供给侧改革视角下的中国医改探索

2016年,我国医疗领域掀起对"医疗供给侧改革"的讨论热潮.阐述我国实施医疗供给侧改革的意义和策略;"健康中国"战略推进下我国医疗服务供给体系将面临深刻的结构性变革,供给侧改革思路将从构建能够合理分流患者的有序就医格局、以公立医院改革提高优质医疗资源服务质效、引入社会办医力量发展健康服务业三个方面入手引领中国医疗服务体系重构,同时支付制度改革引入预付制、卫生人力资源优化配置以及互联网医疗兴起都将配套医疗服务体系的供给侧改革,从而将以公立医院为主体、以疾病治疗为中心的诊疗模式转变为全面涵盖预防、体检、治疗、康复、健康管理等多环节、多流程的整合型医疗模式.     

A house is not a home: keeping patients at the center of practice redesign

The "patient-centered medical home" has been promoted as an enhanced model of primary care. Based on a literature review and interviews with practicing physicians, we find that medical home advocates and physicians have somewhat different, although not necessarily inconsistent, expectations of what the medical home should accomplish-from greater responsiveness to the needs of all patients to increased focus on care management for patients with chronic conditions. As the medical home concept is further developed, it will be important to not overemphasize redesign of practices at the expense of patient-centered care, which is the hallmark of excellent primary care.     

History and Profile of Diagnosis Procedure Combination (DPC): Development of a Real Data Collection System for Acute Inpatient Care in Japan

DPC, which is an acronym for “Diagnosis Procedure Combination,” is a patient classification method developed in Japan for inpatients in the acute phase of illness. It was developed as a measuring tool intended to make acute inpatient care transparent, aiming at standardization of Japanese medical care, as well as evaluation and improvement of its quality. Subsequently, this classification method came to be used in the Japanese medical service reimbursement system for acute inpatient care and appropriate allocation of medical resources. Furthermore, it has recently contributed to the development and maintenance of an appropriate medical care provision system at a regional level, which is accomplished based on DPC data used for patient classification. In this paper, we first provide an overview of DPC. Next, we will look back at over 15 years of DPC history; in particular, we will explore how DPC has been refined to become an appropriate medical service reimbursement system. Finally, we will introduce an outline of DPC-related research, starting with research using DPC data.Key words: Diagnosis Procedure Combination (DPC), DPC-based Per-Diem Payment System (DPC/PDPS), patient classification system, health policy, Japan     

人口老龄化进程中的医疗卫生支出:WHO成员国的经验分析

基于世界卫生组织(WHO)成员国的经验,本文探讨了人口老龄化进程中医疗卫生支出的基本特征和一般规律。研究表明:世界各国医疗卫生水平存在极大的不平衡。随着人口老龄化的加深,医疗卫生支出中政府支出比例趋于上升,而私人卫生支出比例趋于下降。医疗卫生支出占GDP的比例逐步提高,而政府卫生支出占政府总支出比例也趋于提高,人口老龄化进程中政府在医疗卫生支出中将承担更重要的责任。而且,在政府卫生支出中,医疗保障支出比例趋于提高,并将成为政府卫生支出越来越重要的部分。当一国进入老龄化社会后,医疗卫生支出速度将会递增,经济发展和政府财政将承受越来越重的医疗支出负担。"未富先老"的中国面临着医疗卫生支出急剧增长的严峻挑战,这应该成为医疗卫生体制改革关注的议题。     

Life, death, and liability: duties of health care providers regarding withdrawal of treatment

Many of the issues surrounding refusal and withdrawal of medical treatment are so new and complex that the U.S. society has not resolved the ethical or legal questions involved. Questions such as where life ends and death begins, how to determine the circumstances when withdrawal of treatment is appropriate, and who should make such decisions will have to be resolved before the law in this area can become settled. Naturally, society is a long way from resolving these issues, since they involve such fundamental social, moral, medical, and legal considerations. Nevertheless, a body of law has developed that increasingly recognizes the right of an individual to direct his or her own medical care. To that end, an individual's clearly expressed intention to discontinue medical treatment will generally be honored, even if death results from the withdrawal of that treatment. Legislatures and courts have also encouraged health care providers to abide by the wishes of their patients by giving immunity to health care providers who comply in good faith with the provisions of a living will. Courts have also been reluctant to impose liability on health care providers for withdrawal of treatment absent a living will if it were done in good faith (with the consent of family or guardian) and was in accordance with accepted medical practice. It would appear that as the law gives individuals increased control over the private matter of their own medical treatment, health care providers may face more civil suits for maintaining life support systems against the patient's (or family's) wishes. In any event, while society is in the process of catching up with medical technology, individuals can best protect their right to medical self-determination by expressing their wishes clearly in the form of a living will and durable power of attorney. Health care providers can best protect themselves by keeping abreast of medical and legal developments in connection with these issues and by communicating effectively with their patients as to their wishes regarding life-prolonging medical treatment.     

医疗保险与卫生服务发展研究

医疗保险与卫生服务是辩证统一的关系。医疗保险的推行,对医疗机构既是挑战也是机遇,要求医疗机构转变观念,增强竞争意识和竞争能力,做好监督控制、审核评价工作。成本核算、定额补偿是医院乃至医疗保险发展的核心问题。医疗保险制度的建立和完善有助于优化卫生资源配置,完善医院内部科学管埋体制,提高医疗质量,促进医院发展。社区卫生服务应纳入医疗保险范畴,医疗保险管理邯门从效率角度出发,也应首先选择社区卫生服务机构承担医疗保险任务。社区卫生服务的发展对医疗保障体系的建立和完善将起到重要的推进作用,而医疗保障体系的建立,必将促进社区卫生服务的深入发展。     

Identifying opportunities to improve the management of care: a population-based diagnostic methodology

The growth of managed care and specifically capitation will dramatically change the basis of competition for health care providers. In order for medical groups to succeed in this new environment they must be able to accept the accountability for both managing the care of populations and managing the delivery of individual encounters of care. Being held accountable for the management of populations will require at-risk medical groups to focus on developing three entirely new strategic capabilities: the assessment of health risk, the management of access, and the management of care. This article describes the analytic approach of Deloitte & Touche Consulting Group's population-based diagnostic methodology, which will enable an at-risk organization to identify opportunities for improving the management of care for specific populations and diseases. The hypotheses driving the need for these organizations to establish population-based care management capabilities stem from the plethora of empirical evidence indicating significant variation in costs, utilization, and outcomes in the practice of medicine. Applying a systematic, planned approach to caring for patients who have common, predictable health care needs will result in better outcomes and lower costs for all.     

Allocation of scarce resources after a nuclear detonation: setting the context

The purpose of this article is to set the context for this special issue of Disaster Medicine and Public Health Preparedness on the allocation of scarce resources in an improvised nuclear device incident. A nuclear detonation occurs when a sufficient amount of fissile material is brought suddenly together to reach critical mass and cause an explosion. Although the chance of a nuclear detonation is thought to be small, the consequences are potentially catastrophic, so planning for an effective medical response is necessary, albeit complex. A substantial nuclear detonation will result in physical effects and a great number of casualties that will require an organized medical response to save lives. With this type of incident, the demand for resources to treat casualties will far exceed what is available. To meet the goal of providing medical care (including symptomatic/palliative care) with fairness as the underlying ethical principle, planning for allocation of scarce resources among all involved sectors needs to be integrated and practiced. With thoughtful and realistic planning, the medical response in the chaotic environment may be made more effective and efficient for both victims and medical responders.     

Perspectives in Western health care.

Eleven trends in health care and society are described and used in the construction of a future scenario for health care in Western society: 1) involution in the field of specialist medicine; 2) an epidemiologic shift from acute illness to chronic impairment; 3) more self care and mutual care; 4) more self-responsibility in health maintenance; 5) de-institutionalization; 6) changing personal values and goals; 7) revival of emotional life; 8) new appraisal of dying; 9) towards a participative society; 10) uncoupling the health care wages; 11) the emergence of a "dual strata" society. In such a society, the medical dominance in the health care system will regress. Health maintenance based on more competent self care and social networks, and similar approaches to care for patients with chronic illness, will balance a more restricted medical intervention system.     

Does disclosure of medical records to patients influence medical care?

Disclosure of medical records to patients has been assessed, but the influence of disclosure on medical care has not been well researched. To address this situation, this study was conducted to test three hypotheses: 1) doctors think that the disclosure can influence medical care, 2) whether doctors think disclosure can influence medical care depends on how they rank medical records (for example, as evidence for diagnosis and treatment, a process to reach a diagnosis, a tool to communicate with other medical staff, etc), and on whether they think medical record disclosure could change the content of the record. Questionnaires were sent to 881 doctors who work at two hospitals affiliated with N Medical School and K Medical University. RESULTS: Four hundred eighty-eight doctors responded. The findings related to the hypotheses were as follows: 1) Those who answered that the disclosure could have an influence on medical care were 49.1% of the total. 2) There was no relation between how doctors ranked medical records and whether they thought disclosure could influence medical care. 3) Doctors who answered that there were things that they would not be able to write if medical records were disclosed accounted for 73.5% of the total. These doctors answered "yes" significantly higher to the question that the disclosure could influence medical care than others (Odds 3.6, P < 0.01). Doctors who thought they would not be able to enter the diagnosis, the name of the disease for insurance, self-evaluation, information that could be judged and subjective information answered that disclosure could influence on medical care (P < 0.05). It was assumed that disclosure of medical records to patients could change the content of the medical records and that could influence medical care. How to deal with information will become an important issue if records are disclosed.     

Medical tourism and its impact on the US health care system

The health care industry within the United States continues to face unprecedented increases in costs, along with the task of providing care to an estimated 46 million uninsured or underinsured patients. These patients, along with both insurers and employers, are seeking to reduce the costs of treatment through international outsourcing of medical and surgical care. Knows as medical tourism, this trend is on the rise, and the US health care system has not fully internalized the effects this will have on its economic structure and policies. The demand for low-cost health care services is driving patients to seek treatment on a globally competitive basis, while balancing important quality of care issues. In this article, we outline some of the issues facing legislators, health care policy makers, providers, and health service researchers regarding the impact of medical tourism on the US health care system.     

Impact of Guidelines on Healthcare from the Patient and Payor Perspective

Clinical practice relies on structured learning that is applied to a patient care setting. Patients present with symptoms and providers try to fit these complaints into known disease categories. Providers depend on memorized algorithms to direct diagnosis and treatment. Well thought-out guidelines developed by professional societies and based on the best available evidence have become the standard in modern medical care. Guidelines are developed to assist practitioners in making appropriate healthcare decisions, to help standardize medical care and improve quality. Guidelines attempt to change practice behavior towards an established norm when evidence is available or toward a consensus opinion when randomized trials are lacking. Patients seeking medical care expect that their practitioner is providing up-to-date, quality medical care. The payors of this care are also interested in quality but must pay attention to medical costs. Both the patient and the payor are invested in providers who use the best available evidence in providing care that is clearly based on guideline development and dissemination.The American Pain Society (APS) has written three practice guidelines, the most recent of which is the Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis, published in 2002. Based on high quality research, when available, and consensus opinion from opinion leaders, these guidelines are endorsed throughout the world’s medical community. Like any other guidelines, the goal is to standardize care and improve quality.The future will bring more development of guidelines like those from the APS. As studies improve and trials show more effective treatment paradigms, well researched, appropriately designed guidelines will emerge which are structured for busy practices. But this will not be enough; providers need to be made aware of the guidelines, educated on their use, shown appropriate studies documenting efficacy, given simple strategies to implement these guidelines, repeatedly reminded of the appropriate care and, finally, monitored for compliance. For guidelines to be effective they must be tested, disseminated, and their impact on healthcare outcomes must be assessed.Payors want evidence of the value for their expenditures and guidance by professional societies in allocating limited resources. At the same time, payors are struggling with quality issues. Guidelines can help standardize care that may also be more cost effective as well as satisfy quality concerns from regulatory agencies and the public. Understanding where guidelines make an impact and why resistance develops to well meaning, expert based documents will help us in our disease management efforts.     

The cost of AIDS: an agenda for research.

It is generally not appreciated how much we have learned about AIDS in the relatively short time - about 7 or 8 years - since it made its first appearance in the United States. We have learned not only its cause and its way of transmission, but we also have data, though not perfect data, on its incidence and prevalence as well as an increasing body of data on the medical care costs of persons with AIDS. There are few other diseases for which we have as much information on incidence and prevalence, and especially on costs. In addition, various models have been constructed to project the future incidence and prevalence of the disease and the medical care costs associated with it. Nevertheless, serious gaps in our knowledge remain: inadequacies of current data on the number of persons with AIDS and especially on the number of persons infected with HIV; inadequacies and limitations of the data on the medical care costs of persons with AIDS; and an almost total lack of data on the number of persons infected with HIV with symptoms and conditions other than AIDS and their medical care costs. These gaps in our knowledge will be discussed in detail, and various types of studies to fill them will be suggested.     

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.     

The independent medical specialist and altered legal relations

The relationship between an independent medical specialist and the hospital is governed by the access agreement. On 1 January 2008, the financing of medical specialist care has changed, with dramatic consequences for the legal relationship between independent medical specialists and the hospital. Increased attention to quality control also affects this relationship. The model access agreement needs to be changed on some points as a result of various developments so that the hospital management will have more tools at hand to manage patient care.     

Policy changes and their possible impact on hospital-based ambulatory care

Hospital-based ambulatory care has been an important source of medical care, and most particularly so in New York City. In 1982, there were a total of 10,629,035 visits to outpatient clinics and emergency rooms. In the present climate, there is pressure to shrink numbers of acute care beds, reduced Medicare reimbursement for graduate medical education, and withdraw payment for foreign medical graduates. The hospital by-product of ambulatory care will surely change as hospitals deal with survival in competition for the inpatient market.Dolores Rogers, M.P.A. is an Ambulatory Care Planner with the Health Systems Agency of New York City.     

Medical innovation and age-specific trends in health care utilization: findings and implications

Health care utilization is expected to rise in the coming decades. Not only will the aggregate need for health care grow by changing demographics, so too will per capita utilization. It has been suggested that trends in health care utilization may be age-specific. In this paper, age-specific trends in health care utilization are presented for different health care sectors in the Netherlands, for the period 1981-2009. For the hospital sector we also explore the link between these trends and the state of medical technology. Using aggregated data from a Dutch health survey and a nationwide hospital register, regression analysis was used to examine age-specific trends in the probability of utilizing health care. To determine the influence of medical technology, the growth in age-specific probabilities of hospital care was regressed on the number of medical patents while adjusting for confounders related to demographics, health status, supply and institutional factors. The findings suggest that for most health care sectors, the trend in the probability of health care utilization is highest for ages 65 and up. Larger advances in medical technology are found to be significantly associated with a higher growth of hospitalization probability, particularly for the higher ages. Age-specific trends will raise questions on the sustainability of intergenerational solidarity in health care, as solidarity will not only be strained by the ageing population, but also might find itself under additional pressure as the gap in health care utilization between elderly and non-elderly grows over time. For hospital care utilization, this process might well be accelerated by advances in medical technology.     

Medical marijuana: Challenges and risk issues for health care providers

Laws on medical marijuana and recreational use of marijuana are sweeping the country and presenting real dilemmas for health care providers and facilities. However, due to disagreements between federal and state law, there are no easy answers. Additionally, the case law and statutory law on these issues is exceedingly sparse. It may take years for all of the issues to be ironed out, but health care facilities will need to act in the meantime on what may be little more than educated guesses. It may not be appropriate to simply prohibit the use of medical marijuana, but accommodating it also has risk. This article will address what is known about the subject and what is not known about the subject. Each provider and health care facility will need to devise their own approach to the subject based on principles that are presently known, while keeping an eye on the health and safety of all involved.     

Population-based health principles in medical and public health practice.

Traditionally, medical education, research, and practice have focused on the care of the individual but an increasing emphasis on the care of populations has raised awareness among academic medical centers, integrated delivery systems, and managed care organizations of the value of embracing population-based health principles. Five principles are relevant in this regard: a community perspective, a clinical epidemiology perspective, evidence-based practice, an emphasis on outcomes, and an emphasis on prevention. This article describes these interrelated concepts together with specific strategies to effect implementation. Widespread awareness and adoption of these principles will have a profound impact on medical and public health education, practice, and ultimately the public's health.     

Newly implemented health system reform in Israel: physicians' attitudes

OBJECTIVE: To explore the attitudes of Israeli physicians towards the feasibility and potential consequences of the newly implemented health care reform. DESIGN: Physicians' attitudes were examined soon after the enactment of a National Health Insurance Law, the first element of the reform to be implemented. SETTING: A nationwide mail survey. SUBJECTS: A random sample of 2000 practicing physicians. MAIN OUTCOME MEASURES: Attitudes towards the health care system prior to the reform; predicted effects of the reform on health care and medical practice. RESULTS: Most of the respondents think that the system requires a change. Quality of community-based care is expected to increase, in contrast to hospital care. The reform is believed to exert an adverse effect on medical practice. Attitude is significantly influenced by practice setting and speciality: community setting and general practice correlate with less desire for a major change. Specialists believe that reform elements which will shift the balance towards the hospitals will have the greatest benefit on the health system. GPs, compared to specialists, are more optimistic regarding quality and accessibility of services (P<0.01). CONCLUSIONS: Our survey suggested that Israeli physicians favor a change in the health care system, despite a perceived adverse effect of the reform on medical practice. Since the reform is believed to shift the balance from the hospitals to the community, respondents support changes that will compensate for the imbalance.