| 1.Research BackgroundFamily doctors contract service from family doctors refer to a key measure for the State to cope with challenges in medical and health,improve the efficiency of medical services,and satisfy the people’ s needs for permanent and continuous health care.It also serves as an important fundamental link in the reform of hierarchical medical system.To implement the contractual services from family doctors,it is necessary to give full play to synergy and support of all aspects in the health service system.As the leader in county-level health care service system,the county-level medical centers have gathered excellent regional medical resources and they are undoubtedly the key technical support for county-level contractual services from family doctors.In addition,the implementation of county-level contractual services from family doctors rests with county-level medical centers,but most research on county-level medical centers focused on the roles,limitations,strategies,and suggestions of county-level public hospitals from the perspective of hierarchical medical system,and that few studied the roles,functions and role orientation of county-level medical centers from perspective of contractual services from family doctors.The following questions and assumptions were proposed in the paper,and a preliminary research was performed in:1.The role of county-level medical centers in promoting contractual services from family doctors;2.The major modes and approaches for county-level medical centers to boost contractual services from family doctors;3.Whether the county-level medical centers had assumed the initial role set in the policies,and its status quo,limitations existed in promoting contractual services from family doctors;and 4.The principle influencing factors affecting county-level medical centers in stimulating contractual services from family doctors,and whether there were proposals for improvement put forward by centering on the promotion of county-level medical centers in contractual services from family doctors.2.Research ObjectivesThe research reviewed and analyzed policies related to contractual services from family doctors and explored the role of county-level medical centers in stimulating contractual services from family doctors from the perspectives of value chain,and supply&demand,as well as key modes and approaches to play such role.Taking one county-level medical center in Guangzhou as an example,the paper,through on-site investigation and research,further analyzed the status quo,limitations existed and influencing factors when county-level medical centers promoted contractual services from family doctors,and put forward corresponding countermeasures and solutions,which served as references in solving specific issues for county-level medical centers’ promotion of contractual services from family doctors.3.Research MethodsThis paper adopted literature research method,expert consultation,and semi-structured interviews,which aimed at clarifying the role orientation,value chain structure,stakeholder theory and effect pathways and models of county-level medical centers in promoting contractual services from family doctors.The case analysis method was adopted and a county-level medical center in Guangzhou that promotes contractual services from family doctors was selected as an example;then documents and data related to the role of county-level medical centers in promoting contractual services from family doctors were collected,the background and content of the case was concluded,and the status quo and influencing factors of the county-level medical center in promotion of contractual services from family doctors were summarized.The questionnaire survey method was employed to perform on-site investigation,and it investigated the promotion of county-level medical centers in contractual services from family doctors by distributing questionnaires to residents in the county,referral patients,medical staff at primary medical institutions,and doctors in county-level medical centers.As for residents in the county,the convenient random sampling was applied;A total of 700 questionnaires were distributed,with 685 questionnaires recovered and 674 valid questionnaires,and the effective recovery rate was 96.29%;According to the two-way referral list,referral patients were investigated with the questionnaire,with 90 questionnaires recovered and 82 valid questionnaires among 95 questionnaires distributed,and the effective recovery rate was 86.32%;The stratified sampling was applied to medical personnel of primary medical institutions,with 354 questionnaires recovered and 350 valid questionnaires among 360 questionnaires distributed,and the effective recovery rate was 96.69%.When such sampling was applied to doctors at county-level medical centers,a total of 249 questionnaires were distributed,with 221 questionnaires recovered and 214 valid questionnaires,and the effective recovery rate was 85.9%.The semi-structured interview method was adopted to conduct in-depth interviews with government staff,grass-roots health experts,the dean of county-level medical center in this case,directors from medical treatment alliance department,directors of clinical department engaging in medical treatment alliance,and management personnel of grass-roots hospitals.Through this method,it was possible to know viewpoints,attitude and opinions of main stakeholders of contractual services from family doctors towards the promotion of such practice in county-level medical centers,as well as to know the limitations existed and suggestions proposed.The statistical methods such as analytical induction,in combination with descriptive analysis,correlation analysis,regression analysis,rank sum test was adopted to analyze and conclude qualitative and quantitative data collected,summarize limitations and influencing factors,and to draw conclusions and put forward suggestions.4.Research Results4.1 The role orientation of county-level medical centers in promoting contractual services from family doctors could be defined as follows:①a medical technology support platform for county-level contractual services from family doctors;②the training objects of county-level family doctor team;③the providers of high-quality medical resources required by county-level family doctor team;④one of the supply links in continuous contractual services from family doctors.4.2 The main modes and approaches for county-level medical centers to promote contractual services from family doctors were:①to open and share high-quality resources for family doctors teams of contractual services;②to provide two-way referral guarantee and support for family doctors teams of contractual services;③to offer professional training and professional guidance for family doctors teams of contractual services;④to provide telemedicine services and supports for family doctors teams of contractual services;⑤to jointly construct linkage wards with family doctors teams of contractual services;⑥ to provide accurate oriented assistance for family doctors teams of contractual services;⑦to integrate regional medical and health resources and take a lead in establishing close medical treatment consortium.4.3 Current situations about the promotion of county-level medical centers in contractual services from family doctors:The county-level medical centers play an active role in promoting contractual services from family doctors and it is reflected in the following four aspects:①Through two-way referral platform,it receives patients who cannot be treated by family doctor team and ensures that patients attacked by serious and major illness can have access to reasonable medical services,and it provides technical support for contractual services from family doctors;②It offers family doctor teams with high-quality resources,and provides“one-free and three-priority" service for referral patients to enhance the attraction of contractual services;③It makes medical equipment resources available to family doctor team,such as inspection and examination equipment,in order to provide convenience for referral residents,and improve the residents’ sense of gain;④It provides business training and technical guidance for family doctor team,and enhances business level and capabilities of family doctor team,which is conducive to improve contract service quality and effectively support the performance of agreements.While in this case,there are still limitations for county-level medical centers to improve contractual services from family doctors,which are reflected in the following four aspects:①There lacked unified referral system and guidelines,the referral was arbitrary,and there were difficulties in two-way referral treatment or transferring to medical centers with lower level;②County-level medical centers failed to effectively implement the follow-up feedback,and linkage between upper and lower medical institutions was insufficient,failing to establish a continuous supply chain in contractual services from family doctors;③ The inspection results of county-level medical centers and grass-roots medical institutions could not be identified by each other,and resource sharing fell short of demand.In addition,residents and referral patients argued that equipment for diagnosis and treatment were insufficient,and that some test examination items cannot be performed via existing equipment,which was one limitation that grass-root medical institutions should make improve;④It failed to establish interconnected information platform for contractual services from family doctors,and information was unavailable to contracting residents,resulting in information isolated island.It was believed by grass-roots medical staff and doctors in county-level medical centers that two-way referral was hindered by unavailable sharing of patient information.4.4 The major factors affecting the promotion of county-level medical centers in contractual services from family doctors were as follows:①The staff in county-level medical centers could not fully recognize the necessity and functions for county-level medical centers to participate in contractual services from family doctors,and were unmotivated by what they do;② The business guidance and technical training provided by county-level medical centers failed to meet the needs of elementary medical personnel;③There were no common interests among medical institutions,as there were cross-function and interest-driven competition among medical institutions at different levels;④The three-medical coordination(namely the coordinated reform of medical services,medical insurance,and the medicine industry)failed to play synergistic effect,and superior and subordinate institutions were not motivated by medical insurance policies,and the cohesion of pharmaceutical reform was inadequate;⑤The performance system to evaluate contractual services from family doctors was far from perfect,and there were no operational indicators and evaluation mechanism that were systematic and could comply with the reality of local counties;⑥ The construction of health information system and health service platform lagged behind,and failed to establish an integrated information platform for family doctors,which made cooperation more difficult.⑦The grass-roots medical institutions were incapable of providing services,which deprived the residents’confidence in the ability of family doctors teams of contractual services,and made it difficult for lower-level-transfer of county-level medical centers.4.5 The main suggestions are given for county-level medical centers to promote contractual services from family doctors,including:Advice to the government:①Clarify division of labor in medical institutions at all levels,formulate standardized two-way referral guidelines,and improve referral security system;②Construct close medical treatment combination,and form community of interests between county-level medical centers and family doctor teams;③Improve supporting policies for health insurance,medicine,and performance evaluation,and provide system guarantee for county-level medical centers to promote contractual services from family doctors;④Establish an interconnected information platform for contractual services from family doctors,and boost contractual services from family doctors via"Internet + Medical Care" eventually.Advice to the county medical center:①Improve the cognition of Medical personnel on the contract service of family doctors;②Provide accurate business training and technical guidance by centering on demands;③Implement follow-up feedback work,open two-way referral channels,and strengthen communication with family physician teams;④Set linkage wards in superior and subordinate medical institutions by taking chronic disease as an entry poin.Advice to primary medical institutions:①Improve the cognition of medical personnel on Referral standards and regulations,green referral channels;②Define functional positioning and strengthen communication with superior hospitals;③Attach importance to the ability building of medical staff,and provide learning opportunities for family doctors to improve their team ability.Advice to family doctors:①Make full use of the county medical center’s quality resources;②Follow up the patients with upper transfer,and contact the doctors of higher level hospitals;③Take the initiative to improve medical service ability;④Take contract service as an opportunity to build long-term customers.Advice to residents:Improve the awareness of family doctor contract services,provide personalized health courses,and enhance the sense of service of family doctor contract. |
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