| Objective: This study is carried out in a systematic way,which is based on researches and related policies.The study defines the concepts of hierarch medical system and medical treatment combination,and it summarizes the related theories.The study summarizes and analyzes the typical reform of medical treatment combination in China.Two following representative forms of medical treatment combination of Guangxi are chosen: county medical community and medical treatment combination.Furthermore,this paper will evaluate the development of medical treatment combination of Guangxi,analyze the existing problems and influencing factors and put forward a sustainable development of medical treatment combinations.Method: 1.This paper is based on research and analysis of relevant policies,and discusses the definition of hierarchical medical system,the meanings of medical treatment combination and conclusion of the relevant theory.Four typical models of medical treatment combinations in China are city medical group,county medical community,cross regional specialist union and telemedicine cooperation network.Some typical cases will be analyzed in terms of practical experience and practices.2."County medical community" reform evaluation in Guangxi.Taking the "county medical community" in Shanglin county of Guangxi as a case for evaluation.Survey objects:(1)members of the medical community.Including the county people’s hospital,Chinese medicine hospital,maternal and child health hospital,and all township health centers(11 in total).(2)Medical staff.The medical staff of the county people’s hospital,Chinese medicine hospital,maternal and child health hospital,and township hospitals.Including doctors,nurses,medical technicians,and management personnel.There were 50 people were investigated in each county hospital(20 physicians,20 nurses,5 medical technicians and 5 administrative staff).According to the hospital staff numbers to take a systematic sampling;requirements department,professional titles distributed evenly.10 staff members were randomly selected according to their staff numbers in each township hospitals.(3)Patients.The patients of county People’s hospital,Chinese medicine hospital,maternal and child health hospital,and township hospitals.The convenience sampling method was used to select 50 patients from each county hospital,including 25 outpatients and 25 inpatients.Randomly selected 3 township hospitals and collected 30 hospitalized patients from each township hospital in convenient sampling method.Survey contents and methods:(1)Collection of existing qualitative data.Relevant policies,work summaries and other information related to the medical community reform were collected from the relevant departments of Shanglin county government,county-level hospitals and other institutions.(2)Questionnaire survey of members of the medical community.The member organizations of the medical community fill out the questionnaire.The contents of the survey mainly included the status of medical resources,the provision of medical services,operating efficiency,medical expenses,revenue and expenditure,and its structure,financial status,and two-way referral,and the assistance of county hospitals to township health centers.(3)Questionnaire survey of medical staff.Self-administered questionnaires were used for surveys.The contents of the survey mainly include the understanding,cognition,attitude and willingness of the hierarch medical system and the medical community.(4)Questionnaire survey of patients.The outpatient survey used the method of encounter sampling at the outpatient clinic outlet to collect patients for investigation until the number of cases meeting the investigation requirements is completed.Inpatients are patients who have completed hospitalization and are about to be discharged from the hospital.The day before the patient is discharged,all patients who have completed the inpatient treatment would be investigated until the number of cases that meet the investigation requirements.The survey collected data by training investigators to ask the surveyee.And the survey contents mainly include the satisfaction of medical service;the understanding,cognition,attitude and willingness of hierarch medical system and medical community.Statistical analysis methods: Applied the Epi Data3.0 software to the collected data,double-entry to establish a database,and set the corresponding logic control and verification procedures in the entry program,and carefully cleaned and checked the data.Application spss19.0 statistical software for statistical analysis of data.Descriptive statistical analysis was used to analyze the operation of the member institutions of the medical community and medical staff and patients’ perception and evaluation of medical community.The TOPSIS method was used to conduct a comprehensive evaluation of the effects of the implementation of the reform of the member organizations of the medical community.3.Case review of Guangxi’s “third-level-secondary medical treatment combination” reform case.The assessment was conducted using the case of " third-level-secondary medical treatment combination " of Liuzhou workers’ hospital-Sanjiang people’s hospital in Guangxi.Survey objects:(1)The leading unit of the medical federation-Liuzhou workers’ hospital and the trustee-Sanjiang county people’s hospital.(2)Medical staff.The working medical staff of Liuzhou workers’ hospital and Sanjiang county people’s hospital include doctors,nurses,medical technicians and management personnel..There were 100 people were investigated in each hospital(40 physicians,40 nurses,10 medical technicians and 10 administrative staff).According to the hospital staff numbers to take a systematic sampling;requirements department,professional titles distributed evenly.10 staff members were randomly selected according to their staff numbers in each township hospitals.(3)Patients.Patients in Liuzhou workers’ hospital and Sanjiang county people’s hospital.The convenience sampling method was used to select 100 patients Separately from Liuzhou workers’ hospital and Sanjiang county people’s hospital,including 50 outpatients and 50 inpatients in each hospital.Survey contents and methods:(1)Collection of existing qualitative data.Relevant policies,work summaries and other information related to the medical treatment combination reform were collected from the relevant departments of Sanjiang county government,Liuzhou workers’ hospital and Sanjiang county people’s hospital and other institutions.(2)Questionnaire survey of members of the medical treatment combination.The survey contents and methods are similar to those of the above-mentioned member organizations of the medical community.(3)Questionnaire survey of medical staff.The content and methods of investigation are similar to those of the medical community medical staff questionnaire mentioned above.(4)Questionnaire survey of patients.The content and methods of investigation are similar to the above-mentioned survey of medical community patients.Statistical analysis methods: similar to the above-mentioned medical community statistical analysis methods.Results: 1.Cases analysis of typical model of medical treatment combination in China The medical treatment combination has formed four organizational models including the urban medical group,the county medical community,the specialist alliance,and the telemedicine collaboration network in China.Zhenjiang rehabilitation medical group of Jiangsu province has achieved the goal of reform,including the management system has been completely streamlined and the management cost has decreased significantly;the effectiveness of the two-way referral division of labor and coordination mechanism has been significant;the enthusiasm of medical staff has been fully mobilized;the burden on the public for medical treatment has been effectively reduced,and Improve social satisfaction,by integrating assets as a link,implementing a separate corporate governance structure,and establishing a division of labor and institutionalized,humane incentive mechanism for public hospitals and community health organizations;and carrying out the reform of prepaid system payment method with "Number of People" as its core.Tianchang city,in Anhui province,took three county-level hospitals as the lead unit,cooperated with 14 county township hospitals and two community health service centers,established three county medical communities.Through the integration of county and township medical and health service resources,implementation of regional group management,establishment of a division of labor and coordination mechanism,transformation of medical service delivery models,and the implementation of county health reforms by the medicare fund to implement county-level medical and community reforms based on the total amount of heads of insurance participants.The overall efficiency of the allocation and use of medical resources at the county level have been improved,the county-township medical service capacity has been enhanced,and the county-wide medical consultation rate and county residents’ health level have been promoted.Tianjin chest hospital relies on the advantages of the construction and development of the “chest pain center” and uses information technology to establish links between the hospital and the secondary medical institutions,the grassroots community and patients,and strengthen the establishment of the chest pain specialist league.Initially form a chest pain specialist league covering Tianjin,popularizing Hebei,radiating North China,and facing the grassroots community.From the perspective of specialist hospitals,the structure of the supply side of medical resources is optimized,and high-quality medical resources are sank to facilitate patients to seek medical care at the grassroots level and enhance the sense of access to the people.In view of the imbalanced allocation of medical resources to the islands,poor sharing of quality medical resources between urban and rural areas,relatively weak service capacity at the primary level,and inconveniences and high costs for remote island residents,Zhoushan city created the “Zhoushan islands network hospital” to build a remote medical collaboration network.Effectively broke through the restrictions of urban and rural areas,regions,and transportation,so that island residents can enjoy the services of experts in tertiary hospitals without leaving the island.2.Typical cases evaluation of Guangxi medical treatment combination 2.1 Reform measures: In 2016,Shanglin County took the lead in Guangxi to explore the reform of the county medical treatment combination.The county medical treatment combination is composed of three county-level public hospitals(county people’s hospital,county traditional Chinese medicine hospital and county maternity and child care hospital)and all township hospitals.The county medical treatment combination was led by the county people’s hospital and set up an internal management committee for the integration of medical service and county-township reform to coordinate the reforms.The principle of “three invariability” is implemented for each member unit: Firstly,the institution setting and the administrative system do not change.Each member unit involved in the reform retains the original institutional setup and administrative establishment;Secondly,the functions and tasks undertaken are not changed;Thirdly,charges do not change.Implement uniform personnel management,unified business management and unified financial management;establish and improve the division of labor and cooperation,two-way referral mechanism;county government to establish fiscal security measures to support the county medical treatment combination reform and construction.2.2 The achievements of the reform:(1)The hierarchical medical system model was initially formed in the county.Patients transferred from county hospitals to township hospitals increased year by year,which increased 32.56% in 2017 comparing to 2015.The growth of outpatients in county hospitals lowered,and the growth rate was 4.03% in 2017(lower than 7.51% in 2016).The number of discharged patients increased year by year,which increased 22.84% in 2017 comparing to 2015.(2)The medical service quantity of township hospitals increased,and the diagnosis and treatment capacity was improved.County-level hospitals provide assistance for township hospitals,and take training courses,consultations,ward rounds,and special operations to help township hospitals improve capacity for diagnosis and treatment.Compared with 2015,discharged patients of township hospitals increased by 17.38%.The number of inpatient operation increased by 7.55%.(3)Human resources in township hospitals improved.Compared with 2015,each township health center increased 12 licensed(assistant)physicians and 41 registered nurses in 2017.The ratio of doctor to nurse increased from 1:1.92 in 2015 to 1:2.05 in 2017.(4)Patients have high degree of satisfaction.Satisfaction rate was 78.8% for outpatient in county-level hospitals,81.2% for inpatients,and 70.2% for patients in township hospitals.Patients satisfaction rate for referral services was 74.5% in county-level hospitals,and 69.3% in township hospitals.2.3 Problems in reform:(1)The division of labor cooperation mechanism needs to be improved and there are still difficulties in the transfer of patients between the superior and subordinate medical institutions.There was a lack of close horizontal cooperation among the county people’s hospital,the county hospital,and the county maternal and child health hospital in medical community.The number of upwards referral patients from township health centers increased year by year.Compared with 2015,the number of transfers from county hospitals to township hospitals increased by 32.56% in 2017.However,the number of downward referral patients from county hospitals to township hospitals decreased year by year.Compared with 2015,the number of downward referral patients dropped by 20.47%.(2)The medical expenses of medical members in the community grew by a large margin.In 2017,the average per capita cost of outpatient in county people’s hospital increased by 10.67%,and the average per capita cost of hospitalization increased by 11.51%.The average per capita cost of outpatient in township hospitals increased by 25.27%,and the average per capita cost of hospitalization increased by 12.57%.(3)The relevant supporting policies for medical insurance payment need to be established and perfected.In operation of Shanglin county medical community,medical insurance individually payed the health services provided by member agencies,and the related policies for the medical insurance payment of the medical community had not been established.(4)The government’s investment in the construction of the medical treatment combination needs to be strengthened.The proportion of financial and subsidy income in total income decreased year by year,from 15.74% in 2015 to 7.55% in 2017.(5)The integration of information resources sharing needs to be enhanced.The medical information resource sharing platform between the county hospital and the township hospital had not been established.The medical information system could not be interconnected among the three county hospitals.The issue of "information isolated islands" had become one of the bottlenecks in the construction and development of medical communities.(6)The comprehensive benefits of various members of the medical community are still not obvious.(7)The medical workers’ job satisfaction is low.Job satisfaction rate of medical staff was 59.63% in county people’s hospital,50.95% in county maternal and child health hospital,22% in county Chinese medicine,45.80% in township hospitals.Income satisfaction rate of medical staff is 39.60% in county people’s hospital,27.10% in county maternal and child health hospital,12.00% in county Chinese medicine,23.00% in township hospitals.(8)The medical staff and patients have low awareness of the medical treatment combination.Only 24.9% of medical staff in county hospitals understood the medical community policy,and 30.4% in the township hospital.27.9% of the patients in county hospitals understood the medical community policy,and 19.1% in the township hospital.3.Case of “third-level-secondary” medical treatment combination 3.1 Reform measures: In 2016,Sanjiang county people’s government signed a contract with Liuzhou workers’ hospital for hosting the Sanjiang county people’s hospital,and also established the Sanjiang Branch of the Liuzhou workers’ hospital.After the implementation of custody,Sanjiang county people’s hospital implemented the “five changes,three rights conversion”,that is,the affiliation of the Sanjiang county people’s hospital remains unchanged;the identity of the hospital staff remains unchanged;the hospital assets remain unchanged;the hospital’s original claims and debts are not change;the nature of the hospital unit remains unchanged;the general hospital has the right to propose adjustments to the leadership of the branch;staff management rights and middle-level cadre appointment and removal rights;and the right to perform performance distribution.The legal representative of the Sanjiang county people’s hospital was the dean of the Sanjiang county people’s hospital who delegated by the Liuzhou workers’ hospital and was appointed by the Sanjiang county people’s government.After the trusteeship,the financial management of county people’s hospital still implemented by the deputy director of the county people’s hospital;the county people’s hospital will take 3%-8% of the actual income and the business income of the previous year as a percentage of the implementation of custody management and personnel training.3.2 The achievements of the reform:(1)The medical service capabilities of county people’s hospital has significantly improved.Compared with 2015,in 2017 county people’s hospital increased 14.99% of discharge patients,23.43% of hospitalized surgical patients,14.81% of operations and 163.64% of Class III operations.(2)The growth rate of patients’ medical expenses in county people’s hospitals have decreased and the burden has been reduced.In 2017,the growth rate of per capita cost in county people’s hospital was 2.03%,which decreased 8.52 percentage points from 10.55% in 2016.The growth rate of per capita hospital cost was 7.99%,which decreased 12.23 percentage points from 20.22% in 2016.(3)Patients in medical treatment combination have higher satisfaction.Service satisfaction rate of the patient in Sanjiang County People’s Hospital was 83.3%,and in Liuzhou Workers’ Hospital was 99.0%.3.3 Problems in reform:(1)There are still difficulties in the transfer of patients between the superior and subordinate medical institutions.Sanjiang county people’s hospital did not receive patients transferred from Liuzhou Workers’ Hospital from 2015 to 2017.(2)Medical insurance payment related supporting policies need to be established and improved.(3)The county government needs to strengthen the investment in the construction of medical associations.The Sanjiang government has not yet established a financial subsidy mechanism for the construction and development of medical treatment combination.At the same time,the relative lack of financial subsidies for the county people’s hospital had caused a relatively heavy liability.(4)The integration of information resources sharing within the medical treatment combination needs to be improved.The information platforms between Liuzhou workers’ hospital and Sanjiang county people’s hospital are isolated from each other,and the medical information systems of the two hospitals are not yet interconnected.(5)The resources of county-level hospitals subordinated to different medical treatment combinations in the county area lack co-integration.(6)The comprehensive benefits of various members of the medical treatment combination are still not obvious.(7)The satisfaction of medical staff in county people’s hospital is relatively low.The job satisfaction rate of medical staff in Sanjiang county people’s hospital was 27.8%,which was lower than 65.0% in Liuzhou workers’ hospital;income satisfaction rate was 13.1% in Sanjiang county people’s hospital,lower than 42.0% in Liuzhou workers’ hospital.(8)Medical staff and patients have low awareness of the medical treatment combination policy.Only 20.8% of medical staff in Sanjiang county hospital knew about the medical community policy,32% in Liuzhou worker’s hospital.34% of the patients in Sanjiang county hospital knew about the medical conjoined system,and only 8.51% in Liuzhou worker’s hospital.Conclusions: Throughout the country,medical associations(hereinafter referred to as medical treatment combination)will be established as an important carrier for the establishment of a hierarchical medical system and active exploration will be carried out.Four types of organizational models have been formed: urban medical group,county medical community,specialist alliance,and telemedicine collaboration network.And achieved certain results.However,from the perspective of empirical studies in Guangxi,the time for the construction of the medical treatment combination is not long,the construction model is still in the exploratory period,and the framework of the theory and practice is not yet perfect.Therefore,the effect of the construction of medical treatment combination remains to be further observed,and the model needs to be further improved.Policy proposal: 1.Establish and improve the corporate governance structure of medical treatment combination.2.Government should increase the investment in the construction and development of medical treatment combination.3.Establish and improve two-way referral and its supporting measures.4.Give full play to the basic role of medical insurance in the construction of medical association.5.Establish a unified information platform to promote the sharing of medical resources and information.6.Establish an incentive mechanism which adapt to the development of the medical treatment association.7.Strengthen the publicity and guidance of the medical association policy to increase the awareness of patients and medical personnel. |
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