我国医师多点执业研究综述

  目的  了解陕西省医师多点执业现状及其障碍因素,为推动陕西省医师多点执业提供参考依据。  方法  于2015年7月 — 2016年5月采用分层整群随机抽样方法在陕西省关中、陕南和陕北地区6家三级甲等医院抽取366名医师进行问卷调查,并应用文献分析法提炼障碍因素。  结果  陕西省366名医师中,有12.6 %的医师非常了解多点执业政策,有80.6 %的医师赞成多点执业政策,在条件允许的情况下有78.4 %的医师愿意多点执业;有多点执业行为的医师152人,占41.5 %,不同性别、年龄、职称、工作年限医师多点执业行为比例均不同,差异均有统计学意义（均P < 0.05）;医师多点执业的障碍因素主要涉及法律法规（包括多点执业制度未立法、配套法律法规不完善、执业管理办法地域差异大）,第一执业机构（医院反对、人事管理制度限制、薪酬待遇有差异、未来发展受限）,第二和第三执业机构（病人少、科研弱、硬件差、团队协调弱）;医生个人（时间受限、身份受限、影响薪酬和晋升、担心医疗风险大）,医疗责任险（赔偿额度少、赔付范围窄、责任主体划分不明确、险种可选择性小）等5个方面。  结论  陕西省医师多点执业比例较低,加快医师多点执业制度的法律化、确立医师和执业机构的劳动（劳务）合同关系、完善医疗责任险,可更好的推进医师多点执业。     

Do they work? Regulating for-profit providers in Zimbabwe

The experience of low- and middle-income countries (LMC) with respect to regulation and legislation in the health sector is in marked contrast to that of Canada and Europe. It is suggested that the degree to which regulatory mechanisms can influence private sector activity in LMC is quite low. However, there has been little work done on exploring just how, and to what extent, these regulations fail. Through the use of stakeholder interviews, this study explored the effectiveness of regulations directed at the private-for-profit sector (general practitioners, private clinics and hospitals) in Zimbabwe. The study found that there was limited and asymmetric knowledge of basic regulations among government bodies and private providers. However, there was a clear feeling that regulations are not being implemented and enforced effectively. A variety of opportunistic practices have been observed among private providers, including: practices of self-referral, where patients are sent to other services the provider has a financial interest in; over-servicing; doctor-patient collusion to collect health insurance payments; and the use of unlicensed staff in private facilities. Key factors limiting effectiveness of regulation in the health sector include the over-centralization and lack of independence of the regulatory body, the absence of legal mechanisms to control the price of care, and the lack of knowledge by patients of their rights. The study also identified a number of potential strategies for improving the current regulatory environment. For example, in order to improve monitoring, 'informal' arrangements between the centralized regulatory body and local authorities developed. There is a need to develop ways to formalize the role of these authorities. In addition, professional associations of private providers are also identified as key players through which to improve the impact of regulation among private providers. Increasing consumer access to information and knowledge is another potential way to improve information within the regulatory process as well as implementation.     

How and why public sector doctors engage in private practice in Portuguese-speaking African countries

OBJECTIVE: To explore the type of private practice supplementary income-generating activities of public sector doctors in the Portuguese-speaking African countries, and also to discover the motivations and the reasons why doctors have not made a complete move out of public service. DESIGN: Cross-sectional qualitative survey. SUBJECTS: In 1996, 28 Angolan doctors, 26 from Guinea-Bissau, 11 from Mozambique and three from S Tomé and Principe answered a self-administered questionnaire. RESULTS: All doctors, except one unemployed, were government employees. Forty-three of the 68 doctors that answered the questionnaire reported an income-generating activity other than the one reported as principal. Of all the activities mentioned, the ones of major economic importance were: public sector medical care, private medical care, commercial activities, agricultural activities and university teaching. The two outstanding reasons why they engage in their various side-activities are 'to meet the cost of living' and 'to support the extended family'. Public sector salaries are supplemented by private practice. Interviewees estimated the time a family could survive on their public sector salary at seven days (median value). The public sector salary still provides most of the interviewees income (median 55%) for the rural doctors, but has become marginal for those in the urban areas (median 10%). For the latter, private practice has become of paramount importance (median 65%). For 26 respondents, the median equivalent of one month's public sector salary could be generated by seven hours of private practice. Nevertheless, being a civil servant was important in terms of job security, and credibility as a doctor. The social contacts and public service gave access to power centres and resources, through which other coping strategies could be developed. The expectations regarding the professional future and regarding the health systems future were related mostly to health personnel issues. CONCLUSION: The variable response rate per question reflects some resistance to discuss some of the issues, particularly those related to income. Nevertheless, these studies may provide an indication of what is happening in professional medical circles in response to the inability of the public sector to sustain a credible system of health care delivery. There can be no doubt that for these doctors the notion of a doctor as a full-time civil-servant is a thing of the past. Switching between public and private is now a fact of life.     

Carrot and stick: state mechanisms to influence private provider behavior

The behavior of private sector health care providers will depend critically on the environment within which they operate. A bewildering array of possible regulatory and incentive setting structures exist. Most developing countries have the basic legislation for regulation, but there are frequently difficulties in enforcing such controls. While process aspects of quality of care regulation are often the responsibility of professional organizations, these organizations may have limited incentives to be active in ensuring high quality medical car.e There has been less experience with the use of incentives to encourage appropriate behavior amongst private providers: this appears a promising area for further work. Above all, adequate information is essential both for the enforcement of regulations and the application of incentive mechanisms.     

德国家庭医生执业路径及服务模式

德国“家庭医生”包含全科医生、家庭内科医生和儿科医生三类医师。除门诊开业外,家庭医生执业场所可延伸至医院,医院通过加强私人诊所与医院之间的良好互动从而发展整合医疗。家庭医师协会作为家庭医生职业群体代理,在福利报酬等方面与政府医保支付机构进行谈判。“家庭医生服务模式”下,疾病保险基金通过改进与家庭医生的服务购买协议,从而达到激励患者和服务提供方主动依从“守门人”制度的效果。     

A new face for private providers in developing countries: what implications for public health?

The use of private health care providers in low- and middle-income countries (LMICs) is widespread and is the subject of considerable debate. We review here a new model of private primary care provision emerging in South Africa, in which commercial companies provide standardized primary care services at relatively low cost. The structure and operation of one such company is described, and features of service delivery are compared with the most probable alternatives: a private general practitioner or a public sector clinic. In a case study of cost and quality of services, the clinics were popular with service users and run at a cost per visit comparable to public sector primary care clinics. However, their current role in tackling important public health problems was limited. The implications for public health policy of the emergence of this new model of private provider are discussed. It is argued that encouraging the use of such clinics by those who can afford to pay for them might not help to improve care available for the poorest population groups, which are an important priority for the government. Encouraging such providers to compete for government funding could, however, be desirable if the range of services presently offered, and those able to access them, could be broadened. However, the constraints to implementing such a system successfully are notable, and these are acknowledged. Even without such contractual arrangements, these companies provide an important lesson to the public sector that acceptability of services to users and low-cost service delivery are not incompatible objectives.     

论非法行医法律规制策略

根治非法行医重在制度完善,我们应按照社会需要完善其整体立法。非法行医罪犯罪主体宜定为一般主体,将单位列为犯罪主体,细化《刑法》第336条中有关"情节严重"内涵;明确卫生技术人员的概念、范围;修改《医疗机构管理条例》,使其有关非法行医条款与《执业医师法》吻合;弥补立法盲区,出台医师执业地点两个以上的管理规定,制定行政法规遏制医疗机构出租承包科室、雇用"医托"等违规行为。     

Effects of decentralisation and health system reform on health workforce and quality‐of‐care in Indonesia, 1993–2007

The impact of decentralisation, socioeconomic changes and healthcare reforms in Indonesia on type and distribution of healthcare providers and quality‐of‐care has been unclear. We examined workforce trends for healthcare facilities from 1993 to 2007 using the Indonesian Family Life Surveys. Each included a sample of public and private healthcare facilities, used standardised interviews for numbers and composition of staffing, and quality‐of‐care vignettes. There was an increase in multiprovider facilities and shift in profile of solo providers—increasing proportions of midwives and drop in doctors in rural areas (including facilities with doctors) and nurses in urban areas. Quality‐of‐care scores were low, particularly for nurses as solo providers. Despite increased numbers of healthcare workers and growth of the private sector, outer Java‐Bali and rural areas continued to be disadvantaged in workforce capacity and quality‐of‐care. The results have implications for accreditation and in‐service training requirements, the legal status of nurses and private sector regulation. Copyright © 2014 John Wiley & Sons, Ltd.     

Public-private partnership organizations in health care: cooperative strategies and models

Value-adding partnerships have emerged as a preferred strategy of private health care providers to achieve high-quality, low-cost provider status. This same strategy can be applied by public sector providers through the creation of public-private partnership organizations (3POs). Strategies to build 3POs between local governments and their medical communities currently under development are outlined. The conceptual and practical aspects of implementing 3POs are presented.     

某院妇幼医师依法执业知识知晓率调查

目的调查某三甲医院妇幼医师依法执业知识知晓情况，为有效开展培训提供依据。方法对该院已获得执业医师资格证书并注册执业的164名妇产科与儿科医师进行依法执业知识调查。结果依法执业知识平均得分为（23.13±2.24）分，总平均知晓率为82.62%。其中，医疗技术、病历书写规范、处方管理、会诊相关知识平均知晓率最高，为84.93%；医师执业基础知识平均知晓率为81.12%；计划生育与母婴保健依法执业知识平均知晓率最低，为80.77%。妇产科与儿科医师之间得分差异无统计学意义（P＞0.05），不同年龄、不同职称之间得分差异具有统计学意义（P＜0.01）。结论医院可通过设立“依法执业专员”搭建管理部门与临床科室间的沟通桥梁；通过关口前移、畅通咨询途径，为临床一线医师提供多种形式的依法执业知识培训和查询途径；营造医院依法执业文化氛围，进一步提升培训效果。     

Pharmacovigilance amongst doctors in private hospitals in Lagos West Senatorial District, Nigeria

Appropriate practice of pharmacovigilance in Nigeria will require total involvement of the private medical practitioners considering their number and closeness to the community. Thus, the understanding and attitude of Doctors practicing in the private sectors, towards Pharmacovigilance, was investigated. A consecutive sampling was used to distribute two hundred and seventy questionnaires to consenting doctors in the private hospitals of the Lagos West Senatorial District. The response rate was 93% and the results showed that majority of the respondents, 208 (82.9%), have heard about pharmacovigilance and a large percentage (79.3%) defined pharmacovigilance correctly. However, most of the respondents, 141 (56.2%), did not know how to report ADRs and where to obtain the ADR forms (71.7%). Only 14 (5.6%) of the respondents reported ADRs in the last one month. However, the majority of the respondents (89.6%) were willing to practice pharmacovigilance if they are trained. There were significant associations (p < 0.05) between previous areas of practice of the respondents; the respondents' academic qualifications; years of experience and reporting of ADRs. The NPC has already been organizing series' of trainings for doctors on pharmacovigilance, however, more periodic trainings should be organized for doctors especially those practicing in private hospitals. The curriculum of medical schools should be reviewed for its pharmacovigilance content.     

强化医院科室的环节管理

为探索做好医院科室日常管理工作的有效办法,笔者从落实规章制度入手,加大了以下环节的管理力度:①医护人员的执业准入和技术培训;②病情告知的规范和工作流程的确立;③疑难病人的诊断和危重病人的抢救;④有创诊疗的指导和病历质量的审核;⑤重要岗位的配置和重点人员的管理;⑥医疗成本的监控和医德医风的检查。通过强化关键环节的管理,调整影响环节管理的主要因素,创新管理办法,科室的管理水平和医疗服务质量明显提高。     

青羊区家庭医生服务效果的探索与实践

目的:实践并探索青羊区家庭医生服务效果,并为相关政策的制定提供理论及数据参考.方法:选取新华和草御中心试点研究家庭医生服务效果.结果:家庭医生知晓率增加,慢病病人治疗费用下降,家庭医生满意度增长,并在健康教育中作用上升.结论:家庭医生服务已取得初步成效,需进一步的抓住政策的支持与引导,完善家庭医生团队建设,提高家庭医生自身专业素质与服务水平,促进其持续发展.     

Public-private partnerships for equity of access to care for tuberculosis and HIV/AIDS: lessons from Pune, India

The private medical sector is an important and rapidly growing source of health care in India. Private medical providers (PMP) are a diverse group, known to be poorly regulated by government policies and variable in the quality of services provided. Studies of their practices have documented inappropriate prescribing as well as violation of ethical guidelines on patient care. However, despite the critique that inequitable services characterise the private medical sector, PMPs remain important and preferred providers of primary care. This paper argues that their greater involvement in the public health framework is imperative to addressing the goal of health equity. Through a review of two research studies conducted in Pune, India, to examine the role of PMPs in tuberculosis (TB) and HIV/AIDS care, the themes of equity and access arising in private sector delivery of care for TB and HIV/AIDS are explored and the future policy directions for involving PMPs in public health programmes are highlighted. The paper concludes that public-private partnerships can enhance continuity of care for patients with TB and HIV/AIDS and argues that interventions to involve PMPs must be supported by appropriate research, along with political commitment and leadership from both public and private sectors.     

基于安徽省影像云的医用电子胶片应用探索

从政府医疗体制改革、医院节省影像检查成本和医患开展远程医疗需求的角度论述了安徽省医用电子胶片应用的重要意义,从医学影像信息系统(PACS)系统发展、医生阅片习惯、受检者观念、医院发展需求和国家相关政策法规等方面分析医用电子胶片应用的可行性,并结合安徽省影像云医用电子胶片的架构和建设实践中发现的问题提出进一步优化存储与传输频率、出台相关行业标准与法规等建议。     

中国社会办医的现状分析

通过系统分析中国社会办医的现状,为进一步促进社会办医提出政策建议。根据国内外文献,社会办医疗机构和公立医疗机构在医疗费用和服务质量方面并没有显著差异,并且由于社会办医促进市场开放与公平竞争,公立医院和整个医疗卫生服务市场的绩效也因此有所提高（正向溢出效应）。尽管如此,由于中国长期计划经济自上而下的资源配置与行政干预,社会办医长期未能得到健康发展,主要政策障碍包括准入方面存在隐形限制、经营方面缺乏税收鼓励、用人方面缺少优质医师资源。因此,建议调整区域卫生规划的功能从“封顸”向“兜底”过渡,尽快制定有利于社会办医的土地政策和人才政策,进一步完善相关配套措施,促进社会办医在中国的健康发展。     

The emergence of market competition in the U.S. health care system: Its causes,likely structure,and implications

This paper addresses three issues. First, why did market competition emerge in the U.S. health care system? Second, once free of regulatory constraints, how is the structure of the medical care system likely to evolve? Three, what are the implications of market competition for the public as well as for providers? The medical system in the U.S. was highly regulated and conventional wisdom assumed a continuation of these trends. Further, the economic motivation of existing providers was to maintain the status quo; market competition threatens their economic well being. Market competition was primarily a result of private sector forces. Several actions by the government, both intentional and unintentional, aided these private forces. Second, economies of scale and consumer preferences for different delivery systems appear to be important determinants of the new market structure. Lastly, market competition is forcing a redistribution of incomes, both between providers as well as between providers and taxpayers. There is also increasing concern over the plight of the medically indigent, as inadequate government payments become more obvious in a price competitive system.     

注册医师多点执业政策利益诉求与博弈分析 —基于政府和医院角度

摘要:目的　探究我国医师多点执业政策实施效果不佳的原因和决策建议。方法　利用完全信息动态博弈模型,对政府、第一执业医院和第二（三）执业医院进行博弈分析。结果　博弈最佳策略组合为政府深入实施政策,第一执业医院阻碍医师外院执业,第二（三）执业医院积极表达需求并施加影响,印证我国政策推行的实际情形。结论　政府部门应关注第一执业医院对政策的态度和反应,在横向流动名额配置、首诊转诊制度以及医疗行为保障等方面加以完善。     

Private medicine in socialist China: A survey of the private medical market in Guangzhou

This study analyses the size and the characteristics of the private medical market in Guangzhou. Legislations related to the regulation of private medical establishments are examined. Data collected reveal that private sector provision of health services in China is still small and lacks sophistication. The article recommends further reforms in the fees and charges system; loosening of the restrictions of public doctors to undertake private practice; contracting-out some of the state health services to private practitioners; and, creating a more favourable environment for private investment in the health care industry.