| Rural health care delivery system to some extent determines the quality of medical services. Apparent defects have been demonstrated by researches. It not only turns out that the grass-roots health care services system’s ability of supplying medical services is poor because of the lack of health human resource as well as the low efficiency and effectiveness of medical services, but also turns out that the rural health care delivery system is highly fragmented for the lack of coordination and communication between organizations. Nowadays, a single medical institution can no longer meet the demand of patients; what’s more, the coordination and continuity of care are needed. Therefore, the core mission to improve medical services in rural areas is to emphasize the coordination in the medical service supply chain rather than to focus on the quality of a certain medical institution.1. ObjectivesThis dissertation focused on the coordination in the longitudinal medical service chain rather than the medical service provision and utilization in a single medical institution. Based on the theory of supply chain, this dissertation described the present status of longitudinal medical service chain in rural China from the point of external institutional environment, patient flow and information flow. And then put forward strategies of improving longitudinal medical service chain in rural China.2. MethodsThe data of this dissertation came from three channels.(1) Literature research. Literatures were used to do some theoretical research.(2) Field survey.4counties were selected to investigations:a) Out-patients and in-patients questionnaire surveys were conducted to analyze the patient flow such as daily first medical institution selection, patient flows in the certain disease period and in the specific time period, and information from the patients’ perspective. b) Medical personnel questionnaire surveys were employed to do the analysis of information flow from the providers’ point of view, c) In-depth interview were used to analyze the external policy environment.(3) Medical insurance data were employed to explore demographic characteristics and disease attributes of inpatients that had the experience of using medical services supplied by more than one institution.Qualitative and quantitative methods were both used. Qualitative methods were used to do some theoretical researches and quantitative methods were employed to analyze questionnaires and insurance data. In this dissertation, hierarchical clustering method was used to select survey site. The statistical analysis was employed to describe the patient flow and information flow and some demographic characteristics, what’s more, chi-square statistical tests were used for the test of the probability distribution difference, binary logistic regression model was used for the analysis of the density, dispersion and sequence of medical institutions’ visits, and multinomial Logistic regressions were employed for the influencing factors of patient flow in the certain disease period and patients’ carrying of medical records.3. ResultsBased on the theory of supply chain and combined with particularity of medical service, this dissertation explored the concept and model of medical service chain, as well as the nature characteristics and intrinsic value of it. Because of the difference of service and products, medical service chain emphasizes not only provision but also utilization, which means regularizing patient flow as well as improving coordination between medical institutions should be paid attention.Longitudinal medical service supply chain was demonstrated unformed by this research. The reasons were as follows. Firstly, there was no driving force for medical institutions to coordinate with each other. Medical insurance failed to play the promoting and regulating role. Secondly, on the basis of theory of constraints, cast effect was ubiquity and there were remarkable differences between different regions. Thirdly, there were not enough available medical service providers in the rural areas.Patient flow in rural Chain was unreasonable for the reason that hierarchical visits were poor.67.65%patients went to county hospitals directly without referrals, causing a waste of37.36billion Yuan. Besides, the disease attributes of in-patients who had the experience of hospitalizing in different medical institutions in the same disease period were found as follows:the same diseases for in-patients who changed the medical institutions from low level to high level or from high to low level were acute or chronic gastroenteritis, malignant tumor, cerebrovascular disease, cervicitis and peritonitis; the distinct diseases for in-patients who changed medical institutions from low to high level were bronchitis (or expand), coronary heart disease angina pectoris, gallstone and cholecystitis, pneumonia and so on so forth; and the distinct diseases for in-patients who changed medical institutions from high to low level were fracture, intracranial injury and internal injuries.Information flow in rural China was obstructed. For one thing, no medical information sharing mechanism and media existed. Regional medical information sharing platform and the mechanism had not yet been established. Worse still, doctors in high level medical institutions had a low degree of trust for the outcomes engendered by low level medical institutions. For another, taking patients as the main medical information transfer was lack of rationality.4. DiscussionsBased on the theoretical and empirical researches, this dissertation brought up policy suggestions from three perspectives.Firstly, develop a proper environment for longitudinal medical service chain in rural China. Promote health care delivery system reform through changing medical insurance policy. And improve the ability of diagnosis and treatment of village clinics and township medical institutions as well as change clinical pathway to integrated care pathway to increase the available medical service providers in the longitudinal medical service chain. Besides, encourage medical institutions to do some coordination and cooperation in a variety of forms like vertical integration and virtual integration.Secondly, develop the three-step development strategies to regulate the patient flow. The first step is to equip patients suffering from chronic diseases with family doctors. The second step is to improve the function of family doctor and broaden their responsibilities. The third step is to implement hierarchical visits, the first-visit system and the referral system under the dual incentive and constraint effect of insurance.Thirdly, break the information island effect and smooth information flow. Construct the regional information sharing platform to smooth information sharing in the longitudinal medical service chain. Regional medical inspection center should be set up to improve the credibility of examination results and the mutual recognition of test results.5. InnovationsTheoretically, the theory of supply chain has been promoted and the theory of medical service chain has been raised by this dissertation. The research perspective of supply chain has been changed from products and commercialization service to the highly professional "pure medical service". And consider that not only the coordination of care but also how to regulate patient flow should be paid attention. Empirically, previous researches focused on the medical service provision and utilization in a single medical institution and ignored medical service delivery by multiple levels of institutions. This dissertation analyzed utilization of medical services provided by multiple levels of institutions, including patients’ demographic characteristics, disease attributes, hierarchical visits and the waste caused by disordered patient flow. What’s more, the obstacles and the influential factors of longitudinal medical service chain were revealed.6. LimitationsFirstly, though the theory of medical service chain was explored by this research, how to build the coordination mechanism and how to select medical institutions to establish longitudinal medical service chain have not been solved. Secondly, though the idea of medical insurance payment reform was put forward, the detailed strategies of encouraging medical institutions to establish medical service supply chain and regulating patient flow remains to be worked out. Thirdly, goals and functions of different medical institutions in the longitudinal medical service chain and the integrated care pathway need to be designed. |
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