香港医疗机构卫生监管体制特点及其启示

香港通过公立和私立医疗机构为市民提供多种医疗服务.本文通过考察、交流、实地走访等方式,了解食物及卫生局、医院管理局、卫生署、香港医务委员会、行业协会等机构在医疗机构卫生监管中履行的职能,分析其卫生监管体制的特点,为内地医疗机构卫生监管体制改革提供参考.     

建立基层医疗卫生机构补偿机制的路径选择

将基层医疗机构的门诊医疗服务纳入基本公共卫生服务项目的范畴,基层医疗机构为居民提供免费的门诊医疗服务;将社会医疗保险门诊基金按年度划转为基本公共卫生服务经费,解决基层医疗卫生机构基本药物改革后医疗机构的补偿问题;促使基层医疗卫生机构全面回归公益性,让人民群众真正享有全面、便捷、实惠的基本公共卫生服务。     

转诊患者对分级医疗服务体系构建的认知行为分析

目的 探讨转诊患者对上下级医疗机构医疗服务、转诊服务的认知行为及其影响因素,以期明确“患者角度”医疗服务体系存在的问题,并提出构建与优化分级医疗服务体系的建议.方法 分别在东、中、西地区选择有转诊经验的患者为样本,收集其基本情况、健康状况、就诊行为、对双向转诊的认知、满意度情况及其评价等信息,运用卡方检验、秩和检验和Ordinal Logistic进行分析.结果 82.7％的患者赞成疾病首诊应在基层医疗机构,但缺乏对基层医疗机构的信任.在患者看来,提高基层医务人员水平和医疗费用报销比例是影响其择医的主要因素.患者对医疗机构间转诊制度满意程度受地区、患者年龄、就医方便程度、转诊过程的方便程度等因素影响.结论 患者对于分级医疗的认识存在误区,且对基层医疗机构明显缺乏信任感,应从改善基层医疗机构服务能力、加强信息引导和健康教育、梯度化医疗保险制度等方面优化分级医疗体系建设.     

智能监管系统在基层医疗机构综合监管工作中的应用

目的探讨智能监管系统在基层医疗机构综合监管工作中的应用与体会,改进医疗质量,确保医疗安全。方法将智能监管系统应用于基层医疗机构医疗质量的综合监管工作中,对总体监管结果及违规排名前十的项目监管情况进行比较、分析,总结监管效果,改进监管方法,提高医疗服务质量。结果通过综合监管,比较2017年9月和2018年11月的监管数据,总问题单据占比下降了16.12%,不合理诊疗问题单据占比下降了6.91%,不合理收费问题单据占比下降了2.62%,不合理用药问题单据占比下降了4.15%,异常数据占比下降了1.77%,违规排名前十名的单据占比下降了13.2%,数据显示:通过实施医疗服务智能监管,效果显著,差异有统计学意义(P<0.01)。结论通过实施医疗服务智能监管,能有效提高基层医疗机构医疗服务监管效率及服务水平,改进医疗服务质量,保障医疗安全。     

中国基层医疗机构医疗废物管理调查

目的了解中国基层医疗机构医疗废物管理现状。方法2016年对全国5个省份95所基层医疗机构医疗废物管理进行调查。结果95所基层医疗机构中,进行医疗废物集中处置的90所(94.74%）,医疗废物分类收集的92所（96.84%）, 医疗废物暂存处理且单位有交接登记的89所（93.68%）,医院有污水处理设施并设专/兼职人员负责的46所（48.42%）。2000年以前仅4所（4.21%）基层医疗机构开展了医疗废物分类管理、集中处置,2014年分别增加至92所（96.84%）、90所（94.74%）;2000年以前仅5所（5.26%）基层医疗机构开展了医疗废物暂存处理,2014年增加至89所（93.68%）。结论基层医疗机构医疗废物管理现状已明显改善,但仍存在不足,需加强基层医务人员医疗废物管理相关知识的培训,规范医疗废物管理程序,健全医疗废物管理监管系统。     

镇江市基层医疗机构抗菌药物使用现状分析与对策

目的：分析基层医疗机构抗菌药物的使用现状,并提出相关建议与对策,旨在强化基层医疗机构抗菌药物合理使用的意识,从源头上减少和杜绝不合理用药现象。方法：通过对镇江市所辖7个市（区）的35家社区卫生服务中心或乡镇卫生院2015抗菌药物的采购及使用情况进行调查,了解基层医疗机构抗菌药物的实际使用情况。结果：基层医疗机构在抗菌药物的选择、使用上存在较多的误区,抗菌药物使用管理,存在的问题也较多,基层医务人员对抗菌药物正确使用方法和抗菌药物治疗使用基本原则等知晓率偏低。结论：目前对基层医疗卫生机构使用抗菌药物的监管仍处于盲区,加强对基层医疗机构抗菌药物合理用药的指导和监管,促进基层医疗机构健康有序的发展,对遏制细菌耐药计划的实现具有十分重要的意义。     

新农合门诊统筹报账基金风险分析与防范措施

四川省南江县自2005年开始实施新农合试点工作以来，覆盖面不断扩大，筹资水平不断提高，但受益面还是偏窄，3年来新农合基金结余较多，2008年开展了新农合门诊统筹报账，但也面临着基金总量不足、医疗费用上涨过快和医疗服务环节、监管环节等多方面的基金风险。文章结合南江县在开展门诊统筹报账试点工作中的有益探索，认为要搞好门诊统筹报账，必须要科学制定补偿方案，严格控制医疗费用上涨，严格定点医疗机构准入．提高基层医疗机构服务能力，在强化医疗机构监管上狠下功夫，才能确保新农合基金的安全。     

基层医疗机构如何防范医疗事故

乡镇卫生院设备、资金、人才、技术条件与二、三级医疗机构存在巨大差距。设备简陋、人才短缺、技术落后是基层医疗机构的客观现实。基层医疗机构存在不少医疗服务缺陷：一是由于医疗设备非常简陋，部分机构仍然依靠“老三件”和经验医学诊治疾病，误诊误治率相对较高；二是病人稀少，病种单一，医务人员充当“万精油”，内、外、妇、     

日本私立医疗服务机构及相应政府职能简介

通过对日本私立医疗服务机构的发展历程、现有数量与规模、服务功能、经营状况等进行介绍,揭示了私立医疗机构在日本医疗服务体系中的地位及其对整个国家卫生系统绩效的贡献.同时,介绍了日本政府对私立医疗服务机构进行培育和监管的相关职能,并重点介绍了政府如何通过制定规则和举办公立医疗服务机构来参与竞争,确保私立医疗服务机构的健康成长.由此探讨我国的医疗卫生改革如何借鉴日本的经验,充分运用市场机制和政府职能的调节手段,提高我国医疗资源的运营绩效.     

基层医疗机构卫生装备现状及建议

基层医疗机构的卫生装备是其履行工作任务所必须的物质基础,占有很重要的地位。基层医疗机构担负着所属部队的医疗、保健、卫生防疫等任务,医疗卫生装备在平时的战备执勤、训练演习、抗险救灾中发挥了重大作用。随着部队现代化建设步伐的加快,基层医疗机构(师、旅、团)的医疗装备,特别是野战医疗装备不断增多,但基层医疗机构专业人员缺乏,保管、维护不利,病人不多,经费不足,利用率低,致使医疗装备管理及使用上存在较多问题,甚至有的医疗装备下发后从未使用过,如部分急救设备,在基层医疗机构特别是团卫生队,按照救治范围要求及其它因素,不可…     

鼓励发展民办医疗事业是“新医改”的题中之义

我国医疗事业的全面、协调、可持续发展离不开民办医疗事业的发展,在建设覆盖城乡居民的医药卫生服务和保障体系中,民办医疗不是或有或无的补充地位,而应鼓励发展：明确民办医疗的价值定位;制定整体发展规划;排除民办医疗事业发展的障碍;积极回应投资人、举办人的合理诉求;平等对待公办、民办医疗机构的管理人员和医务人员,等等。     

Sharing responsibility for the public's health: a new perspective from the Institute of Medicine.

The health of a community is a shared responsibility of many entities. Within this context, specific entities should identify, and be held accountable for, the actions they can take to contribute toward the community's health. Governmental public health agencies, especially at the state and local levels, can take the lead in getting public and private community organizations to advance the health of the community, and should play a leadership role by developing partnerships with managed care organizations and community-based organizations.     

Well-being revisited: improving the health of a population

Changes in society and the healthcare system are challenging healthcare executives to do more than provide medical services. Leaders now take broader responsibility for the health and well-being of the people and communities they serve. Health--the "state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (World Health Organization 1944)--is determined by four forces: environment, heredity, lifestyle, and medical care services. Health-care managers who want to improve the health of their served populations must improve these forces. Strategic and operational lessons can be learned from the pioneering work done by several hospitals, health plans, and healthcare systems to improve their local environment, heredity, lifestyles, and medical care services. Managers who wish to improve health in their communities should strongly embrace and commit to "health" rather than mere "medical services" in their mission, vision, and values. They should collaborate with many other organizations and people--such as schools, churches, police, and businesses--to build partnerships that extend beyond the healthcare sector into the total community. Healthcare organizations should provide some resources and funds to improve the health of their served populations, and they should view this commitment as an investment (especially if there are capitated lives) rather than as an expense. They should also obtain public and private grant funds and leverage the resources of their collaborative partners to improve their local environment, heredity, lifestyles, and medical care services. Finally, leaders can advocate and support public policy that would improve the four forces that shape health.     

民营社区卫生服务机构就诊患者的情况分析

目的:通过对武汉市民营社区卫生服务机构的调查,针对就诊患者就医情况、服务态度进行分析。结果:“服务便利性”是患者选择民营社区卫生服务的主要目的;民营社区卫生服务机构重视服务质量,讲究服务理念,以良好的服务、较低的价格赢得市场竞争,但其还不太重视公共卫生服务,居民对此满意度较低。结论:纳入区域卫生规划、注重服务态度、提供简捷便利的医疗服务是民营社区卫生服务机构赖以生存和发展的基础。提高医疗技术水平、降低医疗药品价格、改变服务方式、完善公共服务的功能是民营社区卫生服务尚需努力的方向。     

民办非营利性医疗机构发展问题及对策

新医改方案中提出鼓励和引导社会资本发展医疗卫生事业,鼓励社会资本依法兴办非营利性医疗机构。发展民办医疗机构尤其是民办非营利性医疗机构对深化医药卫生体制改革具有重要意义。然而当前民办非营利性医疗机构的发展困难重重。试图从民间组织理论的视角出发,从社会环境、内部治理和外部监督管理等方面对民办非营利性医疗机构发展面临的问题进行分析,进而提出政策建议,希望为进一步发展民办非营利性医疗机构提供思路和经验借鉴。     

The key role of health insurance in a cost-effective health care system. Towards regulated competition in the Dutch medical market.

The previous two sessions of this Symposium have dealt with incentives for cost-effective provider behaviour. Although incentive-reimbursement, which rewards the providers for delivery medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not rewards the providers for delivering medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not sufficient. As long as the insured consumers have both comprehensive health insurance coverage and freedom of choice of provider, providers will have great difficulty in resisting consumers' demand for ever more costly medical care, and politicians or other decision-makers will have great difficulty in restricting capacity and in preventing overcapacity. Fear of losing patients or voters might dominate. Therefore, in this session we shall focus on the key role of health insurance in a cost-effective health care system and on consumer incentives and insurer behaviour. If the consumers have a choice between several provider-insurer organizations. Although market forces do play an important role in a competitive health-care system, competition should not be confused with a "free market". Besides financial arrangements to protect the poor, pro-competitive regulation is needed to guarantee a "fair competition". Currently there is much consensus that the present Dutch health insurance system, in which 60% of the population is publicly insured and 40% is privately insured, should be replaced by a national health insurance scheme, which uniformly applies to the entire population. A few years ago, I made a proposal for such a scheme, which was based largely on the ideas of Ellwood, McClure, and Enthoven on competition between alternative delivery systems. The main features of this proposal will be discussed. In my opinion, the long-term prospects for regulated competition in the Dutch medical market seem rather favourable.     

Non-governmental health planning: Is the Rochester approach an alternative to regulatory certificate of need?

ObjectiveHealth planning is the process of identifying community needs for health care, facilities and technology and allocating resources to meet those needs to the exclusion of redundant capacity. Health planning in the United States was pioneered in Rochester, New York through private sector efforts but today, health planning is generally understood in the US as referring to a governmental function: “certificate of need” regulation. Yet health planning need not be, and indeed is not today, an exclusively governmental function. The original conception of a health planning agency as a civil society-based, non-governmental organization survives in Rochester. This study assesses the, viability of this private option as an alternative to regulation.MethodOutcomes of applications to a, non-governmental health planning entity in the Rochester region (CTAAB) were compared to, outcomes from the state agency (DOH) for two adjacent regions.ResultsThe non-governmental, approach to health planning appeared to be more restrictive, with the Rochester region spending less. There are numerous extraneous commas in the text as it appears on my screen. Are they part of the document? Iif so, they need to be removed. If they were not added to the document, the document does not look right in the Online Proofing application. Overall and in particular, utilizing less advanced imaging.ConclusionsThe Rochester NY region, appears to demonstrate that cooperative efforts by stakeholders can lower health care costs. For such, voluntary efforts to succeed, policymakers need not regulate—they can engage with community, leaders by convening them to analyze local utilization patterns, review options for chartering or, subsidizing non-governmental organizations to implement planning, and delineate safe harbors from, antitrust or other potential liability arising from collective action     

New arrangements, new scrutiny. The IRS reconsiders hospital-physician relationships at tax-exempt facilities

The pressure to maintain adequate operating margins has forced many not-for-profit hospitals to adopt more overtly competitive behavior than they have in the past. However, in struggling to remain economically viable, these facilities should carefully avoid actions that would threaten their tax-exempt status. Not-for-profit facilities should be particularly careful that their arrangements with physicians, which often appear designed to increase referrals, do not violate the criteria according to which the Internal Revenue Code extends tax exemption to charitable organizations. Section 501(c)(3) of the code exempts organizations "no part of the net earnings of which inures to the benefit of any private shareholder or individual." According to this provision, "insiders" (i.e., those with a personal interest in or opportunity to influence organization activities from the inside) are entitled to no more than reasonable payment for their goods or services. The Internal Revenue Service (IRS) takes the position that, as employees or individuals having a close professional working relationship with a hospital, physicians are insiders. Thus a hospital that pays physicians what the IRS judges to be more than fair market value for services (or charges physicians less than fair market value for office rental) may find its exemption in jeopardy. If not-for-profit hospitals want to maintain their tax-exempt status, they must be certain the arrangements they enter into with physicians truly further their exempt purpose: to promote the health of the community.     

The missing voice: Impacts of health system change on low-income communities

Unique problems in obtaining adequate health care face poor urban communities. These include the rising number of uninsured, abuses in the managed-care system, the unwillingness of private providers to deliver health care for either Medicaid recipients or the uninsured, and an insufficient supply of primary care physicians in minority neighborhoods. If the managed-care system is to bring decent health care to poor urban communities, it must avoid the mistakes of the past. The health care system must be community based, oriented toward primary care, sufficiently funded, and universally accessible. There needs to be better coordination between medical schools and community health requirements and better support for public health facilities. Without adequate health care for the poor, urban living will eventually become more onerous for all.     

Simulation Suggests that medical group mergers won't undermine the potential utility of health information exchanges

Federal and state agencies are investing substantial resources in the creation of community health information exchanges, which are consortia that enable independent health care organizations to exchange clinical data. However, under pressure to form accountable care organizations, medical groups may merge and support private health information exchanges. Such activity could reduce the potential utility of community exchanges-that is, the exchanges' capacity to share patient data across hospitals and physician practices that are independent. Simulations of care transitions based on data from ten Massachusetts communities suggest that there would have to be many such mergers to undermine the potential utility of health information exchanges. At the same time, because hospitals and the largest medical groups account for only 10-20 percent of care transitions in a community, information exchanges will still need to recruit a large proportion of the medical groups in a given community for the exchanges to maintain their usefulness in fostering information exchange across independent providers.