System. A case study was carried out from 1982 through 1986. Documentary parliamentary data, the medical press, national magazines and journals, and press reports by political, social, and public health actors were analyzed. The first version of the General Health Act presented by the Spanish Socialist Workers' Party (PSOE) proposed a health system with funding and public administration aimed at achieving universal health coverage, integrated care, community participation, and health education. This proposal was submitted to a complex negotiating process with business groups, unions, and health professionals. The General Health Act as finally approved excludes the principles of equity and incorporates private interests in health: "free choice of doctor and hospital", public funding and private administration of the health system, and the establishment of Social Security as the core of the entire health system.