基于单病种付费的分级诊疗实施效果及影响因素研究

目的：探索基于单病种付费的分级诊疗对于引导住院患者合理流动的政策实施效果，分析政策范围内住院患者机构选择的主要影响因素。方法：本研究以甘肃省渭源县新农合住院患者为研究对象，对比政策前后住院患者就医流向变化情况，并采用logistic回归分析乡级分级诊疗病种范围内住院患者就诊流向的影响因素。结果：病种分级诊疗实施后，住院患者选择乡级医疗机构的比例呈上升趋势，选择县级医疗机构的患者比例呈逐步下降趋势，住院患者县域内就诊率2016年达89.69%；分级诊疗住院病种范围内住院患者就医流向趋于合理。年龄、疾病种类、距县医院车程、患者居住地所在乡镇卫生院服务能力均为影响乡级病种范围住院患者就诊流向的重要因素。结论：基于单病种付费的分级诊疗其对政策范围内住院患者的流向起到了积极的引导作用，制定合理分级诊疗病种，提升基层医疗机构能力是保障政策发挥积极作用的关键。

Study on the effect and determinants of hierarchical medical system implementation on single disease payment

Objective: To explore the effect of the hierarchical medical system implementation which is based on single disease payment on guiding the rational flow of inpatients,and to analyze the main factors influencing the selection of medical institutions by inpatients within the range of the policy. Methods: The New Rural Cooperative Medical Scheme (NRCMS) hospitalized patients in Weiyuan, Gansu Province, were selected as research subjects. The changes in the choice of medical institutions for inpatients before and after the policy were compared, and the logistic regression was used to analyze factors influencing the hospitalized patients'' selection behavior within township-level graded medical diagnosis and treatment. Results: After the implementation of disease-based hierarchical medical system, the proportion of inpatients choosing township-level medical institutions underwent an upward trend, and the proportion of patients who selected county-level medical institutions gradually declined. The rate of inpatients in the county reached 89.69% in 2016 and their flow within graded medical diagnosis tends to be rational. The age, disease type, location, and health service capacity were all found to be the key factors affecting the flow of inpatients in the township-level hospitals. Conclusions: The hierarchical medical system which is based on single disease payment has played a positive role in guiding the flow of inpatients within the range of the policy. Formulating a reasonable graded medical diagnosis and treatment of diseases and improving the capacity of primary medical institutions is the key to ensuring the positive role of policies.